Bilevel positive airway pressure (BiPAP) NIV BiPAP is commonly used in the care of patients with chronic respiratory disease, such as COPD, so it may be useful in COVID-19 for patients who have co-morbidities such as COPD plus COVID-19.18 In COVID-19, BiPAP may have a clinical use to improve the work of breathing. However, it carries a risk that inappropriate settings may allow the patient to take an excessively large tidal volume causing baro and volutrauma. BiPAP allows for a high driving pressure coupled with a low driving pressure. This resembles CPAP but provides some additional support. Prior to commencing BiPAP, the patient must be assessed for a pneumothorax, ideally by a chest X-Ray or ultrasound. Due to the need for PPE chest auscultation for COVID-19 patients, is not recommended as it increases the risk of transmission to the Healthcare professional.19 ,  20 Inspiratory Positive Airway Pressure (IPAP) settings can be varied to achieve adequate tidal volumes, by allowing patients to breath to a pre-set inspiratory pressure. To achieve adequate tidal volumes, the IPAP can range from 12 to 35cmH2O. Expiratory Positive Airway Pressure (EPAP) works on the same principles as PEEP in CPAP devices, preventing alveolar collapse on expiration which is maintained above atmospheric pressure. To overcome the difficulty of breathing on a ventilator (including valves) and increase of dead space from the ventilator tubing is achieved by pressure support. Pressure support is calculated by minus IPAP from EPAP, and it is recommended that there should be a difference of at least 8cmH2O, 5 with supplementary oxygen provided, if needed, to achieve oxygenation. Some BiPAP ventilators offer a ‘ramp’ setting, also termed ‘rise time’, which allows the pressure to be slowly increased over the first few minutes of ventilation until the required pressure is reached. This prevents barotrauma and is considered less distressing for the patient when treatment is commenced. Using this approach, a 25% rise time will take up 25% of the total inspiratory time before the peak pressure is reached.21 Given BiPAP may be used where there are multiple co-morbidities, decisions regarding escalation in treatment must be agreed prior to the treatment. BiPAP may be used as a trial, with a view to intubation if this fails. The treatment escalation plan should have been discussed with the patient and relatives prior to commencing treatment (if it is not life threatening). Patients and families need to be aware of when BiPAP is the ceiling of treatment and should have discussed palliation and end of life care.