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Noninvasive ventilation in adults with acute respiratory failure: Benefits and contraindications

Noninvasive ventilation in adults with acute respiratory failure: Benefits and contraindications
Literature review current through: Jan 2024.
This topic last updated: May 08, 2023.

INTRODUCTION — Noninvasive ventilation (NIV) refers to the delivery of positive pressure ventilation through a noninvasive interface (eg, nasal mask, face mask, or nasal plugs), rather than an invasive interface (endotracheal tube, tracheostomy).

NIV can be used as ventilatory support for patients with acute or chronic respiratory failure. Data that support NIV use in adult patients with acute respiratory failure are discussed here. The practical aspects of initiating NIV in patients with acute respiratory failure and use of NIV for treating chronic respiratory failure (eg, neuromuscular disorders, chest wall disease, or obesity hypoventilation syndrome) are described separately. (See "Noninvasive ventilation in adults with acute respiratory failure: Practical aspects of initiation" and "Noninvasive positive airway pressure therapy for the obesity hypoventilation syndrome" and "Noninvasive ventilation in adults with chronic respiratory failure from neuromuscular and chest wall diseases: Patient selection and alternative modes of ventilatory support".)

CHOOSING NONINVASIVE VERSUS INVASIVE VENTILATION — For patients who present with acute respiratory failure, general principles that underlie the decision to choose NIV or invasive mechanical ventilation include the following [1]:

The presence of conditions that are typically responsive to NIV – In general, provided no contraindications are present, a short trial of NIV is justified in most patients with acute hypercapnic respiratory failure due to an acute exacerbation of chronic obstructive pulmonary disease and patients with acute cardiogenic pulmonary edema. Patients with other etiologies are less likely to benefit. Importantly, since delayed mechanical ventilation is associated with a poor outcome, trials of NIV should be short (eg, two hours or less); during NIV patients should be monitored and assessed frequently to ensure rapid intubation, when needed. Factors that predict success are listed in the table (table 1). (See 'Patients likely to benefit' below and 'Patients less likely to benefit' below.)

The presence of contraindications to NIV (including the emergent need for intubation) – The contraindications to NIV are listed on the table (table 2). The need for emergent intubation is an absolute contraindication and all others are relative or many have exceptions. In such cases, discussion with experts in NIV is appropriate so that an informed decision can be made to implement NIV. (See 'Contraindications' below and "The decision to intubate".)

The values and preferences of the patient – When feasible, the advantages and disadvantages of a noninvasive approach compared with an invasive approach should be explained to the patient or their caregiver. The major benefit of NIV is the avoidance of intubation and the attendant risks of invasive mechanical ventilation. For example, NIV appears to decrease the incidence of nosocomial infections likely as a consequence of fewer ventilator-associated pneumonias due to avoidance of intubation; NIV may also decrease the incidence of other nosocomial infections (eg, sinusitis, line sepsis) due to a shorter length of stay and shorter duration of invasive monitoring [2]. Complications are few, are generally minor, and are often related to the interface (eg, local irritation or ulceration, air leaks, nasal dryness or congestion, gastric distension and aspiration). Barotrauma is rare. The major disadvantages of NIV compared with invasive mechanical ventilation are that it can be poorly tolerated in an awake patient, ventilation may be less effective due to air leaks, and it should only be used for short periods (eg, 24 hours to a few days). (See "Clinical and physiologic complications of mechanical ventilation: Overview" and "Noninvasive ventilation in adults with acute respiratory failure: Practical aspects of initiation", section on 'Complications' and "Complications of the endotracheal tube following initial placement: Prevention and management in adult intensive care unit patients" and "Direct laryngoscopy and endotracheal intubation in adults", section on 'Complications'.)

Choosing between high-flow oxygen delivered via nasal cannulae (HFNC) and NIV in hypoxemic patients is discussed separately. (See "Heated and humidified high-flow nasal oxygen in adults: Practical considerations and potential applications", section on 'General principles of application'.)

PATIENTS LIKELY TO BENEFIT — Conditions known to respond well to NIV include:

Acute exacerbations of chronic obstructive pulmonary disease (AECOPD) that are complicated by hypercapnic acidosis (arterial carbon dioxide tension [PaCO2] >45 mmHg [6 kPa] or pH <7.35) (see 'Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with hypercapnic respiratory acidosis' below)

Acute cardiogenic pulmonary edema (ACPE) (see 'Acute cardiogenic pulmonary edema (ACPE)' below)

NIV use in AECOPD has increased over time [3] but despite clear evidence of efficacy, it may still be underutilized [4].

