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Review
. 2025 Aug;51(8):1476-1489.
doi: 10.1007/s00134-025-08036-3. Epub 2025 Jul 24.

Noninvasive respiratory supports in ICU

Jean-Pierre Frat  1   2   3   4 , Domenico L Grieco  5 , Audrey De Jong  6 , Kevin Gibbs  7 , Guillaume Carteaux  8   9 , Oriol Roca  10   11 , Virginie Lemiale  12 , Lise Piquilloud  13 , Nuttapol Rittayamai  14 , Lara Pisani  15   16 , Gonzalo Hernandez  17   18   19   20 , Arnaud W Thille  21
Affiliations
Free article
Review

Noninvasive respiratory supports in ICU

Jean-Pierre Frat et al. Intensive Care Med. 2025 Aug.
Free article

Abstract

Background: Noninvasive respiratory supports are routinely applied in critically ill patients with acute respiratory failure to avoid intubation and invasive mechanical ventilation, thereby reducing the risk of related complications, and to facilitate successful weaning from mechanical ventilation after extubation. They are also applied during the intubation procedure for preoxygenation with the aim of enhancing oxygenation and ensuring the safety of the procedure.

Main body: High-flow nasal oxygen decreases airway dead space, provides a stable concentration of inspired oxygen, generates low level of flow-dependent positive airway pressure, and optimizes comfort. Positive-pressure noninvasive supports include continuous positive-airway pressure and noninvasive ventilation and enable providing higher end-expiratory pressure, thereby further improving oxygenation. Noninvasive ventilation, but not continuous positive-airway pressure, better decreases inspiratory effort, and increases tidal volume and transpulmonary driving pressure.

Conclusion: High-flow nasal oxygen has become the first-line therapy in acute hypoxemic respiratory failure, while noninvasive ventilation remains the reference treatment during exacerbations of chronic obstructive pulmonary disease, in patients with respiratory acidosis. In patients requiring intubation, noninvasive ventilation is the optimal technique for preoxygenation to decrease the risk of hypoxemia, while high-flow nasal oxygen is an alternative option for non-hypoxemic patients or those with contraindications to noninvasive ventilation. After extubation in patients at high risk of reintubation, prophylactic noninvasive ventilation, eventually alternating with high-flow nasal oxygen, improves weaning outcome compared to other strategies; high-flow nasal oxygen alone outperforms conventional oxygen in low-risk patients.

Keywords: Acute respiratory failure; CPAP; High-flow oxygen; Hypercapnia; Hypoxemia; NIV; Noninvasive ventilation; Post-extubation; Preoxygenation.

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Conflict of interest statement

Declarations. Conflicts of interest: Jean-Pierre Frat has received personal fees for lectures, travel expense coverage to attend scientific meetings from Fisher and Paykel Healthcare, grant for randomized clinical trial; personal fees as member of a scientific board and travel expense coverage to attend scientific meetings from SOS Oxygène; grant for clinical studies from the Bourse du souffle. Audrey De Jong has received fees for lectures from Medtronic, Fisher-Paykel, Drager, Sanofi, and Viatris. Orio Roca reported a research grant from Hamilton Medical AG and Fisher&Paykel Healthcare Ltd, speaker fees from Hamilton Medical AG, Fisher&Paykel Healthcare Ltd, and Aerogen Ltd, and non-financial research support from Timpel; all outside the submitted work. Minority stakeholder of Tesai Care SL, a spin-off of Vall d’Hebron and Parc Taulí University Hospital. Lise Piquilloud has received lectures fees and travel expense coverage to attend scientific meetings from Fisher and Paykel, Medtronic, Healthcare, GE Healthcare, Hamilton Medical, Getinge, Air Liquid Medical system. Lise Piquilloud has also received consultant fees from Getinge. Nuttapol Rittayamai has received personal fees for lectures and/or research equipment from Fisher and Paykel Healthcare, Aerogen, and Vapotherm. Gonzalo Hernandez has received personal fees for lectures, travel expense coverage to attend scientific meetings from Fisher and Paykel Healthcare. Gonzalo Hernandez is Section Editor for Intensive Care Medicine. He has not taken part in the review or selection process of this article.

References

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