0811

EM Critical Care
UNDERSTANDING AND CARING FOR

CRITICAL ILLNESS IN EMERGENCY MEDICINE
Noninvasive Ventilation:
Update On Uses For The
Critically Ill Patient
Abstract
Robert T. Arntfield, MD, FRCPC

Instructor, Department of
Emergency Medicine, Mount Sinai
School of Medicine, New York, NY
Associate Editor
Scott Weingart, MD, FACEP
Assistant Professor, Department of
Emergency Medicine, Mount Sinai
School of Medicine, New York,
NY; Director of Emergency Critical
Care, Elmhurst Hospital Center,
New York, NY
Editorial Board
Benjamin S. Abella, MD, MPhil,
FACEP
Assistant Professor, Department
of Emergency Medicine and
Department of Medicine / Section
of Pulmonary Allergy and Critical
Care, University of Pennsylvania
School of Medicine, Philadelphia,
PA; Clinical Research Director,
Center for Resuscitation Science,
Philadelphia, PA
Jose Dionisio Torres, Jr., MD
Clinical Instructor in Emergency Medicine, New York Hospital

Queens, Flushing, NY
Michael S. Radeos, MD, MPH
Research Director, Department of Emergency Medicine,

Flushing, NY; Assistant Professor of Emergency Medicine, Weill
Cornell Medical College, New York, NY
Peer Reviewers
oninvasive ventilation (NIV) is a method of delivering

oxygen by positive pressure mask that allows the clinician to
postpone or prevent invasive tracheal intubation in patients who
present to the emergency department (ED) with acute respiratory
failure (ARF). There are 2 primary modalities of NIV: continuous
positive airway pressure (CPAP) and bi-level positive pressure
ventilation (BPAP) where the inspiratory positive airway pressure (IPAP) is higher than the expiratory positive airway pressure
(EPAP). Continuous positive airway pressure appears to be more
effective in reducing the need for tracheal intubation and possibly
mortality in patients presenting with acute cardiogenic pulmonary
edema (ACPE). Bi-level positive pressure ventilation appears to
be more effective in reducing mortality and the need for tracheal
intubation in patients with an acute decompensation of chronic
obstructive pulmonary disease (COPD). Proper patient selection
is critical in the use of NIV for ED patients. They must be able
to cooperate with the respiratory therapist and tolerate the often
uncomfortable nasal or face mask. The emergency clinician must
be vigilant for signs of clinical deterioration in these patients as
they may need an emergent definitive airway placed. This issue of
EMCC examines the evidence supporting the use of NIV in various
causes of ARF and reviews potential complications.
Editor-in-Chief
Volume 1, Number 2
Authors
Lillian L. Emlet, MD, MS, FACEP

Critical Care Medicine, Department
of Emergency Medicine, University
of Pittsburgh Medical Center,
Pittsburgh, PA; Program Director,
EM-CCM Fellowship of the
Multidisciplinary Critical Care
Training Program, Pittsburgh, PA
Thomas J. Abramo, MD, FAAP, FACEP
Professor of Pediatrics & Emergency Medicine, Division Chief,

Medical Director of Pediatric Emergency Medicine, Department
of Pediatrics, Division of Pediatric Emergency Medicine,
Director, Pediatric Emergency Medicine Fellowship Program,
Medical Director of Pediatric Transport, Monroe Carell Jr.
Childrens Hospital at Vanderbilt, Nashville, TN
John M. Litell, DO
Chief Fellow, Division of Pulmonary and Critical Care Medicine,

Mayo Clinic, Rochester, MN
Ryan G. K. Mihata, MD, MPH, FAAEM
Clinical Assistant Professor of Emergency Medicine, Wright

State University, Boonshoft School of Medicine, Dayton, OH
CME Objectives
Upon completion of this article, you should be able to:
1.
2.
3.
4.
5.
Describe the potential advantages of NIV over

endotracheal intubation.
Describe the various forms of NIV.
Describe techniques for initiation of NIV in the ED.

Recognize the contraindications to NIV.
Summarize the current evidence relating to the use of

NIV.
Date of original release: August 1, 2011

Date of most recent review: July 10, 2011
Termination date: August 1, 2014
Medium: Print and Online
Method of participation: Print or online answer form and
evaluation
Prior to beginning this activity, see CME Information on the
back page.
Andy Jagoda, MD, FACEP

Julie Mayglothling, MD
Professor and Chair, Department
of Emergency Medicine, Mount
of Emergency Medicine,
Sinai School of Medicine; Medical
Department of Surgery, Division
Director, Mount Sinai Hospital, New
of Trauma/Critical Care, Virginia
York, NY
Commonwealth University,
Richmond, VA
William A. Knight, IV, MD
Assistant Professor of Emergency Christopher P. Nickson, MBChB,
Medicine, Assistant Professor
MClinEpid
Michael A. Gibbs, MD, FACEP
of Neurosurgery, Emergency
Supervising Registrar, Department
Professor and Chief, Department
Medicine Mid-Level Program
of Emergency Medicine, Sir
of Emergency Medicine, Maine
Medical Director, University of
Charles Gairdner Hospital, Perth,
Medical Center, Portland, ME; Tufts
Cincinnati College of Medicine,
Australia
University School of Medicine,
Cincinnati, OH
Boston, MA
Jon Rittenberger, MD, MS
Haney Mallemat, MD
Robert Green, MD, BSc, DABEM,
Associate Professor, Department
of Emergency Medicine,
of Critical Care / Emergency
FRCPC
University of Pittsburgh School
Medicine, University of Maryland
Associate Professor, Department
of Medicine, Pittsburgh, PA;
Medical Center, Baltimore, MD;
of Anaesthesia: Division of Critical
Attending, Emergency Medicine
Department of Critical Care, Shock
Care Medicine, Department of
and Post-Cardiac Arrest Services,
Trauma Center, Baltimore, MD
Emergency Medicine, Dalhousie
UPMC-Presbyterian Hospital,
University, Halifax, Nova Scotia,
Pittsburgh, PA
Canada
Evie Marcolini, MD, FAAEM
Emergency Medicine and Critical
Care, Yale School of Medicine,
New Haven, CT
Emanuel P. Rivers, MD, MPH, IOM

Vice Chairman and Director
of Research, Department of
Emergency Medicine, Senior
Staff Attending, Departments
of Emergency Medicine and
Surgery (Surgical Critical Care),
Henry Ford Hospital, Detroit, MI;
Clinical Professor, Department of
Emergency Medicine and Surgery,
Wayne State University School of
Medicine, Detroit, MI
Isaac Tawil, MD
Surgery, Department of Emergency
Medicine, University of New
Mexico Health Science Center,
Albuquerque, NM
Research Editor
Jennifer L. Galjour, MD, MPH
Department of Emergency
Medicine, Mount Sinai School of
Medicine, New York, NY
Case Presentation
needs immediate tracheal intubation. In this issue of

EMCC, we will examine the evidence and various
recommendations for the use of NIV in a variety of
patient presentations.
The triage nurse calls you to the resuscitation room where

you find a morbidly obese male who is gasping for air and
is cool, pale, and diaphoretic. He is seated in the tripod position with nasal flaring, pursed-lip breathing, and rales
to the apices, and he is speaking in 1-2 word sentences.
His blood pressure is 240/160. EMS providers have given
sublingual nitroglycerin but were unable to obtain IV access and have therefore not given furosemide. You realize
that attempting tracheal intubation on this patient is a
recipe for disaster. You have used NIV for patients with
COPD, but you havent tried it in patients with ACPE.
You page the respiratory therapist to bring the noninvasive ventilator, hoping that NIV will help the patient
avoid the need for a difficult intubation. The respiratory
therapist asks whether you want bi-level NIV or CPAP.
You are not sure, so you ask the respiratory therapist
which modality she believes is best. She recommends
CPAP but wants to know what pressure to deliver. Again
you defer to her knowledge, and she replies 10 cm H2O.
Finally, she wants to know whether you prefer a nasal
mask, a face mask, or a helmet. You reply: Whatever you
think is best is fine with me. As you closely monitor the
patient on NIV, you set up for RSI, just in case.
Indications For Noninvasive Ventilation In

Acute Respiratory Failure
There is no clear consensus on the indications for

NIV in the various forms of ARF, and each study has
unique inclusion and exclusion criteria. A simple
way to approach the use of NIV in ARF is to assess for the presence of certain commonly accepted
absolute contraindications. (See Table 2.) Unfortunately, there is no clear threshold for determining
who needs immediate intubation. In the absence of
contraindications, many dyspneic patients may be
suitable candidates for a trial of NIV. Furthermore,
in those patients needing definitive airway control,
some authors have suggested that NIV may be useful in the preoxygenation phase of rapid sequence
intubation (RSI). Note that a blood gas result may
not return fast enough to guide decision-making.
Introduction
Acute respiratory failure is encountered in the
prehospital setting, the ED, the medical wards, and
the intensive care unit (ICU). In these challenging clinical scenarios, NIV can provide emergency
clinicians with a promising treatment modality for
acutely dyspneic patients. While tracheal intubation is considered the definitive method of airway
control, this intervention is associated with additional risks and morbidity, related both to induction
and tube placement, as well as ventilator-associated
complications. While intubation is often instinctual
for emergency clinicians confronted with a patient in
respiratory failure, accumulating evidence suggests
that NIV can decrease the need for tracheal intubation, decrease hospital length of stay, and save lives.

