Prehospital Emergency Care

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Prehospital Noninvasive Ventilation: An NAEMSP

Position Statement and Resource Document

Andrew M. McCoy, Dylan Morris, Kaori Tanaka, Angela Wright, Francis X.

Guyette & Christian Martin-Gill

To cite this article: Andrew M. McCoy, Dylan Morris, Kaori Tanaka, Angela Wright, Francis
X. Guyette & Christian Martin-Gill (2022) Prehospital Noninvasive Ventilation: An NAEMSP
Position Statement and Resource Document, Prehospital Emergency Care, 26:sup1, 80-87, DOI:
10.1080/10903127.2021.1993392

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PREHOSPITAL NONINVASIVE VENTILATION: AN NAEMSP POSITION STATEMENT
AND RESOURCE DOCUMENT
Andrew M. McCoy, Dylan Morris, Kaori Tanaka, Angela Wright, Francis X. Guyette
Christian Martin-Gill
ABSTRACT
Noninvasive ventilation (NIV), including bilevel positive
airway pressure and continuous positive airway pressure,
is a safe and important therapeutic option in the manage-
ment of prehospital respiratory distress.
NAEMSP recommends:
 NIV should be used in the management of pre-
hospital patients with respiratory failure, such as
those with chronic obstructive pulmonary dis-
ease, asthma, and pulmonary edema.
 NIV is a safe intervention for use by Emergency
Medical Technicians.
 Medical directors must assure adequate training
in NIV, including appropriate patient selection,
NIV system operation, administration of adjunct-
ive medications, and assessment of clin-
ical response.
 Medical directors must implement quality assess-
ment and improvement programs to assure opti-
mal application of and outcomes from NIV.
 Novel NIV methods such as high-flow nasal can-
nula and helmet ventilation may have a role in
prehospital care.
Key words: noninvasive ventilation; prehospital; CPAP;
BiPAP; NIPPV
PREHOSPITAL EMERGENCY CARE 2022;26:80–87
Received September 11, 2021 from University of Washington,
Department of Emergency Medicine, Seattle, Washington (AMM);
University of Pittsburgh, Department of Emergency Medicine,
Pittsburgh, Pennsylvania (DM, CM-G); University of Buffalo,
Department of Emergency Medicine, Buffalo, New York (KT);
University of Colorado, Department of Emergency Medicine,
Aurora, Colorado (AW, FXG). Revision received October 10,
2021; accepted for publication October 10, 2021.
Address correspondence to Andrew M. McCoy
mccoya2@uw.edu
ß 2021 The Author(s). Published with license by Taylor &
Francis Group, LLC.
This is an Open Access article distributed under the terms of the
Creative Commons Attribution-NonCommercial-NoDerivatives
License (http://creativecommons.org/licenses/by-nc-nd/4.0/),
which permits non-commercial re-use, distribution, and
reproduction in any medium, provided the original work is
properly cited, and is not altered, transformed, or built upon in
any way.
doi:10.1080/10903127.2021.1993392
, and
INTRODUCTION
Noninvasive ventilation (NIV) is a form of mech-
anical ventilatory support delivered through a face
or nasal mask, without the use of an endotracheal
tube, laryngeal tube, or other invasive airway device
(1). NIV is a widely used method of supporting res-
piration that has been used by advanced life sup-
port (ALS) personnel in the prehospital setting for
over two decades (2). More recently, following the
addition of NIV at the Emergency Medical
Technician (EMT) level in the 2019 National EMS
Scope of Practice Model, basic life support (BLS)
EMS systems are increasingly incorporating use of
NIV (3). Methods of delivering NIV include continu-
ous positive airway pressure (CPAP) and bilevel
positive airway pressure (BiPAP) ventilation. Novel
devices for the delivery of NIV, such as high-flow
nasal cannula (HFNC) and positive pressure hel-
mets, are evolving but less proven methods of NIV
being used in the prehospital setting. This resource
document reviews the rationale and data supporting
the use of NIV in the prehospital setting.
