Don't Bypass When There's Bilevel Positive Airway Pressure (BiPAP): Successful Management of Respiratory Distress and Atrial Flutter in a 77-Year-Old Woman Using BiPAP.

Acute decompensated heart failure (ADHF) often presents with respiratory distress and tachyarrhythmias such as atrial flutter, driven by autonomic dysregulation. Noninvasive ventilation, particularly bilevel positive airway pressure (BiPAP), can improve hemodynamic status and reduce respiratory effort. A 77-year-old woman with no prior cardiac history presented with acute shortness of breath, orthopnea, and paroxysmal nocturnal dyspnea. Examination of the ECG revealed atrial flutter with rapid ventricular response (HR: 144 bpm), hypoxemia (SpO₂: 89%), and pulmonary congestion. Imaging showed cardiomegaly and vascular redistribution; brain natriuretic peptide was elevated. She was initiated on BiPAP, resulting in rapid clinical improvement, including rate control and resolution of hypoxemia. This case demonstrates BiPAP's hemodynamic and autonomic benefits in ADHF. Evidence supports its role in reducing sympathetic overactivity, improving heart rate variability, and decreasing preload and afterload. Early BiPAP use may prevent intubation and improve outcomes in appropriately selected patients. Early initiation of BiPAP should be considered a cornerstone in the guideline-directed management of ADHF, particularly in patients with respiratory distress and atrial flutter.