14 July 2020

Are CPAP and BiPAP Mistakes contributing to COVID-19 Deaths?

“The definition of insanity is doing the same thing over and over and expecting different results.”
- Albert Einstein/ Others ((German born Theoretical Physicist – 1879 – 1955)

Since last month’s blog post, COVID-19 or Coronavirus deaths have increased by more than 170,000 to nearly 580,000 deaths worldwide. This figure is increasing at an alarming rate! Could any of these deaths and long term damage to patients have been avoided? How many patients that have “recovered” will have ongoing serious medical issues including mental health issues? Are CPAP and BiPAP or Bilevel mistakes contributing to COVID-19 Deaths and long term damage to patients?  

To avoid confusion, BiPAP is a Registered Trademark owned by Philips Respironics. Bilevel refers to all other brands such as ResMed.   

The explanation of my concerns with some of the medical protocols is going to be done on a practical level based on my own personal experience, patient comments and various research studies. There will be others with more knowledge and a medical background who can explain better from a technical point of view.

I may be misunderstanding the medical situation as I am not a medical doctor working in the hospitals and have not looked at any patient history. However, I am hearing and reading articles and comments being made by various medical workers and patients. 

Examples of current medical protocols being used during COVID-19 are at: 

When a patient with COVID-19 initially presents to the hospital an assessment is made on the patient’s health. Where appropriate, I understand one of the medical protocols is for a CPAP machine to be prescribed using high pressure of up to 15 to 20 cmH2O. 

Why? From my personal experience and many others on the various sleep apnea forums, using CPAP with high pressure of 15 cmH2O or more on a patient can be a big mistake!

On the blog post Lack of Coronavirus Ventilators: Use Bilevel and CPAP dated 15 March, 2020, I advised only as a last resort, I suggest using CPAP. This is due to a person needing to be able to breathe on their own as they will need to initiate all of their breaths.  

As I write this blog post in July 2020, I am surprised to see medical workers still using CPAP as one of the main treatment options during COVID-19.  
Prior to COVID-19, there is an estimated 80% or more than 15 million people who are non-compliant, failing and non-successful on sleep apnea therapy. This high non-successful rate is due to the many CPAP side effects and issues that a patient may have to deal with. The medical specialists have had many years to work out how to overcome and stop these side effects and issues for the patient as CPAP was invented 40 years ago! More details are on blog pages Why is CPAP Compliance Rate Low? and Secrets to Success: Answer is FREE.

How can the specialists and other medical workers use ventilators, BiPAP and Bilevel and CPAP machines when they do not understand how they truly work? How will they be able to apply these machines successfully to the patients during the COVID-19 pandemic?

The sleep and respiratory medical specialists have not performed successfully treating sleep apnea for patients during normal times before the pandemic. During the COVID-19 pandemic, how will the specialists and other medical workers be able to perform successfully with many patients, especially those that have both COVID-19 and sleep apnea or other serious health issues? 

The medical specialists have a mistaken belief that CPAP is the “Gold Standard” in treating obstructive sleep apnea. It is my view that BiPAP and Bilevel machines are the “Gold Standard” due to their ability to adjust both inhale and exhale pressure and to use more pressure support than CPAP and overcome all CPAP side effects and issues.

It is the mistake of believing that CPAP is the “Gold Standard” before COVID-19 that is causing the medical specialists to make the same mistake in using CPAP as a frontline treatment option during the Pandemic. Unfortunately, this mistake may be contributing to patients ending up on a ventilator and a high likelihood of dying given the very high death rate when using ventilators. For those that survive, patients may end up with long-term lung damage and other serious medical issues.

From my personal experience and many thousands of other people on the various sleep apnea forums (listed right hand side), CPAP is not well tolerated and many people would consider CPAP is a failure!

This statement is supported by the following comment by Assistant Professor Rajkumar Rajendram on March 31, 2020:

“CPAP is associated with worse outcomes in patients with pneumonia. …Where CPAP has been tried in Covid-19 there are reports suggesting a high failure rate. So these patients eventually require intubation.”

Rajendram, Rajkumar. (2020). Re: CPAP machine as supportive positive airway pressure in lieu of COVID19 ventilator shortage? https://www.researchgate.net/post/CPAP_machine_as_supportive_positive_airway_pressure_in_lieu_of_COVID19_ventilator_shortage/5e8342793c05186c827d9b5f/citation/download.

More details of the various CPAP side effects and issues and Contraindications are in a recent medical Study dated June 1, 2020. 

Pinto VL, Sharma S. Continuous Positive Airway Pressure (CPAP) [Updated 2020 Jun 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK482178/

Many patients will likely not be receiving the optimal treatment in the hospital when using a CPAP machine. In addition, using a CPAP machine with high pressure may be making a patient’s condition worse not better! The medical specialists may be causing anxiety, stress, pain and suffering to them. Using CPAP may be contributing to the deterioration in the health of the patients who may eventually end up on a ventilator. As everyone is aware, patients using a ventilator have a high likelihood of dying.