METHODS
To inform this position statement and resource
document, we performed a structured rapid review
of the literature relevant to the use of NIV. Rapid
reviews serve as a streamlined approach to synthe-
size evidence based on the principles of a systematic
review of the literature, simplified to produce infor-
mation in a timely manner (4). We searched
PubMed (via National Library of Medicine) using
EndNote X9.3.3 (Clarivate, Inc., Philadelphia, PA)
at for articles published before June 2021. The key-
words and search strategy are described in Table 1.
The search strategy first identified published litera-
ture containing terms relevant to noninvasive venti-
lation, including variations of CPAP and BiPAP
ventilation. These publications were then restricted
to those containing terms relevant to emergency
medical services (EMS), including prehospital and
transport medicine. Non-English publications were
excluded. The strategy identified 391 articles avail-
able for screening. We reviewed titles and abstracts
for articles relevant to the use of NIV in the EMS
80
A. M. McCoy et al. NAEMSP POSITION STATEMENT AND
TABLE 1. Search terms and strategy of rapid
literature review.
# Search Terms (All Fields)
1 nippv OR ‘noninvasive ventilation’ OR
‘noninvasive ventilation’ OR
‘noninvasive positive pressure’ OR
‘noninvasive positive pressure’ OR
‘noninvasive positive-pressure’ OR
‘noninvasive positive-pressure’ OR
‘noninvasive pressure support’ OR
‘noninvasive pressure support’
2 cpap or ‘continuous positive
airway pressure’
3 bipap OR ‘bilevel positive airway pressure’
OR ‘bilevel positive pressure’ OR ‘bilevel
noninvasive ventilation’ OR ‘bilevel
noninvasive ventilation’ OR ‘bi-level
positive airway pressure’ OR ‘bi-level
positive pressure’ OR ‘bi-level
noninvasive ventilation’ OR ‘bi-level
noninvasive ventilation’
4 #1 OR #2 OR #3
5 #4 AND [‘emergency medical service’ OR
‘emergency health service’ OR
prehospital OR pre-hospital OR out-of-
hospital OR ambulance]
6 #4 AND [emt OR ‘emergency medical
technician’ OR ‘paramedic’]
7 #4 AND [‘air medical’ OR ‘air medicine’
OR aeromedicine OR aeromedical OR
‘aero medicine’ OR ‘aero medical’]
8 #4 AND [interfacility OR ‘inter-facility‘ OR
interhospital OR ‘inter-hospital’]
9 #5 OR #6 OR #7 OR #8
10 #9 AND [English]
setting, resulting in 125 articles retained for consid-
eration by all authors to inform this position state-
ment and resource document on prehospital NIV
use. Additional publications were identified by the
authors, including through bibliography searches.
SAFETY AND EFFICACY OF PREHOSPITAL
NONINVASIVE VENTILATION
NIV should be used in the management
of prehospital patients with respiratory
failure, such as those with chronic
obstructive pulmonary disease, asthma,
and pulmonary edema.
Both hypoxic and hypercarbic respiratory failure
are worsened by collapse of small airways. Positive
airway pressure ventilation stents open these air-
ways, allowing for better delivery of oxygen and
more gas exchange to occur. Positive pressure
RESOURCE DOCUMENT 81
maintained throughout the respiratory cycle allows
small airways and alveoli to stay open, of particular
Articles
benefit to patients with obstructive diseases that
compromise exhalation and are characterized by
8,492 CO2 retention (5). Additionally, it has been postu-
lated that positive pressure ventilation provides
hydrostatic pressure that can assist with moving
fluid out of the alveoli (6), a beneficial effect in the
treatment of patients with pulmonary edema. These
beneficial effects of positive pressure ventilation
15,333
make chronic obstructive pulmonary disease,
asthma, and pulmonary edema the most common
1,210 targets for NIV use. In addition, for each of these
conditions NIV decreases the work of breathing,
providing needed support for patients in decompen-
sated respiratory failure. NIV may also be beneficial
for augmenting oxygenation prior to endotracheal
intubation, though this has not been studied in the
prehospital setting (7).
23,064
Of concern in the use of NIV is that excess intra-
360
thoracic pressure can decrease cardiac filling and
preload, subsequently decreasing cardiac output.
This is of particular concern in patients with cardio-
102 genic or hypovolemic shock where NIV use should
12
be considered with caution. Additionally, positive
pressure ventilation may exacerbate a pneumo-
thorax or pneumomediastinum, examples of relative
20 contraindications to its use.
