Risk for transmission of viral infection during treatment with non-invasive ventilation using CPAP or BiPAP

Viral infections caused by SARS-CoV-2, SARS-CoV-1 or MERS-CoV can lead to severe respiratory failure and the need for hospital care. The ventilation treatment can be invasive or non-invasive. Continuous positive airway pressure and Bi positive airway pressure (CPAP and BiPAP) are open non-invasive ventilation systems in which viral infection may be transmitted via aerosol.


What scientific studies are there on the risk for transmission of SARS-CoV-2, SARS-CoV-1 or MERS-CoV infections during treatment with non-invasive ventilation?


SBU’s Enquiry Service identifies and summarizes systematic reviews or scientific studies which answer specific questions posed by decision makers and health care personnel. For this response, PubMed, Embase, Cinahl and Cochrane Library were systematically searched in March 2020. Records relevant to the question posed were identified and assessed for risk of bias by two independent persons. Systematic reviews were assessed for risk of bias using AMSTAR [1] and the identified primary studies were assessed for risk of bias using a translation of ROBINS-I [2]. This response does not attempt to weigh together or grade the reliability of the results presented.

Identified literature

We identified one relevant systematic review that had been published twice [3,4] and four primary studies [5–8]. Only two out of ten studies included in the systematic review reported results on CPAP or BiPAP. These studies were also identified in the literature search and therefore the systematic review was not tabulated [5,7]. All four primary studies were judged to have a high risk of bias from confounders and retrospective data collection.


  1. Shea BJ, Hamel C, Wells GA, Bouter LM, Kristjansson E, Grimshaw J, et al. AMSTAR is a reliable and valid measurement tool to assess the methodological quality of systematic reviews. J Clin Epidemiol 2009;62:1013-20.
  2. Sterne JA, Hernán MA, Reeves BC, Savović J, Berkman ND, Viswanathan M, et al. ROBINS-I: a tool for assessing risk of bias in non-randomised studies of interventions. BMJ 2016;355:i4919.
  3. Tran K, Cimon K, Severn M, Pessoa-Silva C, Conly J. Aerosol generating procedures (AGP) and risk of transmission of acute respiratory diseases (ARD): A systematic review. BMC Proceedings 2011;5.
  4. Tran K, Cimon K, Severn M, Pessoa-Silva CL, Conly J. Aerosol generating procedures and risk of transmission of acute respiratory infections to healthcare workers: A systematic review. PLoS ONE 2012;7.
  5. Fowler RA, Guest CB, Lapinsky SE, Sibbald WJ, Louie M, Tang P, et al. Transmission of severe acute respiratory syndrome during intubation and mechanical ventilation. American Journal of Respiratory & Critical Care Medicine 2004;169:1198-1202.
  6. Heinzerling A, Stuckey MJ, Scheuer T, Xu K, Perkins KM, Resseger H, et al. Transmission of COVID-19 to Health Care Personnel During Exposures to a Hospitalized Patient - Solano County, California, February 2020. MMWR Morb Mortal Wkly Rep 2020;69:472-6.
  7. Raboud J, Shigayeva A, McGeer A, Bontovics E, Chapman M, Gravel D, et al. Risk factors for SARS transmission from patients requiring intubation: a multicentre investigation in Toronto, Canada. PLoS One 2010;5:e10717.
  8. Yu IT, Zhan HX, Tsoi KK, Yuk LC, Siu WL, Xiao PT, et al. Why did outbreaks of severe acute respiratory syndrome occur in some hospital wards but not in others? Clinical Infectious Diseases 2007;44:1017-25.

SBU Enquiry Service Consists of structured literature searches to highlight studies that can address questions received by the SBU Enquiry Service from Swedish healthcare or social service providers. We assess the risk of bias in systematic reviews and when needed also quality and transferability of results in health economic studies. Relevant references are compiled by an SBU staff member, in consultation with an external expert when needed.

Published: 6/8/2020
Report no: ut202020
Registration no: SBU 2020/382