The term "BiPAP" is a familiar search term to the general public. This article uses it to facilitate easier searching of content. The medical term for a two-level pressure device is bilevel positive airway pressure, or BPAP. This type of device separates the pressure during inhalation and exhalation.¹ Unlike continuous positive airway pressure (CPAP) machines, which deliver a consistent, single pressure level determined by the healthcare team.¹

Simply put, BiPAP has two pressure levels, while CPAP has a single, continuous pressure level. However, this difference doesn't mean BiPAP is better for everyone. This article will help you understand the principles and prepare questions to discuss with your healthcare team. It should not be used as a substitute for diagnosis, choosing a machine, or setting pressure yourself.

What is BiPAP?

BPAP stands for bilevel positive airway pressure, meaning it uses two pressure levels, one during inhalation and another during exhalation.^1,6 This device belongs to the positive airway pressure (PAP) therapy group, just like CPAP.

This article uses the term "BiPAP" in its title, based on reader familiarity, but the medical term is "bilevel PAP." The name only indicates the pressure pattern; it doesn't specify what condition you have or which type of device you should use. If the cause of your symptoms is unknown, you should start with an evaluation.

What are inspiratory pressure airway pressure (IPAP) and expiratory pressure airway pressure (EPAP)?

Inspiratory positive airway pressure (IPAP) is the pressure the machine delivers during inhalation, while expiratory positive airway pressure (EPAP) is the pressure the machine delivers during exhalation.⁶

This article uses the term "noninvasive ventilation (NIV)" as a keyword throughout. In this context, it refers to positive pressure ventilation without inserting a tube into the trachea. Typically, the machine delivers pressure through a mask covering the nose, or both the nose and mouth.^6,7

For individuals with chronic alveolar hypoventilation (CAH), this term refers to persistently insufficient breathing for an extended period. A stable phase refers to a period when symptoms are not acutely worsening or relapsing. The medical team will select the appropriate mask and pressure to suit each individual's needs.⁶ These terms are meant to help you read documents and communicate with the healthcare team, not to be used to make up your own numbers.

How does BiPAP differ from CPAP?

CPAP delivers a continuous, single pressure level as determined by the healthcare team, while BiPAP separates the pressure during inhalation and exhalation.¹ This is simply a difference in how pressure is delivered, so it's not enough to determine which machine is better for you.

The diagram compares a CPAP machine that delivers a continuous, single pressure level with a BiPAP/BPAP machine that separates pressure during inhalation (IPAP) and exhalation (EPAP), without showing numerical values or suggesting manual settings. — CPAP and BiPAP/BPAP differ in their pressure delivery methods, but this difference isn't enough to determine which machine is more suitable for each individual. The healthcare team must assess and configure the settings appropriately.^1,6

For the treatment of obstructive sleep apnea (OSA) in adults, the American Academy of Sleep Medicine (AASM) conditionally recommends that physicians should choose CPAP (auto-adjusting positive airway pressure) machines over BPAP machines, and specifies that diagnosis should be made through appropriate sleep studies and follow-up should be done after the start of treatment.²

The term "conditional recommendation" sounds like technical jargon, but in simple terms, it means that doctors still need to consider each individual's data; it's not a hard and fast rule, and it doesn't mean that BiPAP is prohibited.² In some adult patients with OSA, physicians may consider BiPAP when a higher therapeutic pressure of over 20 centimeters of water (cm H₂O) is required, which conventional CPAP machines often cannot deliver, or when the patient cannot tolerate the high pressure of CPAP/APAP even after the medical team has helped resolve the issue and used an expiratory pressure reduction system.² This number is information for the treatment team to use in making decisions; it is not a value that should be used to set the device yourself. Having OSA (Obstructive Sleep Apnea) or loud snoring does not automatically make BiPAP the first choice. Doctors must consider test results, symptoms, comorbidities, and follow-up data together. For more basic information, please see... What is CPAP?

How does BiPAP differ from CPAP?
Issue	CPAP	BiPAP/BPAP
Pressure pattern	Continuous, single-level pressure as per the planned schedule.¹	Separate the pressure during inhalation and exhalation.¹
The role of obstructive sleep apnea (OSA) treatment in general adults.	The AASM has made a conditional recommendation that physicians should choose CPAP or APAP over BPAP.²	It is not automatically the first choice for OSA in adults in general.²
Things you shouldn't do	For OSA in adults, patients should not select modes or adjust pressure themselves. The healthcare team should monitor and help resolve the problem.²	For chronic shallow breathing in the stable phase, do not adjust IPAP/EPAP yourself. This should be done by a trained team.⁶

In what cases might a doctor consider BiPAP?

Doctors won't choose BiPAP based on a single symptom, but will consider the underlying condition, test results, what kind of help is needed, and how the results will be monitored. Therefore, experiencing discomfort while using CPAP doesn't necessarily mean BiPAP is the next step.

