Guideline sources The following summarized guidelines for the management of noninvasive ventilation (NIV) are prepared by our editorial team based on guidelines from the European Respiratory Society (ERS 2017). 1 Guidelines 1. Specific circumstances Immunocompromised patients: consider early NIV for immunocompromised patients with acute respiratory failure. C Patients on mechanical ventilation: consider using NIV to facilitate weaning from mechanical ventilation in patients with hypercapnic respiratory failure. C Patients with COPD exacerbation: initiate bilevel NIV for patients with acute respiratory failure leading to acute or acute-on-chronic respiratory acidosis due to COPD exacerbation. A Show 2 more Patients with asthma exacerbation: insufficient evidence to make a recommendation on the use of NIV for patients with acute respiratory failure due to asthma. Patients with cardiogenic pulmonary edema: deliver either bilevel NIV or CPAP to patients with acute respiratory failure due to cardiogenic pulmonary edema. B Patients with de novo acute respiratory failure: https://web.pathway.md/diseases/recGjfVM4WpKscm7P 1/3 6/30/23, 1:20 AM Noninvasive ventilation Pathway Insufficient evidence to recommend the use of NIV for patients with other types of de novo acute respiratory failure (excluding cardiogenic pulmonary edema and postoperative respiratory failure) in patients with no prior chronic respiratory disease. Consider offering a trial of NIV to carefully selected patients with hypoxemic respiratory failure, community-acquired pneumonia or early ARDS if they are being managed by an experienced clinical team, have contraindications to NIV (such as abnormal mental status, shock or multiorgan system failure), are closely monitored in the ICU, reassessed early after starting NIV, and intubated promptly if they are not improving. Patients with postoperative respiratory failure: consider NIV for patients with postoperative acute respiratory failure. C Landmark trials: NIVAS In patients with hypoxemic acute respiratory failure following abdominal surgery, non-invasive ventilation (NIV), as compared with standard oxygen therapy, reduced tracheal reintubation within 7 days (33.1% vs. 45.5%, p = 0.03; absolute difference -12.4%, 95% CI -23.5% to -1.3%). In the two corresponding groups (NIV vs. standard oxygen therapy), there was significantly more invasive ventilation-free days (25.4 vs. 23.2 days, p = 0.04; absolute difference -2.2 days, 95% CI -0.1 to 4.6 days) and reduced health care-associated infections (31.4% vs. 49.2%, p = 0.003; absolute difference -17.8% 95% CI -30.2% to -5.4%). In the two corresponding groups, there was reduction in the 90-day mortality (14.9% vs. 21.5%, p = 0.15; absolute difference -6.5%, 95% CI -16.0% to 3.0%). No significant differences in gas exchange were noted. Jaber S et al. JAMA. 2016 Apr 5. Patients with post-extubation respiratory failure: Consider the use of NIV to prevent post-extubation respiratory failure in high-risk patients. C Consider avoiding the use of NIV in the treatment of patients with established post-extubation respiratory failure. D Patients with chest wall trauma: consider initiating NIV in patients with chest wall trauma and acute respiratory failure. C Patients undergoing palliative care: consider offering NIV to dyspneic patients for palliation in the setting of terminal cancer or other terminal conditions. C Clinical findings Past medical history Social history Asthma Can be considered for chronic/home use COPD Covid-19 infection https://web.pathway.md/diseases/recGjfVM4WpKscm7P 2/3 6/30/23, 1:20 AM Noninvasive ventilation Pathway Cystic fibrosis Imaging findings Cardiac exam Pulmonary edema Acute cardiogenic pulmonary edema Studies 2016 NIVAS In patients with hypoxemic acute respiratory failure following abdominal surgery, non-invasive ventilation (NIV), as compared with standard oxygen therapy, reduced tracheal reintubation within 7 days (33.1% vs. 45.5%, p = 0.03; absolute difference -12.4%, 95% CI -23.5% to -1.3%). In the two corresponding groups (NIV vs. standard oxygen therapy), there was significantly more invasive ventilation-free days (25.4 vs. 23.2 days, p = 0.04; absolute difference -2.2 days, 95% CI -0.1 to 4.6 days) and reduced health care-associated infections (31.4% vs. 49.2%, p = 0.003; absolute difference -17.8% 95% CI -30.2% to -5.4%). In the two corresponding groups, there was reduction in the 90-day mortality (14.9% vs. 21.5%, p = 0.15; absolute difference -6.5%, 95% CI -16.0% to 3.0%). No significant differences in gas exchange were noted. Jaber S et al. JAMA. 2016 Apr 5. References 1. Rochwerg B, Brochard L, Elliott MW et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017 Aug 31;50 2 . pii: 1602426. Open https://web.pathway.md/diseases/recGjfVM4WpKscm7P 3/3