CHEST Postgraduate Education Corner

CONTEMPORARY REVIEWS IN CRITICAL CARE MEDICINE

Noninvasive Ventilation for Critical

Care*
Erik Garpestad, MD, FCCP; John Brennan, MD; and
Nicholas S. Hill, MD, FCCP

Noninvasive ventilation (NIV), the provision of ventilatory assistance without an artificial airway,
has emerged as an important ventilatory modality in critical care. This has been fueled by
evidence demonstrating improved outcomes in patients with respiratory failure due to COPD
exacerbations, acute cardiogenic pulmonary edema, or immunocompromised states, and when
NIV is used to facilitate extubation in COPD patients with failed spontaneous breathing trials.
Numerous other applications are supported by weaker evidence. A trial of NIV is justified in
patients with acute respiratory failure due to asthma exacerbations and postoperative states,
extubation failure, hypoxemic respiratory failure, or a do-not-intubate status. Patients must be
carefully selected according to available guidelines and clinical judgment, taking into account
risk factors for NIV failure. Patients begun on NIV should be monitored closely in an ICU or other
suitable setting until adequately stabilized, paying attention not only to vital signs and gas
exchange, but also to comfort and tolerance. Patients not having a favorable initial response to
NIV should be considered for intubation without delay. NIV is currently used in only a select
minority of patients with acute respiratory failure, but with technical advances and new evidence
on its proper application, this role is likely to further expand. (CHEST 2007; 132:711–720)

Key words: acute respiratory failure; COPD; mechanical ventilation; noninvasive ventilation

Abbreviations: ALI ⫽ acute lung injury; APACHE ⫽ acute physiology and chronic health evaluation;
CHF ⫽ congestive heart failure; CI ⫽ confidence interval; CPAP ⫽ continuous positive airway pressure;
CPE ⫽ cardiogenic pulmonary edema; DNI ⫽ do not intubate; Fio2 ⫽ fraction of inspired oxygen; NIV ⫽ noninvasive
ventilation; PEEP ⫽ positive end-expiratory pressure

O nefieldofofthemechanical
most important developments in the
ventilation over the past 15
years has been the emergence of noninvasive venti-
lation (NIV) as an increasing part of the critical care
armamentarium. Although similar techniques such
*From the Division of Pulmonary, Critical Care, and Sleep
Medicine, Tufts-New England Medical Center, Boston, MA.
Dr. Hill has received honoraria and research grants from and
served on the medical advisory boards of ResMed, Inc., and
Respironics, Inc. He has received a research grant from Ver-
samed, Inc. Drs. Garpestad and Brennan have no conflicts of
interest to disclose.
Manuscript received October 28, 2006; revision accepted March
12, 2007.
Reproduction of this article is prohibited without written permission
from the American College of Chest Physicians (www.chestjournal.
org/misc/reprints.shtml).
Correspondence to: Nicholas S. Hill, MD, FCCP, Division of
Pulmonary, Critical Care and Sleep Medicine, Tufts-New En-
gland Medical Center, 750 Washington St, Boston, MA 02111;
e-mail: nhill@tufts-nemc.org
DOI: 10.1378/chest.06-2643
as intermittent positive pressure breathing were used
widely during previous decades, unlike NIV they
were used mainly to provide intermittent aerosol
therapy. The term NIV includes other forms of
ventilatory assistance that avoid airway invasion, such
as negative pressure ventilation, but the vast majority
of NIV applications now use positive pressure. Non-
invasive application of continuous positive airway
pressure (CPAP) will be considered a form of “NIV”
here when used to treat certain types of respiratory
failure, but it is not a “true” form of ventilatory
assistance because the positive pressure does not
increase intermittently to assist inspiration.