Despite this, NIV is a temporizing measure that
must be used selectively. Patients must be closely
monitored to detect failure of therapy so that more
definitive management is not delayed. Acute exacerbations of asthma and/or COPD and ACPE are 2 of the
diagnoses that appear to benefit the most from NIV.

The terminology used to describe NIV (Table
1) can be confusing, a fact that can interfere with
communication between emergency clinicians and
respiratory therapists, complicating the prompt application of time-sensitive therapy. In this article, the
term NIV will be used routinely to refer to all modes
of noninvasive ventilation.

It is critical to recognize the patient in whom it is
safe to try NIV and to avoid NIV in the patient who
EMCC 2011
Table 1. Noninvasive Ventilation Glossary
ACPE
Acute cardiogenic pulmonary edema
ARF
Acute respiratory failure
BPAP
Bi-level positive airway pressure, in which the

ventilator delivers different levels of pressure
during inspiration and expiration. (While often
used as a generic term, BiPAP and BIPAP are
actually trademarked modes of NIV.)
CPAP
Continuous positive airway pressure; a fixed positive pressure throughout the respiratory cycle
EPAP
Expiratory positive airway pressure
HARF
Hypoxemic acute respiratory failure
IPAP
Inspiratory positive airway pressure
NIV
Ventilation delivered without an orotracheal or

tracheostomy tube, including bi-level NIV via
mask as well as negative pressure or abdominal
compressive devices
NPPV
Noninvasive positive pressure ventilation; this

differs from the term NIV only by its exclusion
of negative pressure ventilation. Due to the
rarity of the latter approach, NPPV and NIV are
frequently used interchangeably
PEEP
Positive end-expiratory pressure
Pressure
Support
The difference between inspiratory and expiratory

positive airway pressure (IPAP - EPAP)
VE
Minute ventilation
VT
Tidal volume
www.ebmedicine.net Volume 1, Number 2
Critical Appraisal Of The Literature
blood gases. Finally, is the timing of NIV important?

Does faster door-to-mask time improve outcomes?
This review of the existing data will take all of these
considerations into account.
Ovid MEDLINE and PubMed were searched for

the best literature pertaining to NIV in ARF from
1950 to the present. The Cochrane Library, CINAHL,
and EMBASE were also searched. Over 300 articles
were retrieved, and the references from relevant
articles were searched for any articles that the
search may have missed. In addition, the National
Guideline Clearinghouse (www.guidelines.gov) was
searched for NIV guidelines pertinent to the patient
with acute respiratory distress. (See Table 3 on page
pages 4 & 5.)

When reviewing the sizable literature on NIV,
it is important to remember an issue that makes the
interpretation of results difficult. The point at which
an eligible patient is enrolled in an NIV study is
challenging to standardize. Studies that compare
NIV with emergent intubation can suffer from confounding by indication. In other words, the intubated group is often sicker at baseline and may be more
likely to have increased morbidity and mortality
than the NIV group. However, as Voltaire said, the
perfect is the enemy of the good. The evidence base
for NIV in various indications and for its use in the
ED setting is far from complete. Readers are encouraged to tread cautiously through the dense thicket
of literature as it pertains to the acutely dyspneic
patient in the ED.

In addition to the difficulty in choosing eligible
patients and comparing groups with equal chances
of outcomes, it is essential to agree on relevant outcomes. Published outcomes range from decreased
mortality to increased comfort of breathing. Additional possibilities include decreased respiratory
rates, ease of breathing, decreased work of breathing, improved patient comfort, rates of tracheal
intubation, ICU length of stay, and improvement in
Going Deeper: How Noninvasive

Ventilation Works
In acute respiratory failures of any etiology, the
patient is at risk of hypoxemic cardiac arrest. Historically, if these patients did not improve with a
100% nonrebreather mask, the clinician prepared for
RSI. Noninvasive ventilation provides the clinician
an opportunity to avoid tracheal intubation with its
inherent complications,2 including hypoxemia due
to prolonged attempts, esophageal intubation, dental or airway trauma, loss of protective reflexes with
aspiration, and barotrauma. Nasal intubation, an
occasional alternative to RSI, can result in sinusitis
and posterior epistaxis.3

In simple terms, the various forms of NIV involve
a pressurized oxygen/air mixture delivered by a
mechanical ventilator through several types of mask.
When a fixed pressure is used, this is referred to as
CPAP. Alternatively, this fixed EPAP can be combined
with a higher IPAP that is triggered by the patients
inspiratory effort. The difference between EPAP and
IPAP, called pressure support, augments ventilation
and reduces work of breathing, both of which can
reverse hypercapneic respiratory failure. This mode is
called bi-level positive airway pressure, which is commonly referred to as BiPAP, although this is a proprietary name.

Noninvasive ventilation improves lung mechanics by improving laminar airway flow by stenting
closed airways or semi-obstructed airways thus
decreasing atelectatic alveoli, improving pulmonary
compliance, and reducing the work of breathing.
Continuous positive airway pressure appears to mediate its therapeutic effects in ACPE through several
interesting mechanisms. Contrary to popular belief,
NIV does not simply force edema fluid out of flooded alveoli. Rather, the effects are due to the addition
of positive pressure to the thoracic compartment,
resulting in both preload and afterload reduction.4 In
a study of acute lung injury (ALI) in pigs, Carvalho
et al used invasive monitoring and computed tomography scanning to determine that improvements in
oxygenation in pressure support ventilation were
due to redistribution of pulmonary blood flow rather
than recruitment of dependent zones.5 In addition,
positive airway pressure reduces venous return to
the heart. In patients without congestive heart failure
(CHF), this decrease in preload may be clinically
insignificant. In one study of 19 patients with COPD
and acute respiratory failure, Confalonieri and colleagues found no significant changes in pulmonary
artery pressures and cardiac output by Doppler echo-
Table 2. Absolute And Relative

Contraindications To Noninvasive
Ventilation1
Absolute Contraindications

Need for immediate endotracheal intubation

Decreased level of consciousness

Excess respiratory secretions and risk of vomiting and aspiration

Past facial surgery precluding mask fitting
Relative Contraindications

Hemodynamic instability

Severe hypoxia and/or hypercapnia, PaO2/FiO2 ratio of < 200
mm Hg, PaCO2 > 60 mm Hg

Poor patient cooperation

Lack of trained or experienced staff
Used with permission from European Respiratory Society 2010.
EMCC 2011
Patient Selection
cardiography in 15 patients; 4 patients (21%) showed

a significant reduction (> 15%) of cardiac output
during NIV.6 Naughton and colleagues demonstrated
another important hemodynamic benefit of CPAP
in CHF.7 They studied 15 patients with CHF and 9
healthy controls, applying CPAP for 75 minutes and
measuring inspiratory esophageal pressures and
calculated left ventricular wall stress. Among CHF
patients, CPAP seems to benefit patients with ACPE
by decreasing left ventricular (LV) afterload and
decreasing the inspiratory work of breathing without
negatively affecting the cardiac index. Continuous
positive airway pressure had no effect on healthy
volunteers.
While NIV has reported benefits in various etiologies of ARF, it is important to avoid its use in patients with absolute contraindications. There are no
uniform indications for NIV, as each study focuses
on one type of ARF and often excludes patients with
alternative diagnoses. Table 4 on page 7 shows indications and initial ventilator settings described in the
methods sections of selected clinical trials.
Noninvasive Ventilation In The Prehospital

