Noninvasive Ventilation - Overview, Methods of Delivery, General Considerations

1/10/2021 Noninvasive Ventilation: Overview, Methods of Delivery, General Considerations
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Noninvasive Ventilation
Updated: Jun 18, 2020
Author: Guy W Soo Hoo, MD, MPH; Chief Editor: Zab Mosenifar, MD, FACP, FCCP more...
OVERVIEW
Overview
Noninvasive ventilation (NIV) refers to the administration of ventilatory support without using an
invasive artificial airway (endotracheal tube or tracheostomy tube). The use of noninvasive ventilation
(see the video below) has markedly increased over the past two decades, and noninvasive ventilation
has now become an integral tool in the management of both acute and chronic respiratory failure, in
both the home setting and in the critical care unit. Noninvasive ventilation has been used as a
replacement for invasive ventilation, and its flexibility also allows it to be a valuable complement in
patient management. Its use in acute respiratory failure is well accepted and widespread. It is the
focus of this review. The role of noninvasive ventilation in those with chronic respiratory failure is not
as clear and remains to be defined.
0:00 / 0:42
Noninvasive ventilation. Courtesy of Therese Canares, MD, and Jonathan Valente, MD, Rhode Island Hospital, The Warren
Alpert Medical School of Brown University.
https://emedicine.medscape.com/article/304235-overview 1/30
Methods of Delivery
Noninvasive positive-pressure ventilation
Positive-pressure ventilation delivered through a mask has become the predominant method of
providing noninvasive ventilatory support and is the focus of this and subsequent sections. Early
bedside physiologic studies in healthy patients and in patients with respiratory conditions document
successful ventilatory support (ie, reduction in respiratory rate, increase in tidal volume, decrease in
dyspnea) with reduction in diaphragmatic electromyography (EMG), transdiaphragmatic pressures,
work of breathing and improvement in oxygenation with a reduction in hypercapnia.
Ventilatory support can be achieved through a variety of interfaces (mouth piece or nasal, face, or
helmet mask), using a variety of ventilatory modes (eg, volume ventilation, pressure support, bilevel
positive airway pressure [BiPAP; see the image below], proportional-assist ventilation [PAV],
continuous positive airway pressure [CPAP]) with either ventilators dedicated to noninvasive
ventilation (NIV) or those capable of providing support through an endotracheal tube or mask. Older
models of noninvasive ventilators required oxygen to be bled into the system, but current models
incorporate oxygen blenders for precise delivery of the fraction of inspired oxygen (FIO2).
Screen shot of ventilator graphics and information panel of a patient undergoing BiPAP ventilation.
General Considerations
The key to the successful application of noninvasive ventilation is in recognizing its capabilities and
limitations. This also requires identification of the appropriate patient for the application of noninvasive
ventilation (NIV). Patient selection is crucial for the successful application of noninvasive ventilation.
Once patients who require immediate intubation are eliminated, a careful assessment of the patient
and his or her condition determines if the patient is a candidate for noninvasive ventilation. This
requires evaluation on several levels, and it may involve a trial of noninvasive ventilation. The
following variables and factors help identify patients who may be candidates for noninvasive positive-
pressure ventilation.
Absolute contraindications are as follows:
Coma
Cardiac arrest
Respiratory arrest
Any condition requiring immediate intubation
Other contraindications (rare exceptions) are as follows:
Cardiac instability - Shock and need for pressor support, ventricular dysrhythmias, complicated
acute myocardial infarction
GI bleeding - Intractable emesis and/or uncontrollable bleeding
Inability to protect airway - Impaired cough or swallowing, poor clearance of secretions,

depressed sensorium and lethargy
Status epilepticus
Potential for upper airway obstruction - Extensive head and neck tumors, any other tumor with
extrinsic airway compression, angioedema or anaphylaxis causing airway compromise
Other considerations that may limit application are as follows:
Implementation - Staff learning curve and time requirements (nursing and respiratory therapy),
potential for delay in definitive therapy (limit trials of therapy)
After eliminating unsuitable candidates for noninvasive ventilation, successful application of

noninvasive ventilation mandates close assessment and selection of patients and identification of
conditions best suited for treatment. Not all patients with diagnoses capable of management with
noninvasive ventilation (eg, chronic obstructive pulmonary disease [COPD]) are suitable candidates
for treatment with noninvasive ventilation. Patients with mild disease or very severe distress may not
benefit from noninvasive ventilation, which is best suited for patients with a moderate severity of
illness.
Patient inclusion criteria are as follows:
Patient cooperation (an essential component that excludes agitated, belligerent, or comatose
patients)
Dyspnea (moderate to severe, but short of respiratory failure)
Tachypnea (>24 breaths/min)
Increased work of breathing (accessory muscle use, pursed-lips breathing)
Hypercapnic respiratory acidosis (pH range 7.10-7.35)
Hypoxemia (PaO2/FIO2< 200 mm Hg, best in rapidly reversible causes of hypoxemia)
Not all respiratory conditions are suitable for treatment with noninvasive ventilation. Conditions that
have garnered the most experience and success are generally conditions that also respond relatively
quickly to treatment, for which noninvasive ventilation provides an important adjunctive support to
other simultaneously administered therapeutics. These are listed below and are discussed in
subsequent sections. Be aware that the list and indications continues to change as more experience is
accumulated in these and newer conditions.
Suitable clinical conditions for noninvasive ventilation (most patients) are as follows:
Chronic obstructive pulmonary disease
Cardiogenic pulmonary edema
Suitable clinical conditions for noninvasive ventilation (selected patients) are as follows:
After discontinuation of mechanical ventilation (COPD)
Community-acquired pneumonia (and COPD)
Asthma
Immunocompromised state (known cause of infiltrates)
Postoperative respiratory distress and respiratory failure
Do-not-intubate status
Neuromuscular respiratory failure (better in chronic than acute; avoid if upper airway issues)
Decompensated obstructive sleep apnea/cor pulmonale
Cystic fibrosis
Mild Pneumocystic carinii pneumonia
Rib fractures
Use with caution in the following clinical conditions:
Idiopathic pulmonary fibrosis (exacerbation)
Acute respiratory distress syndrome (consider helmet ventilation)
Application of Noninvasive Ventilation

Several considerations can enhance the likelihood of successful noninvasive ventilation (NIV). In
addition to these factors, the experience and expertise of front-line health care providers, specifically
nursing and respiratory therapy staff, cannot be underestimated. This is not a concern in hospitals
where noninvasive ventilation is well established, but it is an important factor in facilities where
noninvasive ventilation has been infrequently administered or not used at all.
Location of application
It can be used in the ICU, especially if there is the possibility of intubation.
It can be used in a step-down unit (lower severity of illness), as follows:
Moderately severe COPD (pH >7.30)

Do-not-intubate status
Intermittent or nocturnal ventilatory support
It can be used in the ward setting (not recommended if intubation is a consideration), as follows:
Suitable in specialized units