Multiple studies have investigated the use of NIV
441
391 in the emergency department and intensive care
unit settings, demonstrating patient-centered out-
come benefits, including lower rates of intubation
and decreases in mortality compared to conven-
tional oxygen therapy (8–10). Following this experi-
ence, NIV was adapted to the prehospital setting for
use by ALS personnel and supported in its early
implementation primarily by observational studies
establishing its safe use in prehospital
patients (11–15).
An early quasi-randomized prospective trail of
BiPAP use for prehospital patients with presumed
congestive heart failure demonstrated improved
oxygen saturation in the BiPAP versus standard
care group (11). Though the study did not find a
difference in hospital length of stay, intubation rate,
or mortality, the authors commented on the EMS
personnel’s perceived safety of using BiPAP in pre-
hospital patients, with 97% reporting it was easy to
use and appeared to improve patients' dyspnea and
respiratory distress. A subsequent prospective RCT
that compared the use of prehospital CPAP for
acute respiratory failure versus standard care dem-
onstrated a 30% decrease in intubation and 21%
decrease in mortality for the CPAP group (16).
While small in enrollment, this study demonstrated
82
a large effect size and clinical impact of prehospital
CPAP use.
Supporting these studies from the United States
are several RCTs from other countries demonstrat-
ing the safety and improved outcomes for prehospi-
tal patients receiving NIV. In a physician-staffed
French EMS system, prehospital patients with car-
diogenic pulmonary edema randomized to CPAP,
compared to usual medical care, experienced
improvements in a dyspnea clinical score and in
arterial blood gas measurements (17). Patients also
experienced a reduced incidence of endotracheal
intubation and in-hospital mortality. Similarly,
another study of patients with cardiogenic pulmon-
ary edema randomized to CPAP in addition to
standard care versus standard care alone had
improvement in a composite endpoint that included
death, presence of intubation criteria, and persist-
ence of respiratory distress criteria (18). These and
other studies were summarized in a systematic
review and meta-analysis of 10 randomized or
quasi-randomized studies that found that CPAP
reduced both mortality and intubation rate com-
pared to standard care (19). A smaller systematic
review of five randomized and non-randomized
comparative studies found a similar effect with
reductions in the number of intubations and mortal-
ity in patients treated with prehospital CPAP (20).
The most recently published RCT found in our
review was from an Australian EMS system with
paramedics of similar practice capability to U.S.
ALS-level care, where 708 prehospital patients with
acute respiratory distress were randomized to
receive CPAP and usual care versus usual care
alone (21). While this study did not demonstrate a
difference in mortality or hospital length of stay,
CPAP was associated with a greater decrease in
dyspnea scores and respiratory rate.
The two primary delivery modalities for administer-
ing CPAP or BiPAP are through a venturi blended air
system powered by pressurized oxygen or by a tur-
bine-driven battery-powered ventilator. No prehospi-
tal studies were identified in our literature review that
have compared pressurized air versus turbine ventila-
tor systems head-to-head; however, many EMS sys-
tems have adopted pressurized air systems as they
are simpler and generally lower priced. Because of the
mechanics of these devices, they require large
amounts of pressurized oxygen to maintain ventilator
pressure, which can limit the length of time they can
be used (22). The masks are also difficult to use in
patients with facial hair, edentulous patients, or other
craniofacial abnormalities that limit the ability for
appropriate mask fitting. Additionally, not all masks
and devices are created equally. Brusasco et al.
PREHOSPITAL EMERGENCY CARE JANUARY 2022 VOLUME 26 / NUMBER S1
evaluated two different devices and found that many
kits were unable to deliver all necessary features, such
as delivering the maximal air-flow output (23). When
selecting an NIV system, and EMS agency and med-
ical director should consider the anticipated pressures
and FiO2 that are intended to be used, the availability
of oxygen in the transport vehicle, and the financial
costs of both the device and accessories (23).
The selection of CPAP vs BiPAP in the prehospi-
tal environment has not been sufficiently studied.
