Moffitt Pearls 6.7.17 – Hypercalcemia and Indications for BiPAP

Thank you to Geoffrey for presenting 2 mini cases today in report. In the first case we discussed an elderly woman presenting from an OSH with hypercalcemia who was found to have a retroperitoneal mass w/ histology c/f B-cell lymphoma! We broadly discussed the differential and diagnostic approach to hypercalcemia. In the next case, we discussed a middle aged man presenting with severe hypoxemic and hypercapnic respiratory failure from unknown trigger c/f COPD exacerbation and the indications for BiPAP and ICU admission. There are never bad cases!!


Key Learning Pearls

  1. Approach hypercalcemia by looking at PTH (see image below)
  2. Indications for BiPAP include the following:
    1. Cardiogenic pulmonary edema
    2. Moderate to severe COPD exacerbation
    3. Hypoxemic respiratory failure
    4. Post-extubation
    5. Immunocompromised patient with acute respiratory failure
    6. Those with neuromuscular or chest wall disease
  1. Consider intubation with pH < 7.2 or RR >35  For those who would like more information


For those who would like more information. 🙂


  1. Clinical Indications for NIPPV:
  • Moderate-severe COPD exacerbation (PaCO2 >45 mmHg or pH <7.3): BiPAP is first-line treatment.
  • Decreased mortality, intubation rate, treatment failure, hospital length of stay and complications related to treatment.
  • Cardiogenic pulmonary edema: CPAP and BiPAP decrease afterload, decrease wall stress, improve oxygenation, and improve dyspnea.
  • Shown to lower in-hospital mortality.
  • Hypoxemic respiratory failure:
  • Decreased ICU mortality and intubation in patients with community-acquired pneumonia WITHOUT significant secretions
  • Decreased ICU mortality, intubation rate, and ICU length of stay in immunosuppressed patients with pulmonary infiltrates and fever (likely due to decreased ventilator-associated pneumonia in these vulnerable patients).


  • Immediately post-extubation (planned NIPPV)
  • Decreased all-cause mortality, ICU length of stay, hospital length of stay, and rates of VAP. No increased rate of extubation failure or reintubation. Benefits greatest in COPD patients.
  • Severe asthma exacerbation:
  • Data inconclusive, though suggest decreased rate of hospitalization


Diagnostic Approach and Differential Diagnosis for Hypercalcemia



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