Same considerations as step-down unit
Emergency department - Local considerations, expertise may mirror ICU or step-down unit
Patient interfaces
In its simplest terms, noninvasive ventilation differs from invasive ventilation by the interface between
the patient and the ventilator. Invasive ventilatory support is provided via either an endotracheal tube
or tracheostomy tube. Noninvasive ventilatory support uses a variety of interfaces, and these have
continued to evolve with modifications based on patient comfort and efficacy. Many of the interfaces or
masks were initially used in patients with obstructive sleep apnea before they were adapted for use in
patients to provide noninvasive ventilatory support.
Nasal masks and orofacial masks were the earliest interfaces, with subsequent development and use
of full face masks, mouthpieces, nasal pillows, and helmets. Nasal masks and orofacial masks are still
the most commonly used interfaces. Orofacial masks are used almost twice as frequently as nasal
masks. Both have advantages and disadvantages in the application of noninvasive ventilation.
Note the images below.
Nasal mask. Courtesy of Philips Healthcare (previously Respironics).
Full face mask. Courtesy of Philips Healthcare (previously Respironics).
Total face mask. Courtesy of Philips Healthcare (previously Respironics).
Helmet mask. Courtesy of Harol S. R. L.
Proper fitting of the mask or other interface is another key component to successful noninvasive
ventilation. The mask or interface may be held in place (without straps applied) by the patient or
therapist to familiarize the patient with the mask and ventilator. Typically, the smallest mask providing
a proper fit is the most effective. Straps hold the mask in place, with care to minimize excess pressure
on the face or nose. Leaks are the bane of all of the interfaces, but excess pressure applied with the
straps increases the risk of pressure necrosis and skin breakdown. Straps should be tight enough to
prevent leaks, but with enough slack to allow passage of one or two fingers between the face and the
straps.
The nasal and orofacial masks may be first-line and second-line options, specifically in patients who
may have prior familiarity with these interfaces or in those who may have had difficulty with orofacial
or nasal masks. Clinical trials have not demonstrated the superiority of any interface, although the
nasal mask may be more effective in patients with a lower severity of illness. [4] In patients with a
higher severity of illness, the orofacial mask and total face mask appear to result in comparable
outcomes.
The main considerations regarding the choice of an orofacial mask or nasal mask are outlined below.
Orofacial mask general advantages are as follows:
Best suited for less cooperative patients
Better in patients with a higher severity of illness
Better for patients with mouth-breathing or pursed-lips breathing
Better in edentulous patients
Generally more effective ventilation
Orofacial mask cautions and disadvantages are as follows:
Claustrophobic
Hinder speaking and coughing
Risk of aspiration with emesis
Nasal mask general advantages are as follows:
Best suited for more cooperative patients
Better in patients with a lower severity of illness
Not claustrophobic
Allows speaking, drinking, coughing, and secretion clearance
Less aspiration risk with emesis
Generally better tolerated
Nasal mask cautions and disadvantages are as follows:
More leaks possible (eg, mouth-breathing or edentulous patients)
Effectiveness limited in patients with nasal deformities or blocked nasal passages
While orofacial masks and nasal masks are the most commonly used interfaces, other patient
ventilator interfaces through which noninvasive ventilation can be applied include mouthpieces, nasal
pillows, total face masks, and even a helmet device, which encompasses the entire head. Experience
with helmet devices is limited but increasing, and it has been successful in patients who are unable to
tolerate the nasal or orofacial devices.
Ventilators
The choice of ventilators available to provide noninvasive ventilatory support has continued to expand.
Early noninvasive ventilatory support was applied using either large bedside critical care volume
ventilators or smaller volume or pressure specialty ventilators devoted to noninvasive ventilation.
While the critical care ventilators had more options, they were also less tolerant of leaks. The specialty
ventilators had fewer options and range, but they were more leak tolerant.
Many critical care ventilators currently in use also have a noninvasive ventilation option, either as part
of the original device or available as an upgrade option. The ideal device is dependent on a number of
factors, including familiarity by staff and available options. The differences between the bedside critical
care ventilator and specialty noninvasive ventilator continue to diminish as differences related to
ventilator options, range of support, and leak tolerance are corrected in both devices. The distinction
in function and capability has blurred, and there are devices that are capable of providing both
invasive and noninvasive ventilation with a mere switch of ventilator settings. Nevertheless, most
hospitals continue to provide noninvasive support with the specialty ventilator.
Modes of ventilation
Choosing the initial mode of ventilation is based in part on past experience, in part on the capability of
ventilators available to provide support, and in part on the condition being treated. Most patients who
are provided noninvasive ventilation are provided support with pressure ventilation, with continuous
positive airway pressure (CPAP), which is the most basic level of support. CPAP may be especially
useful in patients with congestive heart failure or obstructive sleep apnea.
Bilevel positive airway pressure (BiPAP) is probably the most common mode noninvasive positive
pressure ventilation and requires provisions for inspiratory positive airway pressure (IPAP) and
expiratory positive airway pressure (EPAP). The difference between IPAP and EPAP is a reflection of
the amount of pressure support ventilation provided to the patient, and EPAP is synonymous with
positive end-expiratory pressure (PEEP). Some noninvasive ventilation is provided using proportional-
assist ventilation (PAV), which provides flow and volume assistance with each breath. Clinical trials
have not demonstrated a significant difference between PAV and pressure-support ventilation with
BiPAP. [5, 6] However, BiPAP is the most commonly available and more frequently used modality for
noninvasive ventilation. PAV remains available on many ventilator models, but use is much less
common than BiPAP.
While volume ventilators can be used to provide noninvasive ventilatory support, the previously
described modes are preferred because they provide better patient comfort and synchrony and are
more tolerant of the leaks that accompany all noninvasive ventilatory interfaces.
Initial ventilator settings and adjustments

Adequate ventilation and oxygenation, correction of respiratory failure, and adequate patient tolerance
and comfort are the primary goals of noninvasive ventilation, and adjustments are made to achieve
these endpoints. Initial settings focus on achieving adequate tidal volumes, usually in the range of 5-7
mL/kg. Additional support is provided to reduce the respiratory rate to less than 25 breaths/minute.
Oxygen is adjusted to achieve adequate oxygenation, with a pulse oximetry goal of greater than 90%.
Serial arterial blood gas measurements are essential to monitor the response to therapy and to guide
further adjustments in the ventilator. The following provides some guidance on titration of ventilator
settings in patients with respiratory distress and who have never been placed on noninvasive
ventilation. In those patient who may have chronic noninvasive support, the initial values should be
based on prior support levels. The listed levels may be inadequate and would thus increase the
likelihood of intolerance or failure. If there is uncertainty, it is important to perform a bedside titration
with increasing levels based on patient comfort or exhaled tidal volumes. These adjustments can be
made within minutes and can be done without obtaining blood gases.
Initial IPAP/EPAP settings are as follows:
Start at 10 cm water/5 cm water
Pressures less than 8 cm water/4 cm water not advised as this may be inadequate
Initial adjustments to achieve tidal volume of 5-7 mL/kg (IPAP and/or EPAP)
Subsequent adjustments based on arterial blood gas values are as follows:
Increase IPAP by 2 cm water if persistent hypercapnia
Increase IPAP and EPAP by 2 cm water if persistent hypoxemia
Maximal IPAP limited to 20-25 cm water (avoids gastric distension, improves patient comfort)
Maximal EPAP limited to 10-15 cm water
FIO2 at 1.0 and adjust to lowest level with an acceptable pulse oximetry value
Back up respiratory rate 12-16 breaths/minute
Pressure control (PC) and average volume assured pressure support (AVAPS)
ventilation
The above considerations and approach to adjustment are best suited for those with COPD or chronic
heart failure as the primary cause of their hypercapnia or hypoxemic respiratory distress and failure.
Patients with neuromuscular disorders (amyotrophic lateral sclerosis, postpolio syndrome, muscular
dystrophy) or thoracic cage disorders (severe kyphoscoliosis) may fare better with other ventilatory
modalities. The most current noninvasive ventilators have PC or average AVAPS options. In PC
ventilation, both the inspiratory pressure and the inspiratory time are set and fixed. This differs from
BiPAP in which the patient controls the inspiratory time. This modality may be useful in the
neuromuscular disease patient who does not have the respiratory muscle strength to generate an
adequate inspiratory time. Setting an increased inspiratory time may increase the tidal volume
provided, but it may also increase patient-ventilator dyssynchrony if the set inspiratory time is longer
than the patient's desired inspiratory time.
AVAPS is another option in these neuromuscular disease patients and has also been used in those
with severe obesity-hypoventilation syndrome. It should be noted that AVAPS is not generally used for
those patients with acute respiratory distress and is better suited for management as they recover or
have recovered from their acute decompensated state. Although most experience with AVAPS in
COPD is with chronic respiratory failure, some investigators have noted favorable outcomes when
used in acutely decompensated COPD patients. [7]
As with any pressure-cycled mode, the dependent variable is volume and it may vary widely if there is
patient dyssynchrony, changes in lung compliance, or changes in resistance that can occur with
changes in body position that occurs in the very morbidly obese. [8] A fixed pressure support setting
will not compensate for these changes, and, as a result, delivered tidal volume will fall. AVAPS allows
a target tidal volume to be identified with a range of pressure support settings that fluctuate to meet
the target tidal volume. AVAPS uses an internal algorithm to make changes in the pressure support
supplied to achieve the target volume, but these changes are small and occur over minutes (typically
1-2.5 cm water per minute). That is why rapidly changing, acute respiratory conditions are not suited
for AVAPS as the ventilator adjustments may not be timely enough to meet the patient's requirements.
Typically, the pressure support required to produce the target volume during bedside titration is used
to identify the minimal pressure with the set minimal pressure (min P), typically 2-3 cm water lower to
allow flexibility for adjustment in the AVAPS mode. The maximal pressure (max P) is typically set in
the 20-25 cm water range as higher pressures are not well tolerated. The min P is at least 8 cm water
and usually higher. Additional parameters that are part of AVAPS setting are the target tidal volume,
respiratory rate, EPAP, and inspiratory time.
Predictors of successful noninvasive ventilation

Importantly, recognize that certain parameters may predict successful noninvasive ventilation or failure
of noninvasive ventilation, so that patients are not subjected to continued treatment when optimal
treatment requires intubation and mechanical ventilation. This includes changes during a trial of
noninvasive ventilation. The changes, in turn, are a reflection of the patient's ability to cooperate with
noninvasive ventilation, patient-ventilatory synchrony, and noninvasive ventilation effectiveness. Trials
of noninvasive ventilation are usually 1-2 hours in length and are useful to determine if a patient can
be treated with noninvasive ventilation. Extended trials without significant improvement are not
recommended because this only delays intubation and mechanical ventilation (unless patients are do-
not-intubate status).
Predictors of success, with a response to a trial of NIV (1-2 h), are as follows:
Decrease in PaCO2 greater than 8 mm Hg
Improvement in pH greater than 0.06
Correction of respiratory acidosis