The emergence of NIV has been fueled by its
relative ease of application compared to alternative
forms of noninvasive ventilation, as well as its dem-
onstrated ability to improve patient outcomes in
certain forms of acute respiratory failure compared
to previously standard therapy, including endotra-

www.chestjournal.org CHEST / 132 / 2 / AUGUST, 2007 711

cheal intubation.1 This update will focus on recent
developments regarding acute applications of NIV,
including the expanding evidence base, technical
advances, and assessment of current utilization. We
emphasize techniques for proper patient selection
and implementation that are critical if success rates
reported in the literature are to be duplicated.
NIV for Acute Respiratory Failure
Recommended Indications
Many applications of NIV have been tried in the
critical care setting, but as of yet, only four are
supported by multiple randomized controlled trials
and metaanalyses.
COPD Exacerbations
The strongest level of evidence, including multiple
randomized controlled trials,2–7 supports the use of
NIV to treat exacerbations of COPD. Also, meta-
analyses by Ram et al8 and Keenan et al9 demon-
strate more rapid improvements in vital signs and gas
exchange as well as reductions in the need for
intubation (relative risk, 0.41; 95% confidence inter-
val [CI], 0.33 to 0.53; risk reduction, 28%), de-
creased mortality (relative risk, 0.52; 95% CI, 0.35 to
0.76; risk reduction, 10%), and decreased hospital
length of stay (⫺ 3.24 days; 95% CI, ⫺ 4.42 to
⫺ 2.06 days and ⫺ 4.57 days, respectively). The
Cochrane analysis8 also noted more rapid improve-
ments in vital signs, pH, and gas exchange, and
reduced complication rates and hospital lengths of
stay. Based on these observations, NIV should now
be considered the ventilatory modality of first choice
to treat acute respiratory failure caused by exacerba-
tions of COPD.
Acute Cardiogenic Pulmonary Edema
Similarly strong evidence supports the use of
noninvasive positive pressure techniques to treat
acute cardiogenic pulmonary edema (CPE).10 –17 Re-
cent metaanalyses18 –20 on the use of NIV to treat
acute pulmonary edema have shown that both CPAP
and NIV lower intubation and mortality rates com-
pared to conventional therapy with oxygen, although
the reduction in mortality rate was statistically sig-
nificant only in one of the metaanalyses.20. A ran-
domized trial17 comparing CPAP directly to NIV
showed no difference in outcomes between the two
to treat CPE, a finding confirmed in a recent
metaanalysis by Ho and Wong.21 Accordingly, by
virtue of its greater simplicity and lesser expense,
CPAP has been suggested as the initial noninvasive
712
choice for acute CPE. However, some studies22 have
observed more rapid improvements in gas exchange
and vital signs with NIV than with CPAP alone, so
NIV may be preferable for patients with persisting
dyspnea or hypercapnia after initiation of CPAP.
Facilitating Extubation in COPD Patients
Another NIV application supported by multiple
randomized trials is to facilitate extubation in COPD
patients. Candidates for early extubation are those
who were intubated for COPD exacerbations be-
cause they were poor candidates for or failed NIV
initially and are unable to pass a T-piece trial even
though they have improved sufficiently to tolerate
NIV. Ferrer et al23 confirmed earlier findings of
Nava et al24 in such patients, randomizing 43 patients
with “persistent” weaning failure (failure of three
consecutive T-piece trials) to be extubated to NIV or
weaned using conventional methods. They observed
that NIV-treated patients had shorter durations of
intubation (9.5 days vs 20.1 days) and ICU (14 days
vs 25 days) and hospital stays (14.6 days vs 40.8 days),
decreased incidence of nosocomial pneumonia (24%
vs 59%), and improved ICU and 90-day survivals
(80% vs 50%) [all p ⬍ 0.05]. These studies strongly
support the use of NIV to facilitate extubation in
patients with hypercapnic respiratory failure and to
avoid the complications of prolonged intubation. But
it must be applied cautiously: only in patients who
are otherwise good candidates for NIV and were not
difficult intubations.
