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Chapter 11: Noninvasive Ventilation

Introduction

Objectives

  1. Discuss patient selection for noninvasive ventilation (NIV).

  2. Compare interfaces for NIV.

  3. List advantages and disadvantages of various ventilator types for NIV.

  4. List the steps in the initiation of NIV.

One of the significant advances in respiratory critical care over the past 20 years has been the emergence of noninvasive ventilation (NIV). NIV is used increasingly in patients with acute respiratory failure. In appropriately selected patients, need for intubation is reduced with the use of NIV. Because an artificial airway increases the risk of nosocomial pneumonia, it is not surprising that use of NIV decreases the incidence of ventilator-associated pneumonia. In some clinical settings, such as chronic obstructive pulmonary disease (COPD) exacerbation or acute cardiogenic pulmonary edema, the use of NIV affords a survival benefit. This chapter covers clinical and technical issues related to use of NIV.

Patient Factors

Patient Selection

The strength of evidence for the use of NIV for various causes of acute respiratory failure is summarized in Table 11-1. High-level evidence supports the effectiveness of NIV for COPD exacerbation. Equally strong evidence supports the use of NIV for acute cardiogenic pulmonary edema. There is also evidence to support the use of NIV in patients with respiratory failure following solid organ transplantation and those who are immunosuppressed. Although some evidence supports the use of NIV for acute asthma, the evidence in this setting is weak. The use of NIV as an alternative to invasive ventilation in severely hypoxemic patients with acute respiratory distress syndrome is not recommended.

Table 11-1Strength of evidence supporting use of noninvasive ventilation for acute respiratory failure
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Table 11-1 Strength of evidence supporting use of noninvasive ventilation for acute respiratory failure
COPD exacerbation Many randomized controlled trials support lower rate of intubation and improved survival
Cardiogenic pulmonary edema Many randomized controlled trials support lower rate of intubation and improved survival
Prevent extubation/decannulation failure A few randomized controlled trials and observational studies support the use of NIV in patients at risk for postextubation respiratory failure
Transplantation and immunocompromise A few randomized controlled trials and observational studies support the use of NIV
Respiratory failure following lung resection surgery A few randomized controlled trials and observational studies support the use of NIV
Neuromuscular disease A few randomized controlled trials and observational studies support the use of NIV
Obesity hypoventilation syndrome Observational studies support the use of NIV
Asthma A few randomized controlled trials and observational studies support the use of NIV
Do not intubate/do not resuscitate Observational studies support NIV in patients with COPD exacerbation or cardiogenic pulmonary edema
Acute respiratory distress syndrome Evidence does not support use in most patients
Failed extubation Beneficial only for postextubation respiratory failure with hypercapnia

Abbreviations: COPD, chronic obstructive pulmonary disease; NIV, noninvasive ventilation.

NIV can be used to allow ...

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