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Hypercapnic respiratory failure, also known as Type 2 or ventilatory respiratory failure, is a severe condition characterized by the body's inability to effectively remove carbon dioxide (CO2) from the bloodstream. It leads to an arterial CO2 pressure (PaCO2) exceeding 45 mmHg and a blood pH above 7.35. This situation indicates that the body's ventilatory demand, or the ventilation needed to maintain normal PaCO2 levels, surpasses its supply or the maximum gas flow achievable without causing...

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AVAPS Versus BiPAP in Acute Hypercapnic Respiratory Failure: A Systematic Review and Meta-Analysis.

Bryan Gregory¹, Charles Ezenwanne², Ahmed Dawood Al Mahrizi³

¹Department of Critical Care Medicine, Robert Wood Johnson Barnabas Health, 600 Kaplan Court, Toms River, NJ, 08753, USA.

|June 8, 2026

Summary

Average volume assured pressure support (AVAPS) significantly reduces endotracheal intubation in acute hypercapnic respiratory failure compared to BiPAP. While survival benefits were not significant, AVAPS may be a preferred option for certain patients.

Keywords:

Noninvasive ventilation (NIV)hypercapnic respiratory failure (HRF)

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Preoxygenation Techniques for Tracheal Intubation in Critically Ill Adults Utilizing Oxygen Mask and Noninvasive Ventilation

Preoxygenation Techniques for Tracheal Intubation in Critically Ill Adults Utilizing Oxygen Mask and Noninvasive Ventilation

Published on: December 5, 2025

Area of Science:

Pulmonology and Critical Care Medicine
Respiratory Physiology
Medical Technology Assessment

Background:

Noninvasive ventilation (NIV) is crucial for managing hypercapnic respiratory failure (HRF).
BiPAP is the traditional standard, but Average Volume Assured Pressure Support (AVAPS) offers potential advantages in CO2 clearance.
Comparative clinical effectiveness of AVAPS versus BiPAP in acute HRF remains uncertain.

Purpose of the Study:

To systematically review and meta-analyze the clinical effectiveness of AVAPS compared to BiPAP in adults with acute HRF.
To compare primary outcomes of endotracheal intubation and short-term mortality.
To evaluate secondary outcomes including arterial blood gases and hospital length of stay.

Main Methods:

Systematic review and random-effects meta-analysis (Hartung-Knapp) adhering to PRISMA 2020 guidelines.
Searched multiple databases (MEDLINE, EMBASE, Cochrane CENTRAL, etc.) and gray literature.
Included RCTs and comparative cohort studies of adults with acute HRF comparing AVAPS and BiPAP.

Main Results:

AVAPS significantly reduced the risk of endotracheal intubation compared to BiPAP (RR 0.43, p=0.027), a 57% relative risk reduction.
No significant difference in short-term mortality was observed between AVAPS and BiPAP (RR 0.87, p=0.62).
Physiological outcomes (pH, pO2, pCO2) and hospital length of stay were similar between the two ventilation modes.

Conclusions:

In adults with acute HRF, AVAPS demonstrates a significant reduction in intubation rates compared to BiPAP.
Current evidence does not show a clear short-term survival benefit for AVAPS over BiPAP.
AVAPS may be a preferred NIV strategy for selected acute HRF patients, pending further high-quality RCTs on mortality.