Immunocompromised Patients
The use of NIV is also well supported for immu-
nocompromised patients who are at high risk for
infectious complications from endotracheal intuba-
tion, such as those with hematologic malignancies,
AIDS, or following solid-organ or bone marrow
transplants. In a randomized trial25 of patients with
hypoxemic respiratory failure following solid-organ
transplantation, NIV use decreased intubation rate
(20% vs 70%, p ⫽ 0.002) and ICU mortality (20% vs
50%, p ⫽ 0.05) compared with conventional therapy
with oxygen. Hilbert et al26 observed fewer intuba-
tions (46% vs 77%) and a lower mortality rate (50%
vs 81%) [both p ⬍ 0.05] among immunocompro-
mised patients (mainly hematologic malignancies,
but some after solid-organ transplantation or with
AIDS) with acute respiratory failure randomized to
NIV as opposed to conventional therapy. The sizable
reductions in mortality in these studies strongly
support the early use of NIV as the initial ventilatory
modality in immunocompromised patients with
acute respiratory failure, although morbidity and
mortality rates are still likely to be high.
Postgraduate Education Corner
Conditions for Which NIV Should Be Considered
These applications are supported by a single ran-
domized controlled trial, historically controlled trials,
or multiple trials yielding conflicting evidence. NIV
can be tried if patients are selected and monitored
carefully.
Asthma
Several uncontrolled series27–29 and one random-
ized trial30 support the use of NIV for acute asthma.
In the randomized trial,30 a pilot, 33 patients with
acute dyspnea but not in respiratory failure were
randomized to standard therapy with nasal bilevel
ventilation for 3 h or standard therapy with sham
NIV. NIV improved expiratory flow rates more
rapidly (80% of patients had a ⬎ 50% increase in
FEV1 in the first hour, compared to only 20% in the
sham group) and reduced the need for hospitaliza-
tion.30 The authors speculated that the positive
pressure had a salutary effect on airway dilatation,
although these results have yet to be replicated. A
case report31 raised concerns about the use of NIV
for asthma, and a recent metaanalysis by Ram et al32
concluded that routine use of NIV in severe acute
asthma could not be recommended. We believe that
a cautious trial should still be considered in asthmat-
ics not responding to the first hour of conventional
therapy, but more study is warranted.
Postoperative Respiratory Failure
Either NIV or CPAP may be helpful in averting
postoperative respiratory failure by preventing atel-
ectasis and/or improving gas exchange as suggested
by three randomized controlled trials in patients
undergoing different surgical procedures. Following
thoracoabdominal aneurysm repair, prophylactic use
of CPAP reduces overall pulmonary complications.33
Squadrone et al34 compared CPAP vs conventional
oxygen therapy in patients with hypoxemic respira-
tory failure after major elective abdominal surgery.
The CPAP group had lower rates of intubation,
pneumonia, and sepsis. In the only randomized,
controlled trial of NIV in postoperative patients,
Auriant et al35 found that NIV reduced intubation
and mortality rates in patients with hypoxemic respi-
ratory failure following lung resection. These trials
indicate that either CPAP or NIV should be strongly
considered to prevent or treat postoperative respira-
tory failure, mainly after lung resection in patients
with underlying COPD or congestive heart failure
(CHF). Although multiple studies support this ap-
plication, further studies need to focus on the use of
NIV following specific surgical procedures before
firmer recommendations can be made.
www.chestjournal.org
Do-Not-Intubate Patients
Use of NIV for patients with acute respiratory
failure who have a do-not-intubate (DNI) status has
aroused debate. Concerns have been raised that the
modality might merely prolong the dying process
while mask discomfort outweighs any palliative ef-
fect.36 However, a prospective observational study by
Levy et al37 showed that patients with reversible
diagnoses such as COPD and CHF had a better-
than-even chance of surviving the hospitalization if
treated with NIV (52% and 75%, respectively),
whereas those with pneumonia or cancer had much
lower likelihoods of hospital survival. Schettino et
al38 reported similar findings in their observational
cohort and noted low success rates for NIV in
postextubation respiratory failure, hypoxemic respi-
ratory failure, and end-stage cancer.
