Non-Invasive Ventilation in Acute Respiratory Failure

Introduction to NIV

The American Thoracic Society recommends bi-level pressure support ventilation (BiPAP) for acute COPD exacerbations with hypercapnic respiratory failure, with initial IPAP 10-15 cmH₂O, EPAP 4-8 cmH₂O, targeting SpO₂ 88-92%, and backup rate 10-14 breaths/min 1
Bi-level pressure support ventilation (BiPAP) is the preferred mode for NIV, simpler to use and validated in the majority of randomized controlled trials 2, 1

For acute COPD exacerbations, use bi-level pressure support (BiPAP) with initial IPAP 10-15 cmH₂O, EPAP 4-8 cmH₂O, targeting SpO₂ 88-92%, and backup rate 10-14 breaths/min 1
The European Respiratory Society suggests using Spontaneous/Timed (S/T) mode with backup rate if patient has frequent central apneas or inappropriately low respiratory rate 1
Obtain arterial blood gases before initiating ventilation to guide therapy, and recheck ABGs after 30-60 minutes of ventilation or if clinical deterioration occurs 1

The Society of Critical Care Medicine states that NIV should be used with extreme caution in ARDS and is generally not recommended as first-line therapy due to high failure rates and risk of delayed intubation 2
If NIV is attempted in mild ARDS, use bi-level pressure support with close monitoring for failure 2
Intubate early if no improvement within 1-2 hours, and monitor for signs of NIV failure: worsening hypoxemia, increased work of breathing, altered mental status 2

The American Heart Association recommends CPAP at 8-12 cmH₂O as first-line therapy for acute cardiogenic pulmonary edema, or BiPAP if hypercapnia is present 5
Monitor for rapid improvement in dyspnea, respiratory rate, and oxygenation within 30-60 minutes, and consider BiPAP or intubation if no improvement or worsening 5

The Infectious Diseases Society of America suggests that NIV has a limited role in pneumonia alone but may be considered in patients with underlying COPD or immunocompromise, using BiPAP with IPAP 12-16 cmH₂O, EPAP 5-8 cmH₂O 4
Recheck arterial blood gases 30-60 minutes after initiating ventilation, and monitor for auto-PEEP by performing end-expiratory hold maneuver 4

The American Thoracic Society states that NIV is generally NOT recommended for acute asthma exacerbations due to high failure rates and risk of barotrauma, and prioritizes aggressive medical management and early intubation if needed 2
If NIV is attempted, use bi-level pressure support with IPAP 8-12 cmH₂O, EPAP 3-5 cmH₂O, and backup rate 10-12 breaths/min, with a low threshold for intubation 2

The Society of Critical Care Medicine recommends CPAP 8-10 cmH₂O for atelectasis/hypoxemia, or BiPAP with IPAP 12-15 cmH₂O, EPAP 5-8 cmH₂O if hypercapnia is present 5
Monitor for improvement in oxygenation and respiratory rate within 1-2 hours, and wean CPAP/BiPAP as patient improves, typically over 24-48 hours 5

The American Association for Respiratory Care suggests that bi-level pressure support ventilators are simpler to use, cheaper, and more flexible than other types currently available, and have been used in the majority of randomized controlled trials 2
Arterial blood gases are fundamental and should be obtained before initiating ventilation, and recheck ABGs 30-60 minutes after initiating or adjusting ventilation 6, 1
Monitor respiratory rate, work of breathing, mental status, and patient-ventilator synchrony continuously, and assess for auto-PEEP with end-expiratory hold maneuver in obstructive lung disease 2, 6, 4