Noninvasive Ventilation For Acute Respiratory Distress: COPD, Cardiogenic Pulmonary Edema, Asthma | EB Medicine
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Noninvasive Ventilation For Patients In Acute Respiratory Distress: An Update

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Table of Contents
Table of Contents
  1. Abstract
  2. Case Presentations
  3. Introduction
  4. Critical Appraisal of the Literature
  5. Types Of Respiratory Failure
  6. Clinical Application Of Noninvasive Ventilation
    1. Positive Pressure Ventilation
    2. Types Of Noninvasive Ventilation
    3. Noninvasive Ventilation Settings And Types
      1. Modes
      2. Pressure Settings
      3. Mask Types
      4. Disposable CPAP Systems
      5. Indications And Contraindications To Noninvasive Ventilation
    4. Patient Selection Based Upon Underlying Pathology
      1. Undifferentiated Dyspnea In The Prehospital Setting
      2. Chronic Obstructive Pulmonary Disease Exacerbation
      3. Asthma Exacerbation
      4. Cardiogenic Pulmonary Edema
      5. Community-Acquired Pneumonia
      6. Interstitial Lung Disease
      7. Submersion Injury
      8. Pediatric Patients
  7. Clinical Course In The Emergency Department
    1. Chronic Obstructive Pulmonary Disease
    2. Asthma
    3. Cardiogenic Pulmonary Edema
    4. Community-Acquired Pneumonia
    5. Clinical Deterioration On Noninvasive Ventilation
    6. Complications Of Noninvasive Ventilation
      1. Risk Of Aspiration
      2. Barotrauma
      3. Cardiac Ischemia
  8. Special Circumstances
    1. Acute Lung Injury/Acute Respiratory Distress Syndrome
    2. Do-Not-Intubate Orders And Palliative Care
    3. Neuromuscular Respiratory Failure
    4. Blunt Chest Trauma
    5. Cystic Fibrosis
  9. Controversies And Cutting Edge
    1. Sedation For Noninvasive Ventilation
    2. Noninvasive Ventilation In Procedural Sedation
  10. Disposition
  11. Summary
  12. Risk Management Pitfalls For Noninvasive Ventilation
  13. Time- And Cost-Effective Strategies
  14. Case Conclusions
  15. Clinical Pathway For Managing Patients In Respiratory Distress
  16. Tables and Figures
    1. Table 1. Types Of Respiratory Failure And Their Management Approaches
    2. Table 2. Ventilation Mask Types And Uses
    3. Table 3. Absolute And Relative Contraindications To Noninvasive Ventilation
    4. Table 4. Signs Of Noninvasive Ventilation Failure
    5. Figure 1. Physiologic Pathway Of Postive Pressure Ventlation
    6. Figure 2. The Boussignac CPAP System
  17. References


Over the last 20 years, noninvasive ventilation (NIV) strategies have been used with increasing frequency. The ease of use of NIV makes it applicable to patients presenting in a variety of types of respiratory distress. In this review, the physiology of positive pressure ventilation is discussed, including indications, contraindications, and options for mask type and fit. Characteristics of patients who are most likely to benefit from NIV are reviewed, including those in respiratory distress from chronic obstructive pulmonary disease exacerbation and cardiogenic pulmonary edema. The literature for other respiratory pathologies where NIV may be used, such as in asthma exacerbation, pediatric patients, and community-acquired pneumonia, is also reviewed. Controversies and potential future applications of NIV are presented.

Case Presentations

Just as you are able to sit down for the first time in hours in the ED, a colleague walks by and says, “I don’t know what’s going on with your new patient, but she doesn’t look good.” You hurry to find a frail, elderly woman sitting upright, mouth agape. She is tachypneic, with a respiratory rate of 40 breaths/min, and is using accessory respiratory muscles. According to EMS, her pulse oximetry reading improved from 67% on 2-L nasal cannula to 80% on a 15-L nonrebreather mask. She has virtually no breath sounds on lung auscultation except for occasional faint wheezing. You initiate bilevel noninvasive ventilation (NIV), and inline continuous nebulizer treatments are started. The respiratory therapist suggests endotracheal intubation, and you suspect that extubation in the ICU will be difficult, further along the treatment course. As the respiratory therapist sets the bilevel NIV at a PIP 12 over PEEP 5, she asks you, “What parameters would make you decide to proceed with endotracheal intubation?”