Some have proposed resolving the conflict about
the use of NIV in DNI patients by specifying the
goals of therapy.39 Patients with reversible processes
such as COPD exacerbations or CHF may wish to
survive the acute illness and thus use NIV as a form
of life support. They are willing to endure some
discomfort to achieve this aim. Others desire pallia-
tion, aiming to alleviate dyspnea or briefly prolong
survival to settle affairs. In these latter circum-
stances, excessive mask discomfort would justify
stopping therapy because the goal of palliation is not
being met. Differentiating between and agreeing on
these aims requires close and effective communica-
tion between caregivers, patient and family.
Hypoxemic Respiratory Failure
Randomized controlled trials suggest that patients
with hypoxemic respiratory failure (ie, severe respi-
ratory distress, Pao2/fraction of inspired oxygen
(Fio2) ⬍ 200 and a non-COPD cause for respiratory
failure) benefit from use of NIV.40,41 In 105 such
patients, Ferrer et al41 found that compared to
conventional therapy, NIV reduced the intubation
rate (52 to 25%), the incidence of septic shock (31 to
12%) and ICU mortality (39 to 18%), and improved
90-day mortality (all p ⬍ 0.05). Notably, almost one
third of the patients had CPE, which would be
expected to respond favorably to NIV, but patients
with pneumonia were the ones that benefited the
most in this study.
This latter finding contrasts with earlier trials that
showed an association between pneumonia and NIV
failure42– 44 and the need for intubation in approxi-
mately two thirds of patients with pneumonia treated
initially with NIV.45 One randomized controlled
trial46 studying patients with severe community-
acquired pneumonia showed that NIV improved
outcomes including survival at 2 months but only in
CHEST / 132 / 2 / AUGUST, 2007 713
patients with underlying COPD. In one prospective
cohort study,47 risk factors for NIV failure in patients
with acute hypoxemic respiratory failure included
the diagnoses of ARDS or severe community-ac-
quired pneumonia, more severe hypoxemia (Pao2/
Fio2 ⬍ 146 after the first hour of treatment), and
age ⬎ 40 years. In another study48 of NIV to treat
hypoxemic respiratory failure, shock, severe hypox-
emia, and severe metabolic acidosis were associated
with poor outcomes. In a prospective analysis49 of
selected patients with acute lung injury (ALI)/ARDS
treated with NIV as the initial ventilator modality, a
simplified acute physiology score II ⬎ 34 and a
Pao2/Fio2 ⱕ 175 after 1 h of therapy predicted
failure. The outcome of NIV is also very poor when
used to treat hypoxemic respiratory failure in pa-
tients with idiopathic pulmonary fibrosis,48 and this
application should be discouraged.
A concern that must be stressed is that the
diagnostic category of hypoxemic respiratory failure
is very broad and benefits accruing to certain subsets
of patients within the larger diagnostic category
could obscure adverse consequences in smaller sub-
groups. Thus, with the exception of use for CPE,
which is supported by strong evidence, NIV should
be used only with caution in carefully selected
patients with hypoxemic respiratory failure, and
those at high risk for failure should be considered for
early intubation, especially if oxygenation fails to
improve substantially within the first hour or two
(Fig 1).
Extubation Failure
The use of NIV to prevent or treat extubation
failure has also raised concerns. Respiratory failure
following extubation imparts a poor prognosis; the
duration of mechanical ventilation is lengthened, the
likelihood of discharge to a chronic care facility is
increased, and mortality may reach 40%.50 Esteban
et al51 evaluated the ability of NIV to avoid extuba-
tion failure by randomizing patients to NIV or
conventional therapy if risk factors developed, in-
cluding hypercapnea, hypoxemia, acidemia, or tachy-
pnea, after a routine extubation. Surprisingly, NIV
not only failed to lower the reintubation rate com-
pared to conventional therapy (approximately 50% in
both groups) but it also increased ICU mortality.