I implore the medical specialists to seriously consider reviewing the medical protocols being used. Do not be like the medical specialist when I had an eye tear duct DCR operation in 2015 who would not listen and made a mistake as detailed in the blog post Coronavirus Deaths due to Mistakes using Ventilators and BiPAP. The same night after the operation, the medical specialist set oxygen at 4 l/min. Oxygen will not be going down the airway as 4 l/min is not enough force to open the airway when a person has obstructive sleep apnea. Hence, the oxygen desaturation alarm set at 93% was going off all night!

Using a nasal cannula with oxygen at 1l/ min to 6 l/min will not be effective for most of the patients with COVID-19 and obstructive sleep apnea (OSA). Based on current cases of more than 13.2 million cases, nearly 530,000 people have been hospitalised with COVID-19 and OSA. In addition, more than 130,000 people have central and/ or complex sleep apnea. Further details are on the blog post Coronavirus Deaths using Ventilators, BiPAP and CPAP. 
As advised in previous Blog Posts, during the Pandemic in the initial stages of a patient having COVID-19 and when a person is in recovery phase, I believe that the optimal treatment for many patients is to consider using the machine that I use, ResMed S9 VAuto bilevel auto adjusting pressure machine with oxygen (where necessary). Note this machine has been superseded by ResMed AirCurve 10 VAuto. This will be of critical importance where hospitals have a shortage or lack of equipment and oxygen supplies.

There would seem to be sufficient BiPAP and Bilevel machines available at a far lower cost than ventilators as they are in daily use by many people with sleep apnea around the world.

Using these machines is supported by recent medical studies dated June 2020 and an old study dated May 2007.
Medical Study - June 4, 2020
That Non-invasive oxygenation strategies compared with standard oxygen therapy were significantly associated with lower risk of death. Compared with standard oxygen therapy there was a statistically significant lower risk of death with helmet noninvasive ventilation (risk ratio, 0.40) and face mask noninvasive ventilation (risk ratio, 0.83).

Standard oxygen therapy, typically at flow rates of less than 15 l/min, has been the conventional approach to delivering supplemental oxygen to patients with acute hypoxemic respiratory failure. 

Ferreyro BL, Angriman F, Munshi L, et al. Association of Noninvasive Oxygenation Strategies With All-Cause Mortality in Adults With Acute Hypoxemic Respiratory FailureA Systematic Review and Meta-analysisJAMA. 2020;324(1):57–67. doi:10.1001/jama.2020.9524

Medical Study – June 20, 2020 

Due to the massive number of COVID-19 cases all over the world, the ventilator requirement is increasing, and these traditional ventilators are quite expensive and are occupied for the critical cases, thus available in limited numbers. In this regard, BiPAP (Bilevel Positive Airway Pressure) ventilation support can be used for the less critical cases where patients do not require intubation by specialized staff and also minimizing the risk of infection during the procedure. Hence, alternative respiratory support systems reduce the required number of ventilators. A BiPAP machine is much easier to operate and inexpensive as compared to ventilators. 

Singh, G.P., Sardana, N. Affordable, Compact and Infection-Free BiPAP Machine. Trans Indian Natl. Acad. Eng. (2020). https://doi.org/10.1007/s41403-020-00134-6

Medical Study - May 21, 2007

Yet growing research suggests that inhaling straight oxygen can actually harm the brain.  For decades, the medical community has championed 100 percent oxygen as the gold standard for resuscitation. But no one has reported what happens inside our brains when we inhale pure oxygen," said Ronald Harper, distinguished professor of neurobiology at the David Geffen School of Medicine at UCLA. 

Earlier data on high oxygen's harmful effects have already resulted in policy changes overseas. Instead of using straight oxygen, many European hospitals now resuscitate patients with room air, which contains a mixture of nitrogen, oxygen and carbon dioxide, or with a blend of oxygen and carbon dioxide.

My personal experience and from other experienced sleep apnea users on various sleep apnea forums who have used different brands of BiPAP and Bilevel machines; the ResMed Bilevel VAuto machine is the preferred machine. This is due to the superior machine algorithm and the fact that it has additional settings compared to other brands. Such settings include breathing sensitivity on inhale (trigger setting) and exhale (cycle setting) and a setting for how long the time you inhale/ breathe in for (TI Min and TI Max settings). 

These settings as well as having available pressure support up to 10 cmH2O enable the machine to be tailored and fine-tuned for each patient giving optimal treatment and making it far superior to a CPAP machine. More details are on blog page CPAP Vs Bilevel Settings Example. By using a bilevel machine I was able to overcome all the CPAP side effects and issues such as insomniatreatment-emergent central apnea and mask leaks. Some mornings I feel ready to go and climb Mount Everest after waking up fully refreshed and energized!