Predictors of failure are as follows:
Severity of illness - Acidosis (pH < 7.25), hypercapnia (>80 and pH < 7.25), Acute Physiology
and Chronic Health Evaluation II (APACHE II) score higher than 20
Level of consciousness - Neurologic score (>4 = stuporous, arousal only after vigorous
stimulation; inconsistently follows commands), encephalopathy score (>3 = major confusion,
daytime sleepiness or agitation), Glasgow Coma Scale score lower than 8
Failure of improvement with 12-24 hours of noninvasive ventilation
Late admission predictors of failure (>48 h after initiation of noninvasive ventilation) are as follows:
Lower functional status (Activity score < 2 = dyspnea light activity)
Initial acidosis (pH ≤7.22)
Hospital complications (pneumonia, shock, coma)
Certain patients may benefit from a trial of therapy; however, limiting trials is important to avoid delays
in definitive therapy. Trials may be as short as a few minutes, in patients with immediate failure, and
probably should not exceed 2 hours if patients fail to improve.
Objective criteria for discontinuation are important to limit trials in patients in whom noninvasive
ventilation ultimately fails. This specifically refers to intubation criteria, which carry a subjective
element but have been defined in the literature in investigational studies. All these criteria are subject
to some degree of interpretation in the context of the patient's clinical status. Importantly, recognize
the following as guidelines to assist with the decision to intubate a patient. Most patients who meet
these criteria are candidates for intubation, but a few may be able to be managed with continued
noninvasive ventilation.
Prediction of failure to high-flow nasal cannula oxygen

Although the focus has been on noninvasive ventilation (NIV), there has been increasing use of high-
flow nasal cannula (HFNC) oxygen in clinical situations where NIV had previously been used. This
also warrants objective measures that may identify patients in whom HFNC oxygen support fails and
who require intubation. This is important, as delayed intubation of patients with progressive hypoxemic
respiratory failure has been associated with increased mortality. This led to the identification of the
ROX index, defined as the ratio of pulse oximetry oxygen saturation and fraction of inspired oxygen to
respiratory rate [(SpO2/FIO2)/RR]. In an inception and validation cohort of patients with pneumonia
and on HFNC oxygen, values of the ROX index greater than 4.88 measured at 2, 6, and 12 hours, 18
and 24 hours after initiation of HFNC were found to identify those patients who would not need
intubation. [9] Lower ROX index scores not only identified those requiring intubation, but was also
associated with poor outcomes, specifically mortality. The authors identified the hours between the
12th and 24th hours as the most vulnerable in their cohort, with an increased risk of failure in those
with ROX index scores lower than 3.85.
Intubation criteria
Major criteria (any one of the following) are as follows [10, 11] :
Respiratory arrest
Loss of consciousness with respiratory pauses

Gasping for air
Psychomotor agitation requiring sedation
Heart rate less than 50 bpm with loss of alertness
Hemodynamic instability with systolic blood pressure less than 70 mm Hg
Minor criteria (two of the following) are as follows:
Respiratory rate greater than 35 breaths/minute
pH less than 7.25 and decreased from onset
PaO2 less than 45 mm Hg despite oxygen
Increase in encephalopathy or decreased level of consciousness
Intubation guidelines
Any one of the following [12] :
pH less than 7.20
pH 7.20–7.25 on 2 occasions 1 hour apart
Hypercapnic coma (Glasgow Coma Scale score < 8 and PaCO2 >60 mm Hg)
PaO2 less than 45 mm Hg
Cardiopulmonary arrest
Two or more of the following in the context of respiratory distress:
Respiratory rate greater than 35 breaths/minute or less than 6 breaths/minute
Tidal volume less than 5 mL/kg
Blood pressure changes, with systolic less than 90 mm Hg
Oxygen desaturation to less than 90% despite adequate supplemental oxygen
Hypercapnia (PaCO2 >10 mm increase) or acidosis (pH decline >0.08) from baseline
Obtundation
Diaphoresis
Abdominal paradox
Noninvasive Ventilation in COPD
Patients with underlying chronic obstructive pulmonary disease (COPD) who present with an
exacerbation of their COPD and hypercapnic respiratory distress or respiratory failure are the group
most likely to be successfully treated with noninvasive ventilation (NIV). Exacerbations increase the
work of breathing in these patients and may exceed the patient's ability to adequately ventilate
through a variety of mechanisms, including increasing hyperinflation with decreased diaphragmatic
excursion and strength, increasing intrinsic positive end-expiratory pressure (PEEP), ineffective or
inadequate tidal volume generation, respiratory patterns, and increased respiratory frequency.
Noninvasive ventilation effectively unloads the respiratory muscles, increasing tidal volume,
decreasing the respiratory rate, and decreasing the diaphragmatic work of breathing, which translates
to an improvement in oxygenation, a reduction in hypercapnia, and an improvement in dyspnea.
Noninvasive ventilation is an important adjunct to other conventional therapy (eg, bronchodilators,

corticosteroids, antibiotics). COPD is an ideal condition for noninvasive ventilation, given the rapid
reversibility with treatment and added support that can be provided by noninvasive ventilation. Most
experience with noninvasive ventilation has accrued with either bilevel positive airway pressure
(BiPAP) or pressure support ventilation, less so with volume ventilation and continuous positive airway
pressure (CPAP), which is infrequently used as a mode of ventilatory support in these patients.
While prospective randomized trials have involved relatively small numbers of patients (< 1000 total),
a consistent treatment benefit has been demonstrated, and noninvasive ventilation has been
recommended as first-line therapy in the management in COPD patients with hypercapnic respiratory
failure. Systematic reviews and meta-analyses have all come to the same conclusion. Noninvasive
ventilation reduces the need for intubation, mortality, complications, and length of stay in patients with
COPD.
However, the magnitude of the benefit of noninvasive ventilation differs given some inconsistencies in
the included studies. The largest review concluded that noninvasive ventilation decreased the
intubation rate by 28% (95% confidence interval [CI], 15-40%), in-hospital mortality rate by 10% (95%
CI, 5-15%), and absolute reduction in length of stay by 4.57 days (95% CI, 2.30-6.38 d). [13] The
benefit was most pronounced in patients with more severe COPD exacerbations, defined by an initial
pH of less than 7.30. The magnitude of effect was even more pronounced in this group, with intubation
rates decreased by 34% (95% CI, 22-46%), mortality reduction of 12% (95% CI, 6-18%), and absolute
reduction in the length of stay by 5.59 days (95% CI, 3.66-7.52 d). Investigations with less severely
affected patients did not demonstrate any benefit in any of these outcomes.
In another review, greater improvement in respiratory acidosis, hypercapnia, and tachypnea was
noted after 1 hour on noninvasive ventilation, along with fewer complications related to intubation. [14]
Additional experience with noninvasive ventilation in hypercapnic COPD has helped to identify
possible thresholds for its application. Severely hypercapnic patients with severe respiratory acidosis
and lethargy or even frank coma related to the hypercapnia were often excluded from trials of
noninvasive ventilation because of concerns for progressive respiratory failure and an inability to
cooperate with noninvasive ventilation as a result of their carbon dioxide narcosis.
In some centers, patients with an initial pH of less than 7.25 and a Glasgow Coma Scale score of less
than 11 had noninvasive ventilation failure rates of 70% or greater. [15] Some report successful
application of noninvasive ventilation in patients with a Glasgow Coma Scale score less than 8 and an
average pH of 7.13 ± 0.06 (mean ± standard deviation), with 76 (80%) of 95 patients responding to
treatment with noninvasive ventilation. [16] Others have had less success, grading sensorium using a
Kelly score of 4 or more defined as a stuporous patient, only intermittently able to follow commands,
and an average pH of 7.22, where the success rate was 55% in a group of 20 patients. [17] However,
in all of these series, improvement after 1-2 hours noninvasive ventilation was predictive of success.
Local experience and expertise also play significant roles in determining the successful limits of
noninvasive ventilation in COPD patients. Patients who are not cooperative and have a pH that
approaches 7.20 must be evaluated with caution because they have a higher risk of failure with
noninvasive ventilation and would therefore benefit from earlier intubation (if an option), especially if
they do not respond to a short trial of noninvasive ventilation.
Another benefit with noninvasive ventilation may be a reduction in nosocomial infections associated
with its application. This was a finding suggested by earlier investigations, because averting
endotracheal intubation also avoids a major risk factor for ventilator-associated pneumonia (ie, the
endotracheal tube). Experience in a case-control study suggests a reduction in nosocomial
pneumonia from 22% to 8%, with fewer days in the ICU and lower mortality (26% down to >4%) in
those treated with noninvasive ventilation as opposed to those who received endotracheal intubation.
[18, 19]
The case for first-line use of noninvasive ventilation in the management of acute exacerbations of
COPD has been further supported by review of large administrative databases. [20, 21] Noninvasive
ventilation has better outcomes than invasive mechanical ventilation when used as the initial treatment
in those with acute exacerbations of COPD on several levels, including length of stay, hospital-
acquired pneumonia, and mortality. However, those in whom noninvasive ventilation fails and who
require intubation have a worse outcome, about three times higher than those initially treated with
noninvasive ventilation. However, successfully treated patients do not have the same severity of
illness as those who are initially subject to intubation and mechanical ventilation, and those in whom
noninvasive ventilation fails likely represent a group whose worse outcomes are further testaments to
their borderline status. [22] This further emphasizes the importance of proper patient selection for
noninvasive ventilation, with the best-suited patients identified from the clinical trials summarized
below.
Summary
COPD is the most suitable condition for noninvasive ventilation.
Noninvasive ventilation is most effective in patients with moderate-to-severe disease
Hypercapnic respiratory acidosis may define the best responders (pH 7.20-7.30). Noninvasive
ventilation is also effective in patients with a pH of 7.35-7.30, but no added benefit is appreciated if the
pH is greater than 7.35. The lowest threshold of effectiveness is unknown, but success has been
achieved with pH values as low as 7.10.
Obtunded COPD patients can be treated, but the success rate is lower.
Improvement after a 1- to 2-hour trial may predict success.
Also see the clinical guidelines summary, Global strategy for the diagnosis, management, and
prevention of chronic obstructive pulmonary disease. [23]
Noninvasive Ventilation in Cardiogenic Pulmonary Edema