This was thought to be related to delayed reintuba-
tions in the NIV group, an average of 10 h later than
in the conventional therapy group. The authors51
concluded that NIV is “not effective in averting the
need for reintubation in unselected patients in whom
respiratory failure develops after extubation” and
that it “may in fact be harmful.” However, only 10%
of the enrolled patients had COPD. Also, approxi-
714
mately 25% of the conventional therapy group was
crossed over to NIV when they met criteria for
respiratory failure, and only 25% of these patients
required reintubation. Thus, results of the study51 do
not apply to COPD patients and suggest that rather
than initiating NIV early in patients deemed at risk
for postextubation failure, one should wait until
there are clear indications for NIV so that appropri-
ate patients can be selected.
Two subsequent trials support these latter infer-
ences. Ferrer et al52 identified patients at risk for
postextubation failure by virtue of age ⱖ 65 years, a
history of CHF, or an APACHE (acute physiology
and chronic health evaluation) II score ⱖ 12. Al-
though postextubation respiratory failure and need
for intubation were significantly reduced by NIV
overall, most of the benefit was attributable to the
hypercapnic subgroup, amounting to about one third
of the patients, who also had a significantly lower
mortality rate than control subjects (4% vs 41%,
p ⬍ 0.05). Nava et al53 used NIV in patients at “high
risk” for extubation failure, using criteria similar to
those of Esteban et al,51 but risk was higher because
patients had to have failed at least one T-piece trial.
Once again, the need for reintubation (8% vs 18%,
p ⫽ 0.027) was reduced compared to the conven-
tional therapy group. Also, ICU mortality was 10%
less in the NIV group (p ⬍ 0.01) mediated by the
reduced need for reintubation. Thus, a trial of NIV
appears to be warranted in patients at high risk for
extubation failure, particularly if they have hypercap-
nic respiratory failure.
Selection of Patients for NIV
Selection of appropriate patients is crucial for the
optimization of NIV success rates and resource
utilization. Often, NIV must be started before labo-
ratory data are available because patients may dete-
riorate during the delay and increase the risk of NIV
failure. As depicted in Figure 1, patients with respi-
ratory distress and an appropriate diagnosis should
be considered for NIV. At the bedside, the clinician
must make two fundamental judgments: (1) whether
the patient needs ventilatory assistance based on
symptoms and signs of increased work of breathing
or arterial blood gas derangements, and (2) whether
such patients are candidates for NIV or should be
promptly intubated. These determinations are key to
the appropriate application and outcome of NIV and
are based on the diagnosis, bedside observations, the
clinician’s experience, and consideration of available
guidelines (Table 1). The timing of NIV initiation is
important too. NIV should be started early, as soon
Postgraduate Education Corner
 Figure 1. Algorithm illustrating the principles of patient selection and practical application of NIV.
Patients are started on NIV if respiratory distress develops in the setting of de novo or acute-on-chronic
respiratory failure, or following surgery or extubation. They should have an appropriate diagnosis and
meet guidelines demonstrating the need for ventilatory assistance and absence of contraindications.
After starting NIV, they should be closely monitored and checked at 1 to 2 h to establish that they are
responding favorably. If they have ALI/ARDS and are not good candidates, have contraindications or
fail the 1- to 2-h checkpoint, they should be intubated unless they have a DNI status, in which case
some patients might still benefit from palliation of respiratory distress. NIV to facilitate weaning should
be considered for intubated patients. Patients who respond favorably to NIV should be monitored
closely and reassessed periodically to determine whether they are ready to attempt weaning, which is
usually accomplished by temporary discontinuation. If they have persisting respiratory failure after
temporary discontinuation, long-term nocturnal NIV should be considered.