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with hypercapnic respiratory acidosis — For patients with AECOPD complicated by hypercapnic (ie, respiratory) acidosis (PaCO2 >45 mmHg [6 kPa] or pH <7.35), we recommend an initial trial of bilevel NIV (also known as bilevel positive airway pressure [BPAP]). Evidence from large randomized trials and meta-analyses consistently indicates that bilevel NIV improves important clinical outcomes in patients having an AECOPD complicated by hypercapnic acidosis [1,5-9]. For example, one meta-analysis of 17 randomized trials of patients with AECOPD and acute hypercapnia (PaCO2 >45 mmHg [6 kPa]) reported an almost 50 percent reduction in mortality in patients treated with NIV plus standard therapy compared with standard therapy alone (18 versus 10 percent; risk ratio [RR] 0.54, 95% CI 0.38-0.76; number needed to treat for benefit [NNTB] 12) [9]. Bilevel NIV also reduced the rate of intubation by 65 percent (12 versus 34 percent; RR 0.36, 95% CI 0.28 to 0.46; NNTB 5) as well as hospital length of stay, complications unrelated to NIV (eg, ventilator-associated pneumonia, multiorgan failure), and indices of gas exchange. The mechanism by which bilevel NIV improves hypercapnic respiratory failure in AECOPD is due to improved alveolar ventilation as evidenced by improved respiratory mechanics (eg, decreased respiratory rate, an increased tidal volume, and an increased minute ventilation) and improved gas exchange parameters (eg, increase in arterial oxygen tension [PaO2] and decrease in the PaCO2) [10].

While data in the past suggested that patients with severe exacerbations were more likely to benefit from bilevel NIV [6,11,12], a 2017 Cochrane analysis of 17 trials reported no differences between those with mild (defined as a pH between 7.3 and 7.35) or severe exacerbations (defined by those with a pH <7.3) [9].

While bilevel NIV is the mode of choice, continuous positive airway pressure (CPAP), pressure support ventilation (PSV), and other modes (eg, neurally adjusted ventilatory assist [NAVA]) have also been shown to result in success in patients with acute hypercapnic respiratory failure due to AECOPD [1,5-9,13,14]. However, these modes are less likely to improve alveolar ventilation and do not have a strong body of evidence to support their use in patients with AECOPD. Modes like PSV and NAVA may be suitable for those who find bilevel NIV uncomfortable or who are dyssynchronous with the ventilator. (See "Noninvasive ventilation in adults with acute respiratory failure: Practical aspects of initiation", section on 'Uncommon modes' and "Noninvasive ventilation in adults with acute respiratory failure: Practical aspects of initiation", section on 'Rarely used modes'.)

The practical aspects of applying bilevel NIV, the potential role for nocturnal NIV in COPD, and the medical management of AECOPD are discussed separately. (See "Noninvasive ventilation in adults with acute respiratory failure: Practical aspects of initiation", section on 'Bilevel noninvasive ventilation' and "Nocturnal ventilatory support in COPD" and "COPD exacerbations: Management" and "Management of infection in exacerbations of chronic obstructive pulmonary disease".)

Acute cardiogenic pulmonary edema (ACPE) — The mechanism by which NIV improves ACPE is thought to be due to preload reduction, the prevention of alveolar collapse at end expiration, and decreased left ventricular afterload. For patients with ACPE, we recommend a trial of NIV, typically with CPAP. Meta-analyses of small randomized trials in patients with ACPE, report that NIV decreases the need for intubation, improves clinical and laboratory indices of respiratory failure (eg, heart rate, dyspnea, hypercapnia, acidosis), and improves mortality [1,7,15-23]. As an example, a 2013 meta-analysis of 32 studies (2916 patients) that included both modalities of NIV (CPAP and bilevel), reported that NIV significantly reduced hospital mortality in patients with ACPE compared with standard medical care (RR 0.66, 95% CI 0.48-0.89) [21]. NIV also reduced rates of endotracheal intubation (RR 0.52, 95% CI 0.36 to 0.75) but did not have any impact on hospital length of stay. We prefer to use CPAP as initial therapy in patients with ACPE, since evidence using this mode of NIV is more robust in this population; however some patients may be initiated on bilevel NIV (eg, patients with acute hypercapnia due to ACPE).

The impact of NIV on mortality in patients with ACPE is variable and may relate to differences in the type of NIV used and the presence or absence of acute hypercapnia. As examples:

A meta-analysis of 13 trials that included 1369 patients found that patients with ACPE who received CPAP plus standard care had a lower hospital mortality than those who received standard care alone (10.3 versus 15.8 percent; RR 0.64, 95% CI 0.44-0.92) [19]. However, in the same analysis, treatment with bilevel NIV (nine trials, 1091 patients) was only associated with a trend towards improved mortality that did not reach statistical significance (9.6 versus 11.9 percent; RR 0.82, 95% CI 0.58-1.15).

