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Objectives

  1. Identify appropriate patients for noninvasive ventilation (NIV) and high-flow nasal cannula (HFNC).

  2. Compare interfaces for NIV and HFNC.

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

  4. List the steps in the initiation of NIV and HFNC.

  5. Discuss technical aspects of HFNC.

Introduction

Noninvasive respiratory support (Figure 11-1) such as noninvasive ventilation (NIV), continuous positive-pressure ventilation (CPAP) and high-flow nasal cannula (HFNC) are now established therapies in respiratory critical care. NIV, noninvasive CPAP, and HFNC are used increasingly in patients with acute respiratory failure. In appropriately selected patients, need for intubation is reduced with the use of these therapies. 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. HFNC might also provide a survival benefit in selected patients with acute hypoxemic respiratory failure. This chapter covers clinical and technical issues related to use of NIV, CPAP, and HFNC.

Figure 11-1

Noninvasive ventilation (NIV), continuous positive-pressure ventilation (CPAP), and high-flow nasal cannula (HFNC). Note that NIV provides an inspiratory positive airway pressure (IPAP) greater than the expiratory positive airway pressure (EPAP). CPAP provides a constant pressure. HFNC also provides a small amount of pressure to the airway, but typically less that with CPAP or NIV.

Noninvasive Ventilation

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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