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 Table 1—Selection Guidelines for NIV in the
Acute Setting
Appropriate diagnosis with potential reversibility
Establish need for ventilatory assistance
Moderate-to-severe respiratory distress and
Tachypnea (respiratory rate ⬎ 24/min for COPD, ⬎ 30/min for
CHF); accessory muscle use or abdominal paradox
Blood gas derangement (pH ⬍ 7.35, Paco2 ⬎ 45 mm Hg, or
Pao2/Fio2 ⬍ 200)
Exclude patients with contraindications to NIV
Respiratory or cardiac arrest
Medical instability (hypotensive shock, myocardial infarction
requiring intervention, uncontrolled ischemia or arrhythmias)
Unable to protect airway
Unable to fit mask
Untreated pneumothorax
Recent upper airway or esophageal surgery
Excessive secretions*
Uncooperative or agitated*
*Relative contraindications.
as indications appear, because delay may permit
further deterioration and increase the likelihood of
failure.54
Coma has been considered a contraindication to
NIV in the past, but in a prospective cohort study,
Gonzalez Diaz et al55 observed a high success rate of
NIV in patients with hypercapnic coma. Also, Scala
et al56 showed in a case study that NIV may be
successfully used in COPD patients with acute re-
spiratory failure and altered consciousness, although
more severely impaired consciousness was associated
with higher failure rates.
Predictors of NIV success or failure may also be
helpful in selecting patients (Table 2). The best
predictor of success is a favorable response to NIV
within the first 2 h. In a prospective cohort study of
nearly 800 COPD patients treated with NIV, Con-
falonieri et al57 identified four factors—APACHE II
score, pH, respiratory rate, and Glasgow coma
score—that, when combined in a chart, showed good
predictive value at baseline. These factors had even
better predictive value after 2 h of NIV use; if all four
factors were favorable, the chance of success was
97%; whereas if all were unfavorable, failure was a
virtual certainty (99%).
Antonelli et al47 made similar observations in
patients with hypoxemic respiratory failure: if Pao2/
Fio2 failed to increase ⬎ 146 after the first hour of
NIV therapy, or if the patient had pneumonia and
ARDS, the risk of NIV failure was increased. These
observations, combined with those of Esteban et al,51
demonstrating worse outcomes in NIV-treated pa-
tients having delayed reintubations, emphasize the
importance of carefully reassessing patients soon
after NIV initiation (1- to 2-h checkpoint as depicted
in Fig 1). If they fail to improve sufficiently, they
716
Table 2—Factors Associated With NIV Success in the
Acute Setting
Synchronous breathing with ventilator
Dentate
Less air leaking
Fewer secretions
Good tolerance
Respiratory rate ⬍ 30/min*
Lower APACHE II score (⬍ 29)*
pH ⬎ 7.30*
Glasgow coma score 15*
Pao2/Fio2 ⬎ 146 after first hour if hypoxemic respiratory failure
COPD, CPE
No pneumonia, ARDS
Best predictor of success is a good response to NPPV within 1 to
2 h:
Reduction in respiratory rate
Improvement in pH
Improvement in oxygenation
Reduction in Paco2
*If all four are present in COPD patients at baseline, the likelihood
of success is 94%; if present after 2 h of therapy, the likelihood of
success is 97%.46
should be promptly intubated because a delay in
needed intubation permits the development of a
respiratory crisis, requiring emergent intubation and
increasing the likelihood of morbidity or mortality.
Advances in Technology
Interfaces
A well-fitting and comfortable interface (or mask)
is crucial to the success of noninvasive ventilation.
Although nasal masks have certain advantages over
oronasal (or full face) masks including greater com-
fort, less likelihood of causing claustrophobia, and
easier speech and expectoration, they also permit
more air leakage through the mouth and have been
associated with a higher rate of initial intolerance
during acute applications of NIV.58 Thus, oronasal
masks are preferred initially for most critical care
applications, although a nasal mask should still be
considered for patients with claustrophobia or fre-
quent expectoration or for long-term applications.