Setting
Plaisance and colleagues performed a prehospital
Table 3. Selected Published Guidelines For The Use Of Noninvasive Ventilation (continued on page 5)
Organization
Topic
Type of
Guideline
Recommendations
American College of Emergency Physicians (ACEP) Clinical

Policies Subcommittee
(Writing Committee) on Acute
Heart Failure Syndromes8
Clinical Policy: Critical

Issues in the Evaluation and Management
of Adult Patients
Presenting to the
Emergency Department with Acute Heart
Failure Syndromes
Evidence-based
Use 5 to 10 cm H2O CPAP by nasal or face mask as therapy for

dyspneic patients with AHF syndrome without hypotension or the
need for emergent intubation to improve heart rate, respiratory
rate, and blood pressure and to reduce the need for intubation
and possibly inhospital mortality (Grade B).
Consider using bi-level NIV as an alternative to CPAP for dyspneic
patients with AHF syndrome; however, data about the possible
association between bi-level NIV and myocardial infarction remain
unclear (Grade C).
British Thoracic Society9
Update of 2002 British

Thoracic Society
guideline for ARF in
COPD
Evidence-based
NIV should be considered in all patients with an acute exacerbation

of COPD in whom a respiratory acidosis (pH < 7.35, PaCO2 > 6
kPa [45 mm Hg]) is present (Not graded).
Quality Standards Subcommittee of the American Academy

of Neurology10
Practice Parameter
Update: The Care
of the Patient with
Amyotrophic Lateral
Sclerosis: Drug, Nutritional, and Respiratory Therapies
Evidence-based
NIV should be considered to treat respiratory insufficiency in ALS,

both to lengthen survival (Level B) and to slow the decline of
forced vital capacity (Level B).
NIV may be considered to improve quality of life (Level C).
American College of Physicians American Society of

Internal Medicine (ACPASIM) and the American
College of Chest Physicians
(ACCP)11
Management of Acute
Exacerbations of
Chronic Obstructive
Pulmonary Disease:
A Summary and Appraisal of Published
Evidence
Evidence-based
Bi-level NIV is a beneficial support strategy that decreases the

risk for invasive mechanical ventilation and possibly improves
survival in selected hospitalized patients with respiratory failure
(Not graded).
Global Initiative for Chronic

Obstructive Lung Disease
(GOLD)12
Global Strategy for the

Diagnosis, Management, and Prevention
of Chronic Obstructive Pulmonary
Disease
Evidence-based
NIV improves respiratory acidosis (increases pH and decreases

PaCO2) and decreases respiratory rate, severity of breathlessness, and length of hospital stay in patients with acute exacerbations of COPD (Evidence A).
Mortalityor its surrogate, intubation rateis reduced by this
intervention (Not graded).
American College of Critical

Care Medicine13
Recommendations for
end-of-life care in the
intensive care unit: a
consensus statement
by the American
Academy of Critical
Care Medicine
Consensus
A patient who has specifically refused intubation but desires other

aspects of intensive care with the goal of prolonging survival may
choose NIV (Not graded).
NIV may be used as a palliative technique to minimize dyspnea.
When used for the latter indication, NIV should be stopped when
it is no longer effective at relieving that symptom (Not graded).
EMCC 2011
study to determine whether the timing of NIV mattered.14 They enrolled patients with clinical signs of
pulmonary edema and SpO2 < 90% but excluded
anyone with COPD. They compared immediate
CPAP versus a 15-minute delay in administering
CPAP and found that dyspnea scores were significantly improved in the early group compared with
the delayed group at 15 minutes (4 2 vs 7 2, P =
0.003). There was an impressive reduction in tracheal intubation between the groups, which was
statistically significant (1 of 63 in the early CPAP
group vs 8 of 61 in the late group, P = 0.01). In a
systematic review, Simpson and Bendall found only
3 randomized trials that enrolled mostly patients
with ACPE.15 Their results suggest that prehospital

NIV may reduce both mortality and tracheal intubation by approximately 75%. The number of patients
remains small, but the potential benefits of the relatively unexplored area of prehospital NIV may be
substantial. Overall, noninvasive ventilation shows
promise in the prehospital setting, but more research
is needed to determine its cost-effectiveness.
Acute Exacerbation Of Chronic Obstructive

Pulmonary Disease
Ram and colleagues performed a Cochrane systematic review of NIV in acute exacerbations of
COPD based on 14 clinical trials including 758 total
Table 3. Selected Published Guidelines For The Use Of Noninvasive Ventilation (continued from page 4)
Organization
Topic
Type of
Guideline
Recommendations
Infectious Diseases Society of

America/American Thoracic
Society16
Consensus Guidelines
on the Management
of CommunityAcquired Pneumonia
in Adults
Consensus
Patients with hypoxemia or respiratory distress should receive a

cautious trial of NIV unless they require immediate intubation because of severe hypoxemia (PaO2/FiO2 ratio < 150) and bilateral
alveolar infiltrates (Moderate recommendation; level I evidence).
National Heart, Lung, and

Blood Institute Expert Panel
Report 317
Expert Panel Report

3: Guidelines for the
Diagnosis and Management of Asthma
Evidence-based
Other adjunct therapies to avoid intubation include intravenous

beta2-agonists, intravenous LTRAs, and NIV; however, insufficient
data are available to make recommendations regarding these
possible adjunct therapies (Evidence D).
European Society of Cardiology18
European Society of
Cardiology Guidelines
for the Diagnosis and
Treatment of Acute
and Chronic Heart
Failure
Evidence-based
NIV with PEEP should be considered as early as possible in every

patient with acute cardiogenic pulmonary oedema and hypertensive AHF as it improves clinical parameters including respiratory
distress. NIV with PEEP improves LV function by reducing LV
afterload. NIV should be used with caution in cardiogenic shock
and RV failure; however, the authors were unable to find evidence
to support this cautious approach in RV failure or cardiogenic
shock (Class I, Level C).
Early application of NIV in patients with acute cardiogenic pulmonary oedema reduces both the need for intubation and short-term
mortality (Class IIa, Level B).
Intubation and mechanical ventilation should be restricted to patients in whom oxygen delivery is not adequate by oxygen mask
or NIV and patients with increasing respiratory failure or exhaustion as assessed by hypercapnia (Class IIa, Level B).
Surviving sepsis campaign19
International Guidelines for Management

of Severe Sepsis and
Septic Shock
Evidence-based
The guideline committee suggests that noninvasive mask ventilation only be considered in the minority of ALI/ARDS patients
with mild-moderate hypoxemic respiratory failure (responsive to
relatively low levels of pressure support and PEEP) with stable
hemodynamics who can be made comfortable and easily arousable, are able to protect the airway, are able to spontaneously
clear the airway of secretions, and are anticipated to recover
rapidly from the precipitating insult. A low threshold for airway
intubation should be maintained (Grade 2B).
Abbreviations: AHF, acute heart failure; ALI, acute lung injury; ALS, amyotrophic lateral sclerosis; ARDS, acute respiratory distress syndrome; ARF,
acute respiratory failure; COPD, chronic obstructive pulmonary disease; CPAP, continuous positive airway pressure; LTRAs, leukotriene receptor
antagonists; LV, left ventricular; NIV, noninvasive ventilation; PEEP, positive end-expiratory pressure; RV, right ventricular.
EMCC 2011
patients. They found that it reduced mortality by

approximately 50% (risk ratio [RR] 0.52; 95% CI,
0.35-0.76), decreased the need for intubation by approximately 60% (RR 0.41; 95% CI, 0.33-0.53), and
reduced treatment failures by 52% (RR 0.48; 95% CI,
0.37-0.63). Additionally, patients on NIV showed
a rapid improvement within the first hour in pH
(weighted mean difference [WMD] 0.03; 95% CI,
0.02-0.04), PaCO2 (WMD -0.40 kPa; 95% CI. -0.78 to
-0.03), and respiratory rate (WMD -3.08 breaths per
minute; 95% CI, -4.26 to -1.89). Complications associated with treatment and length of hospital stay were
also reduced in the bi-level group.20

The evidence shows impressive results in patients with an acute exacerbation of COPD. Its use
should be strongly considered in these patients upon
their arrival to the ED.
bi-level NIV group and 28.5 22.6% in the control

group (P = 0.006). Hospitalization was required for
3 of 17 patients (17.6%) in the bi-level NIV group as
compared to 10 of 16 patients (62.5%) in the control
group (P = 0.0134). Among the studies included in
the Cochrane review was one by Meduri and colleagues. They performed an observational study of
17 patients with acute asthma and provided bi-level
NIV using a face mask connected to a conventional
ventilator.23 While first applying the mask, initial settings included 10 cm H2O IPAP and 0 cm H2O EPAP.
Once the mask was sealed to prevent air leaks, 3 to 5
cm H2O EPAP was added on, and pressure support
ventilation was increased to maintain a tidal volume
(VT) of 7 mL/kg. All but 1 of the patients tolerated
NIV, demonstrating improvements in PCO2 and
PaO2/FiO2. The other patients did not show improvement in the blood gas and were intubated.