Meanwhile, you are alerted to an EMS arrival in the resuscitation bay. They have brought an obese 60-something-year-old man, who was “found down.” Initial evaluation was remarkable for somnolence with arousal to painful stimuli. He has been unable to provide his name or past medical history. His vital signs are remarkable for a respiratory rate of 10 breaths/min and hypoxia with a SpOin the mid-80s on room air. He has right lower lung basilar crackles. According to EMS, his hypoxia did not improve on a nonrebreather mask, so CPAP was initiated in the field. Since then, his SpOhas improved marginally to the high 80s, but he still arouses only to painful stimuli. During your initial assessment, the patient vomits into the NIV mask, aspirates, and his SpOplummets when the face mask is removed. As you scramble to assemble RSI and intubation materials, you wonder if CPAP was contraindicated and if this airway catastrophe could have been prevented.

Mulling over your stressful patient load, you walk to the bedside of a 9-year-old girl with a past medical history of cerebral palsy. Although she is only minimally interactive, she is accompanied by her attentive parents who are deeply involved with her medical care. Her mother looks worried and explains that her daughter “isn’t breathing right” and that she feels warm. The father mentions a history of a worsening cough. On chart review, you note that her restrictive lung disease from underlying cerebral palsy is worsening, and that she now requires BPAP at night. On examination, you see a mentally and developmentally delayed girl with subcostal retractions, tachycardia to 125 beats/min, tachypnea to 35 breaths/min, and an oral temperature of 38.3°C (101°F), but she is maintaining an oxygen saturation of 97% on room air. A chest x-ray confirms a right upper lobar pneumonia. The patient shows increased work of breathing, and you wonder if NIV would help.


Acute respiratory failure is an emergency that requires a management strategy tailored to the individual patient and to the resources available. Endotracheal intubation is definitive airway management, but it can have complications. In addition, rapid sequence intubation (RSI) requires a degree of preparation and time that might not be available in the acutely distressed patient. For example, important equipment needs assembly, often the clinical environment is not optimal (such as with refractory hypoxia or abnormal anatomy that makes RSI riskier), or the patient has an underlying condition that could lead to further complication as a result of paralysis (such as in acidosis). Ultimately, with RSI there is a level of risk to the patient, both during the initial procedure of induction, sedation, laryngoscopy, and tube delivery, as well as post procedure, with ventilator-associated risks such as pulmonary barotrauma or ventilator-associated pneumonia.

In consideration of risks associated with definitive airway management, noninvasive strategies that include continuous positive airway pressure (CPAP) and bilevel positive airway pressure (BPAP) are viable management options. These techniques provide a “fast-on” intervention that provides more respiratory support than nasal cannula or a conventional face mask. Unlike endotracheal intubation, NIV is not definitive airway management, and the patient must be closely monitored for signs of clinical deterioration. Nonetheless, NIV can improve the patient’s condition sufficiently to either reverse the underlying acute illness or, alternatively, it may serve to safely delay intubation until proper setup is available.In the case of patients who have a “do not intubate” (DNI) directive, NIV may also allow for temporary life-sustaining support while a potentially reversible process is addressed.2

NIV was introduced for management of acute respiratory failure in the 1940s, but became a mainstay of respiratory management only in the last 20 years. A multicenter database review over a 15-year study period from 1997 to 2011 showed that first-line NIV use increased from 29% to 42%, and the success rate improved from 69% to 84%.Success was defined as not requiring use of mechanical ventilation and increased patient survival.

A comprehensive understanding of the physiologic benefits of NIV can lead to efficient and clinically appropriate management decisions. As there was an excellent review article by Torres and Radeos published in a 2011 issue of EM Critical Care,this review is designed to provide an update of the literature since then, and to offer evolving perspectives on the increasing utilization of NIV in the setting of acute respiratory distress.

Critical Appraisal Of The Literature

Searches were conducted through PubMed and OVID Medline® for literature from 2010 to 2016. Keywords included noninvasive ventilation, with and without the qualifying inclusion of the term acute respiratory failure, to limit the resources to acute conditions. The search was restricted to studies available in the English language. The references from the articles identified were then searched for additional references, retrieving more than 700 articles. Priority was given to articles addressing commonly occurring emergent medical conditions, with additional special attention given to topics falling under the category of emerging areas of research.

