What’s the difference between Vapotherm and BiPAP? This is a commonly asked question, but before we can tackle the answer, we first need to clarify why it’s technically asking “what’s the difference between this company and this device?”
When people say “Vapotherm,” they refer to Vapotherm Inc., which is a medical device company which produces Precision Flow® devices to treat patients in respiratory distress. Precision Flow systems provide Hi-VNI® Technology which delivers High Velocity Nasal Insufflation (HVNI) therapy.
BiPAP, which stands for Bilevel Positive Airway Pressure, is a trademark identifying a respiratory device manufactured by the company Philips Respironics. That device provides Noninvasive Positive Pressure Ventilation (NiPPV) to treat patients in respiratory distress.
So, the initial question really is asking: What’s the difference between HVNI and NiPPV?
One Is a New Major Innovation, the Other Is a Known Standard
NiPPV is considered the gold standard for treating respiratory distress patients, but HVNI is the first major noninvasive ventilation (NIV) innovation in the past 30 years which expands options for practitioners.
Comparable Efficacy and Outcomes
In 2018, Doshi et al. published the results of a randomized controlled trial that looked at how Vapotherm Hi-VNI Technology compares to NiPPV when treating adult emergency department patients in undifferentiated respiratory distress.1 This trial concluded that HVNI is noninferior to NiPPV. In other words, for that patient population clinical outcomes of HVNI are comparable to those of NiPPV.
Similar to NiPPV, HVNI therapy offers ventilatory support for patients in respiratory distress, including hypercapnia, hypoxemia, dyspnea, and respiratory distress secondary to other medical conditions.
One is Mask-Free, the Other One Isn’t
Most clinicians strongly associate the provision of ventilatory support with a sealed mask interface and positive pressure. But Vapotherm’s Hi-VNI Technology is an open system that flushes CO2 out of the upper airway and uses a Precision Flow cannula interface. Although it can offer ventilatory support, its primary mechanism of action is velocity not pressure. This can be illustrated by going back to the basics of the alveolar ventilation equation:
Alveolar Ventilation = (Tidal Volume – Dead Space) x Respiratory Rate
While traditional NiPPV works by impacting the “Tidal Volume” aspect of the above equation, HVNI works by reducing the “Dead Space.” Because HVNI is noninferior to NiPPV, and provides noninvasive ventilatory support, Vapotherm’s trademarked term for it is Mask-Free NIV™ for spontaneously breathing patients.
Physicians Rate One More Highly in Patient Response, Patient Comfort, and Simplicity of Use
In the secondary outcomes of the Doshi et al. trial, physicians were asked to rate the two therapies. NiPPV and HVNI had similar results in terms of the need for monitoring and technical difficulty. However, HVNI was rated as superior when it came to physicians’ perceptions of patient response, patient comfort, and simplicity of use, as shown in Figure 1.
Figure 1: Selected Secondary Outcomes – monitoring need and technical difficulty had similar results. Used Doshi et al. HVNI in the Treatment of Respiratory Failure, Ann of Emerg Med, 2017;1:11. (Adult, Multi, Clinical trial, Prospective, Randomized, Multi-Center, n=201)
As many clinicians know, not all patients feel comfortable with a tightly sealed mask. About 33% of NiPPV failure is attributed to mask intolerance.2 HVNI is an attractive alternative to NiPPV, especially for this patient population. The mask-free nature of the therapy may have contributed to the superior ratings illustrated here.
One is a De-Escalation Therapy, the Other One Isn’t
Because HVNI is an open system, it is safe to start patients at high flow rates to rescue fast, and then titrate down for comfort and clinical effect. Unlike the sealed mask of NiPPV, the non-occlusive Precision Flow cannula creates an open system with the patient, and as a result, there is little risk of generating inadvertent excess pressure. In contrast, NiPPV is initiated at a lower pressure and then carefully titrated up to achieve clinical efficacy.
Similar FDA Indications
The FDA indication of the Precision Flow Hi-VNITM system is very similar to pressure based non-invasive ventilation products. This system may be used to augment breathing of spontaneously breathing patients suffering from respiratory distress in the acute setting.
Although Hi-VNI Technology is sometimes confused with High Flow Nasal Cannula (HFNC), Hi-VNI Technology is included in the FDA’s QAV product code category, as opposed to commodity high flow oxygen products which are only in the BTT (or respiratory humidifier) product category.
Both Work Across the Age Spectrum of Patients
Although this piece focuses exclusively on the comparable efficacy between NiPPV and HVNI in adults, you can read more about similar outcomes between HVNI and nCPAP/BiPAP in neonates here.