Several studies found that patients with ACPE who present with acute hypercapnic respiratory failure derive the greatest mortality benefit, although this benefit has not been directly attributed to CPAP or bilevel NIV [22,24].

A randomized trial that compared CPAP with PSV delivered noninvasively found no difference in either mortality or the frequency of intubations, although respiratory distress appeared to resolve sooner among patients who received PSV, probably because it is a more comfortable mode of ventilation [25].

The practical aspects of applying CPAP and the medical treatment of acute decompensated heart failure are discussed separately. (See "Noninvasive ventilation in adults with acute respiratory failure: Practical aspects of initiation", section on 'Continuous positive airway pressure (CPAP)' and "Treatment of acute decompensated heart failure: General considerations".)

PATIENTS LESS LIKELY TO BENEFIT — Other conditions where NIV may be initiated but data to confirm its efficacy are less robust, lacking, or conflicting include:

Acute hypoxemic nonhypercapnic respiratory failure due to conditions other than acute cardiogenic pulmonary edema (ACPE) (see 'Hypoxemic nonhypercapnic respiratory failure not due to ACPE' below)

Acute respiratory failure due to asthma exacerbation (see 'Asthma exacerbation' below)

Postextubation, postoperative, or chest trauma-induced acute respiratory failure (see 'Others' below)

Hypoxemic nonhypercapnic respiratory failure not due to ACPE — For patients with hypoxemic respiratory failure not due to ACPE, an individualized approach is reasonable given the heterogeneity of the population and conflicting evidence among select populations. Choices include high-flow oxygen delivered via a nasal cannulae (HFNC), NIV, or low-flow oxygen. We prefer NIV or HFNC rather than low-flow oxygen. Choosing either option in this population should take into consideration the etiology of hypoxemic respiratory failure [26]. If either HFNC or NIV is chosen, it is prudent to start early and have a low threshold to perform intubation. Further details regarding HFNC are provided separately. (See "Evaluation and management of the nonventilated, hospitalized adult patient with acute hypoxemia", section on 'Humidified, high-flow oxygen delivered via nasal cannulae (HFNC)'.)

This cautious approach to NIV is because data are not as supportive in this population compared with patients who have acute hypercapnic respiratory failure due to an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) or acute respiratory failure due to ACPE. Consequently, the benefit from NIV likely varies. The variable response may be due to the wide range of underlying etiologies. For example, a prospective observational study reported a failure rate of 61 percent for those with acute respiratory failure due to septic shock compared with 23 percent in those with acute respiratory failure who did not have sepsis [27]. In addition, limited data suggest a high failure rate of NIV in patients with Middle East respiratory syndrome (MERS) [28] and influenza [29]; as a consequence NIV is typically avoided in patients with acute hypoxemic respiratory failure from coronavirus disease 2019 (COVID-19). (See "COVID-19: Respiratory care of the nonintubated hypoxemic adult (supplemental oxygen, noninvasive ventilation, and intubation)", section on 'Choosing oxygen via high-flow nasal cannulae versus noninvasive ventilation'.)

There is conflicting evidence about whether NIV is beneficial to patients with hypoxemic nonhypercapnic respiratory failure not due to ACPE [30-39]. As examples:

A meta-analysis of 11 studies that excluded patients with AECOPD and ACPE showed that NIV reduced the intubation rate (relative risk [RR] 0.59, 95% CI 0.44-0.79) and hospital mortality (RR 0.46, 95% CI 0.24-0.87) compared with low-flow oxygen [37]. However, confidence intervals are wide suggesting that benefit from NIV likely varies among individuals.

A network meta-analysis (NMA) of 25 randomized trials examined outcomes in patients with acute hypoxemic respiratory failure who were treated with noninvasive modalities (helmet NIV, face mask NIV and high-flow oxygen delivered via nasal cannula [HFNC]) and compared them with patients who were treated with low-flow oxygen [40]. Mortality was lower in patients treated with helmet or face mask NIV compared with low-flow oxygen (helmet NIV: RR 0.40, 95% CI 0.24-0.6, absolute risk difference -0.19, low certainty; face mask NIV: RR 0.83, 95% CI 0.68-0.99, absolute risk difference -0.06, moderate certainty). All three noninvasive modalities reduced intubation rates (helmet NIV: RR 0.26, 95% CI 0.14-0.46, absolute risk difference -0.32, low certainty; face mask NIV: RR 0.76, 95% CI 0.62-0.90, absolute risk difference -0.12, moderate certainty; HFNC, RR, 0.76, 95% CI 0.55-0.99, absolute risk difference -0.11; moderate certainty). However, this NMA should be interpreted with caution since there was significant heterogeneity and risk of bias due to lack of blinding, as well as a wide range of etiologies for respiratory failure and illness severity among the included studies. In addition, the mortality benefit was not found among patients with severe hypoxemia (eg, arterial oxygen tension/fraction of inspired oxygen ratio <200 mmHg).