Other mask types that are receiving attention
include the Total Face Mask (Respironics; Murrys-
ville, PA), which seals around the perimeter of the
face and may enhance mask tolerance in some
patients, and the helmet, which has not yet been
approved by the Food and Drug Administration for
NIV in the United States but has been investigated
in Europe.59,60 The latter device consists of a plastic
cylinder that fits over the head and seals around the
neck and shoulders. Compared to the full face mask
in a case-control study61 of NIV to treat COPD
Postgraduate Education Corner
patients with acute respiratory failure, the helmet
achieved similar improvements in vital signs, equiv-
alent intubation and mortality rates and caused fewer
complications, but Paco2 tended to be higher at the
end of the treatment period despite a higher level of
pressure support. Also, noise levels within the hel-
met may be as high as 100 decibels, compared to 70
decibels with a full-face mask.62 Thus, although the
helmet has some advantages over the full face mask
with regard to comfort and complications, it has
other disadvantages including less efficient CO2
removal and noisiness that limit its current utility.
Dead Space and Rebreathing
By virtue of its single-ventilator-circuit design,
bilevel ventilation has raised concerns about re-
breathing.63 A lung model study64 demonstrated that
masks with smaller volumes were associated with less
rebreathing and an in-mask exhalation port mini-
mized rebreathing compared to an in-line port.
Another lung model study65 used a mannequin face
to demonstrate that an in-mask exhalation port over
the bridge of the nose minimized dynamic dead
space, sometimes to levels below physiologic, pre-
sumably by flushing CO2 from the nose and mouth.
The correlation between dynamic dead space and
actual mask volume was poor, probably because of
air streaming, and dead space was also minimized if
positive expiratory pressure flushed CO2 from the
ventilator tubing. Whether these differences in dead
space and rebreathing are clinically important re-
mains unclear, but these studies support the use of
in-mask exhalation ports and positive expiratory
pressure during bilevel ventilation.
Ventilators
NIV is usually delivered either by blower-based
portable positive pressure “bilevel” ventilators de-
rived from home-based CPAP systems or “critical
care” ventilators designed to deliver invasive me-
chanical ventilation. No study has shown better NIV
success rates for one type of ventilator than the
other, but the ventilator mode used and specific
settings are important for patient comfort and de-
creased work of breathing. Pressure support ventila-
tion is rated as more tolerable by patients than
assist-control modes,66 and some studies67– 69 have
demonstrated greater comfort with proportional as-
sist ventilation than with pressure support, presum-
ably because it is targeted to inspiratory flow as a
surrogate of patient effort and can respond nearly
instantaneously to changes in demand. Proportional-
assist ventilation has only recently been approved by
the Food and Drug Administration, but it has been
available elsewhere in the world for almost a decade.
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The perceived need for multiple adjustments to
compensate for patient elastance and resistance as
well as added cost have probably limited greater use
of this mode despite the finding in one of the
controlled trials that proportional assist required
fewer adjustments than pressure support.68
Other desirable attributes of ventilators for NIV
include the ability to compensate for air leaks, which
helps to assure delivery of adequate tidal volumes.70
Because NIV lowers humidity of delivered gas,
humidification is useful to bring relative humidity
back toward the ambient range, possibly enhancing
comfort.71 Heated passover humidifiers have mini-
mal effects on delivered pressures, whereas heat and
moisture exchangers are to be avoided because they
can interfere with the ability of NIV to reduce work
of breathing.72
Ventilator Settings
L’Her et al73 showed that patients with acute lung
injury treated with NIV require pressure support
levels of at least 10 to 15 cm H2O to reduce work of
breathing. Not surprisingly, higher levels of positive
end-expiratory pressure (PEEP) [10 cm H2O vs 5 cm
H2O] were more effective at improving oxygenation.