A few other studies suggest that there may
be a benefit of NIV in acute asthma. Subsequent
to the Cochrane review, Soma and colleagues
enrolled 44 patients with acute exacerbation of
asthma who received nebulized medications and
hydrocortisone. The patients were randomized
into either high pressure (8 cm H2O IPAP and 6 cm
H2O EPAP) or low-pressure (6 cm H2O IPAP and
4 cm H2O EPAP) bi-level NIV groups. The only
improvements they noted were in wheezing and
accessory muscle use scores.24

Summarizing these findings, it is reasonable to
consider NIV for patients with an acute exacerbation
of asthma, but the effect will likely be modest, and
the emergency clinician must remain prepared to
intubate.
Acute Exacerbation Of Asthma
While NIV is considered an effective first-line treatment for acute exacerbation of COPD, the evidence
supporting NIV for asthma is less convincing. This
may be explained by the fundamental difference between asthma and COPD. The hallmark of emphysema is the destruction of pulmonary architecture
that leads to premature collapse of the airways. This
leads to inadequate ventilation and retention of CO2.
Inspiratory positive airway pressure may functionally stent these terminal airways and allow for more
effective ventilation. On the other hand, asthma is
manifested by inflammation, edema, and partial or
complete obstruction of small airways. Noninvasive
ventilation pressures, as they are currently used,
may not be sufficient to overcome this degree of obstruction and associated resistance. This is reflected
by the inconsistent pressure support settings that appear in the literature regarding NIV in acute asthma.

Ram and colleagues performed a Cochrane
systematic review and meta-analysis. Starting with
11 clinical trials, they excluded 10, leaving only 1
randomized controlled trial.21 They concluded that
the evidence supporting NIV for exacerbations of
asthma was potentially promising but that a large
randomized controlled trial was needed. In a pilot
prospective randomized trial, Soroksky and colleagues enrolled ED patients whose forced expiratory
volume in 1 second (FEV1) was < 60% predicted after
30 minutes of standard treatment.22 They excluded
patients with hemodynamic instability or who
smoked for more than 10 years. Patients were randomized to either bi-level NIV or a sham NIV, which
was set at 1 cm H2O of positive airway pressure and
had holes drilled in the tubing to eliminate positive
pressure. Eighty percent of patients in the bi-level
NIV group reached the predetermined primary end
points (an increase of at least 50% in FEV1 as compared to baseline) versus 20% of control patients (P
< 0.004). Mean rise in FEV1 was 53.5 23.4% in the
EMCC 2011
Acute Cardiogenic Pulmonary Edema
For years, it appeared that CPAP might be effective

in reducing mortality in patients with ACPE. However, a large multicenter randomized controlled trial
comparing CPAP, bi-level NIV, and standard oxygen
therapy brings the mortality benefit into question.
The Three Interventions in Cardiogenic Pulmonary
Oedema (3CPO) trial enrolled 1069 patients, of
which 367 received standard oxygen therapy, 346
received CPAP, and 356 received bi-level NIV.25
There was no significant difference in 7-day mortality between the groups. There was also no difference
in rates of tracheal intubation. The only significant
improvements seen with either NIV group were
modest reductions in dyspnea score, heart rate,
acidosis, and hypercapnia. It also made no difference if the patient used CPAP or bi-level NIV. In a
recent meta-analysis by Weng and colleagues, the
authors reviewed 31 randomized controlled trials
involving 2887 patients, including the 3CPO trial.33
They concluded that CPAP versus standard therapy
reduces mortality (RR 0.64; 95% CI, 0.44-0.92), and
both CPAP and bi-level ventilation reduce the need
6
Table 4. Indications For Noninvasive Ventilation

Study
Diagnosis
Enrollment Criteria
NIV Settings
26
Gupta et al.
Asthma
RR > 30
HR > 100
SpO2 < 92% or PaO2 < 60 mm Hg
8 cm H2O IPAP, 4 cm H2O EPAP, titrated in 2 cm H2O

increments to a maximum of 20 cm H2O IPAP and 10
cm H2O EPAP
Soma et al.24
Asthma
SpO2 > 90% on room air

EXCLUDED COPD, CHF, pneumonia, and pregnancy
Low pressure group: 6 cm H2O IPAP and 4 cm H2O

EPAP
High pressure group: 8 cm H2O IPAP and 6 cm H2O
EPAP
Delay et al.27
Morbid obesity
BMI > 40 kg/m2

Elective surgery
EXCUDED emergency procedures
and other comorbidities
6 cm H2O IPAP and 4 cm H2O EPAP, after 20 seconds

increased to 8-10 cm H2O IPAP and 6 cm H2O EPAP
Plaisance et al.14
ACPE
Clinical ACPE, SpO2 < 90% on

15 L/min face mask
EXCLUDED COPD
Early CPAP at 7.5 cm H2O

Late CPAP at 7.5 cm H2O begun 15 minutes after early
CPAP group
Moritz et al.28
ACPE
Clinical ACPE, SpO2 < 90% on >

5 L/min face mask
EXCLUDED COPD, pneumonia,
and renal failure
CPAP at 10 cm H2O delivered by Boussignac mask

compared with bi-level NIV with EPAP of 5 cm H2O
and IPAP that was adjusted to maintain a VT of 8 to 10
mL/kg. The pressure support needed to reach this VT
was approximately 12. Thus, IPAP was approximately
17 cm H2O.
Ferrer et al.29
AHRF
ICU patients
PaO2 < 60 mm Hg for > 6 hours or
SpO2 < 90% on > 5 L/min face
mask
EXCLUDED hypercapnia PaCO2 >
45 mm Hg
16 3 cm H2O IPAP (range 10-24)

7 2 cm H2O EPAP (range 4-12)
Conti et al.30
Acute exacerbation of COPD
ICU consults of ED patients

pH < 7.32
Bicarbonate > 30 mEq/L
PaCO2 > 45 mm Hg
PaO2 < 45 mm Hg on room air
Bi-level NIV at IPAP of 21 2 cm H2O and EPAP of 5

cm H2O (pressure support 16 2 cm H2O) compared
with mechanical ventilation
Jolliet et al.31
Severe CAP
ICU
Focal or multilobar pneumonia
RR 30/min
PaCO2 45 mm Hg
PaO2/FiO2 < 300
BP systolic 90 mm Hg and diastolic 60 mm Hg
Vasopressor use 4 hours
Bi-level NIV at 20 cm H2O IPAP and 5 cm H2O EPAP

(pressure support 15 cm H2O)
Confalonieri et al.32
CAP
RR > 35/min
PaO2 > 68 mm Hg while on FiO2
0.4
PaO2/FiO2 < 250 while on FiO2
0.5
PaCO2 50 mm Hg
BP systolic 90 mm Hg and diastolic 60 mm Hg
Vasopressor use 4 hours
Bi-level NIV with 19.7 4.7 cm H2O IPAP and 4.9 1.7
cm H2O EPAP (pressure support 14.8 4.7 cm H2O)
Abbreviations: ACPE, acute cardiogenic pulmonary edema; AHRF, acute hypoxemic respiratory failure; BMI, body mass index; BP, blood pressure;
CAP, community-acquired pneumonia; CHF, congestive heart failure; COPD, chronic obstructive pulmonary disease; CPAP, continuous positive airway
pressure; ED, emergency department; EPAP, expiratory positive airway pressure; HR, heart rate; ICU, intensive care unit; NIV, noninvasive ventilation;
RR, respiratory rate; VT, tidal volume.
EMCC 2011
Clinical Pathway: Management Of Patients With Respiratory Distress

And Special Circumstances Using Noninvasive Ventilation
Does the patient have blunt thoracic
trauma?
YES
Is the patient hypoxic despite 100%

oxygen supplementation?
NO
YES
Use bi-level NIV, start at 10 cm H2O

IPAP and 6 cm H2O (Class II)
NO
Does patient appear to have a neuromuscular cause for their respiratory

failure?
YES
Continue conventional trauma resuscitation (Class I)
Improving with oxygen?
NO
YES
Does patient appear to have a DNI

order or is patient on palliative care?