However, in some retrospective reviews, both have
been shown to be feasible and have potentially
improved patient outcomes (24). While the majority
of studies focus on CPAP, there are some that also
examine BiPAP and have similar conclusions
regarding safety and feasibility (11,24–26). The
above cited literature suggests that, when applied to
the appropriate patient population (primarily CHF
and COPD), CPAP and BiPAP can improve most
objective markers of respiratory distress (SpO2
measurements, respiratory rate, and work of breath-
ing), and can also improve clinical outcomes such as
need for subsequent intubation and overall mortal-
ity. The majority of studies are small (most less than
100 patients enrolled), and many demonstrate a
neutral outcome when focusing on major clinical
endpoints such as decreased intubation rates and
mortality. However, a meta-analysis suggests posi-
tive outcomes in many endpoints, including rates of
endotracheal intubation, hospital and intensive care
unit length of stay, and vital signs with the preho-
spital administration of NIV, making it an important
branch of the prehospital treatment algorithm for
respiratory distress and failure (27). Additional
investigation would be beneficial to exploring the
differential use of CPAP versus BiPAP in the preho-
spital setting.
In aggregate, the existing literature, consisting of
both observational and multiple randomized con-
trolled trials, has established the safety and efficacy
of using NIV in the prehospital setting for the man-
agement of patients with acute severe dyspnea. No
evidence exists to make a recommendation regard-
ing CPAP versus BiPAP, or pressurized oxygen ver-
sus turbine-driven battery-powered ventilators in
the prehospital setting.
USE OF NIV BY BLS PERSONNEL
NIV is a safe intervention for use by
Emergency Medical Technicians.
Improvement in patient outcomes and the relative
simplicity of administering noninvasive ventilation
through a simple mask interface has led to the
A. M. McCoy et al. NAEMSP POSITION STATEMENT AND RESOURCE DOCUMENT
transition of NIV from an ALS to a BLS skill in
many EMS systems. Without the availability of NIV,
BLS personnel otherwise have limited treatment
options to assist ventilation and oxygenation other
than supplemental oxygen unless the patient
reaches extremis, at which point manual ventilation
with a bag-valve-mask is performed.
Wisconsin was the first of several states to exam-
ine this issue (28). State officials developed a train-
ing program and subsequently implemented a pilot
study in 2005 involving BLS use of CPAP. The pri-
mary question was to determine if patients who
received CPAP by BLS personnel would suffer
greater complications than those given CPAP by
ALS personnel. After a year of study, the investiga-
tors found no difference in rate of administration or
complications of CPAP between levels and noted a
reduction in the need for ALS intervention in these
patients. In several instances, the patients had
improved significantly and did not require ALS
assistance, thus freeing up ALS resources for other
critical calls. This study resulted in Wisconsin
becoming the first state in the country to add CPAP
to the BLS scope of practice.
Cheskes et al. similarly studied the feasibility of
prehospital CPAP use by paramedics trained to the
primary care (PCP) level as compared to the
advanced care (ACP) level in Ontario, Canada (29).
For reference, a PCP possesses training similar to an
Advanced EMT in the United States, while an ACP
is similar to the U.S. paramedic scope of practice.
Training for these providers in CPAP techniques
involved 6 hours of didactic, scenario-based training
and evaluation. This retrospective observational
study was performed in two regions in the province
of Ontario over a 1-year period. The authors defined
compliance as 100% adherence to the Ontario pro-
vincial medical directive, which included specifics
of patient presentation, vital signs, and appropriate
documentation by the paramedic. A total of 302
cases of CPAP use were included in the study, 212
cases by ACP and 90 cases by PCP. The study iden-
tified similar rates of documentation and protocol
compliance among these personnel. The authors
concluded that CPAP use by PCP-level paramedics
may be feasible, but that further studies were
needed to determine whether compliance could
translate into safety.
We identified only one study that focused on the
safety of prehospital use of CPAP by BLS personnel.
Sahu et al. performed a retrospective observational
study over a 3-year period from 2009 to 2012 of the
Delaware BLS CPAP pilot program (30). Providers
at included agencies received 4 hours of training;
2 hours didactic and 2 hours hands on as part of this
83
pilot program. In Delaware, BLS personnel arrived
on-scene 4 minutes prior to ALS personnel for
“respiratory distress” calls 60% of the time, demon-
strating an opportunity to initiate early CPAP at the
BLS level. The authors aimed to determine whether
BLS personnel could appropriately identify patients
who would benefit from CPAP, apply the device,
and monitor the patient prior to ALS arrival.
