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

Noninvasive Ventilation For Patients In Acute Respiratory Distress: An Update

Below is a free preview. Log in or subscribe for full access. Or, get a free sample article Emergency Department Management of Abnormal Uterine Bleeding in the Nonpregnant Patient:
Please provide a valid email address.

*NEW* Quick Search this issue!

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.

  1. Weingart SD, Trueger NS, Wong N, et al. Delayed sequence intubation: a prospective observational study. Ann Emerg Med. 2015;65(4):349-355. (Multicenter prospective observational; 62 patients)
  2. Nava S, Ferrer M, Esquinas A, et al. Palliative use of non-invasive ventilation in end-of-life patients with solid tumours: a randomised feasibility trial. Lancet Oncol. 2013;14(3):219- 227. (Randomized; 200 patients)
  3. Schnell D, Timsit JF, Darmon M, et al. Noninvasive mechanical ventilation in acute respiratory failure: trends in use and outcomes. Intensive Care Med. 2014;40(4):582-591. (Multicenter review; 1232 patients)
  4. Torres JD RM. Non-invasive ventilation: update for uses in the critically ill patient. EM Critical Care. 2011;1. (Review)
  5. Carlson JN, Wang HE. Noninvasive airway management. In: Cline DM, Ma OJ, Cydulka RK, et al. Tintinalli’s Emergency Medicine: A Comprehensive Study Guide, 7th ed. New York, NY: The McGraw-Hill Companies; 2012. (Textbook)
  6. Bersten AD, Holt AW, Vedig AE, et al. Treatment of severe cardiogenic pulmonary edema with continuous positive airway pressure delivered by face mask. N Engl J Med. 1991;325(26):1825-1830. (Prospective; 39 patients)
  7. Masip J, Roque M, Sanchez B, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and meta-analysis. JAMA. 2005;294(24):3124-3130. (Meta-analysis; 15 studies, 843 patients)
  8. Ho KM, Wong K. A comparison of continuous and bi-level positive airway pressure non-invasive ventilation in patients with acute cardiogenic pulmonary oedema: a meta-analysis. Crit Care. 2006;10(2):R49. (Meta-analysis; 7 studies, 290 patients)
  9. * Siegel TA. Mechanical ventilation and noninvasive ventilatory support. In: Marx JA, Hockberger RS, Walls RM, et al, eds. Rosen’s Emergency Medicine, 8th ed. Philadelphia, PA: Elsevier Saunders; 2014. (Textbook)
  10. Navalesi P, Fanfulla F, Frigerio P, et al. Physiologic evaluation of noninvasive mechanical ventilation delivered with three types of masks in patients with chronic hypercapnic respiratory failure. Crit Care Med. 2000;28(6):1785-1790. (Randomized; 26 patients)
  11. Girault C, Briel A, Benichou J, et al. Interface strategy during noninvasive positive pressure ventilation for hypercapnic acute respiratory failure. Crit Care Med. 2009;37(1):124-131. (Prospective randomized controlled; 90 patients)
  12. Silva RM, Timenetsky KT, Neves RC, et al. Adaptation to different noninvasive ventilation masks in critically ill patients. J Bras Pneumol. 2013;39(4):469-475. (Observational; 245 patients)
  13. Chacur FH, Vilella Felipe LM, Fernandes CG, et al. The total face mask is more comfortable than the oronasal mask in noninvasive ventilation but is not associated with improved outcome. Respiration. 2011;82(5):426-430. (Prospective randomized; 60 patients)
  14. Lemyze M, Mallat J, Nigeon O, et al. Rescue therapy by switching to total face mask after failure of face mask-delivered noninvasive ventilation in do-not-intubate patients in acute respiratory failure. Crit Care Med. 2013;41(2):481-488. (Prospective observational; 74 patients)
  15. Ozlem CG, Ali A, Fatma U, et al. Comparison of helmet and facial mask during noninvasive ventilation in patients with acute exacerbation of chronic obstructive pulmonary disease: a randomized controlled study. Turk J Med Sci. 2015;45(3):600-606. (Randomized; 50 patients)
  16. Yang Y, Sun L, Liu N, et al. Effects of noninvasive positive-pressure ventilation with different interfaces in patients with hypoxemia after surgery for Stanford type A aortic dissection. Med Sci Monit. 2015;21:2294-2304. (Randomized; 40 patients)