IPAP and 5 cm H2O EPAP (Class II)
Continue conventional therapy (Class I)
NO
YES
Improving with oxygen and care appropriate for underlying disease process?
NO
YES
NO
Does patient appear to have ALI/ARDS
or acute chest syndrome from sickle
cell as a reason for their respiratory
distress?
Use NIV, depending on underlying

disease process (Class I for COPD
and ACPE)
YES
NIV cannot be recommended at this

time (Class Indeterminate)
Please see Class of Evidence definitions on page 10

Abbreviations: ACPE, acute cardiogenic pulmonary edema; ALI, acute lung injury; ARDS, acute respiratory
distress syndrome; COPD, chronic obstructive pulmonary disease; DNI, do not intubate; EPAP, expiratory
positive airway pressure; IPAP, inspiratory positive airway pressure; NIV, noninvasive ventilation
EMCC 2011
Clinical Pathway: Management Of Patients With Respiratory Distress

With Noninvasive Ventilation
Is patient obtunded, hypoxemic, or unable to protect airway?
YES
Prepare for rapid sequence tracheal intubation (Class I)

Consider using NIV for pretreatment to intubation (Class I)
NO
Does patient appear to have an acute

exacerbation of COPD or asthma?
YES
Improving with albuterol, ipratropium

and methylprednisolone?
YES
NO

IPAP and 5 cm H2O EPAP (COPD:
Class I; Asthma: Class II)
NO
Does patient appear to have ACPE?
YES
Improving with oxygen, nitoglycerin and

furosemide or other diuretic?
YES
NO
Does patient appear to have pneumonia

with hypoxia?
YES

NO
YES
Use CPAP, start at 10 cm H2O (Class I)
Improving with oxygen

and IV antibiotics?
YES
Does patient appear to have another

reason for their respiratory distress?
NO
NO

IPAP and 5 cm H2O EPAP (Class I)
Go to Clinical Pathway: Management Of Patients With Respiratory Distress And Special

Circumstances Using Noninvasive Ventilation on page 8
Please see Class of Evidence definitions on page 10

Abbreviations: ACPE, acute cardiogenic pulmonary edema; CPAP, continuous positive airway pressure;
COPD, chronic obstructive pulmonary disease; EPAP, expiratory positive airway pressure; IPAP, inspiratory
positive airway pressure; IV, intravenous; NIV, noninvasive ventilation
EMCC 2011
Clinical Pathway: The Reevaluation Of Patients

Placed On Noninvasive Ventilation
Is the patient deteriorating clinically
(decreasing mental status, hypotension,
hypoxemia rising PCO2?
YES
Prepare for immediate tracheal intubation (Class I)
YES
Consider sedation with remifentanil or

dexmedetomidine (Class III)
YES
Improving with change of mask?
NO
Is the patient complaining or becoming

more anxious?
NO
Is the patient complaining about the

mask or is there air leak?
NO
YES
Change NIV settings to maximize

tidal volume, oxygenation, and PCO2
(Class I)
NO
Does patient appear to be tolerating NIV

and improving clinically?
YES
Admit to appropriate service and level of

care (Class Indeterminate)
Abbreviations: EPAP, expiratory positive airway pressure; IPAP, inspiratory positive airway pressure; NIV,
noninvasive ventilation
Class Of Evidence Definitions

Each action in the clinical pathways section of EMCC receives a score based on the following definitions.
Class I
Always acceptable, safe
Definitely useful
Proven in both efficacy and
effectiveness
Level of Evidence:
One or more large prospective
studies are present (with rare
exceptions)
High-quality meta-analyses
Study results consistently positive and compelling
Class II
Safe, acceptable
Probably useful
Level of Evidence:
Generally higher levels of
evidence
Non-randomized or retrospective studies: historic, cohort, or
case control studies
Less robust RCTs
Results consistently positive
Class III
May be acceptable
Possibly useful
Considered optional or alternative treatments
Level of Evidence:
Generally lower or intermediate
levels of evidence
Case series, animal studies,
consensus panels
Occasionally positive results
Indeterminate
Continuing area of research
No recommendations until
further research
Level of Evidence:
Evidence not available
Higher studies in progress
Results inconsistent, contradictory
Results not compelling
Significantly modified from: The
Emergency Cardiovascular Care
Committees of the American
Heart Association and represen-
tatives from the resuscitation

councils of ILCOR: How to Develop Evidence-Based Guidelines
for Emergency Cardiac Care:
Quality of Evidence and Classes
of Recommendations; also:
Anonymous. Guidelines for cardiopulmonary resuscitation and
emergency cardiac care. Emergency Cardiac Care Committee
and Subcommittees, American
Heart Association. Part IX. Ensuring effectiveness of communitywide emergency cardiac care.
JAMA. 1992;268(16):2289-2295.
This clinical pathway is intended to supplement, rather than substitute for, professional judgment and may be changed depending upon a patients individual
needs. Failure to comply with this pathway does not represent a breach of the standard of care.
Copyright 2011 EB Medicine. 1-800-249-5770. No part of this publication may be reproduced in any format without written consent of EB Medicine.
EMCC 2011
10
for tracheal intubation.

Adverse effects of the hemodynamic changes associated with NIV have been reported. Hypotension
is possible in hypovolemic patients, due the reduction in preload and cardiac output. A randomized
controlled trial by Mehta and colleagues comparing
CPAP to bi-level NIV in patients with ACPE suggested a concerning relationship between NIV and
myocardial ischemia.34 This study was terminated
early due to an excess of myocardial infarction (MI)
in the bi-level NIV group. Newer and larger trials
have refuted these findings, including the 3CPO trial. Bellone and colleagues specifically examined the
occurrence of MI in patients presenting with ACPE
and found no statistical difference in MI between the
CPAP and bi-level NIV groups.35
Pediatric Use Of Noninvasive Ventilation
Community Acquired Pneumonia
There are many ways to deliver NIV, and it is essential for the emergency clinician to communicate with
the respiratory therapy department to know what is
available in their facility. For a detailed overview of
equipment options, we refer the reader to excellent
reviews by Scala and Naldi38 and Schnhofer and
Sorter-Leger.39 We will cover the key issues regarding the application of NIV in the ED. The goal of
NIV in the ED patient is to stabilize their respiratory
status. Using the techniques discussed in this article
mask sizing, delivery of sufficient but not excessive pressures, and management of patient anxiety
by offering reassurance and possibly sedation the
patients ED course will be optimized.

The evidence base for NIV in pediatrics is limited

but suggests that there may be benefit in ARF. Yanez
and colleagues performed a randomized controlled
trial in 50 patients in 2 pediatric ICUs.40 Patients
predominantly had respiratory syncytial virus/
bronchiolitis. Noninvasive ventilation was applied
as bi-level NIV with IPAP ranging from 12 to 18 cm
H2O and EPAP ranging from 6 to 12 cm H2O. The
investigators found a significant reduction in tracheal intubation: 7 of 25 NIV patients versus 15 of 25
controls (RR 0.47; 95% CI, 0.23-0.9, P = 0.046).
Tools And Techniques: Practical

Considerations For Noninvasive Ventilation
The evidence supporting NIV in CAP is also conflicting. Carron and colleagues studied 64 patients on ICU
admission and placed them on bi-level NIV starting
at 15 cm H2O IPAP and 5 cm H2O EPAP (thus providing 10 cm H2O of pressure support).36 Noninvasive
ventilation was successful in avoiding intubation in
28 (44%) patients and failed in 36 (56%) patients. In
a logistic regression model, the change in PaO2/FiO2
and the oxygenation index (OI = mean airway pressure FiO2 100/PaO2) was statistically associated
with failure of NIV and need for intubation.36 In their
guidelines on the management of CAP,16 the Infectious Diseases Society of America and the American
Thoracic Society recommend cautious usage of NIV.
They suggest that NIV be tried in patients with CAP
and hypoxia and respiratory distress unless they
require immediate intubation. They define need for
immediate intubation as severe hypoxemia (PaO2/
FiO2 < 150) or bilateral alveolar infiltrates.