Obstructive sleep apnea (OSA)

For the treatment of OSA in adults, the AASM generally recommends, conditionally, that physicians should choose CPAP or APAP over BPAP.² If using CPAP is uncomfortable, or the machine's data isn't meeting expectations, the healthcare team should investigate the cause before deciding to switch machines. For a small number of patients, physicians may try BiPAP when the required pressure exceeds the limits of CPAP/APAP, or when the patient cannot tolerate the high pressure even after the healthcare team has helped resolve the issue and used an expiratory pressure reduction system.²

Obesity hypoventilation syndrome (OHS)

Obesity-related shallow breathing (OHS) requires examination and evaluation by a doctor; it cannot be judged based solely on weight, drowsiness, or snoring. The American Thoracic Society (ATS) explains that treatment plans may involve CPAP or NIV with two pressure levels, with the doctor choosing the most suitable option for each individual.¹

Chronic obstructive pulmonary disease (COPD)

For chronic obstructive pulmonary disease (COPD), it's crucial to differentiate between exacerbations and long-term care. During exacerbations, the UK's National Institute for Health and Care Excellence (NICE) suggests that physicians may use NIV (Non-Invasive Intensive Care) when carbon dioxide buildup leads to blood acidosis and appropriate treatments are insufficient. This care must be provided in a well-equipped facility with skilled personnel.³

For COPD patients with chronically elevated and stable blood carbon dioxide levels, ATS (Acute Rapid Transits) conditionally suggests that physicians may consider nocturnal NIV (Non-Invasive Medicine) in conjunction with routine treatment.⁴ If a patient has recently been hospitalized due to an exacerbation of a disease accompanied by respiratory failure and carbon dioxide retention, guidelines suggest that long-term NIV should not be initiated during hospitalization, but that the healthcare team should reassess the patient 2 to 4 weeks after the acute phase has subsided.⁴

Therefore, COPD doesn't mean everyone needs BiPAP. Doctors must select the type of device, mode, and NIV settings according to each individual's situation. You shouldn't start or adjust it yourself.

OSA, OHS, and COPD mentioned above are just examples, not a self-diagnostic checklist. If a patient with COPD experiences a severe flare-up and difficulty breathing, seek emergency medical assistance immediately. Do not wait to adjust the breathing apparatus at home.³

How should BiPAP be evaluated, set up, and monitored?

Before using BiPAP, the healthcare team must know what they are treating and what assistance the device is intended to provide. For OSA in adults, a diagnosis should be made through appropriate tests, and follow-up should be done after starting PAP.² NIV adjustment in patients with chronic shallow breathing during the stable phase should be performed by an experienced team with ongoing monitoring.⁶

Before starting or changing a plan, prepare the following information for the medical team to review. Do not use it to select equipment or configure settings yourself.^2,6

Sleep study results, breathing test results, or documents used by a doctor for diagnosis.
List of pre-existing medical conditions, medications, ventilators, and oxygen currently being used.
Machine model, mode, and current values as per prescription or treatment plan.
Data from the device, such as usage hours, mask leaks, and reported events.
Symptoms or problems that occurred after starting to use the product, along with the time they occurred.

For patients using NIV due to chronic shortness of breath in the stable phase, a trained team should monitor the use of the device, side effects, breathing, and oxygen levels.⁶ This guideline does not cover COPD patients and is not a criterion for who should start NIV.

The medical team may check for mask leaks, dryness or nasal congestion, and comfort while using the device.⁶ If you encounter a problem, note down what happened and when it occurred, then discuss it with the treatment team. Avoid trying to adjust multiple things at once on your own.

For patients using NIV due to chronic shortness of breath during the stable phase, the medical team will assess oxygen levels separately from the machine setup; not everyone needs it.⁶ If your doctor has prescribed oxygen sharing, connect the device and use the specified flow rate. Do not connect, increase, or change it yourself.

What BiPAP might help with, and limitations you should be aware of.

For the treatment of OSA in adults, BiPAP is generally not the automatic first choice.² For patients using NIV due to chronic shortness of breath in the stable phase, monitoring of data from the device, side effects, breathing, and oxygen levels is necessary.⁶ Therefore, one should not expect the same results for everyone, nor believe guarantees that using it will definitely improve sleep, reduce fatigue, stop snoring, or prevent complications.

BiPAP is not a diagnosis and should not be chosen based on symptoms alone. For the general treatment of OSA in adults, the AASM also provides conditional recommendations that physicians should choose CPAP or APAP over BPAP.²
For patients using NIV due to chronic shortness of breath during the stable phase, the medical team must monitor data from the device, side effects, breathing, oxygen levels, mask leaks, and discomfort.⁶

Both the symptoms and the data from the device should be discussed with the medical team. Do not use only one type of data to decide whether to replace the device or adjust settings.

