Guidelines for selecting patients with chronic respiratory failure for noninvasive nocturnal ventilation*

Physiologic evidence of respiratory muscle weakness (one or more of the parameters below)

Forced vital capacity <50% predicted

Maximum inspiratory pressure below –60 cm H₂O (ie, less negative than –60 cm H₂O; eg, –50 cm H₂O)

Maximum expiratory pressure <40 cm H₂O

Vital capacity <15 to 20 mL/kg, <60% predicted, <1 liter, or decrease >30 to 50% compared with baseline

Sniff-nasal inspiratory force <40 cm H₂O

Chronic hypoventilation^¶

Daytime PaCO₂ ≥45 mmHg OR

Nocturnal hypoventilation with sustained O₂ desaturation (eg, O₂ saturation ≤88% for >5 consecutive minutes) AND symptoms (eg, morning headache, hypersomnolence, etc)

Appropriate diagnosis

Neuromuscular disease (eg, amyotrophic lateral sclerosis, muscular dystrophy, spinal cord injury)

Chest wall deformity (eg, kyphoscoliosis)

Reversible contributing factors treated (eg, heart failure)

Adequate upper airway function (eg, no bulbar dysfunction)

Patient is awake, alert, appropriate cognition, and does not have uncontrollable seizures

* There are no data-driven standards for deciding when to initiate noninvasive ventilation, but these are commonly employed and can be used as a general guideline.
¶ In patients with progressive neuromuscular disorders, clinicians should not wait for frank hypoventilation to occur and in most instances noninvasive ventilation should be started when respiratory muscle weakness is evident (refer to the physiologic parameters in this table).

Graphic 79358 Version 7.0

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Guidelines for selecting patients with chronic respiratory failure for noninvasive nocturnal ventilation*