Respiratory insufficiency due to cardiogenic pulmonary edema or congestive heart failure (CHF) is
another condition that is effectively treated with noninvasive ventilation (NIV). Respiratory failure due
to heart failure is potentially a rapidly reversible condition, similar in its reversibility to decompensated
chronic obstructive pulmonary disease (COPD), and noninvasive ventilation is an ideal adjunct to the
other treatments used in the management of CHF.
The pathophysiology of respiratory failure in CHF is related to a combination of pulmonary vascular

congestion, interstitial edema, and alveolar fluid accumulation. This leads initially to hypoxemic
respiratory failure, and patients with CHF who further deteriorate manifest hypercapnic respiratory
failure. Positive-pressure ventilation is beneficial because it recruits alveoli, increases functional
residual capacity, and allows breathing on the more compliant portion of the lung's pressure-volume
curve, thereby decreasing the work of breathing, improving ventilation-perfusion relationships, and
eventually correcting hypoxemia and hypercapnia. Positive intrathoracic pressure also decreases
preload and left ventricular afterload, both beneficial effects in patients with intravascular volume
overload.
These beneficial effects can be achieved with continuous positive airway pressure (CPAP), which has
been recommended as a first-line therapy in CHF patients. The other ventilator modalities, such as
bilevel positive airway pressure (BiPAP), pressure support ventilation, or volume ventilation, have also
been used and some controversy exists regarding their efficacy when compared with CPAP.
Note that CPAP has long been recognized as effective in the management of CHF, with initial reports
dating from as early as 1938 using very simple pressure devices. Randomized prospective trials
comparing its efficacy with oxygen were not conducted for almost 50 years, and small trials also
confirmed its effectiveness in correcting gas exchange abnormalities, even in patients with profound
respiratory acidosis, with a general benefit of both a reduction in intubation rates and mortality rates.
The experience with noninvasive ventilation provided using BiPAP or pressure support modalities,
however, has been mixed. Some investigators found no benefit with their applied noninvasive
ventilation, and some noted more complications, specifically higher rates of myocardial infarction.
Other investigators found greater benefit in symptom relief and oxygenation but no differences in
intubation rates or mortality rates or benefits in a post hoc analysis involving hypercapnic patients.
Meta-analyses do suggest a benefit with CPAP, with a risk reduction in intubation of 60% (RR, 0.40;
95% CI, 0.27-0.58) and a decrease in mortality rate of 47% (RR, 0.53; 95% CI, 0.35-0.81).
Noninvasive ventilation has also demonstrated a risk reduction in intubation rates of 52% (RR, 0.48;
95% CI, 0.34-0.76), but not for mortality rates. No differences were noted when comparing CPAP and
noninvasive ventilation. [24, 25]
The largest randomized trial comparing oxygen, CPAP, and noninvasive ventilation as adjunctive
treatments to conventional therapy in patients with CHF did not identify any intubation or mortality
benefit. [26] Patients with CPAP and noninvasive ventilation (BiPAP) did have more rapid resolution of
symptoms and correction of gas exchange abnormalities and pH compared with the oxygen group. No
difference was noted between CPAP and noninvasive ventilation (BiPAP).
Do note, however, that this trial randomized and treated patients in an emergency department setting,
and treatment with noninvasive ventilation averaged approximately 2 hours. Admission to a critical
care unit was an outcome measure, and the overall intubation rate for all of the groups was less than
3%. This is distinctly different from other trials, in which the intubation rates for the control groups were
approximately 31%. This raises some question about the comparability of these three groups of
patients with patients reported in other trials, which included patients requiring ICU-level care.
Noninvasive ventilation is effective in patients with CHF. CPAP is probably the most effective mode,
achieving a reduction in intubation rates and mortality rates, with a little less effectiveness noted with
noninvasive ventilation (BiPAP). Subsequent experience with BiPAP has not identified an increased
risk with therapy, specifically no increased risk of myocardial infarction; therefore, the choice of
ventilatory support may be a local or patient-based decision. Subsequent trials comparing BiPAP or its
equivalent with CPAP have failed to demonstrate the superiority in patient outcomes of one mode to
the other. [27] Patients with CHF who can be treated in an emergency department setting may only
realize a symptom or dyspnea benefit from noninvasive ventilation (whether CPAP or BiPAP) as
opposed to oxygen alone.
Summary
Noninvasive ventilation is well suited for patients with cardiogenic pulmonary edema.
CPAP and BiPAP modalities both are effective, with CPAP possibly being more effective.
The greatest benefits are realized in relief of symptoms and dyspnea.
A decrease in intubation and mortality rates is not a universal experience.
Patients with hypercapnic respiratory acidosis may derive the greatest benefit from noninvasive
ventilation.
Importantly, adjust to standard therapy, including diuresis.
Benefit may be seen with as few as 2 hours of support.
Noninvasive Ventilation and High-Flow Nasal Cannula Oxygen