  17. Antonaglia V, Ferluga M, Molino R, et al. Comparison of noninvasive ventilation by sequential use of mask and helmet versus mask in acute exacerbation of chronic obstructive pulmonary disease: a preliminary study. Respiration. 2011;82(2):148-154. (Prospective randomized; 53 patients)
  18. Wong DT, Tam AD, Van Zundert TC. The usage of the Bous-signac continuous positive airway pressure system in acute respiratory failure. Minerva Anestesiol. 2013;79(5):564-570. (Review; 19 references)
  19. Templier F, Dolveck F, Baer M, et al. ‘Boussignac’ continuous positive airway pressure system: practical use in a prehospital medical care unit. Eur J Emerg Med. 2003;10(2):87-93. (Prospective descriptive; 57 patients)
  20. Fyntanidou B, Amaniti E, Fortounis K, et al. Prehospital use of Boussignac continuous positive airway pressure system in acute cardiogenic pulmonary edema [abstract]. Eur J Anaesthesiol. 2009;26:178. (Abstract)
  21. Freitas P, Limpo B, Sa N, et al. Prehospital Boussignac continuous positive airway pressure: one year experience. Resuscitation. 2010;81:S56. (Abstract)
  22. Dieperink W, Weelink EE, van der Horst IC, et al. Treatment of presumed acute cardiogenic pulmonary oedema in an ambulance system by nurses using Boussignac continuous positive airway pressure. Emerg Med J. 2009;26(2):141-144. (Prospective interventional; 32 patients)
  23. Moritz F, Benichou J, Vanheste M, et al. Boussignac continuous positive airway pressure device in the emergency care of acute cardiogenic pulmonary oedema: a randomized pilot study. Eur J Emerg Med. 2003;10(3):204-208. (Randomized; 30 patients)
  24. Dieperink W, Jaarsma T, van der Horst IC, et al. Boussignac continuous positive airway pressure for the management of acute cardiogenic pulmonary edema: prospective study with a retrospective control group. BMC Cardiovasc Disord. 2007;7:40. (Prospective interventional; 66 patients)
  25. Moritz F, Brousse B, Gellee B, et al. Continuous positive airway pressure versus bilevel noninvasive ventilation in acute cardiogenic pulmonary edema: a randomized multicenter trial. Ann Emerg Med. 2007;50(6):666-675. (Randomized; 120 patients)
  26. Nouira S, Boukef R, Bouida W, et al. Non-invasive pressure support ventilation and CPAP in cardiogenic pulmonary edema: a multicenter randomized study in the emergency department. Intensive Care Med. 2011;37(2):249-256. (Randomized; 200 patients)
  27. Leman P, Greene S, Whelan K, et al. Simple lightweight disposable continuous positive airways pressure mask to effectively treat acute pulmonary oedema: randomized controlled trial. Emerg Med Australas. 2005;17(3):224-230. (Randomized controlled; 39 patients)
  28. Weingart SD, Levitan RM. Preoxygenation and prevention of desaturation during emergency airway management. Ann Emerg Med. 2012;59(3):165-175. (Review; 97 references)
  29. Mal S, McLeod S, Iansavichene A, et al. Effect of out-of-hospital noninvasive positive-pressure support ventilation in adult patients with severe respiratory distress: a systematic review and meta-analysis. Ann Emerg Med. 2014;63(5):600-607. (Meta-analysis; 7 studies, 632 patients)
  30. Diaz O, Iglesia R, Ferrer M, et al. Effects of noninvasive ventilation on pulmonary gas exchange and hemodynamics during acute hypercapnic exacerbations of chronic obstructive pulmonary disease. Am J Respir Crit Care Med. 1997;156(6):1840-1845. (Prospective; 10 patients)
  31. * Ram FS, Picot J, Lightowler J, et al. Non-invasive positive pressure ventilation for treatment of respiratory failure due to exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev. 2004(1):CD004104. (Cochrane review; 14 studies)
  32. Brochard L, Mancebo J, Wysocki M, et al. Noninvasive ventilation for acute exacerbations of chronic obstructive pulmonary disease. N Engl J Med. 1995;333(13):817-822. (Prospective randomized; 85 patients)