For some patients, using CPAP pressure at more than 9 cmH2O with humidification is going to cause air to go through the eye tear duct and out the eyes. By doing so, a patient will have terrible, painful red sore eyes as well as being totally exhausted from the lack of quality sleep. In addition, the patient may have an increased risk of eye infection.

Using BiPAP and Bilevel machines instead of a CPAP machine is supported by Drs Stephen Park and Barry Krakow. 

In our clinical and research experience, we believe one of the two largest problems leading to early dropouts are that CPAP is the wrong device for nearly all the patients who fail
CPAP, and they should have switched to BPAP or other more sophisticated technology within one or two weeks of their initial struggle with CPAP. 

Very few (sleep centers) as far as we can tell use the technique we recommend involving manual titration of auto-adjusting dual pressure technology, which means using auto-bilevel (ABPAP) or adaptive servo-ventilation (ASV). When patients are exposed to these advanced forms of PAP, there is greater than 90% chance they will select these modes over CPAP, APAP or even fixed BPAP if for no other reason than comfort. Moreover, in our clinical research, we find their results are objectively better than with traditional PAP modes.    

In the previous blog post, I mentioned that the medical specialists should give serious consideration to using similar settings that I use as outlined on the blog pages Different Bilevel Settings Example and Guide to Success using CPAP and Bilevel. By doing so, will give the optimal treatment to patients from the time that the patient is first admitted to hospital where their medical condition is of low deterioration. 

By having great therapy and quality sleep, a person will be able to build up their immunity system to best overcome the coronavirus. A person may recover faster and leave hospital without the physical and mental scars from using a Ventilator. Such treatment may reduce the horrific death toll and the current high death rate using Ventilators.

In addition, using a bilevel auto machine will be of great importance where it is necessary to preserve valuable oxygen supplies for more serious cases and there is a shortage or lack of equipment.

I feel the best opportunity to use the bilevel auto machine is from the moment when the patient is first admitted to hospital and when a patient is in the recovery phase of COVID-19. 

The ResMed VAuto bilevel auto machine settings that I use and the reasons why are detailed on the blog page Guide to Success using CPAP and Bilevel include:

1. Minute Ventilation (MV) being the total volume of air entering the lungs in a minute of 6 litres/ minute or lower. 

2. Tidal Volume (TV) of 6ml/kg ideal body weight (IBW) or predicted body weight (PBW) instead of actual body weight. 

Further details are on the blog post Use Ideal Body Weight on CPAP and Bilevel

3. Breathing/ Respiratory Rate (RR) of 14 Breaths/ minute. 

I found this was the optimal breathing rate for me using the bilevel auto machine.

4. EPAP or PEEP (Positive End Expiratory Pressure) of 4.2 cmH2O.

Note that I am able to use a low PEEP due to using high Trigger and high/ very high Cycle settings for breathing sensitivity. Otherwise, I would need to use a higher PEEP such as 5 or 6 cmH20.  
5. Pressure Support of 5.0 to 5.6 cmH2O.

Using this amount of pressure support provides much greater ventilation and makes it much easier to breathe against the exhale pressure than CPAP especially for the elderly patients with respiratory issues. Bilevel and BiPAP machines have dual pressure settings which allow a patient to get more air in and out of their lungs and to breathe more easily and regularly throughout the night.

In a recent Medical Study dated June 1, 2020, “If adequate minute ventilation and or oxygenation cannot be achieved (with CPAP); then management should include escalation to BiPAP or intubation with mechanical ventilation following the code status and goals of care.”

Pinto VL, Sharma S. Continuous Positive Airway Pressure (CPAP) [Updated 2020 Jun 1]. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2020 Jan-. https://www.ncbi.nlm.nih.gov/books/NBK482178/

In a Guide on Medical Protocols “COVID-19: ICU for the NON-Intensivist” dated May 6, 2020, it seems that similar settings are used only when the patient’s medical condition has seriously deteriorated.   

From my personal experience, I would argue that the optimal treatment is to use a ResMed VAuto bilevel machine with similar settings above and oxygen (where necessary) as soon as the patient is first admitted to hospital where their medical condition is of low deterioration. By doing so, a medical specialist will give valuable time to the patient to build up their immune system to COVID-19. 

It will take patience and time for some patients in particular the elderly before they may recover. By having patience and giving patients time, the medical specialists will give patients the best chance of survival and making a better recovery.  

My concerns with some of the medical protocols being used and mistakes that I believe are being made during COVID-19 are also detailed on the following blog posts:


If the world’s going to get better, it’s going to be up to you, the medical specialists to CHANGE it!

Should you be having side effects and issues with your sleep apnea therapy; CHANGE what you are doing so that you can wake up feeling refreshed and energized each day.

“Have courage. Be adventurous and Go for it! Overcome your fear.”
- Mrhelpful 


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