In a meta-analysis of 29 randomized trials of mixed population of patients with acute respiratory failure, HFNC was compared with NIV [41]. HFNC resulted in lower mortality (RR 0.44, 95% CI 0.24-0.79), intubation rate (RR 0.71, 95%CI 0.53-0.95), and possibly hospital acquired pneumonia (RR 0.46, 95% CI 0.15-1.45) and improved patient comfort. However, small sample size and heterogeneity in study design, patient population characteristics, type of respiratory failure, and outcomes limit interpretation of the analysis. Despite these limitations, we agree that HFNC appears to be at least non-inferior and is an acceptable choice clinically in this setting.

Helmet NIV has been compared with HFNC in another small study of severely hypoxemic patients [42]. Helmet NIV resulted in greater improvements in oxygenation, reduction in dyspnea and respiratory effort, and similar levels of arterial carbon dioxide tension. The role of helmet NIV in COVID-19 is discussed separately. (See "COVID-19: Respiratory care of the nonintubated hypoxemic adult (supplemental oxygen, noninvasive ventilation, and intubation)".)

If NIV is chosen, we generally prefer bilevel positive airway pressure (BPAP) since it is better studied than other modes, and experience with its use is more widespread. Randomized trials that compared standard therapy alone with standard therapy plus NIV in patients with acute respiratory failure found that NIV improved outcomes when any of the following modes were used: assist control (AC) [43], pressure support ventilation (PSV) [5], or bilevel NIV [30,31,44,45]. Three randomized trials demonstrated that proportional assist ventilation (PAV) and PSV had similar impact on intubation rates and mortality [46-48]. (See "Noninvasive ventilation in adults with acute respiratory failure: Practical aspects of initiation" and "Modes of mechanical ventilation".)

Acute nonhypercapnic respiratory failure due to AECOPD — For patients with acute nonhypercapnic respiratory failure due to acute exacerbation of chronic obstructive pulmonary disease (AECOPD), the derived benefit from bilevel NIV is uncertain compared with patients who have acute hypercapnic respiratory failure due to AECOPD. We agree with the American Thoracic Society guideline group who suggest not using NIV in this population [1]. The recommendation was conditional and of low certainty. Data that support not administering NIV in this population include several small randomized or prospective trials that reported poor tolerance of bilevel NIV as well as no impact of NIV on mortality and conflicting effects on intubation rates in patients with AECOPD who did not have pronounced respiratory acidosis [12,49-52]. However, several patients had mild acidosis and in some studies NIV was started late, which limits interpretation of these data. However, it may be tried on an individualized basis in an effort to prevent the development of acute hypercapnia.

Pneumonia — Benefit from NIV in patients with pneumonia is variable.

Some data suggest that bilevel NIV is beneficial in patients with acute hypoxemic respiratory failure due to pneumonia provided they are able to manage their secretions [30,53-57]. In one trial that demonstrated benefit from NIV in patients with acute hypoxemic respiratory failure of varying etiologies, the mortality benefit and reduced intubation rate associated with NIV use were most evident in the subgroup of patients with pneumonia [30]. In another database analysis of 1109 patients with acute respiratory failure due to pneumonia, improved survival was reported in those who had coexistent COPD or heart failure rather than those without COPD or heart failure [58].

In patients with community acquired pneumonia (CAP), several small randomized trials have also reported that NIV resulted in decreased intensive care unit (ICU) mortality [54], decreased intubation rate [54,55], and improved oxygenation [30,54-56] compared with standard therapy. However, older patients may not derive the same benefit; in a large database analysis, NIV was reported as less effective in patients older than 65 years who have acute respiratory failure due to pneumonia [57]. In another meta-analysis of four randomized trials containing a total of 218 patients with CAP, NIV reduced the intubation rate (RR 0.46, 95% CI 0.26-0.79) and ICU mortality rate (RR 0.3, 95% CI 0.09-0.93) [59].

In contrast, limited data suggest a high failure rate of NIV in patients with MERS [28] and influenza [29]; as a consequence NIV is typically avoided in patients with acute hypoxemic respiratory failure from MERS and influenza. However, NIV may be beneficial in patients with COVID-19. (See "COVID-19: Respiratory care of the nonintubated hypoxemic adult (supplemental oxygen, noninvasive ventilation, and intubation)", section on 'Choosing oxygen via high-flow nasal cannulae versus noninvasive ventilation'.)