  33. Lindenauer PK, Stefan MS, Shieh MS, et al. Outcomes associated with invasive and noninvasive ventilation among patients hospitalized with exacerbations of chronic obstructive pulmonary disease. JAMA Intern Med. 2014;174(12):1982- 1993. (Retrospective cohort; 25,628 patients)
  34. Keenan SP, Sinuff T, Cook DJ, et al. Which patients with acute exacerbation of chronic obstructive pulmonary disease benefit from noninvasive positive-pressure ventilation? A systematic review of the literature. Ann Intern Med. 2003;138(11):861-870. (Systematic review; 15 studies)
  35. Keenan SP, Powers CE, McCormack DG. Noninvasive positive-pressure ventilation in patients with milder chronic obstructive pulmonary disease exacerbations: a randomized controlled trial. Respir Care. 2005;50(5):610-616. (Randomized controlled; 25 patients)
  36. Soroksky A, Klinowski E, Ilgyev E, et al. Noninvasive positive pressure ventilation in acute asthmatic attack. Eur Respir Rev. 2010;19(115):39-45. (Review; 58 references)
  37. Gupta D, Nath A, Agarwal R, et al. A prospective randomized controlled trial on the efficacy of noninvasive ventilation in severe acute asthma. Respir Care. 2010;55(5):536-543. (Prospective randomized controlled; 53 patients)
  38. Meduri GU, Cook TR, Turner RE, et al. Noninvasive positive pressure ventilation in status asthmaticus. Chest. 1996;110(3):767-774. (Prospective; 17 patients)
  39. Soroksky A, Stav D, Shpirer I. A pilot prospective, randomized, placebo-controlled trial of bilevel positive airway pressure in acute asthmatic attack. Chest. 2003;123(4):1018-1025. (Randomized; 30 patients)
  40. Patrick W, Webster K, Ludwig L, et al. Noninvasive positive-pressure ventilation in acute respiratory distress without prior chronic respiratory failure. Am J Respir Crit Care Med. 1996;153(3):1005-1011. (Prospective; 11 patients)
  41. Fernandez MM, Villagra A, Blanch L, et al. Non-invasive mechanical ventilation in status asthmaticus. Intensive Care Med. 2001;27(3):486-492. (Retrospective observational; 58 patients)
  42. Shivaram U, Miro AM, Cash ME, et al. Cardiopulmonary responses to continuous positive airway pressure in acute asthma. J Crit Care. 1993;8(2):87-92. (Retrospective; 58 patients)
  43. 43. Lim WJ, Mohammed Akram R, Carson KV, et al. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database Syst Rev. 2012;12:CD004360. (Cochrane review; 6 studies, 206 patients)
  44. * Nanchal R, Kumar G, Majumdar T, et al. Utilization of mechanical ventilation for asthma exacerbations: analysis of a national database. Respir Care. 2014;59(5):644-653. (Database review)
  45. Weng CL, Zhao YT, Liu QH, et al. Meta-analysis: noninvasive ventilation in acute cardiogenic pulmonary edema. Ann Intern Med. 2010;152(9):590-600. (Meta-analysis)
  46. * Vital FM, Ladeira MT, Atallah AN. Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema. Cochrane Database Syst Rev. 2013;5:CD005351. (Cochrane review; 32 studies, 2916 patients)
  47. Mehta S, Jay GD, Woolard RH, et al. Randomized, prospective trial of bilevel versus continuous positive airway pressure in acute pulmonary edema. Crit Care Med. 1997;25(4):620-628. (Prospective randomized; 27 patients)
  48. Rusterholtz T, Kempf J, Berton C, et al. Noninvasive pressure support ventilation (NIPSV) with face mask in patients with acute cardiogenic pulmonary edema (ACPE). Intensive Care Med. 1999;25(1):21-28. (Prospective; 26 patients)
  49. Sharon A, Shpirer I, Kaluski E, et al. High-dose intravenous isosorbide-dinitrate is safer and better than Bi-PAP ventilation combined with conventional treatment for severe pulmonary edema. J Am Coll Cardiol. 2000;36(3):832-837. (Prospective randomized; 40 patients)
  50. Confalonieri M, Potena A, Carbone G, et al. Acute respiratory failure in patients with severe community-acquired pneumonia. A prospective randomized evaluation of noninvasive ventilation. Am J Respir Crit Care Med. 1999;160(5 Pt 1):1585-1591. (Prospective randomized; 56 patients)
