CPAP & Noninvasive Ventilation

Why this matters

Continuous positive airway pressure (CPAP) is not just a mask. It is pressure that stays on through the whole breath. Noninvasive ventilation (NIV) is a tight mask that pushes air in without a tube.

Both are positive pressure. They can push fluid out of wet lungs. They can hold open collapsing airways in chronic obstructive pulmonary disease (COPD). They can also drop the blood pressure, fill the stomach with air, and blow vomit into the lungs if you pick the wrong patient.

Clinical sequence

1. A candidate is awake enough to protect the airway, is working hard to breathe, and has wet or tight lungs. Your protocol includes CPAP.
2. Explain the mask. Sit the patient up. Start the pressure on your protocol card. Coach the patient to keep a seal.
3. Take the mask off if the patient vomits, the Glasgow Coma Scale (GCS) falls, or the patient fights the mask until the oxygen saturation drops. Switch to a BVM or an advanced airway.
4. Do not use CPAP if the patient is hypotensive, you suspect a pneumothorax, or the patient cannot protect the airway. Still go to a hospital that can continue NIV.
5. If the blood pressure falls after the mask is on, reassess. Positive pressure can drop the blood returning to the heart. Follow your protocol. Adjust the device, take the mask off, or move to the next airway plan.

When It Fits

• Cardiogenic pulmonary edema, or congestive heart failure, fits when the patient is alert, working hard, and has wet lungs, and the blood pressure is high or at least not severely low. Sit the patient up. Use CPAP when your protocol includes it.
• A COPD flare fits when the patient is alert enough to cooperate and the work of breathing is severe. Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2026 supports NIV for selected COPD. NIV or CPAP is often preferred over a tube when the patient can still take part.
• CPAP is not the first move for asthma with a silent chest. That patient needs time to exhale and the medicines in your protocol. See the asthma and COPD ventilation lesson.

When It Does Not

• Do not use it if the patient is unresponsive, or has no gag or cough to protect the airway.
• Do not use it for active vomiting, a large upper gastrointestinal bleed, or secretions you cannot clear.
• Do not use it if you suspect a pneumothorax, the blood pressure is low, or the patient is in shock. Positive pressure can cut the blood returning to the heart.
• Do not keep forcing it if facial trauma breaks the seal, or if the patient pulls the mask off and will not follow coaching.

How to Run the Mask

• Coach the patient: “This will feel tight. Breathe with me.” Then watch blood pressure, alertness, oxygen saturation (SpO₂), and work of breathing.
• Have suction and a BVM ready. If CPAP fails, move to the next airway plan. Do not keep adjusting the device while the patient gets worse.
• Pressure settings and positive end-expiratory pressure belong to your protocol and your device training. This lesson does not set a number.

Common errors

• Putting CPAP on a lethargic patient who then vomits into the lungs.
• Ignoring a falling blood pressure after the mask goes on.
• Leaving CPAP on to delay a tube when the patient needs a tube now.

Practice

Related: CHF / pulmonary edema, Oxygen titration.

Sources & Further Study

Named guidelines for further study. They are not clinical orders and do not replace your protocol or medical direction.

• GOLD 2026 COPD Report — NIV preferred over jumping to intubation in selected COPD exacerbations
• 2022 AHA/ACC/HFSA Heart Failure Guideline — NIV/CPAP for selected acute cardiogenic pulmonary edema
• NASEMSO National Model EMS Clinical Guidelines (2022)
• Use CPAP or NIV for selected alert patients with pulmonary edema or COPD. Do not use it for an unprotected airway, vomiting, or shock. Your protocol owns the settings.