During the study period, 74 patients had CPAP
applied by BLS personnel and CPAP was correctly
indicated and applied for 100% of the patients.
CPAP was appropriately monitored, and respiratory
status appropriately managed, for 98.6% of the
patients. Of the 74 patients, 89.2% showed overall
improvement after CPAP administration, with 6.8%
unchanged, and only 4.1% worsening. Overall, there
was an 84% reduction in the proportion of patients
with SpO2 values <92%, a 55% reduction in patients
experiencing respiratory rates >24 breaths per
minute, and a 58% reduction in cyanosis; all of
which were statistically significant. This study con-
cluded that with appropriate training, quality
review, and medical oversight, CPAP can be safely
used by BLS personnel.
In July 2014, the National Association of State
EMS Officials conducted a survey revealing 14
states used CPAP at the BLS level (30). The
National EMS Information Systems was also queried
at that time and identified that 25 out of 50 US states
and territories were using CPAP at the BLS level. In
2019, the National EMS Scope of Practice Model
added NIV (both CPAP and BiPAP) to the EMT
level (3). Soon after, the national EMS education
standards were updated to include NIV for EMTs
(31). While there is no randomized controlled trial
data available for BLS NIV, we feel that the limited
observational data and widespread adoption sup-
ports safety of NIV at the BLS level.
OVERSIGHT OF NONINVASIVE
VENTILATION USE
Medical directors must assure adequate
training in NIV, including appropriate
patient selection, NIV system operation,
administration of adjunctive medications,
and assessment of clinical response.
Training clinicians for NIV use must address the
pathophysiology of various conditions resulting in
respiratory failure, appropriately identifying
patients who might benefit from NIV and where its
use may be contraindicated, and how to successfully
operate prehospital NIV systems. It is essential for
84
medical directors to ensure adequate initial and con-
tinual education and training is provided to obtain
and retain these skills. Protocols must identify clear
indications and contraindications for the use of NIV
to ensure it is not used in inappropriate circumstan-
ces (e.g., unresponsive patients) where adverse
events such as aspiration may occur. EMS medical
directors must participate in continuous quality
improvement activities regularly. The broader prin-
ciples of airway management training and education
are addressed elsewhere in this compendium (32).
PREHOSPITAL NIV AND QUALITY
IMPROVEMENT
Medical directors must implement quality
assessment and improvement programs to
assure optimal application of and
outcomes from NIV.
Prehospital NIV requires a robust quality manage-
ment program to ensure that use improves patient-
centered outcomes and does not have unacceptable
unintended consequences. Quality improvement
processes for NIV use should focus on informing
the medical director of the effectiveness of NIV
within the specific service and device, as imple-
mented by EMS personnel for their specific patient
population. Subsequent observations should guide
future training and skill maintenance. A comprehen-
sive treatment of quality improvement in prehospi-
tal airway programs is discussed by Vithalani et al.
in this compendium (33).
PREHOSPITAL NIV AND NOVEL
DELIVERY METHODS
Novel NIV methods such as high-flow
nasal cannula and helmet ventilation may
have a role in prehospital care.
High flow nasal cannula (HFNC), sometimes
termed high flow nasal oxygen, and helmet NIV
and are two newer technologies that have demon-
strated patient-oriented benefit for oxygenating and
ventilating hospitalized patients. NIV delivered by
helmet uses a collapsible clear bubble placed over
the head and secured to a flexible collar that seals
around the patient’s neck and is secured below the
axilla. Several manufacturers produce such devices,
which can be used either by Venturi-method
blended air or turbine-driven ventilators (23).
PREHOSPITAL EMERGENCY CARE JANUARY 2022 VOLUME 26 / NUMBER S1
HFNC is a technique that uses a large-bore nasal
cannula to deliver heated and humidified oxygen at
high flow rates and adjustable FiO2. In pediatrics, 1-
2 liters per kilogram per minute of flow are consid-
ered HFNC (34), whereas in adults, 15-60 liters per
minute is typical (35,36). The primary benefits of
HFNC are improved oxygenation and decreased
work of breathing. Though the exact mechanisms of
action are not fully understood, it appears that
HFNC provides consistent FiO2 regardless of tidal
volume, decreases physiologic dead space via upper
airway washout, provides a small amount of PEEP,
and may improve mucociliary clearance compared
to traditional strategies through reduced desiccation
of mucus (35,36).