Confalionieri and colleagues performed a casecontrol study of patients with pneumocystis carinii
pneumonia (PCP) and ARF admitted to an infectious
disease ICU.37 They applied bi-level NIV to 24 patients and matched them with controls that had been
intubated prior to arriving at the ICU. They found
that 67% of the bi-level NIV patients avoided tracheal
intubation and had a shorter course in the ICU. While
the authors tried to match the controls as closely as
possible to the cases, there is still potential for bias,
which might inflate the benefits of bi-level NIV. Yet, it
is tempting to believe that a trial of bi-level NIV may
prevent intubation in patients with PCP. Thus, a cautious trial of bi-level NIV in CAP is warranted, with
tracheal intubation equipment on standby. Patients
in respiratory distress should be tracheally intubated
immediately if there is any doubt that they would be
able to tolerate NIV.16
Pressure Settings
For CPAP, it is reasonable to set the pressure at 10

cm H2O for suspected ACPE. The pressure can be
adjusted up or down depending on patient comfort.
For bi-level NIV, start at 15 cm H2O IPAP and 5 cm
H2O EPAP. The pressure support in this case is 10 cm
H2O (IPAP minus EPAP). These pressures may be
titrated up or down depending on the combination
of clinical effect as well as patient comfort. Based on
the available literature, pressures should not exceed
25 cm H2O at any point, regardless of the mode of
NIV being used. In order to maintain the desired
pressures, it is important to achieve a good seal
with the NIV mask. Nasal masks are the simplest,
but the patient must keep their mouth closed or the
pressures will drop. The more common facial masks
may achieve a better seal. Finally, the patient is key
to the success of NIV. If the patient does not tolerate
the mask or is anxious, the NIV trial may fail. The
patient may also trigger the NIV machine prematurely and initiate an inappropriate breath. Newer
NIV models have been developed with much more
sophisticated circuitry that adjust the pressures and
inspiratory and expiratory times when there is a
leak. An experienced respiratory therapist is essential in successfully implementing NIV in the ED.
11
EMCC 2011
Mask Options And Sizing
pared to the facemask, while leading to significantly

fewer interruptions due to discomfort and complications, such as skin necrosis.45
Nasal Mask
Nasal NIV is often used for the patient who has a
history of obstructive sleep apnea (typically CPAP
mode) or COPD who needs nocturnal ventilation
(typically bi-level NIV mode). With the nasal mask,
the airway is depressurized and no longer a closed
system when the patient opens his or her mouth. It
causes less claustrophobia than the oronasal/facial or
helmet masks. It also minimizes aspiration if vomiting occurs. In order to prevent pressure drop when
the patient opens their mouth, nasal masks should
only be used in ED patients who can reliably keep
their mouth closed or cannot tolerate a face mask.
Boussignac Mask
The Boussignac mask is a promising new mask that
provides CPAP up to 7.5 cm H2O without requiring a
separate flow generator or ventilator. The apparatus
operates with high flow oxygen and compares favorably with bi-level NIV in hypercapnic patients.28
This modality seems ideal for prehospital management of ARF in remote areas, but more research is
needed before it can be recommended as an option
for NIV in the ED. (See Figures 3 and 4.)
Oronasal (Face) Mask

Delivery of NIV via a facemask is the most common
method used by emergency medical service personnel, in the ED, and in the ICU. One mask does not fit
all when it comes to patients faces, and it is therefore important to stock a variety of sizes. A good fit
will allow less air leak and improve patient comfort.
Along with being attentive to the size of the patients
face, the clinician should take note of both the edentulous patient who has no teeth to give the mouth
firm structure and the bearded patient, both of
whom are at risk for a poor mask fit and consequential air leaks. One small randomized controlled trial
demonstrated that facemasks are significantly better
tolerated by patients when compared to nasal masks
for ARF from CHF.41 There was no difference in
performance, however, with similar rates of intubation between these 2 groups. Another study found
that the facemask was less tolerable despite allowing
less air leakage than the nasal mask in patients with
COPD exacerbation.42 (See Figures 1 and 2.)
Figure 1. Typical Noninvasive Ventilation

Interface And Displays
Settings of 5 cm H2O IPAP, 4 cm H2O EPAP, RR 13, FiO2 40%
Cephalic Mask
There are facemasks that cover the entire anterior
surface of the face. The theoretical advantage is that
it spreads out the pressure, reducing the nasal bridge
breakdown of nasal or facial masks. Cuvelier and
colleagues found no difference in 34 patients that
they randomized to cephalic and oronasal masks.43
However, 1 patient from the cephalic group dropped
out due to claustrophobia.
Helmet
The helmet is an uncommonly used interface for
NIV in the ED, though studies outside the ED suggest that it may hold promise for patients who are
intolerant of other masks. In a small study of postabdominal surgery patients, the helmet was better
tolerated with fewer complications (such as air leaks
and pneumonia) compared to face mask.44 In a small
case-control study in immunocompromised ICU patients with hypoxemic ARF, the helmet was shown
to be of equal benefit in avoiding intubation, com-
EMCC 2011
Classic settings of 10 cm H2O IPAP, 5 cm H2O EPAP, RR 12. FiO2

40%
12
Clinical Course In The ED
Oxygen requirement in relation to the pulse

oximetry
Pulse oximetry
Blood gases (see below)
Tidal volumes and minute ventilation
Once the patient is placed on NIV, it is important to

monitor the patient closely for clinical deterioration.
Assume that NIV will fail, and prepare the necessary equipment for RSI. Consult with the respiratory
therapist to ensure that the mask interface is comfortable for the patient and that the NIV modality
CPAP versus bi-level NIV is set up as needed for
the specific disease process.

Clinical parameters that one should follow include:
Patient tolerance of NIV
Increase in secretions
Mental status change
Synchronous breathing with the ventilator
Air leaks
Respiratory rate
Tidal volume changes in relation to respiratory
rate

Respiratory rate and work of breathing should
decrease with intervention. However, respiratory
rate is not the same as ventilation, so it is important
to check an arterial blood gas for pH and PCO2.
There is promising data that pH but not PCO2 in
venous blood gases correlates with arterial blood
gases. This is exciting because it is more convenient
to sample venous blood rather than performing an
arterial puncture.46 A recent meta-analysis by Lim
and Kelly suggests that in COPD patients, pH and
bicarbonate show good correlation, but the correlation between venous and arterial PCO2 is less
reliable.47 There is not enough evidence to support
the use of venous PCO2 in patients with COPD, but
pH may be useful. A rise in pH in a patient placed
on NIV may well reflect improved ventilation and
improvement of their hypercapnia.

Furthermore, Kelly and Klim studied a convenience sample of 46 patients on NIV who needed
a blood gas.48 They measured transcutaneous CO2
(PtCO2) and compared it with the PCO2 from the arterial blood gas (PaCO2). They found very poor correlation between PtCO2 and PaCO2. Indeed, the transcutaneous measurement sometimes dramatically underestimated the true arterial CO2. This is understandable
as each modality of measuring the partial pressure of
CO2 has limitations. The gold standard is the arterial gas, where CO2 is measured after diffusion has
occurred at the alveolar level. The venous CO2 may
reflect hypercapnia, but this value may drop significantly upon passage through the lung. End-tidal CO2
varies with dead space ventilation and may grossly
underestimate the arterial CO2. Transcutaneous CO2 is
dependent upon diffusion through the skin and may
approach arterial levels when the skin is warm and
well perfused. Thus, caution must be exercised when
using PtCO2 in patients on NIV as there is no support
for PtCO2 in this setting. Due to the poor agreement
between PtCO2 and PaCO2, transcutaneous CO2 monitoring in NIV cannot be recommended.
Figure 2. Ideal Fit For Noninvasive

Ventilation Face Mask
Note the tight fit of the mask with head straps to secure it on.
Deterioration
Parameters of failure in a patient on NIV include:

Vomiting
Persistent coughing
Aspiration
Progressive respiratory distress
Respiratory arrest
Loss of consciousness
Respiratory rate rising greater than 35-40
Persistent hypoxia despite supplemental oxygenation
Hemodynamic instability or shock
13
EMCC 2011
Do-Not-Intubate And Palliative Care Patients
Worsening arterial pH, PCO2, PO2, or venous pH

Worsening PaO2/FiO2 ratio
Nursing home or hospice patients often present to

the ED in respiratory distress. While a clear do-notintubate (DNI) order accompanying the patient
makes the decision on whether to intubate less vexing, there is always the option of NIV. By definition,
NIV is not invasive. It is important to explain to the
patient and caregiver that this modality is an option.
There is very little guidance on what the right course
of action is in these cases. Levy and colleagues
enrolled 114 patients on bi-level NIV who also happened to have DNI status. Noninvasive positive
pressure ventilation was provided with 13.4 0.3
cm H2O IPAP and 5.0 1 cm H2O EPAP.51 There was
a 43% survival to discharge. Patients most likely to
survive were those with ACPE and COPD. Additional markers of survival were alert mental status
and good, strong cough. Bulow and colleagues studied 38 patients who had a DNI order and were given
NIV.52 The group with the highest survival was
patients with COPD. They concluded that NIV is
an option for patients with a DNI order and COPD,
while other diagnoses may not fare as well.