Combining higher levels of pressure support with
high-level PEEP can detract from patient comfort,
however, so compromises may be necessary to opti-
mize settings; maximal oxygenation may have to be
sacrificed if patient comfort and reduction in work of
breathing are prioritized. Many noninvasive ventila-
tors now offer adjustable “rise times” or pressuriza-
tion rates—the time taken to achieve the target
inspiratory pressure— to optimize patient comfort.
Prinianakis et al74 found that a rapid pressurization
rate was most effective at reducing work of breathing
in COPD patients, but a slightly slower rate was
associated with better comfort ratings.
Guidelines, Utilization, and Outcomes
Sinuff et al75 found that a NIV guideline influ-
enced caregiver behavior, leading to greater ICU
utilization and more ordering of pulmonary consul-
tations and arterial blood gases. However, overall
mortality rate was unchanged and, of concern, the
mortality rate actually increased in patients without
COPD or CHF as the cause of their acute respira-
tory failure, who were excluded from NIV use by the
guideline. The results highlight the need for ongoing
guideline evaluation and modification because they
could increase resource utilization and the cost of
care if they mandate ICU use and frequent labora-
tory testing among all NIV patients, some of whom
could conceivably be managed in less costly environ-
ments.
CHEST / 132 / 2 / AUGUST, 2007 717
 Studies of NIV utilization in the acute care setting
have found that enormous disparity exists between
different institutions. In a 1997 survey of NIV use in
European ICUs, Carlucci et al76 found that 20% of
ICUs surveyed used no NIV at all and, overall, NIV
was used in 16% of all ventilator starts. A subsequent
UK survey77 found that 52% of hospitals were not
using NIV. A more recent survey78 in the United
States found that although only 1 of 71 responding
hospitals used no NIV, some used it in ⬍ 5% of
ventilator starts and others in ⬎ 50%. Overall aver-
age use among ventilator starts was 20%, but only a
third of patients with COPD or CHF received NIV
as their initial ventilator therapy. Major reasons for
not using NIV more were lack of physician knowl-
edge and inadequately trained staff, suggesting that
education may help to enhance utilization. However,
progress is being made, as indicated by Demoule et
al,79 who found that the overall percentage for NIV
among ventilator starts in European ICUs had risen
to 23% by 2002; and Girou et al,80 who showed that
increasing use of NIV in CHF and COPD patients
(from approximately 20 to 90% of ventilator starts)
over a 7-year period in a French ICU was associated
with a decrease in the rate of nosocomial pneumo-
nias from 20 to 8% and in ICU mortality rate from 21
to 7% (all p ⬍ 0.05). The latter study80 also illustrates
the value of increasing experience using NIV after
establishing an NIV program.
Conclusion
The role of NIV in the management of acute
respiratory failure has been further clarified in re-
cent years. Evidence is strong to support the use of
NIV in the initial management of acute respiratory
failure in patients with COPD exacerbations, acute
CPE, and immunocompromised states, and to facil-
itate extubation in patients with COPD with failed
spontaneous breathing trials. A trial of NIV is justi-
fied in patients with asthma exacerbations, postop-
erative respiratory failure, extubation failure, hypox-
emic respiratory failure or a DNI status, but because
supporting evidence is not as strong, they should be
carefully selected according to available guidelines
and clinical judgment, taking into account risk fac-
tors for NIV failure. Once begun, patients should be
closely monitored in an ICU or step-down unit until
adequately stabilized, paying attention not only to
vital signs and gas exchange, but also to comfort and
tolerance. If patients do not have a favorable initial
response to NIV, clinicians should strongly consider
intubation without delay. When used appropriately,
NIV improves patient outcomes and the efficiency of
care. Although it is still used in only a select minority
718
of patients with acute respiratory failure, it has
assumed an important role in the therapeutic arma-
mentarium. With technical advances and new evi-
dence on its proper application, this role is likely to
expand.
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