After Extubation
Interest in the use of noninvasive ventilation (NIV) after discontinuation of mechanical ventilation is
considerable. Postextubation respiratory insufficiency requiring reintubation can occur in more than
20% of patients. Many of the pathophysiologic derangements discussed in earlier sections also occur
in the postextubation period, including increased respiratory load, hyperinflation, diaphragmatic
dysfunction, and increases in preload and afterload, all of which can contribute singly or in unison to
hypercapnia, hypoxemia, and eventual respiratory failure. In addition, patients may have incurred
some upper airway trauma with intubation or may have developed upper airway edema, which, in turn,
can contribute to partial upper airway obstruction, which is another factor contributing to an increased
respiratory workload.
Noninvasive ventilation can ameliorate some of the pathophysiologic derangements that occur
following extubation and has been used in 2 primary postextubation scenarios. Patients in whom
weaning trials have failed or those who do not meet extubation criteria have been extubated to
noninvasive ventilation support as part of an early extubation approach or as an adjunct to weaning.
Early extubation with noninvasive ventilation support may be able to prevent some of the
complications associated with endotracheal intubation, specifically nosocomial pneumonia. In addition,
noninvasive ventilation allows for speech with preservation of oropharyngeal function. Noninvasive
ventilation has also been applied to patients who were identified as candidates for extubation based
on weaning and/or extubation criteria but then developed postextubation respiratory distress.
While mixed groups of patients are encountered, the vast majority of patients managed with
postextubation noninvasive ventilation support have had underlying chronic obstructive pulmonary
disease (COPD), and this is the population that seems especially suited to noninvasive ventilation in
general and, specifically, to noninvasive ventilation–supported weaning.
A systematic review and meta-analyses of noninvasive ventilation and weaning in slightly more than
500 patients (mostly COPD patients) found that the use of noninvasive ventilation reduced mortality
rates by 45% (RR, 0.55; 95% CI, 0.38-0.79), ventilator-associated pneumonia rates by 71% (RR, 0.29;
95% CI, 0.19-0.45), weighted duration of ICU stay by 6.27 days (95% CI, 8.77-3.78 d), and hospital
days by 7.19 days (10.8-3.58 d) compared with a conventional weaning approach. The duration of
endotracheal intubation was reduced by 7.81 days (95% CI, 11.3-4.31 d), as was the need for
tracheostomy. However, reintubation rates were not decreased. [28] A more recent report suggests that
hypercapnic patients may fare better if treated with noninvasive ventilation following extubation. [29]
These results conflict with reports of increased adverse outcomes (reintubation, mortality) when
noninvasive ventilation is applied later in the course of patients on mechanical ventilation, after they
have fulfilled criteria for extubation, are extubated, and develop respiratory distress. Noteworthy is that
only approximately 10% of the patients in these trials had COPD, and this is the group that seemed to
benefit the most from noninvasive ventilation. [30] On the other hand, in a smaller prospective
randomized trial of 97 high-risk patients with mixed causes of respiratory failure including COPD,
ARDS, and pneumonia, application of NIV 1 hour after extubation was associated with a lower
reintubation rate (8.3 % vs 24.5%, P = .027). [31]
High-flow nasal cannula oxygen (HFNC) may have a role in this setting, probably better than face
mask oxygen. [32] Its potential benefit may lie in its ability to provide higher levels of oxygen and a
small amount of positive pressure compared with standard oxygen therapy. Its performance and role
compared with NIV has undergone additional investigation. A randomized, multicenter trial involving
830 patients following cardiothoracic surgery found comparable failure rates (reintubation) between
HFNC (21%) compared with NIV provided as BiPAP (21.9%). BiPAP-randomized patients had a
higher PaO2/FIO2 than HFNC patients, but no differences were noted in a host of secondary outcome
measures, including PaCO2, pH, respiratory rate, dyspnea score, comfort score, nosocomial
pneumonia, pneumothorax, and length of stay in the ICU or hospital. [33]
A prospective randomized trial involving 604 patients with a mix of initial of both medical and surgical
diagnoses, including ARDS, decompensated heart failure, and COPD exacerbations, and
postoperative patients, with the majority either undergoing abdominal or neurosurgery, compared 24
hours of postextubation support with either HFNC or BiPAP. After 24 hours, patients were switched to
standard oxygen therapy. No differences in reintubation were noted between HFNC and BiPAP in the
first 24 hours, but all-cause reintubation was a little lower with BiPAP (19.1%) versus HFNC (22.8%),
as was respiratory related-reintubation (BiPAP 15.9% vs HFNC 16.9%), but none of these outcomes
was statistically significant and this supports the conclusion of noninferiority of HFNC versus BiPAP for
mixed causes of intubation. [34]
This experience led to a comparison of HFNC alone with HFNC and NIV postextubation in patients at
high risk for extubation failure, defined as those older than 65 years and with underlying chronic
cardiac or pulmonary disease. [35] These entities included those with left ventricular dysfunction
defined by a left ventricular ejection fraction of less than or equal to 45% and prior cardiogenic
pulmonary edema, ischemic heart disease, chronic atrial fibrillation, COPD, obesity-hypoventilation
syndrome, or restrictive lung disease. Patients were also stratified on the presence or absence of
hypercapnia (PaCO2 >45 mm Hg). Randomization to HFNC postextubation represented 48 hours of
continuous HFNC oxygen, whereas the HFNC and NIV group were first treated with NIV for at least 4
hours postextubation and for 12 hours daily with HFNC during the period when off NIV in the 48 hours
after extubation. If those in either group were stable after 48 hours, they were switched to
conventional oxygen. The primary outcome was reintubation within 7 days of extubation ,and the
investigators had preestablished reintubation criteria. Of 641 patients who were randomized, the NIV
and HFNC group had lower reintubation rates at 48 hours, 72 hours, ICU discharge, and 7 days
(11.8% vs 18.2%, P = .02) than the HFNC group. It should be noted that NIV was continued beyond
the initial postextubation window of 48 hours in 25% and HFNC oxygen was continued in that group in
35% of patients. However, mortality was not different between the two groups, whether assessed
during the ICU stay, hospital stay, or at 90 days. Of those in whom HFNC oxygen failed, 20 patients
were then treated with NIV and half of those patient eventually needed reintubation. This report
supports the combined use of NIV and HFNC oxygen as a successful postextubation strategy in those
patients at high risk for respiratory failure.
In a meta-analysis of 18 trials involving 3881 patients, HFNC was associated with lower rates of
intubation compared with conventional oxygen therapy in those with acute respiratory failure.
However, no differences in intubation rates, ICU mortality, or ICU length of stay was found between
HFNC and NIV in patients with acute respiratory failure. [36] This suggests that HFNC oxygen is not
inferior to NIV in the management of these patients and can be an alternative method of support if
there is concern for the use of NIV.
Overall, experience to date suggests that NIV can help facilitate weaning and discontinuation of
mechanical ventilation in selected patients. Patients with underlying COPD are the best candidates,
but other groups may also benefit from an early-extubation approach followed by NIV support. COPD
patients who develop respiratory distress after meeting criteria for extubation are most likely to benefit
from NIV, but this is not established and use of NIV in these patients (as well as any other patient who
develops postextubation respiratory distress) should be done with caution. There are better outcomes
with NIV provided as prophylactic or preemptive ventilatory support after extubation, but before the
development of respiratory distress. For those who may not be able to tolerate NIV interfaces, HFNC
oxygen is an acceptable alternative and in those patients with underlying cardiac and/or respiratory
disease, the combination of NIV and HFNC oxygen reduces the incidence of postextubation
respiratory failure and need for reintubation.
Summary
Noninvasive ventilation is effective as a bridge support after early extubation.
Noninvasive ventilation is an adjunct to weaning (substitutes noninvasive support for invasive

