Noninvasive ventilation in acute respiratory failure: which recipe for success?

Abstract

Noninvasive positive-pressure ventilation (NPPV) to treat acute respiratory failure has expanded tremendously over the world in terms of the spectrum of diseases that can be successfully managed, the locations of its application and achievable goals.The turning point for the successful expansion of NPPV is its ability to achieve the same physiological effects as invasive mechanical ventilation with the avoidance of the life-threatening risks correlated with the use of an artificial airway.Cardiorespiratory arrest, extreme psychomotor agitation, severe haemodynamic instability, nonhypercapnic coma and multiple organ failure are absolute contraindications for NPPV. Moreover, pitfalls of NPPV reduce its rate of success; consistently, a clear plan of what to do in case of NPPV failure should be considered, especially for patients managed in unprotected setting. NPPV failure is likely to be reduced by the application of integrated therapeutic tools in selected patients handled by expert teams.In conclusion, NPPV has to be considered as a rational art and not just as an application of science, which requires the ability of clinicians to both choose case-by-case the best "ingredients" for a "successful recipe" (i.e. patient selection, interface, ventilator, interface, etc) and to avoid a delayed intubation if the ventilation attempt fails.

FIGURE 1

Time frames for the application of noninvasive positive-pressure ventilation in acute respiratory failure (ARF) according to the severity and end-of-life choices of patients. ETI: endotracheal intubation; IMV: invasive mechanical ventilation; NIV: noninvasive ventilation; EXT-F: extubation failure.

FIGURE 2

Evidence-based indications for noninvasive positive-pressure ventilation (NPPV) according to the severity and time of acute respiratory failure (ARF) [18]. COPD: chronic obstructive pulmonary disease; ACPE: acute cardiogenic pulmonary oedema; CAP: community-acquired pneumonia; ARDS: acute respiratory distress syndrome.

FIGURE 3

Integrated strategies to reduce noninvasive positive-pressure ventilation failure in different clinical–physiological scenarios. ECCO₂R: extra-corporeal carbon dioxide removal; HFNC: high-flow nasal cannula; FBO: fibre-optic bronchoscopy; HFCWO: high-frequency chest wall oscillation; IPV: intrapulmonary percussive ventilation; VILI: ventilator-induced lung injury.