Low-quality evidence in hospitalized infants and
children suggests that HFNC may reduce the need
for mask NIV or intubation for a variety of pulmon-
ary conditions (34). HFNC uptake in adults has
increased in the past decade, primarily as result of
the FLORALI trial (37) and more recently, COVID-
19 (38–40). Adult HFNC has demonstrated benefit
to patients with hypoxic respiratory failure based on
in-hospital studies (35,36). However, very few out-
of-hospital studies have been published on HFNC,
and none involve adults. Several observational stud-
ies have been published of pediatric patients receiv-
ing HFNC during interhospital transport by
specialist teams (41–45). These studies report HFNC
can be used safely in the transport environment and
its use has been associated with less need for intub-
ation or other methods of noninvasive ventilation.
No significant complications of HFNC use have
been reported in this environment.
HFNC requires specific commercial devices for
heating and humidification that may present oper-
ational challenges for the transport environment
and must be connected to a turbine driven air
blender or ventilator. These requirements likely
limit HFNC to specialized teams performing primar-
ily interfacility transports. Further, high flow rates
and oxygen consumption limit the range adult
patients can be transported on HFNC. Oxygen con-
sumption calculations and proper arrangements
should be undertaken in advance of mission accept-
ance. The lower flow rates and oxygen consumption
used in pediatrics versus adults makes use of out-
of-hospital HFNC more practical in children.
Helmet NIV offers several advantages over face
mask NIV or HFNC. First, the neck gasket is not
vulnerable to facial hair or atypical facial anatomy.
Some devices have universal neck gaskets that can
be trimmed to fit all patients; therefore, multiple
mask sizes are not need. Second, patients appear to
tolerate helmet NIV better than face masks (46).
A. M. McCoy et al. NAEMSP POSITION STATEMENT AND RESOURCE DOCUMENT
Third, helmet devices are less susceptible to air leak
at high PEEP (46–48).
However, helmet NIV has several potential limita-
tions in the out-of-hospital environment. The add-
itional dead space of the helmet requires flow rates
greater than 60 liters per minute to prevent
rebreathing (23,46). Such high flow rates and oxygen
consumption will limit transport range. Further, the
devices are quite loud, often requiring patients to
wear earplugs, thus limiting communication (49).
Finally, training and familiarization for EMS person-
nel and hospital staff must be coordinated to ensure
appropriate transitions of care, which may
be burdensome.
Limited in-hospital evidence suggests that helmet
NIV is at least equivalent to mask NIV (47,48). A
single-center, high-quality RCT demonstrated a
reduced need for intubation and lower 90-day mor-
tality for ARDS patients treated with helmet versus
mask NIV (46). Several small EMS studies have
demonstrated safety and efficacy of helmet NIV
(49–51). Two Italian studies applied helmet CPAP to
a combined 156 patients whom they compared to
standard medical therapy with high-flow oxygen,
but not mask CPAP, for patients with either hyper-
carbic respiratory failure or acute pulmonary edema
(50,51). They describe no complications, and better
patient-oriented outcomes with CPAP including
reduced hospital length of stay, need for intubation,
and mortality. Beckl offers a descriptive case series
of ten patients with COVID-19 transported with hel-
met CPAP with no complications or need for preho-
spital intubation (49).
In aggregate, limited but growing evidence sug-
gests that HFNC or helmet NIV may be safely and
effectively employed in the out-of-hospital environ-
ment (38,49–51). In pediatrics, evidence also exists
that HFNC, nasal CPAP, bubble CPAP, and oxygen
tent or hood devices may be used for interfacility
transports (42,44,45,52,53). Further EMS-specific
research on these technologies is needed.
CONCLUSION
Noninvasive ventilation in the form of CPAP and
BiPAP is safe and effective in the prehospital envir-
onment. Use at the BLS level has been successfully
and safely implemented in many EMS systems.
Novel methods of noninvasive ventilation such as
HFNC and helmet NIV are promising but require
further research to determine optimal patient popu-
lations and deployment strategies.
85
ORCID
Francis X. Guyette http://orcid.org/0000-0002-
9151-4896
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