  51. * Zhang Y, Fang C, Dong BR, et al. Oxygen therapy for pneumonia in adults. Cochrane Database Syst Rev. 2012;3:CD006607. (Cochrane review; 3 studies, 151 patients)
  52. Nicolini A, Ferraioli G, Ferrari-Bravo M, et al. Early non-invasive ventilation treatment for respiratory failure due to severe community-acquired pneumonia. Clin Respir J. 2016;10(1):98-103. (Prospective; 127 patients)
  53. Raghu G, Collard HR, Egan JJ, et al. An official ATS/ERS/ JRS/ALAT statement: idiopathic pulmonary fibrosis: evidence-based guidelines for diagnosis and management. Am J Respir Crit Care Med. 2011;183(6):788-824. (Practice guideline)
  54. Vianello A, Arcaro G, Battistella L, et al. Noninvasive ventilation in the event of acute respiratory failure in patients with idiopathic pulmonary fibrosis. J Crit Care. 2014;29(4):562-567. (Retrospective chart review; 18 patients)
  55. Gungor G, Tatar D, Salturk C, et al. Why do patients with interstitial lung diseases fail in the ICU? A 2-center cohort study. Respir Care. 2013;58(3):525-531. (Observational cohort; 120 patients)
  56. Yokoyama T, Kondoh Y, Taniguchi H, et al. Noninvasive ventilation in acute exacerbation of idiopathic pulmonary fibrosis. Intern Med. 2010;49(15):1509-1514. (Retrospective chart review; 11 patients)
  57. Mollica C, Paone G, Conti V, et al. Mechanical ventilation in patients with end-stage idiopathic pulmonary fibrosis. Respiration. 2010;79(3):209-215. (Retrospective chart review; 34 patients)
  58. Modell JH, Graves SA, Ketover A. Clinical course of 91 consecutive near-drowning victims. Chest. 1976;70(2):231-238. (Retrospective case review; 91 patients)
  59. Pendergast DR, Lundgren CE. The underwater environment: cardiopulmonary, thermal, and energetic demands. J Appl Physiol (1985). 2009;106(1):276-283. (Review)
  60. Orlowski JP, Szpilman D. Drowning. Rescue, resuscitation, and reanimation. Pediatr Clin North Am. 2001;48(3):627-646. (Review)
  61. Epstein M. Renal effects of head-out water immersion in humans: a 15-year update. Physiol Rev. 1992;72(3):563-621. (Review)
  62. Szpilman D. Near-drowning and drowning classification: a proposal to stratify mortality based on the analysis of 1,831 cases. Chest. 1997;112(3):660-665. (Review; 2304 patients)
  63. Noonan L, Howrey R, Ginsburg CM. Freshwater submersion injuries in children: a retrospective review of seventy-five hospitalized patients. Pediatrics. 1996;98(3 Pt 1):368-371. (Retrospective chart review; 75 patients)
  64. van Berkel M, Bierens JJ, Lie RL, et al. Pulmonary oedema, pneumonia and mortality in submersion victims; a retrospective study in 125 patients. Intensive Care Med. 1996;22(2):101- 107. (Retrospective; 125 patients)
  65. Layon AJ, Modell JH. Drowning: update 2009. Anesthesiology. 2009;110(6):1390-1401. (Review)
  66. Nelson SW, McCorvey SC. Submersion and drowning injuries. 2015. Available at: Accessed September 7, 2016. (Online review)
  67. Szpilman D, Bierens JJ, Handley AJ, et al. Drowning. N Engl J Med. 2012;366(22):2102-2110. (Review)
  68. Mayordomo-Colunga J, Medina A, Rey C, et al. Predictive factors of non invasive ventilation failure in critically ill children: a prospective epidemiological study. Intensive Care Med. 2009;35(3):527-536. (Prospective observational; 116 patients)
  69. Dohna-Schwake C, Stehling F, Tschiedel E, et al. Non-invasive ventilation on a pediatric intensive care unit: feasibility, efficacy, and predictors of success. Pediatr Pulmonol. 2011;46(11):1114-1120. (Retrospective chart review; 74 patients)
  70. Abadesso C, Nunes P, Silvestre C, et al. Non-invasive ventilation in acute respiratory failure in children. Pediatr Rep. 2012;4(2):e16. (Prospective observational; 151 patients)
  71. Vitaliti G, Wenzel A, Bellia F, et al. Noninvasive ventilation in pediatric emergency care: a literature review and description of our experience. Expert Rev Respir Med. 2013;7(5):545- 552. (Review)