support).
Patients with underlying COPD are most likely to benefit from noninvasive ventilation after early
extubation.
Noninvasive ventilation is not as effective in patients with postextubation respiratory distress.
COPD patients are a subgroup who may benefit in that situation.
Preemptive or near-immediate use (as opposed to waiting for respiratory distress) of NIV following
extubation may be more effective in the transition of patients off invasive ventilatory support.
HFNC oxygen is an acceptable option for the transition off ventilatory support following extubation.
While postoperative patients may be especially suited to HFNC, it has been successful with other
causes of respiratory failure.
The combination of NIV and HFNC is more effective than HFNC alone following extubation in patients
with cardiac and respiratory disease.
Noninvasive Ventilation in COVID-19
There are considerable differences in opinion and controversy on the use of noninvasive ventilatory
devices in patients with novel coronavirus disease 2019 (COVID-19). Much of this stems not from
issues with efficacy, but from questions and concerns about aerosolization of potentially infectious
exhaled gas, which may increase the possibility of spreading this infection to other healthcare workers
or patients. Increased exhaled air dispersion has been demonstrated in simulation studies with
mannequins with the amount of noted dispersion increasing with higher applied pressures (IPAP 18
cm water). [37] However, this does not seem to have translated to an increase in infections when
reviewing the experience with severe acute respiratory syndrome (SARS), although in a small number
of patients (20). [38] The authors did note endotracheal intubation was avoided in 70% of the patients
with shorter ICU lengths of stay (3.1 vs 21.3 days, P< .001), with no nosocomial SARS infections
noted in 105 healthcare workers involved with these patients. In addition to good infection control
practices, they also mitigated the potential production of droplets with use of a facial mask (as
opposed to a nasal mask), exhalation device with reduced jet-expired air, and a viral bacterial filter
placed before the exhalation device. On the other hand, in a case control study to identify risk factors
for a super-spreading nosocomial event defined as clusters of more than 3 cases, the use of high-flow
oxygen and BiPAP were risk factors, although BIPAP did not achieve statistical significance in local-
site multivariate models but only in pooled analysis. [39] In addition, the use of a dual-limb circuit
noninvasive ventilator as opposed to one with a single-limb circuit, which typically has a circuit leak or
leak valve to prevent carbon dioxide rebreathing, may also provide additional control of environmental
aerosol generation.
In a retrospective cohort study of 26 healthcare workers who developed SARS, 38% had exposure to
noninvasive ventilation (NIV), whereas 8% were exposed to high-flow oxygen, but neither modality
was identified with increased transmission of SARS in a logistic regression model. [40] In a systematic
review of the literature and risk of infections to healthcare workers with aerosol-generating
procedures, NIV generated an odds ratio (OR) of 3.1 (95% confidence interval [CI], 1.4-6.8), but this
only involved two small cohort studies. No association was noted with high-flow nasal cannula (HFNC)
oxygen, but only one cohort was included in the analysis. [41] In comparison, higher ORs were
identified with tracheal intubation (OR, 6.6; 95% CI, 2.3-18.9) and manual ventilation before intubation
also had an increased OR (2.6; 95% CI, 1.3-6.4). This summarizes the experience and solutions
applied during the SARS epidemic, which was also due to a coronavirus.
Because of the potential risk for nosocomial aerosol transmission, the role of NIV in the management
of hypoxemic respiratory failure due to COVID-19 pneumonia, remains unsettled. While NIV and
HFNC oxygen are options for the management of hypoxemic respiratory failure, some medical centers
have raised concern for their use given the potential risk for nosocomial transmission of coronavirus.
On the other hand, these options have been demonstrated to avoid intubation, which is a crucial
aspect of management as patient demand has exceeded the inventory of ventilators at some sites,
leading to difficult management and possible ethical conflicts in patient care.
The use of HFNC and NIV in the treatment of COVID-19 pneumonia and respiratory failure has varied
greatly in series reported from worldwide sites. This may be in part a reflection of local practices, but it
may also be a reflection of the severity of respiratory failure, as HFNC and NIV are not typically used
in patients with severe hypoxemic respiratory failure, defined as low PaO2/FIO2 less than 200. There
are also risks for aerosolization with both NIV and HFNC, but different practices may mitigate that risk
as outlined above for NIV with the use of lower flows, a surgical mask on the patient, and close
attention to minimizing condensation of tubing. These reports have focused on the overall experience
in managing respiratory failure, and there has not been specific attention to noninvasive therapies
except for one report from China. They retrospectively reviewed their experience and reported on a
small group of 17 patients treated with HFNC in 7 (41%) of their patients, all with PaO2/FIO2 less than
200, but those failures also went on to be treated with NIV and only 2 (11.7% of those treated with
HFNC and NIV) eventually required intubation. [42]
In three series from China, in a group of 138 patients with an overall death rate of 4.3%, 36 of their
patients were treated in the ICU, with 11% receiving HFNC oxygen and 42% NIV, but it is not entirely
clear in how many subjects these modalities had failed. [43] In another cohort of 201 patient with ARDS
and overall death rate of 21.9%, HFNC (includes mask oxygen) use rates were 48% and NIV 30%. [44]
They reported 42% of their cohort had ARDS and 33% were treated with mechanical ventilation, but
they provided no information on the number in who whom HFNC oxygen and NIV failed. In a report
that focused on 168 deaths, 34% received HFNC oxygen and 43% NIV, but only 20% were intubated.
[45]
In the largest reported series from Italy, their cohort consisted of 1591 patients with a 26% mortality
rate at the time of their report. The vast majority of patients were treated with invasive mechanical
ventilation (88%) and 11% were treated with NIV. [46] In four US studies, two from Washington state,
with 24 and 21 patients, respectively, with mortality rates of 50% and 67%, use of HFNC oxygen was
42% and 5%, respectively, NIV was 0% and 19%. [47, 48] In the largest case series from New York of
5700 patients, 2634 who had been discharged or died, the mortality rate was 21%, with 320 (12%)
intubated. Of the intubated patients, the mortality rate was 88%. No information was provided on
HFNC or NIV use. [49] In a cohort from Boston of 66 intubated patients with 16.7% mortality at the time
of the report, only one patient was treated with HFNC or NIV (2%) and that patient was eventually
intubated. [50]
It is evident that use of HFNC oxygen and NIV is much different in China than Italy and the United
States. Until there is further analysis, it will be difficult to ascertain the true impact and/or advantage of
HFNC oxygen and NIV in COVID-19 pneumonia. However, these modalities can be used, and based
on the experiences with SARS, with minimal impact for healthcare workers provided proper infection
control practices are in place. It should also be noted that the vast majority of the SARS experience
occurred in the context of negative-pressure rooms, and this may be an important factor for the use of
these modalities in COVID-19, as this has been largely unreported in these case series. One of the
advantages in past use of HFNC or NIV in patients with hypoxemic respiratory failure was the ability to
avoid intubation. While this may still be the case with COVID-19, the magnitude of this effect remains
to be determined.
The following ventilation clinical practice guidelines in adults with COVID-19 were released by the
European Society of Intensive Care Medicine and the Society of Critical Care Medicine [51] :
It is suggested to start supplemental oxygen if the peripheral oxygen saturation (SPO 2) is less
than 92%. It is recommended to start supplemental oxygen if the SPO 2 is less than 90%.
In the event of acute hypoxemic respiratory failure on oxygen, it is recommended that the SPO 2
be maintained at no higher than 96%.
In patients with acute hypoxemic respiratory failure despite conventional oxygen therapy, it is
suggested that a high-flow nasal cannula be used rather than conventional oxygen therapy.
In patients with acute hypoxemic respiratory failure, it is also suggested that a high-flow nasal
cannula be used over noninvasive positive-pressure ventilation.
In these patients with acute hypoxemic respiratory failure, in the event a high-flow nasal cannula
is not available and the patient has no urgent indication for endotracheal intubation, it is
suggested that a trial of noninvasive positive-pressure ventilation be conducted, with close
monitoring and short-interval assessment for worsening of respiratory failure.
While considered an option, no recommendation was made regarding helmet noninvasive
positive-pressure ventilation versus mask noninvasive positive-pressure ventilation.
In patients receiving either noninvasive positive-pressure ventilation or high-flow nasal cannula,
it is recommended they be closely monitored for worsening respiratory status; early intubation in
a controlled setting is recommended if worsening occurs.
In patients with acute respiratory distress syndrome (ARDS) who are on mechanical ventilation,
it is recommended to use low-tidal-volume ventilation (4-8 mL/kg of predicted body weight)
versus higher tidal volumes (>8 mL/kg).
In patients with ARDS who are on mechanical ventilation, it is recommended to target plateau
pressures at less than 30 cm water.
In patients with moderate-to-severe ARDS who are on mechanical ventilation, it is suggested to
use a higher positive end-expiratory pressure (PEEP) strategy versus a lower PEEP strategy.
When using a higher PEEP strategy (ie, PEEP >10 cm water), monitor patients for barotrauma.
In patients with ARDS who are on mechanical ventilation, it is suggested to use a conservative
fluid strategy versus a liberal fluid strategy.
use prone ventilation for 12-16 hours versus no prone ventilation.
use, as needed, intermittent boluses of neuromuscular blocking agents versus a continuous
infusion, to facilitate protective lung ventilation.
Use of a continuous infusion of neuromuscular blocking agents is suggested in the event of
persistent ventilator dyssynchrony, a need for ongoing deep sedation, prone ventilation, or
persistently high plateau pressures.
In patients with ARDS who are on mechanical ventilation, routine use of inhaled nitric oxide is
not recommended.
In mechanically ventilated patients with severe ARDS and hypoxemia despite optimization of
ventilation and other rescue strategies, a trial of inhaled pulmonary vasodilator is suggested as
rescue therapy; if rapid improvement in oxygenation is not observed, taper off treatment.
In mechanically ventilated patients with severe ARDS and hypoxemia despite optimization of
ventilation, use of recruitment maneuvers is suggested over not using recruitment maneuvers. If
recruitment maneuvers are used, staircase (incremental PEEP) recruitment maneuvers are not
recommended.
In those patients on mechanical ventilation who have refractory hypoxemia despite optimization
of ventilation and who have undergone rescue therapies and proning, it is suggested to use
venovenous extracorporeal membrane oxygenation (EMCO) if available; alternatively, refer the
patient to center that has ECMO. However, because EMCO is resource-intensive and it requires
experienced centers/healthcare workers and infrastructure, it should only be considered in
carefully selected patients with severe ARDS.
Summary
HFNC and NIV have been effective in the treatment of hypoxemic respiratory failure in SARS and
COVID-19.
The severity of hypoxemic respiratory failure defined as PaO2/FIO2 less than 200 may identify
patients better suited for treatment with invasive ventilation.
The risk of transmission of potentially infectious aerosols may be mitigated by the use of filters,
personal protective equipment, and negative-pressure rooms.
Local experience and expertise are important factors in the use of HFNC oxygen and NIV.
HFNC and NIV may avoid intubation in some patients with COVID-19 pneumonia and respiratory
failure, but this remains to be determined and the use of these modalities should be made on a case-
by-case basis.
Noninvasive Ventilation in Other Conditions

Noninvasive ventilation (NIV) has been used in a number of clinical situations, but it seems to be most
effective in patients with acute respiratory failure due to underlying chronic obstructive pulmonary
disease (COPD) or congestive heart failure (CHF). These represent the hypercapnic and hypoxemic
conditions best suited for noninvasive ventilation, but, obviously, other conditions can also be treated
with noninvasive ventilation.
Other diagnoses are regularly added to the list as experience accumulates. The common theme that
suggests successful application noninvasive ventilation for all of these other conditions is a reasonably
rapidly reversible condition with noninvasive ventilation as an adjunct to therapy. Other parameters, as
outlined in General Considerations, are also important for the successful application of noninvasive
ventilation. Noninvasive ventilation is likely to be successful in selected patients with these diagnoses,
but the evidence to date does not support universal application of noninvasive ventilation in these
patients. The following highlights the main considerations in each condition. [52, 53, 54, 55]
In community-acquired pneumonia, note the following:
Noninvasive ventilation not established to be beneficial
Secretions may be limiting factor
Improvement with noninvasive ventilation best achieved in patients also with COPD
Hypercapnic respiratory acidosis may define group likely to respond
Decrease in intubation rate and mortality may be limited to those also with COPD
Clinical guidelines summary -Infectious Diseases Society of America/American Thoracic Society

consensus guidelines on the management of community-acquired pneumonia in adults [56]
In immunocompromised patients and hypoxemic respiratory failure, note the following:
Solid organ transplantation [57] - Single-center trial, approximately 50 patients; subgroup with
cardiogenic pulmonary edema fared best
Febrile neutropenic patients - Single-center trial, approximately 50 patients; mostly hematologic

malignancies or bone marrow transplantations; benefit of noninvasive ventilation in those with an
identified cause of pneumonia; severity of illness relatively modest
In asthma [58] patients, note the following:
Similar pathophysiology to COPD; limited reported experience with noninvasive ventilation
Mostly case series with reported benefit
Prospective, randomized studies based on emergency department settings
Improvement in spirometry main outcome measure
Fewer admissions with noninvasive ventilation; intubation not an outcome measure
Hypercapnic asthma patients not represented in randomized trials
Noninvasive ventilation probably beneficial, but experience limited