Before making a decision, what questions should you ask the medical team?

These questions will help you understand the treatment plan more clearly.

What was my diagnosis, and which test results support this diagnosis?
What does the machine help with, such as opening the airway or helping with adequate breathing?
Why do healthcare teams choose CPAP, APAP, BiPAP, or another method?
Who sets and reviews IPAP, EPAP mode, and shared devices?
When should I follow up, and what information should I bring?
If your mask leaks, you feel uncomfortable, have dry mouth, or can't sleep, who should you contact, and what can you do safely while waiting?
What symptoms warrant an earlier appointment or require emergency assistance?
After a doctor confirms that it's necessary, you should check the details regarding the device, masks, warranty, and services.

The selection of a supplier concerns equipment and services, while diagnosis and treatment selection are the doctor's responsibility. These two aspects should be separated.

Frequently Asked Questions about BiPAP

Why does this article use both the terms BiPAP and BPAP?

This article uses the term BiPAP in its title because it is a term familiar to readers. BPAP stands for bilevel positive airway pressure, meaning a device that separates the air pressure during inhalation and exhalation.^1,6 In medical texts, the terms BPAP or bilevel PAP are frequently encountered.

Is BiPAP better than CPAP?

No, the right machine depends on the problem being treated. For adults with obstructive sleep apnea (OSA), the American Society for Sleep Medicine guidelines prioritize CPAP (automatic pressure booster) over BPAP (biPAP), but it's a recommendation that a doctor must consider based on each individual case.² A doctor may consider BiPAP when the required pressure exceeds the limits of CPAP/APAP, or when the high pressure cannot be tolerated even after the medical team has helped to resolve the issue and used an expiratory pressure reduction system.²

Should I use a BiPAP if I only snore?

BiPAP should not be chosen based solely on snoring. Positive airway pressure (PAP) treatment should begin with a proper diagnosis and evaluation.² If snoring is accompanied by other abnormal symptoms, it's better to note down the information and discuss it with your doctor instead of choosing a snoring device yourself.

Can I configure BiPAP myself?

Patients using non-intubated ventilation (NIV) with chronic shallow breathing—meaning persistently insufficient breathing for an extended period and in a stable condition (not experiencing acute worsening or exacerbation)—should not have their intubation pressure (IPA) adjusted, expubation pressure (EPAP), mode, or other settings manually. A trained team must monitor treatment goals, breathing patterns, oxygen levels, symptoms, and data from the device.⁶ For other illnesses or situations, an approach tailored to that specific problem must be used.

If using a CPAP machine is uncomfortable, should I switch to a BiPAP machine myself?

You shouldn't change it yourself. For adults with obstructive sleep apnea (OSA), if they still can't tolerate the high pressure of CPAP, even after the treatment team helps resolve the issue and uses an expiratory pressure reduction system, your doctor may try BiPAP in some patients.²

Does everyone using BiPAP also need to use oxygen?

No, for individuals using non-intubated ventilation (NIV) due to persistently insufficient breathing and while in a stable condition, the medical team will assess oxygen levels separately from mechanical ventilation. Not everyone needs it.⁶ Do not connect oxygen or change the flow rate yourself.

If using BiPAP, what information should you discuss when following up?

If positive airway pressure (PAP) is used to treat obstructive sleep apnea (OSA) in adults, follow-up should be done after the start of treatment.² For patients using non-intubated ventilation (NIV) due to chronic shallow breathing in the stable phase, monitoring of machine use, side effects, respiration, and oxygen levels is necessary.⁶ Please bring the test results, original plan, data from the device, and symptom log.

summarize

BPAP is a positive pressure device that separates the pressure during inhalation and exhalation.^1,6 CPAP machines deliver a continuous, single pressure level. This article uses the term BiPAP in the title, following a term familiar to readers. The difference in pressure doesn't indicate which machine is best for everyone.

For OSA in adults, the AASM generally provides conditional recommendations that physicians should choose CPAP or APAP over BPAP, but individual cases still need to be considered.²

For OHS, the physician must first confirm the diagnosis before considering a 2-level pressure CPAP or NIV system suitable for each individual.¹ In COPD, the exacerbation phase and the stable phase are different situations.³ For patients with chronically and persistently elevated blood carbon dioxide levels, ATS (Automated Thrombocytopenia) is conditionally suggested, and physicians may consider nighttime NIV (Non-Invasive Vitro Fertilization) in conjunction with routine treatment.⁴

The safe procedure is to discuss the test results, original plan, data from the device, and symptoms with the treatment team. Clearly ask about the specific condition, how the device should assist, who configured the settings, and when follow-up will be conducted. Do not change the device, mode, pressure, or increase oxygen levels based on information in this article.

What is BiPAP, how does it differ from CPAP, and when should doctors consider using it?