  72. Contou D, Fragnoli C, Cordoba-Izquierdo A, et al. Non-invasive ventilation for acute hypercapnic respiratory failure: intubation rate in an experienced unit. Respir Care. 2013;58(12):2045-2052. (Observational cohort; 242 patients)
  73. Pacilli AM, Valentini I, Carbonara P, et al. Determinants of noninvasive ventilation outcomes during an episode of acute hypercapnic respiratory failure in chronic obstructive pulmonary disease: the effects of comorbidities and causes of respiratory failure. Biomed Res Int. 2014;2014:976783. (Prospective; 176 patients)
  74. Antonaglia V, Ferluga M, Capitanio G, et al. Respiratory mechanics in COPD patients who failed non-invasive ventilation: role of intrinsic PEEP. Respir Physiol Neurobiol. 2012;184(1):35-40. (Prospective; 29 patients)
  75. Savi A, Gasparetto Maccari J, Frederico Tonietto T, et al. Influence of FIO2 on PaCO2 during noninvasive ventilation in patients with COPD. Respir Care. 2014;59(3):383-387. (Prospective; 17 patients)
  76. Galindo-Filho VC, Brandao DC, Ferreira Rde C, et al. Noninvasive ventilation coupled with nebulization during asthma crises: a randomized controlled trial. Respir Care. 2013;58(2):241-249. (Randomized controlled; 21 patients)
  77. Carvalho L, Carneiro R, Freire E, et al. Non-invasive ventilation in cardiogenic pulmonary edema in the emergency department. Rev Port Cardiol. 2008;27(2):191-198. (Retrospective observational; 17 patients)
  78. Cosentini R, Brambilla AM, Aliberti S, et al. Helmet continuous positive airway pressure vs oxygen therapy to improve oxygenation in community-acquired pneumonia: a randomized, controlled trial. Chest. 2010;138(1):114-120. (Multicenter randomized controlled trial; 47 patients)
  79. Confalonieri M, Gazzaniga P, Gandola L, et al. Haemodynamic response during initiation of non-invasive positive pressure ventilation in COPD patients with acute ventilatory failure. Respir Med. 1998;92(2):331-337. (Prospective observational; 19 patients)
  80. Peter JV, Moran JL, Phillips-Hughes J, et al. Effect of non-invasive positive pressure ventilation (NIPPV) on mortality in patients with acute cardiogenic pulmonary oedema: a meta-analysis. Lancet. 2006;367(9517):1155-1163. (Meta-analysis; 23 studies)
  81. Liesching T, Nelson DL, Cormier KL, et al. Randomized trial of bilevel versus continuous positive airway pressure for acute pulmonary edema. J Emerg Med. 2014;46(1):130-140. (Randomized; 27 patients)
  82. Agarwal R, Aggarwal AN, Gupta D. Role of noninvasive ventilation in acute lung injury/acute respiratory distress syndrome: a proportion meta-analysis. Respir Care. 2010;55(12):1653-1660. (Systematic review; 13 studies)
  83. Zhan Q, Sun B, Liang L, et al. Early use of noninvasive positive pressure ventilation for acute lung injury: a multicenter randomized controlled trial. Crit Care Med. 2012;40(2):455- 460. (Multicenter randomized controlled; 40 patients)
  84. Quill CM, Quill TE. Palliative use of noninvasive ventilation: navigating murky waters. J Palliat Med. 2014;17(6):657-661. (Case report; 4 patients)
  85. Peters SG, Holets SR, Gay PC. High-flow nasal cannula therapy in do-not-intubate patients with hypoxemic respiratory distress. Respir Care. 2013;58(4):597-600. (Prospective; 50 patients)
  86. Azoulay E, Kouatchet A, Jaber S, et al. Noninvasive mechanical ventilation in patients having declined tracheal intubation. Intensive Care Med. 2013;39(2):292-301. (Prospective observational cohort; 780 patients)
  87. Bulow HH, Thorsager B. Non-invasive ventilation in do-not-intubate patients: five-year follow-up on a two-year prospective, consecutive cohort study. Acta Anaesthesiol Scand. 2009;53(9):1153-1157. (Retrospective observational; 38 patients)
  88. Scarpazza P, Incorvaia C, Amboni P, et al. Long-term survival in elderly patients with a do-not-intubate order treated with noninvasive mechanical ventilation. Int J Chron Obstruct Pulmon Dis. 2011;6:253-257. (Prospective observational; 54 patients)