In postoperative patients, [59] note the following:
Postoperative hypoxemia related to atelectasis or pulmonary edema
Occurrence following multiple types of surgery (eg, lung, cardiac, abdominal) [60, 61, 62]
Randomized trials with postoperative continuous positive airway pressure (CPAP) demonstrate
benefit
Applied as prophylactic support or with development of hypoxemia
Benefit noted with level CPAP levels in 7.5- to 10-cm water range
Lower intubation rates, days in ICU, and pneumonia
High-flow nasal cannula oxygen option (50 L/min and FiO2 = 0.50) may be comparable to
noninvasive ventilation [33]
With rib fractures (traumatic, with nonpenetrating chest injuries), note the following:
Older single report using low-level CPAP (5 cm water)
Fewer episodes of pneumonia, duration of hospitalization
No mortality benefit: Hernandez et al found that in patients with hypoxemia related to severe
thoracic trauma, noninvasive mechanical ventilation reduced intubation rates. In a randomized
clinical trial, patients with PaO2/FiO2 ratio of less than 200 for more than 8 hours while receiving
oxygen by high-flow mask within the first 48 hours after thoracic trauma were randomized to
remain on high-flow oxygen mask or to receive noninvasive mechanical ventilation. The trial was
halted after 25 patients were enrolled in each group because the intubation rate was much
higher in controls than in noninvasive mechanical ventilation patients (40% vs 12%, P = .02). In
addition, length of hospital stay was shorter in noninvasive mechanical ventilation patients (14 vs
21 d, P = .001); however, no difference in survival was observed. [63]
For do-not-intubate status (advanced disease or terminal malignancy), [64] note the following:
Numerous case series
COPD patients comprise most patients
Most with hypercapnic respiratory failure
Report of 60% success rate, but discharge home rate of 40-50%
Median survival following treatment 179 days in one series
One-year survival rate of 30%
Some with more distress from the mask and noninvasive ventilation than benefit
Issues with resource utilization and prolonging the inevitable
Better outcomes in CHF, awake patients, and those with strong cough (mobilized secretions)
Benefit in patients with malignancy if treating reversible condition

Benefit in dyspnea relief for patients with terminal malignancy [65]
For acute respiratory distress syndrome, [66, 67] note the following:
Not recommended as first-line therapy in management
Limited experience, but may benefit those who do not require immediate intubation
Noninvasive ventilation provided via mask or helmet; able to avoid intubation in approximately
half - Ventilator settings in successful noninvasive ventilation are pressure support ventilation of
14 cm water; positive end-expiratory (PEEP) of 7 cm water; successfully treated patients found
to have lower severity of illness (Simplified Acute Physiology Score II < 34 or improvement of
PaO2/FiO2 ratio >175 after 1 h)
High-flow nasal cannula oxygen in a trial compared with high-flow nasal cannula plus
noninvasive face mask ventilation with better mortality outcomes than noninvasive ventilation,
although no statistical difference in primary outcome of intubation [68]
Single-center trial of selected patients with acute respiratory distress syndrome who did not
improve with noninvasive ventilation demonstrated benefit with helmet ventilation with decreased
intubation rate, more ventilator-free days, and decreased mortality [69] ; higher PEEP delivered
and high flow rates (100-200 L/min) may explain benefit of helmet noninvasive ventilation
For severe acute respiratory distress syndrome, [70, 38] note the following:
Successful treatment with noninvasive ventilation during severe acute respiratory distress
syndrome (SARS) outbreak
Noninvasive ventilation able to avoid intubation in 70%
Patients hypoxemic with also relatively low severity of illness (Acute Physiology and Chronic
Health Evaluation II [APACHE II] score < 6)
The remaining conditions have had reports of successful noninvasive ventilation in both acute and
chronic respiratory failure. Most of these processes represent patients with either chronic hypercapnia
or relatively mild hypoxemia. Patients with the following diagnoses who may be candidates for
noninvasive ventilation should be evaluated on a case-by-case basis:
Cystic fibrosis - May be useful as a bridge to lung transplantation and as an adjunct to oxygen
therapy alone during sleep to improve gas exchange [71]
Neuromuscular respiratory disease [72, 73] - Nocturnal use may be especially effective for
daytime hypercapnia; avoid in bulbar dysfunction or excess secretions; effective in patients with
muscular dystrophy, kyphoscoliosis, and postpolio syndrome; some may be able to be treated
with negative-pressure ventilators
Obesity-hypoventilation (or decompensated obstructive sleep apnea) - Corrects hypercapnia,

facilitates diuresis, and provides opportunity for restorative sleep [70]
Upper airway obstruction (partial) - Caution if potential for complete obstruction
Mild Pneumocystis carinii pneumonia - Case series; may avoid intubation in selected patients
Support during invasive procedures - Bronchoscopy, percutaneous gastrostomy [70, 74]

Idiopathic pulmonary fibrosis - Generally poor response to invasive ventilation, much less
noninvasive ventilation; Successfully treated patients with a rapidly reversible cause of
respiratory failure
Complications of Noninvasive Ventilation

Noninvasive ventilation (NIV) has a very different profile of complications compared with complications
associated with endotracheal intubation and mechanical ventilation. This is directly attributable to the
elimination of the endotracheal tube in patient management. Complications associated with its
placement, the duration of placement, and removal of the tube all are averted. In addition, patients are
usually not sedated as they would be if they were intubated, which further reduces complications
related to sedation. Even complications common to both noninvasive ventilation and invasive
ventilation occur less frequently in patients undergoing noninvasive ventilation.
Complications of noninvasive ventilation

For facial and nasal pressure injury and sores, note the following:
Result of tight mask seals used to attain adequate inspiratory volumes
Minimize pressure by intermittent application of noninvasive ventilation
Schedule breaks (30-90 min) to minimize effects of mask pressure
Balance strap tension to minimize mask leaks without excessive mask pressures
Cover vulnerable areas (erythematous points of contact) with protective dressings
For gastric distension, note the following:
Rarely a problem
Avoid by limiting peak inspiratory pressures to less than 25 cm water
Nasogastric tubes can be placed but can worsen leaks from the mask
Nasogastric tube also bypasses the lower esophageal sphincter and permits reflux
For dry mucous membranes and thick secretions, note the following:
Seen in patients with extended use of noninvasive ventilation
Provide humidification for noninvasive ventilation devices
Provide daily oral care
For aspiration of gastric contents, note the following:
Especially if emesis during noninvasive ventilation
Avoid noninvasive ventilation in patient with ongoing emesis or hematemesis
Complications of both noninvasive and invasive ventilation

These include the following:
Barotrauma (significantly less risk with noninvasive ventilation)
Hypotension related to positive intrathoracic pressure (support with fluids)
Complications avoided by noninvasive ventilation

These include the following:
Ventilator-associated pneumonia
Sinusitis
Reduction in need for sedative agents - Sedatives used in less than 15% of noninvasive
ventilation patients in one survey
Other Issues
For use of noninvasive ventilation, note the following:
Utilization highly variable among hospitals, regions, and countries
Used extensively in Europe, with use increasing over time - Noninvasive ventilation (NIV) use
exceeds 80% of patients in some European ICUs [75]
Used less in Canada and United States (20-50%; some areas 0%) [76] - Attributed to (1)
unfamiliarity of physicians and other staff and (2) lack of proper equipment; inaccurate
perception of increased time commitment; respiratory therapy and nursing time not increased
Practice guidelines increase usage of noninvasive ventilation
Coding and reimbursement issues additional impediments to implementation
Cost-analysis of noninvasive ventilation is as follows:
Demonstrated to be cost-effective in patient management - Savings of more than $3000