Immunocompromised patients — Although NIV is frequently used in immunocompromised patients for the treatment of acute hypoxemic respiratory failure, data are conflicting. Reasons for this are unknown but may be due to the wide array of etiologies of acute respiratory failure in patients who are immunosuppressed or the higher likelihood that acute respiratory failure will progress due to the immunosuppression itself. We administer bilevel NIV cautiously in this population ensuring that patients are aggressively monitored, typically in the ICU, and that the threshold for intubation remains low.

Data describing conflicting outcomes in patients with acute respiratory failure who are immunosuppressed include the following:

Several small randomized studies in immunocompromised patients with acute hypoxemic nonhypercapnic respiratory failure report that compared with invasive mechanical ventilation or oxygen (typically low-flow oxygen), NIV is associated with decreased ICU mortality, intubation rate, and ICU length of stay [54,60-62].

In contrast, several trials have shown no benefit and possibly harm with use of NIV as a first-line therapy in this population:

A large randomized trial in immunocompromised patients with acute hypoxemic nonhypercapnic respiratory failure reported that compared with oxygen alone, the early administration of NIV did not reduce 28-day mortality [63]. However, a high proportion (44 percent) of patients in the oxygen group received oxygen via high-flow nasal cannulae (HFNC); thus, the administration of positive end-expiratory pressure (PEEP) from HFNC may have limited the ability of this trial to detect a benefit from NIV. Details regarding the mechanisms and benefits of HFNC are discussed separately. (See "Heated and humidified high-flow nasal oxygen in adults: Practical considerations and potential applications".)

In a randomized trial of unselected patients with hypoxemic nonhypercapnic respiratory failure [26], a post-hoc analysis of the 82 patients who were immunocompromised reported an increase in the rate of intubation in those treated with NIV as a first-line therapy, compared with HFNC (65 versus 43 percent) [64]. Large tidal volumes were observed in the NIV group [65] and the use of NIV was an independent predictor for the likelihood of requiring mechanical ventilation. However, methodologic flaws in this study prohibit firm conclusions regarding the potential harm of NIV.

In a randomized trial of 300 immunocompromised patients that compared NIV (minimum of 12 hours) alternating with HFNC with HFNC alone, no difference in mortality or intubation rates was found [66]. HFNC was more comfortable.

Several observational studies also suggest that a significant proportion of immunocompromised patients with acute respiratory failure do not benefit from NIV [67-70]. As an example, in an observational study of 99 patients with hematologic malignancy and acute respiratory failure, approximately one-half of patients failed a trial of NIV and required endotracheal intubation [67]. The patients who failed NIV had a higher hospital mortality, a longer duration of ICU stay, and a greater risk of nosocomial infection than those who were successfully treated with NIV.

Acute respiratory distress syndrome — Most patients with acute respiratory distress syndrome (ARDS) require invasive mechanical ventilation. However, we reserve bilevel NIV for the occasional patient with mild ARDS who is hemodynamically stable, easily oxygenated, and has no contraindications to its use. The limited evidence that describes NIV use in this population is conflicting and is described separately. (See "Acute respiratory distress syndrome: Ventilator management strategies for adults", section on 'Selecting invasive versus noninvasive ventilation'.)

Asthma exacerbation — Bilevel NIV is commonly used in patients with acute hypoxemic respiratory failure from severe asthma exacerbation. However, data are limited to small randomized trials, one meta-analysis of these trials, and large retrospective study that have not documented a clear, convincing, or consistent benefit on mortality or intubation rates [71-78]. Despite inconclusive data, we suggest that a short trial of NIV (eg, one to two hours, typically BPAP) is appropriate in this population, particularly for those failing medical therapy. However, the threshold to intubate should be low. (See "Invasive mechanical ventilation in adults with acute exacerbations of asthma" and "Noninvasive ventilation in adults with acute respiratory failure: Practical aspects of initiation", section on 'Bilevel noninvasive ventilation'.)

In support of this approach is one trial of 30 patients who presented to the emergency department with a severe asthma exacerbation that was not responding to inhaled bronchodilator therapy [72]. Patients were randomly assigned to receive bilevel NIV or sham (subtherapeutic bilevel NIV) [72]. Bilevel NIV was associated with a reduction in the rate of hospitalization (18 versus 63 percent) and improved predicted forced expiratory volume in one second (FEV1; 80 versus 20 percent). However, in a meta-analysis of five trials, that included this trial, NIV did not reduce the intubation rate; mortality could not be assessed since there were no deaths in any of the studies analyzed [77]. Thus, larger randomized studies are needed to determine the value of NIV in patients with acute respiratory failure due to an acute asthma exacerbation.

Others

Postextubation respiratory failure — NIV has been used in patients who develop acute respiratory failure in the first 24 to 72 hours following extubation. NIV has also been used as a tool to prevent reintubation in patients at high risk of developing acute respiratory failure following extubation; in that setting, NIV is typically compared or combined with oxygen delivered via HFNC. These data are described separately. (See "Extubation management in the adult intensive care unit", section on 'Patients with established postextubation respiratory failure' and "Extubation management in the adult intensive care unit", section on 'Noninvasive ventilation'.)

Postoperative respiratory failure — NIV has also been used to treat patients who develop acute respiratory failure in the postoperative setting, the details of which are provided separately. (See "Overview of the management of postoperative pulmonary complications", section on 'Postoperative respiratory failure'.)

Chest trauma-induced respiratory failure — There is no specific contraindication to NIV in patients who develop acute respiratory failure following trauma to the chest [35,79,80]. (See "Initial evaluation and management of blunt thoracic trauma in adults" and "Initial evaluation and management of penetrating thoracic trauma in adults".)

OTHER SETTINGS — NIV has been traditionally used as an inpatient tool to treat acute respiratory failure in patients who are critically ill. However, NIV has been used in other clinical settings, none of which are routine (eg, oxygenation before and during intubation and palliative ventilation).

Data that support prehospitalization use of NIV are provided separately. (See "Noninvasive ventilation in adults with acute respiratory failure: Practical aspects of initiation", section on 'Timing, site, ancillary staff'.)

Oxygenation before and during intubation — Prior to intubation, patients with hypoxemic respiratory failure are typically preoxygenated with 100 percent oxygen in order to prevent arterial oxygen desaturation during the procedure. NIV has been studied in this setting but is not routine. A randomized trial compared standard preoxygenation (with a bag mask valve) to preoxygenation with NIV [81]. The NIV group had fewer oxyhemoglobin desaturations during intubation and a higher oxyhemoglobin saturation at the end of preoxygenation, during intubation, and following intubation. Other studies have described NIV as a tool to prevent desaturation during intubation, including nasal intubation [82]. Preoxygenation and intubation support strategies are discussed separately. (See "Rapid sequence intubation in adults for emergency medicine and critical care".)

Intubation refusal or palliation — NIV has been used in patients who decline endotracheal intubation [83-88]. Observational studies indicate that up to 43 percent of such patients survive to hospital discharge [87,89]. However, the mortality rate during the next six months is high [89]. NIV may also help reduce symptoms of dyspnea in patients receiving palliation for end-stage pulmonary diseases. Importantly, a do-not-intubate (DNI) order does not mean that NIV cannot be applied temporarily or palliatively. In an observational study of 36 patients with a DNI order, NIV delivered via an oronasal mask resulted in an improvement in eight patients while the remainder improved only after switching to a full-face mask [90]. (See "Assessment and management of dyspnea in palliative care", section on 'Limited role for noninvasive ventilation' and "Noninvasive ventilation in adults with acute respiratory failure: Practical aspects of initiation", section on 'Interface (mask)'.)

CONTRAINDICATIONS — There are several contraindications to NIV that are listed in the table (table 2).

Need for emergent intubation — The need for emergent intubation is an absolute contraindication to NIV (eg, cardiac or respiratory arrest, severe respiratory distress, unstable cardiac arrhythmias). (See "The decision to intubate".)

Others — Several other relative contraindications exist. NIV is generally avoided in such cases, but exceptions exist.

Acute life-threatening nonrespiratory organ failure — Nonrespiratory organ failure that is acutely life-threatening is a contraindication to NIV. There is considerable clinical judgement as to what constitutes acute life-threatening nonrespiratory organ failure but includes patients with severe encephalopathy, severe upper gastrointestinal bleeding (eg, variceal bleeding), and/or hemodynamic instability (eg, persistent hypotension unresponsive to fluid resuscitation or requiring vasoactive medication support).

Facial surgery or trauma — Patients with facial surgery or trauma are not typically candidates for NIV because the interface may fit poorly, cause discomfort, and/or potentially destabilize fractures or cause pneumocephalus. Similarly, patients with facial deformities may not be able to achieve an adequate interface fit, resulting in air leaks which diminish the efficacy of NIV. However, depending on the deformity location or severity of the injury, some patients may tolerate NIV if the optimal interface is chosen. For example, a patient with soft tissue injury only may tolerate a nasal mask while NIV should be avoided in a patient with multiple facial fractures or patients who require zygomatic wiring.

Significant airway obstruction — Patients with significant central lower airway obstruction (eg, tracheal tumor) or significant upper airway obstruction (eg, large laryngeal mass) are not suitable candidates for NIV since superior airway control is achieved, and in some cases, the obstruction can be bypassed with an invasive device (eg, endotracheal tube or tracheostomy).

Inability to protect the airway — NIV increases the risk of aspiration due to gastric distension from pressurized air. Thus, patients who cannot protect their airway should not be treated with NIV. This includes patients with poor mental status who cannot cooperate with NIV, patients with high volumes of secretions, and patients with a weak or no cough reflex; the latter includes those with neuromuscular disorders, stroke, and patients with severely impaired consciousness (eg, Glasgow coma scale <10 (table 3)).

While most patients with severely impaired consciousness should not receive NIV, reduced consciousness due to hypercapnic encephalopathy may be an exception to the rule [91-94]. This is because NIV is a treatment for acute hypercapnia; thus, mental status should improve with NIV. The likelihood that hypercapnic encephalopathy will respond to NIV is inversely related to the severity of the hypercapnia. [93,94]. Such patients should be closely monitored (eg, in an intensive care or high dependency unit); improved consciousness should be apparent within one to two hours after the initiation of NIV. Patients who deteriorate or fail to improve should be promptly intubated.

Prolonged duration of ventilation is anticipated — Clinical judgement is required when anticipating the duration of ventilation. Nonetheless, for patients with acute respiratory failure, NIV is generally considered as a short-term form of ventilation (eg, one to three days) while therapy for the underlying disorder is being treated. If it is anticipated that ventilation will be required for a more prolonged period (eg, ≥4 days), NIV is less appealing and patients should probably be intubated (eg, severe Guillain Barre syndrome). However, anecdotally, some patients with acute respiratory failure have been successfully treated with NIV for up to a week, especially if they are weaning and have "off" periods; in such cases, aggressive hourly monitoring and evaluation of the need for invasive ventilation should be performed, typically in an intensive care unit.

Recent esophageal or gastric anastomosis — We generally avoid NIV after upper gastrointestinal surgery (eg, gastric bypass, esophagectomy) that involves anastomoses, due to the possibility of gastric distention with leakage of gastric contents caused by the pressurized air. However, anecdotal experience and low quality evidence suggests that the risk of anastomotic dehiscence is low in this population. These data are discussed separately. (See "Respiratory problems in the post-anesthesia care unit (PACU)".)

Multiple contraindications — In reality, patients may have more than one contraindication to NIV. In such circumstances, we prefer to intubate these patients with a view to early extubation should they improve quickly.

SOCIETY GUIDELINE LINKS — Links to society and government-sponsored guidelines from selected countries and regions around the world are provided separately. (See "Society guideline links: Noninvasive ventilation in adults".)

SUMMARY AND RECOMMENDATIONS

Definition – Noninvasive ventilation (NIV) is a form of positive pressure ventilation delivered through a noninvasive interface (eg, nasal mask, face mask, nasal plugs) that is frequently used to support patients with acute respiratory failure. (See 'Introduction' above.)

Choosing invasive versus noninvasive ventilation – When assessing patients for NIV, the clinician should identify whether the condition responsible for acute respiratory failure is typically responsive to NIV, evaluate for the presence of contraindications (including the emergent need for intubation) (table 2), and assess whether NIV suits the patient's preferences and values. (See 'Choosing noninvasive versus invasive ventilation' above.)

The major benefit of NIV is the avoidance of intubation and risks of invasive mechanical ventilation.

Since delayed mechanical ventilation is associated with a poor outcome, trials of NIV should be short (eg, two hours or less) and patients should be monitored and assessed frequently to ensure rapid intubation, when needed.

Indications – A trial of NIV is worthwhile for the following patients with acute respiratory failure, provided there are no contraindications to NIV (table 2).

Patients likely to benefit – Patients most likely to benefit include the following (see 'Patients likely to benefit' above):

-Acute hypercapnic respiratory failure due to an acute exacerbation of chronic obstructive pulmonary disease (AECOPD) – For patients with acute hypercapnic respiratory failure (arterial tension of carbon dioxide [PaCO2] >45 mmHg [6 kPa] or pH <7.30) due to an AECOPD, we recommend standard therapy plus a trial of bilevel NIV (also known as bilevel positive airway pressure [BPAP]) rather than standard therapy alone (Grade 1B). Evidence from large randomized trials and meta-analyses consistently indicate that BPAP reduces mortality and the rate of intubation in this population. (See 'Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with hypercapnic respiratory acidosis' above.)

