Updated Guidelines for Noninvasive Ventilation in Acute Respiratory Failure

The European Respiratory Society/American Thoracic Society recently released guidelines regarding the use of noninvasive ventilation (NIV) for acute respiratory failure (ARF) developed by a committee of clinicians, methodologists, and experts in the field of NIV. These guidelines are recommendations for actionable clinical questions, with certainty in effect estimates categorized as high, moderate, low, or very low according to the GRADE (Grading, Recommendation, Assessment, Development, and Evaluation) process.

Recommendations included address the use of NIV in the following conditions:

• Chronic obstructive pulmonary disease (COPD) exacerbations
  
  • Bilevel NIV may be considered in 3 clinical settings: to prevent respiratory acidosis, to prevent endotracheal intubation and invasive mechanical ventilation in patients with mild to moderate acidosis and respiratory distress, and as an alternative to invasive ventilation with severe acidosis and more severe respiratory distress.

• ARF resulting from cardiogenic pulmonary edema (either bilevel NIV or continuous positive airway pressure; strong recommendation, moderate certainty of evidence)
• ARF resulting from acute asthma (no recommendation because of the uncertainty of the evidence)
• ARF in immunocompromised patients (recommended early NIV; conditional recommendation, moderate certainty of evidence)
• De novo ARF (no recommendation because of the uncertainty of the evidence)
• ARF in the postoperative setting (recommended NIV; conditional recommendation, moderate certainty of evidence)
• ARF receiving palliative care (recommended NIV to patients with dyspnea in terminal settings; conditional recommendation, moderate certainty of evidence)
• ARF resulting from chest trauma (recommended NIV; conditional recommendation, moderate certainty of evidence)
• ARF resulting from pandemic viral illness (no recommendation because of the uncertainty of the evidence)
• ARF after extubation from invasive mechanical ventilation
  
  • NIV can be used in high-risk patients to prevent postextubation respiratory failure (conditional recommendation, low certainty of evidence)
  • NIV should not be used in non-high-risk patients to prevent postextubation respiratory failure (conditional recommendation, very low certainty of evidence)
• Weaning patients from invasive mechanical ventilation (recommended NIV in patients with hypercapnic respiratory failure; conditional recommendation, moderate certainty of evidence; no recommendations for patients with hypoxia)

Researchers found that recommendations did not vary greatly from guidelines published within the last 15 years, but slight alterations have been made to recommendations based on the most recently published literature. In addition, clinicians are encouraged to implement these guidelines based on a combination of their clinical judgment as well as consideration of patient factors, individual values, and preferences.

Reference

Rochwerg B, Brochard L, Elliott M, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017;50:1602426.