Curtis and colleagues from the Society of Critical
Care Medicine Palliative Noninvasive Positive Pressure Ventilation Task Force developed an approach
for considering the use of NIV for those who wish to
forego tracheal intubation.53 They provide a detailed approach to communicating with the patient
Complications Of Noninvasive Ventilation
In a comprehensive review, Gay described several

potential complications of NIV.49 Problems start at
the interface, as each type of mask has its problems.
Obstructed nasal passages would preclude using
the nasal mask. Problems related to pressure include
sinus pain, gastric insufflation, and pneumothorax.
Problems related to airflow include dryness, nasal
congestion, and eye irritation. Major complications
include severe hypoxemia and aspiration as well
as the rare occurrences of hypotension and mucus
plugging. Other complications include claustrophobia, air leaks from poor mask seal, and pressure
sores at the nasal bridge.
Special Circumstances
Acute Respiratory Distress Syndrome And

Acute Lung Injury
Acute lung injury is a common condition that is

characterized by acute severe hypoxia that is not
due to left atrial hypertension. The term ALI encompasses a continuum of clinical and radiographic
changes that affect the lungs, with the acute respiratory distress syndrome (ARDS) representing
the more severe end of this continuum. Clinically,
these patients present as non-cardiogenic pulmonary edema and respiratory failure in a critically ill
patient. Despite advances in our understanding of
the pathophysiology and management of ALI, it is
still associated with a high mortality. Agarwal and
colleagues performed a meta-analysis of NIV use
in ALI and ARDS.50 They found an estimated 50%
NIV failure rate, with a pooled intubation rate of
48% (95% CI, 39-58) and a pooled mortality rate of
35% (95% CI, 26-45). The authors urge caution in this
clearly high-risk group.
Figure 4. Boussignac CPAP Schematic

Boussignac CPAP works the same way as the turbines of a jet
engine
Oxygen Supply
Oxygen molecules enter the
chamber
Oxygen Acceleration
The molecules of oxygen are accelerated at the speed of sound as
they pass through micro channels
Figure 3. Boussignac CPAP

Virtual Valve
To
Patient
Oxygen Braking
Establishment of a Virtual Valve
The molecules of oxygen strike The collision of the molecules genera deflector which sends them
ates a turbulence which transforms
back to the central zone (mixthe speed into pressure
ing zone)
Used with permission by Vitaid.
EMCC 2011
Used with permission by Vitaid.
14
and family as well as defining the goals of NIV. For

example, an end-stage COPD patient may wish to
forego tracheal intubation but agree to NIV to ease
the discomfort of dyspnea.
trial was stopped early. The length of stay inhospital

was also shorter in the bi-level NIV group. There was
no change in survival rate. This study demonstrates
the potential for bi-level NIV in blunt chest trauma.
The mortality in each group was 1 patient (4%), which
precludes an assessment of mortality benefit.
Neuromuscular Respiratory Failure
Miller and colleagues from the Quality Standards

Subcommittee of the American College of Neurology
published an evidence-based update of guidelines
on the management of amyotrophic lateral sclerosis
(ALS).10 They recommend that NIV be considered
to treat respiratory insufficiency in ALS, both to
lengthen survival and to slow the rate of forced vital
capacity decline. They give this recommendation a
Level B based upon 1 Class I study and 3 Class III
studies. Bourke and colleagues, who conducted the
Class I study,54 randomized ALS patients to either
bi-level NIV at a mean 15 cm H2O IPAP and mean 4
cm H2O EPAP compared with standard care. Noninvasive ventilation was associated with a survival
benefit of 205 days among patients with ALS and
good bulbar function but not in ALS patients with
poor bulbar function.

Seneviratne and colleagues studied a retrospective cohort of 52 patients who presented with
myasthenic crisis and were admitted to the ICU.55
Fourteen (58%) of the 24 patients initially given bilevel NIV (mean maximal IPAP/EPAP was 15/4 cm
H2O) successfully avoided tracheal intubation.

In general, there is limited evidence of the efficacy
of NIV in patients with neuromuscular respiratory
failure. A cautious trial may be helpful in either ALS
(with good bulbar function) or myasthenic crisis.
Cystic Fibrosis
Moran and colleagues addressed the use of NIV in

cystic fibrosis in a Cochrane review.58 Their review
included many small studies that examined outcomes such as clearance of secretions and sleep
latency. At present, there is insufficient evidence to
suggest that NIV would be helpful in cystic fibrosis
patients who present to the ED, although NIV has
been used with good effect in other settings.
Controversies/Cutting Edge
Sedation In The Anxious Patient
Sedation of a patient in respiratory distress is a

double-edged sword. The benefit is that the patient
may become more cooperative. The risk is that they
may decline due to the underlying respiratory insult
and need for urgent intubation. A few studies have
shown that some agents may benefit the anxious
patient in whom an NIV trial is attempted. Rocco
and colleagues studied 36 patients with hypoxemic
ARF who were not tolerating NIV and who received
remifentanil.59 Twenty-two (61%) patients were able
to continue the NIV and 14 (29%) required intubation. Constantin and colleagues performed a similar
study using remifentanil in patients who were not
able to tolerate NIV.60 For patients still not sufficiently sedated, they added propofol. Twelve of 13
patients were able to avoid intubation.

The sedative dexmedetomidine has also shown
promise. Akada and colleagues administered dexmedetomidine to 10 ICU patients who were agitated
while receiving NIV for ARF.61 All patients were successfully weaned from NIV with no intubations and
no clinically recognized episodes of aspiration.
Acute Chest Syndrome In Sickle Cell

Patients
In a pilot study, Fartoukh and colleagues randomized 67 patients with symptoms suggestive of acute
chest syndrome to either standard oxygen therapy
or bi-level NIV with 12 cm H2O IPAP and 5 cm H2O
EPAP.56 There was no improvement in the primary
outcome of hypoxemia at day 3. Neither was there a
decrease in pain, transfusions, or length of hospital
stay. At this time, NIV cannot be recommended for
acute chest syndrome in sickle cell patients.

Noninvasive Ventilation For Preoxygenation

During Tracheal Intubation
Futier and colleagues randomized 66 morbidly

obese patients undergoing preoxygenation for
tracheal intubation.62 They compared 5 minutes of
spontaneous breathing of 100% O2 with 2 types of
NIV. The first intervention group received bi-level
NIV with no more than 18 cm H2O IPAP and 6-8 cm
H2O EPAP. The other NIV group received these settings plus a recruitment maneuver of 40 cm H2O for
40 seconds immediately following tracheal intubation. At the end of preoxygenation, PaO2 was higher
in both NIV groups compared with conventional
preoxygenation. Delay and colleagues randomized
morbidly obese patients needing tracheal intubation
Blunt Chest Trauma
Hernandez and colleagues studied 50 patients admitted to the ICU within 48 hours of blunt thoracic
trauma whose PaO2/FiO2 ratio remained below 200
for more than 8 hours on high flow oxygen.57 Most
patients in this study developed ARF secondary to
lung contusion. Bi-level NIV was applied at 10 to 12
cm H2O IPAP and 6 cm H2O EPAP, adjusting IPAP
upwards by 2 cm H2O increments and EPAP at 1 cm
H2O increments as needed to maintain oxygenation
and inspiratory volumes. The intubation rate was
higher in the oxygen-only group: 40% compared to
12% in the bi-level NIV group. For this reason, the
15
EMCC 2011
Summary
preoxygenation using either spontaneous breathing

of O2 by mask or NIV with 14 cm H2O IPAP and 6
cm H2O EPAP.27 Patients in the NIV group showed
superior preoxygenation and did so more rapidly
than the conventional O2 group.