Canadian dollars; even greater cost savings if patients managed in a ward setting
Avoids costs of endotracheal intubation and mechanical ventilation
Shorter ICU and hospital stays
Eliminates costs associated with infectious complications - Episodes of ventilator-associated

pneumonia reduced by half or more
Questions & Answers

Overview
What is noninvasive ventilation (NIV)?
What is the historical background of noninvasive ventilation (NIV)?
What is positive-pressure ventilation and how is it delivered?
What are the types of noninvasive ventilation (NIV)?
What is negative-pressure noninvasive ventilation (NIV) and how is it delivered?
What are the advantages of positive-pressure noninvasive ventilation (NIV)?
What is high-flow nasal cannula oxygen noninvasive ventilation (NIV)?
In which patients is high-flow nasal cannula oxygen noninvasive ventilation (NIV) indicated?
What is the basis of patient selection for noninvasive ventilation (NIV)?
What are contraindications for noninvasive ventilation (NIV)?
What other considerations may limit the use of noninvasive ventilation (NIV)?
Which patients are best suited for noninvasive ventilation (NIV)?
What are the patient inclusion criteria for noninvasive ventilation?
Which conditions are most suitable for treatment with noninvasive ventilation?
What are suitable clinical conditions for use of noninvasive ventilation (NIV)?
With which clinical conditions should noninvasive ventilation (NIV) be used with caution?
How does healthcare staff inexperience with noninvasive ventilation (NIV) affect outcomes?
Where is noninvasive ventilation (NIV) utilized for inpatient care?
How does noninvasive ventilation (NIV) differ from invasive ventilation?
How should masks be fitted to ensure successful noninvasive ventilation (NIV)?
What type of mask is most effective in noninvasive ventilation (NIV)?
What are the advantages and disadvantages of an orofacial mask for noninvasive ventilation (NIV)?
What are the advantages and disadvantages of a nasal mask for noninvasive ventilation (NIV)?
What are alternative ventilator interfaces to orofacial or nasal masks for noninvasive ventilation (NIV)?
What are the differences between critical care volume ventilators and specialty ventilators for
noninvasive ventilation (NIV)?
What are the modes of ventilation in noninvasive ventilation (NIV)?
What are primary goals of noninvasive ventilation (NIV) and how should settings be adjusted to meet
goals?
What are initial inspiratory positive airway pressure (IPAP) or expiratory positive airway pressure
(EPAP) settings in noninvasive ventilation (NIV)?
What is the role of pressure control (PC) in noninvasive ventilation (NIV)?
What is the role average volume assured pressure support (AVAPS) in noninvasive ventilation (NIV)?
What are the benefits of average volume assured pressure support (AVAPS) in noninvasive ventilation
(NIV)?
Why are 1-2 hour trials of noninvasive ventilation (NIV) conducted?
What are predictors of success in noninvasive ventilation (NIV)?
What are the predictors of failure in noninvasive ventilation? (NIV)
Why should trials of noninvasive ventilation (NIV) be limited?
What is included in the objective criteria for discontinuation of noninvasive ventilation (NIV)?
What are the predictors of failure in high-flow nasal cannula oxygen?
What are the major criteria for intubation of patients using noninvasive ventilation (NIV)?
What are the minor criteria for intubation of patients using noninvasive ventilation (NIV)?
What are guidelines for intubation?
What is the role of noninvasive ventilation (NIV) in the treatment of chronic obstructive pulmonary
disease (COPD)?
What are the benefits of noninvasive ventilation (NIV) in patients with chronic obstructive pulmonary
disease (COPD)?
What are limitations to noninvasive ventilation (NIV) in patients with chronic obstructive pulmonary
disease (COPD)?
Which patients have a higher risk of failure with noninvasive ventilation (NIV) in chronic obstructive
pulmonary disease (COPD)?
How does noninvasive ventilation (NIV) affect the risk for nosocomial pneumonia in chronic
obstructive pulmonary disease (COPD) patients?
What is the efficacy of noninvasive ventilation (NIV) in the management of acute exacerbations of
chronic obstructive pulmonary disease (COPD)?
Which patients are most suitable for noninvasive ventilation (NIV) in chronic obstructive pulmonary
disease (COPD)?
What is the role of noninvasive ventilation (NIV) in the treatment of cardiogenic pulmonary edema and
congestive heart failure (CHF)?
What are the benefits of noninvasive ventilation (NIV) in the treatment of congestive heart failure
(CHF)?
What is the efficacy of noninvasive ventilation (NIV) using bilevel positive airway pressure (BiPAP) for
cardiogenic pulmonary edema and congestive heart failure (CHF)?
What are the intubation and mortality benefits of noninvasive ventilation (NIV) for congestive heart
failure (CHF)?
What is the efficacy of noninvasive ventilation (NIV) for congestive heart failure (CHF)?
Which patients with cardiogenic pulmonary edema or congestive heart failure (CHF) may have the
greatest benefit from noninvasive ventilation (NIV)?
What is the role of noninvasive ventilation (NIV) after extubation?
What are the benefits of postextubation noninvasive ventilation (NIV) support?
Which patients are suitable for postextubation noninvasive ventilation (NIV) support?
What is the efficacy of postextubation noninvasive ventilation (NIV) support?
What is the role of high-flow nasal cannula oxygen therapy in postextubation noninvasive ventilation
(NIV) support?
Which patients are the best candidates for postextubation noninvasive ventilation (NIV) support?
How can the role of noninvasive ventilation (NIV) after extubation be summarized?
What are ventilation-related recommendations and suggestions for adults with COVID-19?
When is noninvasive ventilation (NIV) indicated?
What is the role of noninvasive ventilation (NIV) in in the treatment of community-acquired

pneumonia?
What is the role of noninvasive ventilation (NIV) in the treatment of immunocompromised patients?
What is the role of noninvasive ventilation (NIV) in the treatment of asthma?
What is the role of noninvasive ventilation (NIV) in the treatment of postoperative patients?
What is the role of noninvasive ventilation (NIV) in the treatment of rib fractures?
What is the role of noninvasive ventilation (NIV) in the treatment of patients with do-not-intubate
status?
What is the role of noninvasive ventilation (NIV) in the treatment of acute respiratory distress
syndrome (ARDS)?
Which patients should be evaluated on a case-by-case basis before receiving noninvasive ventilation
(NIV)?
What are potential complications of noninvasive ventilation (NIV)?
How are facial and nasal pressure injury and sores caused by noninvasive ventilation (NIV) managed?
How is gastric distension caused by noninvasive ventilation (NIV) managed?
How is dry mucous membranes and thick secretions caused by noninvasive ventilation (NIV)
managed?
How is aspiration of gastric contents caused by noninvasive ventilation (NIV) managed?
What are complications of both noninvasive (NIV) and invasive ventilation?
Which complications are avoided by noninvasive ventilation (NIV)?
How do the utilization rates for noninvasive ventilation (NIV) vary among developed countries?
What is the cost-analysis of noninvasive ventilation (NIV) use?
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1/10/2021 Noninvasive Ventilation: Overview, Methods of Delivery, General Considerations

This site is intended for healthcare professionals

Absolute contraindications are as follows:

Any condition requiring immediate intubation

Other contraindications (rare exceptions) are as follows:

GI bleeding - Intractable emesis and/or uncontrollable bleeding

Inability to protect airway - Impaired cough or swallowing, poor clearance of secretions,

Other considerations that may limit application are as follows:

After eliminating unsuitable candidates for noninvasive ventilation, successful application of

Patient inclusion criteria are as follows:

Dyspnea (moderate to severe, but short of respiratory failure)

Tachypnea (>24 breaths/min)

Increased work of breathing (accessory muscle use, pursed-lips breathing)

Hypercapnic respiratory acidosis (pH range 7.10-7.35)

Hypoxemia (PaO2/FIO2< 200 mm Hg, best in rapidly reversible causes of hypoxemia)

Chronic obstructive pulmonary disease

Cardiogenic pulmonary edema

After discontinuation of mechanical ventilation (COPD)

Community-acquired pneumonia (and COPD)

Immunocompromised state (known cause of infiltrates)

Postoperative respiratory distress and respiratory failure

Decompensated obstructive sleep apnea/cor pulmonale

Mild Pneumocystic carinii pneumonia

Use with caution in the following clinical conditions:

Idiopathic pulmonary fibrosis (exacerbation)

Acute respiratory distress syndrome (consider helmet ventilation)

Application of Noninvasive Ventilation

It can be used in the ICU, especially if there is the possibility of intubation.

It can be used in a step-down unit (lower severity of illness), as follows:

Moderately severe COPD (pH >7.30)

Suitable in specialized units

Note the images below.

Nasal mask. Courtesy of Philips Healthcare (previously Respironics).

Full face mask. Courtesy of Philips Healthcare (previously Respironics).

Total face mask. Courtesy of Philips Healthcare (previously Respironics).

Helmet mask. Courtesy of Harol S. R. L.

Orofacial mask general advantages are as follows:

Best suited for less cooperative patients

Better in patients with a higher severity of illness

Better for patients with mouth-breathing or pursed-lips breathing

Better in edentulous patients

Generally more effective ventilation

Orofacial mask cautions and disadvantages are as follows:

Hinder speaking and coughing

Risk of aspiration with emesis

Nasal mask general advantages are as follows:

Best suited for more cooperative patients

Better in patients with a lower severity of illness

Allows speaking, drinking, coughing, and secretion clearance

Less aspiration risk with emesis

Generally better tolerated

Nasal mask cautions and disadvantages are as follows:

More leaks possible (eg, mouth-breathing or edentulous patients)

Effectiveness limited in patients with nasal deformities or blocked nasal passages

Initial ventilator settings and adjustments

Initial IPAP/EPAP settings are as follows:

Start at 10 cm water/5 cm water

Subsequent adjustments based on arterial blood gas values are as follows: