Supplementary Appendix

Supplement to: Munshi L, Mancebo J, Brochard LJ. Noninvasive respiratory support for adults with acute
respiratory failure. N Engl J Med 2022;387:1688-98. DOI: 10.1056/NEJMra2204556

This appendix has been provided by the authors to give readers additional information about the work.
 Noninvasive Respiratory Support for Adults with Acute Respiratory Failure

Laveena Munshi MD, Jordi Mancebo MD, Laurent J Brochard MD

Supplementary Appendix

Figure S1: Noninvasive Respiratory Support Devices

Table S1: Physiologic Effects, Patient, Health Care Team and Institutional Considerations of Noninvasive
Respiratory Support Devices

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Figure S1: Noninvasive respiratory support devices *Facemask may refer to oronasal or total facemask; Abbrev: CPAP: Continuous positive airway pressure,
PEEP: Positive end expiratory pressure; NIV: noninvasive ventilation. Adapted with permission from Sferrazza Papa GF, Di Marco F, Akoumianaki E, Brochard L.
Recent advances in interfaces for non-invasive ventilation: from bench studies to practical issues. Minerva Anestesiol 2012 Oct;78(10):1146-53.

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TABLE S1 Physiologic Patient Health Care Team Institutional
Effect Considerations Considerations Considerations
Benefit Limitation Benefit Limitation Benefit Limitation

High Flow High flows minimize Awake, Occasional Can utilize Transport Lower Oxygen supply
Nasal dilution by ambient spontaneous intolerance to during Potential risk of flows/FiO2 may become
air breathing heat and high intubation pre- patient self- may be outstripped in
Cannula
flows oxygenation inflicted lung managed the setting of
Modest PEEP Comfort
(60-80 L/min) injury outside of an many devices
generation Can use device
Nutrition ICU setting in use
in prone
Dead-space washout with simultaneously
Mobilization position
of naso- monitoring (consideration
oropharyngeal space Secretion Easy to apply during a
clearance and remove
Increased expiratory respiratory
resistance leading to Communication Physiologic pandemic)
a prolonged benefits
expiratory phase
Humidified gas may
assist with secretion
clearance

Facemask* More effective PEEP Awake, Significant skin Can utilize Transport CPAP mode Ideally
Noninvasive generation spontaneous breakdown and during
Difficulty
can be delivered in a
breathing ulcerations may intubation pre- delivered closely
Ventilation Decrease cardiac performing
occur with the oxygenation without a monitored
preload and Temporizing specific
oronasal interface ventilator if setting where
afterload device while Capacity to investigations
limiting resources risk of failure
awaiting effect prone if needed (e.g.,
Positive pressure tolerability of the are limited can be rapidly
of treatment bronchoscopy, CT
delivery during device (can trial Easy to apply identified
for certain imaging)
inspiration full facemask) and remove
rapidly Potential risk of Alternative
Potential mechanical reversible Secretion Physiologic patient self- devices may
effects to overcome conditions clearance benefits inflicted and be required

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 auto-PEEP or airway (e.g., ventilator induced during breaks
Challenge
closure congestive lung injury (e.g., HFNC)
facilitating
heart failure)
nutrition with
nasogastric tube
Potential air leak
Patient must be
awake and not
experiencing
nausea/vomiting
Noise

Helmet Most effective PEEP Awake, Upper limb edema Physiologic Transport CPAP mode Health care
Noninvasive generation spontaneous
Potential risk for
benefits
Difficulty
can be team learning
breathing delivered curve
ventilation Decrease cardiac upper limb Greater performing
without a
preload and Nutrition venous- tolerance, less specific Ideally
ventilator if
afterload thromboembolism needs for investigations delivered in a
ventilator
Greater breaks off of (bronchoscopy, CT closely
Claustrophobia resources
Positive pressure tolerance than device imaging) monitored
Noise are limited
delivery during with facemask- setting where
Time to transition
inspiration NIV risk of failure
to intubation
can be rapidly
Potential mechanical Temporizing longer than other
identified
effects to overcome device while modalities
auto-PEEP or airway awaiting effect
Potential risk of
closure of treatment
patient self
for certain
inflicted and
rapidly
ventilator induced
reversible
lung injury
conditions
(e.g., More challenging
congestive to prone
heart failure)