  89. Servera E, Sancho J, Zafra MJ, et al. Alternatives to endotracheal intubation for patients with neuromuscular diseases. Am J Phys Med Rehabil. 2005;84(11):851-857. (Prospective cohort; 17 patients)
  90. Bourke SC, Tomlinson M, Williams TL, et al. Effects of non-invasive ventilation on survival and quality of life in patients with amyotrophic lateral sclerosis: a randomised controlled trial. Lancet Neurol. 2006;5(2):140-147. (Randomized controlled; 92 patients)
  91. Wanek S, Mayberry JC. Blunt thoracic trauma: flail chest, pulmonary contusion, and blast injury. Crit Care Clin. 2004;20(1):71-81. (Review)
  92. Uretzky G, Cotev S. The use of continuous positive airway pressure in blast injury of the chest. Crit Care Med. 1980;8(9):486-489. (Case report)
  93. Chiumello D, Coppola S, Froio S, et al. Noninvasive ventilation in chest trauma: systematic review and meta-analysis. Intensive Care Med. 2013;39(7):1171-1180. (Systematic review; 10 studies)
  94. McIlwaine M, Button B, Dwan K. Positive expiratory pressure physiotherapy for airway clearance in people with cystic fibrosis. Cochrane Database Syst Rev. 2015;6:CD003147. (Cochrane review; 26 studies)
  95. Moran F, Bradley JM, Piper AJ. Non-invasive ventilation for cystic fibrosis. Cochrane Database Syst Rev. 2013;4:CD002769. (Cochrane review; 7 studies, 106 patients)
  96. Armstrong D. The use of continuous positive airway pressure or non-invasive ventilation as forms of respiratory support in children with cystic fibrosis. Paediatr Respir Rev. 2013;14 Suppl 1:19-21. (Review; 22 references)
  97. Constantin JM, Schneider E, Cayot-Constantin S, et al. Remifentanil-based sedation to treat noninvasive ventilation failure: a preliminary study. Intensive Care Med. 2007;33(1):82- 87. (Prospective; 13 patients)
  98. Rocco M, Conti G, Alessandri E, et al. Rescue treatment for noninvasive ventilation failure due to interface intolerance with remifentanil analgosedation: a pilot study. Intensive Care Med. 2010;36(12):2060-2065. (Prospective; 36 patients)
  99. Huang Z, Chen YS, Yang ZL, et al. Dexmedetomidine versus midazolam for the sedation of patients with non-invasive ventilation failure. Intern Med. 2012;51(17):2299-2305. (Randomized controlled; 62 patients)
  100. Devlin JW, Al-Qadheeb NS, Chi A, et al. Efficacy and safety of early dexmedetomidine during noninvasive ventilation for patients with acute respiratory failure: a randomized, double-blind, placebo-controlled pilot study. Chest. 2014;145(6):1204-1212. (Randomized controlled; 33 patients)
  101. American Society of Anesthesiologists Task Force on Seda-tion and Analgesia by Non-Anesthesiologists. Practice guidelines for sedation and analgesia by non-anesthesiologists. Anesthesiology. 2002;96(4):1004-1017. (Task force recommendations)
  102. Remick J, Sacchetti A, Bages G, et al. Noninvasive positive pressure ventilation in procedural sedation. Am J Emerg Med. 2010;28(6):750 e751-e753. (Case report)
  103. Strayer RJ, Caputo ND. Noninvasive ventilation during procedural sedation in the ED: a case series. Am J Emerg Med. 2015;33(1):116-120. (Case series; 11 patients)
  104. Landoni G, Cabrini L. Noninvasive ventilation outside the ICU. In: JL V, ed. Annual Update of Intensive Care and Emergency Medicine. Berlin, Heidelberg: Springer-Verlag; 2012:207- 218. (Textbook)
  105. Cabrini L, Antonelli M, Savoia G, et al. Non-invasive ventilation outside of the intensive care unit: an Italian survey. Minerva Anestesiol. 2011;77(3):313-322. (Survey questionnaire; 46 hospitals)
Publication Information

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

Publication Date

February 1, 2017

Content you might be interested in
Already purchased this course?
Log in to read.
Purchase a subscription

Price: $449/year

140+ Credits!

Money-back Guarantee
Get A Sample Issue Of Emergency Medicine Practice
Enter your email to get your copy today! Plus receive updates on EB Medicine every month.
Please provide a valid email address.