-Acute respiratory failure from acute cardiogenic pulmonary edema (ACPE) – For patients with acute respiratory failure from ACPE, we recommend a trial of NIV (Grade 1B). We prefer to initially use continuous positive airway pressure (CPAP), although some patients may also benefit from bilevel NIV (eg, patients with hypercapnia from ACPE). Evidence from small randomized trials and meta-analyses report that NIV decreases the need for intubation and improves clinical and laboratory indices of respiratory failure. NIV also reduces mortality in this population, although CPAP may have a greater impact than bilevel NIV. (See 'Acute cardiogenic pulmonary edema (ACPE)' above.)

Patients less likely to benefit – Other patient populations are heterogeneous and have variable outcomes from NIV (see 'Patients likely to benefit' above and 'Patients less likely to benefit' above):

-Hypoxemic nonhypercapnic respiratory failure due to causes other than ACPE – For some patients with hypoxemic nonhypercapnic respiratory failure due to causes other than ACPE (eg, immunocompetent patients with pneumonia) who have failed low-flow oxygen, we suggest a trial of NIV or high-flow oxygen delivered via nasal cannulae (HFNC) before proceeding with invasive mechanical ventilation (Grade 2C). In most cases, we prefer HFNC. This approach is based upon low quality evidence that suggests variability in the response to NIV or HFNC in this population and preliminary data that suggest HFNC may be superior. (See "Evaluation and management of the nonventilated, hospitalized adult patient with acute hypoxemia", section on 'Humidified, high-flow oxygen delivered via nasal cannulae (HFNC)'.)

It is particularly prudent in this population to start NIV or HFNC early, monitor aggressively (eg, in the intensive care unit), and to have a low threshold for intubation; this is especially true in immunocompromised patients, patients with acute respiratory distress syndrome (ARDS), and patients with viral pneumonitis (eg, Middle East respiratory syndrome, influenza, and COVID-2019) since these patient groups have a higher failure rate, with NIV in particular, and often progress to mechanical ventilation. (See 'Hypoxemic nonhypercapnic respiratory failure not due to ACPE' above.)

-Acute nonhypercapnic respiratory failure due to AECOPD – In patients with acute nonhypercapnic respiratory failure due to AECOPD, we suggest not administering NIV (Grade 2C) due to a lack of benefit, although it may be tried on an individualized basis in an effort to prevent the development of acute hypercapnia. (See 'Acute nonhypercapnic respiratory failure due to AECOPD' above.)

-Acute respiratory failure due to an asthma exacerbation – For patients with acute respiratory failure due to an asthma exacerbation who continue to have severe symptoms despite initial bronchodilator therapy, we suggest a trial of NIV rather than invasive mechanical ventilation (Grade 2C). This approach is based upon limited data that suggest decreased hospitalization rates and improved lung function parameters in the absence of a clear impact on mortality or rate of intubation. (See 'Asthma exacerbation' above.)

Special populations – Other applications of NIV include the following:

Extubation, chest trauma – In patients who develop acute respiratory failure following extubation or patients who are at high risk of respiratory failure following extubation and patients with chest trauma-related respiratory failure, a trial of NIV may be appropriate. (See "Extubation management in the adult intensive care unit", section on 'Postextubation management' and 'Others' above.)

Oxygenation peri-intubation, palliation – In addition to treating acute respiratory failure in critically ill inpatients, NIV has also been used in other clinical settings, none of which are routine (eg, oxygenation before and during intubation and palliative ventilation). NIV has also been successfully used in the prehospital setting for the management of acute respiratory failure. (See 'Other settings' above and "Noninvasive ventilation in adults with acute respiratory failure: Practical aspects of initiation", section on 'Timing, site, ancillary staff'.)

Contraindications – There are several contraindications to NIV (table 2). The need for emergent intubation is an absolute contraindication (eg, cardiac or respiratory arrest, severe respiratory distress, unstable cardiac arrhythmias). Relative contraindications include acute life-threatening nonrespiratory organ failure (eg, hemodynamic instability from variceal bleeding), facial abnormalities (eg, surgery, trauma, deformities), significant airway obstruction (eg, obstructing airway mass), inability to protect the airway (eg, patients with neuromuscular disorders, stroke, or severely impaired consciousness), prolonged duration of ventilatory support is anticipated, recent gastric or esophageal anastomoses, or the presence of more than one contraindication. (See 'Contraindications' above.)

ACKNOWLEDGMENT — The UpToDate editorial staff acknowledges Kristy Bauman, MD, who contributed to earlier versions of this topic review.

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Topic 1636 Version 68.0

References

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