Noninvasive mechanical ventilation (NIV) is widely used in the acute care setting for acute respiratory failure (ARF) across a variety of aetiologies. This document provides European Respiratory Society/American Thoracic Society recommendations for the clinical application of NIV based on the most current literature.The guideline committee was composed of clinicians, methodologists and experts in the field of NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology for each actionable question. The GRADE Evidence to Decision framework in the guideline development tool was used to generate recommendations. A number of topics were addressed using technical summaries without recommendations and these are discussed in the supplementary material.This guideline committee developed recommendations for 11 actionable questions in a PICO (population–intervention–comparison–outcome) format, all addressing the use of NIV for various aetiologies of ARF. The specific conditions where recommendations were made include exacerbation of chronic obstructive pulmonary disease, cardiogenic pulmonary oedema,de novohypoxaemic respiratory failure, immunocompromised patients, chest trauma, palliation, post-operative care, weaning and post-extubation.This document summarises the current state of knowledge regarding the role of NIV in ARF. Evidence-based recommendations provide guidance to relevant stakeholders.

In order to confirm that re-intubation can be a risk factor of nosocomial pneumonia in mechanically ventilated patients, a case-control study was performed. Forty consecutive patients needing re-intubation were selected as cases. Each case was paired with a matched control for the previous duration of mechanical ventilation (+/- 2 d). Nineteen (47%) of the cases developed pneumonia after re-intubation compared with 4 (10%) of the controls (odds ratio [OR] = 8.5; 95% confidence interval [CI] 1.7 to 105.9; p = 0.0007). After adjusting for age, sex, and presence of prior bronchoscopy, the conditional logistic regression analysis demonstrated that re-intubation was the only significant factor related to the development of pneumonia (OR: 5.94; 95% CI 1.27 to 22.71; p = 0.023). Sixteen (73%) of the 22 patients lying semirecumbent during the interval between extubation and re-intubation developed nosocomial pneumonia versus three (16%) of the 18 in supine position (p = 0.001). These results indicate that semirecumbency during the period between extubation and re-intubation may play a role in nosocomial pneumonia development in patients who need re-intubation. Total intensive care unit stay (19.4 +/- 10 versus 13.9 +/- 11.9 days, p = 0.0008) and crude mortality (35 versus 20%, p = 0.14) were also higher in re-intubated patients when compared with controls. We conclude that re-intubation is a risk factor for ventilator-associated pneumonia and might be avoided in a substantial number of cases.

Because animal studies have demonstrated that mechanical ventilation at high volume and pressure can be deleterious to the lungs, limitation of airway pressure, allowing hypercapnia if necessary, is already used for ventilation of acute respiratory distress syndrome (ARDS). Whether a systematic and more drastic reduction is necessary is debatable. A multicenter randomized study was undertaken to compare a strategy aimed at limiting the end-inspiratory plateau pressure to 25 cm H2O, using tidal volume (Vt) below 10 ml/kg of body weight, versus a more conventional ventilatory approach (with regard to current practice) using Vt at 10 ml/kg or above and close to normal PaCO2. Both arms used a similar level of positive end-expiratory pressure. A total of 116 patients with ARDS and no organ failure other than the lung were enrolled over 32 mo in 25 centers. The two groups were similar at inclusion. Patients in the two arms were ventilated with different Vt (7.1 ± 1.3 versus 10.3 ± 1.7 ml/kg at Day 1, p < 0.001) and plateau pressures (25.7 ± 5.0 versus 31.7 ± 6.6 cm H2O at Day 1, p < 0.001), resulting in different PaCO2 (59.5 ± 15.0 versus 41.3 ± 7.6 mm Hg, p < 0.001) and pH (7.28 ± 0.09 versus 7.4 ± 0.09, p < 0.001), but a similar level of oxygenation. The new approach did not reduce mortality at Day 60 (46.6% versus 37.9% in control subjects, p = 0.38), the duration of mechanical ventilation (23.1 ± 20.2 versus 21.4 ± 16.3 d, p = 0.85), the incidence of pneumothorax (14% versus 12%, p = 0.78), or the secondary occurrence of multiple organ failure (41% versus 41%, p = 1). We conclude that no benefit could be observed with reduced Vt titrated to reach plateau pressures around 25 cm H2O compared with a more conventional approach in which normocapnia was achieved with plateau pressures already below 35 cm H2O.

The efficacy of noninvasive ventilation (NIV) to avoid intubation and improve survival was assessed in 105 patients with severe acute hypoxemic respiratory failure (arterial O2 tension or saturation persistently 60 mm Hg or less or 90% or less, respectively; breathing conventional Venturi oxygen at a maximal concentration [50%]), excluding hypercapnia, admitted into intensive care units of three hospitals. Patients were randomly allocated within 24 hours of fulfilling inclusion criteria to receive NIV (n = 51) or high-concentration oxygen therapy (n = 54). The primary end-point variable was the decrease in the intubation rate. Both groups had similar characteristics. Compared with oxygen therapy, NIV decreased the need for intubation (13, 25% vs. 28, 52%, p = 0.010), the incidence of septic shock (6, 12% vs. 17, 31%, p = 0.028), and the intensive care unit mortality (9, 18% vs. 21, 39%, p = 0.028) and increased the cumulative 90-day survival (p = 0.025). The improvement of arterial hypoxemia and tachypnea was higher in the noninvasive ventilation group with time (p = 0.029 each). Multivariate analyses showed NIV to be independently associated with decreased risks of intubation (odds ratio, 0.20; p = 0.003) and 90-day mortality (odds ratio, 0.39; p = 0.017). The use of noninvasive ventilation prevented intubation, reduced the incidence of septic shock, and improved survival in these patients compared with high-concentration oxygen therapy.