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PEEP versus CPAP
Question# 944
I have a question about PEEP with COPD patients.
For COPD patients with an elevated respiratory rate, silent (or decreased) lung sounds at bases, and increased work of breathing, would it be appropriate to strap the CPAP mask to the patient, and attach the BVM with a PEEP valve, and have them just breathe into the BVM mask?
There is a one way valve which will allow room air in, (plus low flow oxygen) which would allow us to keep the oxygen saturations within the 88-92% range.
I thought this might be a beneficial treatment option, as with these patients it is often a ventilation issue, and I thought that allowing them to keep their alveoli open by use of low flow oxygen would decrease their hospital time, mortality and other factors associated with hyper oxygenation on a COPD patient.
Of course I understand that if the patient is in severe respiratory distress, and meets the CPAP directive, I would be jumping to CPAP. I just wish there was a way to give PEEP to these.
For COPD patients with an elevated respiratory rate, silent (or decreased) lung sounds at bases, and increased work of breathing, would it be appropriate to strap the CPAP mask to the patient, and attach the BVM with a PEEP valve, and have them just breathe into the BVM mask?
There is a one way valve which will allow room air in, (plus low flow oxygen) which would allow us to keep the oxygen saturations within the 88-92% range.
I thought this might be a beneficial treatment option, as with these patients it is often a ventilation issue, and I thought that allowing them to keep their alveoli open by use of low flow oxygen would decrease their hospital time, mortality and other factors associated with hyper oxygenation on a COPD patient.
Of course I understand that if the patient is in severe respiratory distress, and meets the CPAP directive, I would be jumping to CPAP. I just wish there was a way to give PEEP to these.
Answer:
Thank you for your MedicASK question regarding the use of PEEP in COPD patients who demonstrate respiratory distress.
To address your idea of strapping on a CPAP mask and having the patient breathe through a BVM equipped with a PEEP valve, it’s important to first consider the fundamental differences between PEEP and CPAP.
1. Understanding PEEP vs. CPAP
1. Is Using a BVM + PEEP Valve appropriate?
Applying PEEP outside of a mechanical ventilator setting is effectively the same as providing non‑invasive CPAP. In spontaneously breathing patients, any attempt to provide end-expiratory positive pressure becomes CPAP, regardless of the specific equipment configuration.
Thus, using a BVM + PEEP valve + CPAP mask would not be considered a safe or validated substitute for CPAP. This method has several issues:
1. Why is CPAP used instead
Both PEEP and CPAP help reopen alveoli and prevent collapse, improving oxygenation.
This aligns with the physiology you described: keeping alveoli open, reducing work of breathing, and supporting ventilation.
However, clinical standards require that when positive pressure is needed for spontaneously breathing COPD patients, CPAP—not improvised PEEP—is the appropriate therapy. This ensures:
1. Clinical judgement
You are absolutely right in identifying that:
Your reasoning aligns well with respiratory physiology and the therapeutic goals of PEEP/CPAP.
However, the equipment setup you proposed is not a recognized as a safe way to deliver PEEP in spontaneously breathing patients. If the patient meets CPAP indications, CPAP should be initiated. If they do not, then supportive care (coaching breathing, bronchodilators, titrated O₂, positioning, etc.) is the standard until they either improve or meet criteria for escalation.
1. Summary
To address your idea of strapping on a CPAP mask and having the patient breathe through a BVM equipped with a PEEP valve, it’s important to first consider the fundamental differences between PEEP and CPAP.
1. Understanding PEEP vs. CPAP
- PEEP provides positive pressure only at the end of expiration and is generally applied in mechanical ventilation settings.
- CPAP delivers a continuous positive pressure throughout the breathing cycle and is used when the patient is breathing spontaneously.
- Clinically, these therapies are very similar, and the terminology depends on whether ventilation is invasive or spontaneous: if the patient is breathing on their own (as in your scenario), the therapy is essentially CPAP.
1. Is Using a BVM + PEEP Valve appropriate?
Applying PEEP outside of a mechanical ventilator setting is effectively the same as providing non‑invasive CPAP. In spontaneously breathing patients, any attempt to provide end-expiratory positive pressure becomes CPAP, regardless of the specific equipment configuration.
Thus, using a BVM + PEEP valve + CPAP mask would not be considered a safe or validated substitute for CPAP. This method has several issues:
- It does not deliver consistent, reliable airway pressure the way CPAP devices are designed to do. There is no measured way to titrate up or down and measure how much pressure/oxygen the patient is receiving.
- PEEP valves on BVMs are intended for ventilated breaths, not spontaneously breathing patients. A patient cannot just breathe through a BVM. Utilizing a BVM means providing that mechanical ventilation for them.
- The lack of continuous flow means pressure levels will fluctuate, potentially leading to inadequate support or unintended air trapping, which is particularly concerning in COPD patients, where dynamic hyperinflation is already a risk.
1. Why is CPAP used instead
Both PEEP and CPAP help reopen alveoli and prevent collapse, improving oxygenation.
This aligns with the physiology you described: keeping alveoli open, reducing work of breathing, and supporting ventilation.
However, clinical standards require that when positive pressure is needed for spontaneously breathing COPD patients, CPAP—not improvised PEEP—is the appropriate therapy. This ensures:
- Controlled, continuous airway pressure
- Reliable oxygenation and ventilation support
- Avoidance of complications such as barotrauma or worsened hyperinflation
1. Clinical judgement
You are absolutely right in identifying that:
- COPD exacerbations often involve a ventilation problem
- Avoiding over‑oxygenation is important (targeting 88–92%)
- Maintaining alveolar recruitment may reduce morbidity
Your reasoning aligns well with respiratory physiology and the therapeutic goals of PEEP/CPAP.
However, the equipment setup you proposed is not a recognized as a safe way to deliver PEEP in spontaneously breathing patients. If the patient meets CPAP indications, CPAP should be initiated. If they do not, then supportive care (coaching breathing, bronchodilators, titrated O₂, positioning, etc.) is the standard until they either improve or meet criteria for escalation.
1. Summary
- PEEP and CPAP are functionally similar, but in a spontaneous breathing patients, the correct and safe modality is CPAP.
- Using a BVM with a PEEP valve for a spontaneously breathing patient does not reliably provide PEEP and is not recommended as a substitute for CPAP.