Risk Management Pitfalls For Noninvasive Ventilation

  1. “I wanted to start NIV in the ED, but I did not know the exact etiology of the patient’s respiratory distress.”
    Often, a patient will present to the ED in undifferentiated respiratory distress, but can still benefit from a trial of NIV. However, NIV should not be attempted if the patient meets contraindications, which are detailed in Table 2. An emergency clinician should remain vigilant and be ready for mechanical ventilation if the patient does not improve while on NIV.
  2. “NIV was started via oronasal mask on the patient with respiratory distress, but I had to stop because he complained of nasal dryness and discomfort.”
    There are many options for mask type and fit. As long as the patient remains stable, other modalities should be tried.
  3. “EMS brought a patient to the ED on NIV instead of intubating him. I think they were just novice and were too scared to intubate.”
    It is reasonable to trial NIV in patients in the prehospital setting, and it can reduce in-hospital mortality and the need for invasive ventilation. However, if a patient continues to decompensate, the care team should be prepared for intubation.
  4. “I did not consider that the patient could get a pneumothorax while on NIV.”
    PPV can increase the risk of barotrauma, which can lead to pneumothorax from the increased airway pressure. While rates of these events are lower than in mechanical ventilation, it can still happen. This should be a part of the differential diagnosis in an acutely unstable patient on NIV who initially appeared to have been improving clinically.
  5. “The patient with the do-not-resuscitate order appeared short of breath, so I treated his air hunger with morphine. Now the family is upset with me because the patient passed away before they could get to the ED. I did not want the patient to suffer any longer.”
    The physician can consider starting NIV while the family is en route to the ED, and it may be a safer treatment for air hunger than opioids. This can provide extra time for family to arrive, which may be part of the patient’s end-of-life goals and the process of dying with dignity. However, NIV should, ideally, only be applied with consent after approval from the patient or their duly appointed medical designee.
  6. “I thought the patient was comfortable and starting to fall asleep. I didn’t think that it was possible to be hypercapnic and go into respiratory failure while on NIV.”
    NIV is not an advanced airway, and any patient placed on this intervention must be closely monitored for deterioration. Signs of NIV failure include declining level of consciousness, which may be caused by worsening PaCO2 levels. Serial examinations, blood gas testing, and vital signs are critical for monitoring these patients. Remember that tachypnea and hyperventilation are not the same thing. Patients with rapid, shallow breathing can still accumulate dangerous levels of PaCO2, and NIV does not guarantee a minimum minute ventilation.
  7. “My patient will not stop coughing and her breathing is asynchronous with the NIV machine. I’ll give her opioids to make her more comfortable so that I do not have to intubate her, and she can benefit from NIV.”
    Care must be taken with patients receiving NIV. If they cannot tolerate it or show signs of NIV failure, then they will require intubation. Coughing and asynchrony are signs of ineffective NIV that may lead to failure. While light sedation can be given while on NIV, it must be done with extreme caution to avoid oversedation that may necessitate emergency intubation.
  8. “I know the patient I’m admitting for cellulitis will require ICU admission because he requires BPAP at night.”
    This is not necessarily true. You should consider discussing with the inpatient care team the optimal disposition for the patient. Not all patients who need NIV will require ICU-level care.
  9. “The pediatric patient who presented to the ED in respiratory distress has never been on NIV, so I did not want to start a new therapy in the ED.”
    Although data are lacking, there is reasonable physiologic rationale to support the use of NIV in the ICU in the pediatric patient population, even without previous use. It may prevent intubation, which is important. It is reasonable to try NIV in conjunction with the pediatric ICU team’s directed care.
  10. “The ICU team was upset when I told them that I placed the patient with the asthma exacerbation on NIV. They stated that the exact correlation between NIV use in asthma and physiological improvement is unknown.”
    While it is true that asthma and COPD are fundamentally different in pathophysiology, they are both obstructive processes and NIV can still be helpful, assuming it does not prevent the physician from intubation if the patient deteriorates. It can also be helpful for preoxygenation prior to intubation for the already-hypoxic patient.

Tables and Figures

Table 1. Types Of Respiratory Failure And Their Management Approaches


Evidence-based medicine requires a critical appraisal of the literature based upon study methodology and number of subjects. Not all references are equally robust. The findings of a large, prospective, randomized, and blinded trial should carry more weight than a case report.

To help the reader judge the strength of each reference, pertinent information about the study is included in bold type following the reference, where available. The most informative references cited in this paper, as determined by the authors, are noted by an asterisk (*) next to the number of the reference.

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Publication Information

Nikita Joshi, MD; Molly K. Estes, MD; Kayla Shipley, MD; Hyun-Chul Danny Lee, MD

Publication Date

February 1, 2017

CME Expiration Date

March 1, 2020

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