Noninvasive Ventilation For Acute Respiratory Failure

Publication Date: August 1, 2017
Last Updated: December 16, 2022

Treatment

COPD Exacerbation

Bilevel NIV may be considered in COPD patients with an acute exacerbation in three clinical settings:
  1. To prevent acute respiratory acidosis — i.e., when the arterial CO2 tension (PaCO2) is normal or elevated but pH is normal.
  2. To prevent endotracheal intubation and invasive mechanical ventilation in patients with mild to moderate acidosis and respiratory distress, with the aim of preventing deterioration to a point when invasive ventilation would be considered.
  3. As an alternative to invasive ventilation in patients with severe acidosis and more severe respiratory distress.
Bilevel NIV may also be used as the only method for providing ventilatory support in patients who are not candidates for or decline invasive mechanical ventilation.
We suggest NIV NOT be used in patients with hypercapnia who are not acidotic in the setting of a COPD exacerbation. (C, L)
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We recommend bilevel NIV for patients with acute respiratory failure (ARF) leading to acute or acute-on-chronic respiratory acidosis (pH ≤7.35) due to chronic obstructive pulmonary disease (COPD) exacerbation. (S, H)
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We recommend a trial of bilevel NIV in patients considered to require endotracheal intubation and mechanical ventilation, unless the patient is immediately deteriorating. (S, M)
  1. Bilevel NIV2 should be considered when the pH is ≤7.35, PaCO is >45 mmHg and the respiratory rate is >20–24 breaths/min despite standard medical therapy.
  2. Bilevel NIV remains the preferred choice for patients with COPD who develop acute respiratory acidosis during hospital admission. There is no lower limit of pH below which a trial of NIV is inappropriate. However, the lower the pH, the greater risk of failure, and patients must be very closely monitored with rapid access to endotracheal intubation and invasive ventilation if not improving.
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Cardiogenic Pulmonary Edema

We recommend either bilevel NIV or CPAP for patients with ARF due to cardiogenic pulmonary edema. (S, M)
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We suggest that CPAP or bilevel NIV be used for patients with ARF due to cardiogenic pulmonary edema in the pre-hospital setting. (C, L)
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Acute Asthma

Given the uncertainty of evidence we are unable to offer a recommendation on the use of NIV for ARF due to asthma. (, )
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Immunocompromise

We suggest early NIV for immunocompromised patients with ARF. (C, M)
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De Novo ARF

Given the uncertainty of evidence we are unable to offer a recommendation on the use of NIV for de novo ARF. (, )
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Post-Op

We suggest NIV for patients with post-operative ARF. (C, M)
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Palliative Care

We suggest offering NIV to dyspneic patients for palliation in the setting of terminal cancer or other terminal conditions. (C, M)
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Chest Trauma

We suggest NIV for chest trauma patients with ARF. (C, M)
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Pandemic Viral Illness

Given the uncertainty of evidence we are unable to offer a recommendation for the use of NIV in ARF due to pandemic viral illness. (, )
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Following Extubation

We suggest that NIV be used to prevent post-extubation respiratory failure in high-risk patients post-extubation. (C, L)
Remark: Patients with unplanned extubation are a higher risk group, and further studies are needed to address the use of NIV in this group.
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We suggest that NIV should NOT be used to prevent post-extubation respiratory failure in non-high-risk patients. (C, VL)
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We suggest that NIV should NOT be used in the treatment of patients with established post-extubation respiratory failure. (C, L)
Remark: This recommendation may not apply to post-extubation CHF or COPD patients with respiratory failure; further studies are needed.
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Weaning

We suggest NIV be used to facilitate weaning from mechanical ventilation in patients with hypercapnic respiratory failure. (C, M)
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We do not make any recommendation for hypoxemic patients. (, )
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Recommendation Grading

Overview

Title

Noninvasive Ventilation For Acute Respiratory Failure

Authoring Organizations

American Thoracic Society

European Respiratory Society

Publication Month/Year

August 1, 2017

Last Updated Month/Year

November 22, 2024

Supplemental Implementation Tools

Document Type

Guideline

External Publication Status

Published

Country of Publication

Global

Document Objectives

The purpose of the current European Respiratory Society (ERS)/American Thoracic Society (ATS) guidelines is to provide evidence-based recommendations on the application of noninvasive ventilation (NIV) in acute respiratory failure (ARF). 

PICO Questions

  1. Should NIV be used in COPD exacerbation?

  2. Should NIV be used in ARF due to a COPD exacerbation to prevent the development of respiratory acidosis?

  3. Should NIV be used in established acute hypercapnic respiratory failure due to a COPD exacerbation?

  4. Should NIV be used in ARF due to cardiogenic pulmonary oedema?

  5. Should a trial of CPAP prior to hospitalisation be used to prevent deterioration in patients with ARF due to cardiogenic pulmonary oedema?

  6. Should NIV be used in ARF due to acute asthma?

  7. Should NIV be used for ARF in immunocompromised patients?

  8. Should NIV be used in de novo ARF?

  9. Should NIV be used in ARF in the post-operative setting?

  10. Should NIV be used in patients with ARF receiving palliative care?

  11. Should NIV be used in ARF due to chest trauma?

  12. Should NIV be used in ARF due to pandemic viral illness?

  13. Should NIV be used in ARF following extubation from invasive mechanical ventilation?

  14. Should NIV be used to prevent respiratory failure post-extubation?

  15. Should NIV be used in the treatment of respiratory failure that develops post-extubation?

  16. Should NIV be used to facilitate weaning patients from invasive mechanical ventilation?

Inclusion Criteria

Male, Female, Adult, Older adult

Health Care Settings

Emergency care, Hospital

Intended Users

Nurse, nurse practitioner, physician, physician assistant, respiratory therapist

Scope

Treatment, Management

Diseases/Conditions (MeSH)

D063087 - Noninvasive Ventilation

Keywords

noninvasive ventilation, acute respiratory failure, ARF

Source Citation

Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017; 50.

The guidelines were a cooperative effort among the American Thoracic Society and the European Respiratory Society.

Supplemental Methodology Resources

Technical Review, Evidence Tables, Methodology Supplement