Jaber and colleagues examined NIV as part of
an intubation care bundle.63 Noninvasive ventilation
was given as pressure support of 5 to 15 cm H2O
(specific IPAP and EPAP levels were not provided).
They found a significant decrease in life-threatening
complications at 1 hour post intubation: 21% in
the bundled care intervention versus 34% in the
pre-bundled care intervention. How much of that
improvement in complication rate was due to NIV
is unclear. Weingart provides a useful review on
the topic of issues surrounding preoxygenation and
proposes the use of NIV and ketamine to preoxygenate patients with tenuous oxygenation status, an
approach he calls delayed sequence intubation.64
Noninvasive ventilation is a valuable tool that

should be considered for patients who present to the
ED in respiratory failure. While there is strong evidence for improved outcomes using NIV in certain
subtypes of ARF, one should avoid using NIV for
patients in whom it is absolutely contraindicated.
Potential problems will usually become apparent
in the first 60 minutes of applying NIV. Any patient
who deteriorates clinically must be rescued with a
definitive airway intervention.
Case Conclusion
The respiratory therapist recommended CPAP at 10 cm
H2O. The oxygen saturation rose from the high 60s to
the high 80s, and the patient was no longer diaphoretic.
You placed a large bore peripheral IV, collected blood, and
administered IV furosemide and nitroglycerin. You sent
off a venous blood gas to follow the pH and PCO2. These
returned as pH = 7.20 and PCO2 = 60. Based on the
landmark studies by Kelly and colleagues - having kept
in mind that they studied patients with acute COPD you repeated the venous blood gas and noted that the pH
had risen by 0.10 to 7.30, and the PCO2 had dropped to
50. While the venous PCO2 result may not have correlated well with arterial PCO2, you felt confident that
the pH was going in the right direction. The patient was
no longer diaphoretic and even smiled for the first time.
Chest radiograph confirmed acutely decompensated heart
failure, and you felt satisfied that this patient would not
need tracheal intubation. At least not for now
Noninvasive Ventilation As An Adjunct To

Procedural Sedation
The maintenance of a patent airway and preservation of spontaneous respiration is what distinguishes
deep sedation from general anesthesia. However,
significant relaxation of the muscles of the upper
airway may occur, resulting in upper airway obstruction. Though only described in a case report,
NIV may be a useful adjunct in supporting effective
ventilation during procedural sedation.
Must-Do Markers Of Quality ED Critical Care

Be prepared a protocol in partnership with
respiratory therapy is needed.
Start NIV early in eligible patients it may increase chances for a good outcome.
Reassure the patient NIV may be frightening
to an already anxious patient.
Use sedation/analgesia with extreme care.
Have definitive airway equipment ready in case
the patient deteriorates.
Venous blood gas pH correlates well with arterial pH and may be followed as an objective
marker of improved ventilation.
References
Evidence-based medicine requires a critical ap
praisal of the literature based upon study methodol
ogy 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,
such as the type of study and the number of patients
in the study, are included in bold type following
the reference, where available. In addition, 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.
Disposition
The disposition of patients who require NIV is complex. Unless the patient uses NIV at home, discharging them home may not be possible or desirable. For
patients who need admission, there will be those
who demonstrate a real improvement clinically and
could be admitted to a regular ward, although institutional protocols will vary. Patients who still demonstrate insufficient clinical improvement should be
evaluated for ICU admission, as many may eventually require tracheal intubation.
EMCC 2011
1.
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)
2.* Pingleton SK. Complications of acute respiratory failure. Am
Rev Respir Dis. 1988;137(6):1463-1493. (Review; 420 references)
3. Deutschman CS, Wilton P, Sinow J, et al. Paranasal sinusitis associated with nasotracheal intubation: a frequently
16
4.*
5.
6.*
7.
8.*
9.
10.
11.
12.*
13.
14.*
15.*
16.*
17.*
unrecognized and treatable source of sepsis. Crit Care Med.

1986;14(2):111-114. (Retrospective; 27 patients)
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1991;325(26):1825-1830. (Randomized; 39 patients)
Carvalho AR, Spieth PM, Pelosi P, et al. Pressure support
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Anesth Analg. 2009;109(3):858-865. (Laboratory; 5 pigs)
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failure. Respir Med. 1998;92(2):331-337. (Nonrandomized; 19
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2008;8(5):517-521. (Concise guideline from the UK National
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Miller RG, Jackson CE, Kasarskis EJ, et al. Practice parameter
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2009;73(15):1218-1226. (Evidence-based review; 40 references)
Bach PB, Brown C, Gelfand SE, et al. Management of acute
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summary and appraisal of published evidence. Ann Intern
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Plaisance P, Pirracchio R, Berton C, et al. A randomized
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for acute cardiogenic pulmonary oedema: physiological and
clinical effects. Eur Heart J. 2007;28(23):2895-2901. (Prehospital, randomized; 124 patients)
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studies, 3 randomized)
Mandell LA, Wunderink RG, Anzueto A, et al. Infectious
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of Asthma - Summary Report 2007. 2007. (Evidence-based
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18.* Dickstein K, Cohen-Solal A, Filippatos G, et al. ESC
Guidelines for the diagnosis and treatment of acute and
chronic heart failure 2008. Eur Heart J. 2008;29(19):2388-2442.
(Evidence-based guideline; 252 references)
19.* Dellinger RP, Levy MM, Carlet JM, et al. Surviving Sepsis
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severe sepsis and septic shock: 2008. Intensive Care Med.
2008;34(1):17-60. (Evidence-based guideline; 341 references)
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Cochrane Database Syst Rev. 2004(3):CD004104. (Cochrane
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21. Ram FS, Wellington S, Rowe B, et al. Non-invasive positive
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22. Soroksky A, Stav D, Shpirer I. A Pilot Prospective, Randomized, Placebo-Controlled Trial of Bi-level Positive Airway
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23. Meduri GU, Cook TR, Turner RE, et al. Noninvasive
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25.* Gray A, Goodacre S, Newby DE, et al. Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J
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26. 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.
(Randomized; 53 patients)
27. Delay JM, Sebbane M, Jung B, et al. The effectiveness of noninvasive positive pressure ventilation to enhance preoxygenation in morbidly obese patients: a randomized controlled
study. Anesth Analg. 2008;107(5):1707-1713. (Randomized; 28
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28.* Moritz F, Brousse B, Gellee B, et al. Continuous positive airway pressure versus bi-level noninvasive ventilation in acute
cardiogenic pulmonary edema: A randomized multicenter
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29.* Ferrer M, Esquinas A, Leon M, et al. Noninvasive ventilation
in severe hypoxemic respiratory failure: a randomized clinical trial. Am J Respir Crit Care Med. 2003;168(12):1438-1444.
(Randomized, multicenter; 105 patients)
30. Conti G, Antonelli M, Navalesi P, et al. Noninvasive vs.
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33. Weng C-L, Zhao Y-T, Liu Q-H, et al. Meta-analysis: Noninvasive Ventilation in Acute Cardiogenic Pulmonary Edema.
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17
EMCC 2011
randomized trials, including 2881 patients)

34.* Mehta S, Jay GD, Woolard RH, et al. Randomized, prospective trial of bi-level versus continuous positive airway
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35.* Bellone A, Monari A, Cortellaro F, et al. Myocardial infarction rate in acute pulmonary edema: noninvasive pressure
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36.* Carron M, Freo U, Zorzi M, et al. Predictors of failure of noninvasive ventilation in patients with severe community-acquired pneumonia. J Crit Care. 2010; 25(3):540.e9-14. (Cohort;
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38. Scala R, Naldi M. Ventilators for noninvasive ventilation to
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2008;9(5):484-489. (Randomized trial; 50 pediatric patients)
41. Kwok H, McCormack J, Cece R, et al. Controlled trial of
oronasal versus nasal mask ventilation in the treatment of
acute respiratory failure. Crit Care Med. 2003;31(2):468-473.
42. 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.
43.* Cuvelier A, Pujol W, Pramil S, et al. Cephalic versus oronasal
mask for noninvasive ventilation in acute hypercapnic
respiratory failure. Intensive Care Med. 2009;35(3):519-526.
44. Conti G, Cavaliere F, Costa R, et al. Noninvasive positivepressure ventilation with different interfaces in patients with
respiratory failure after abdominal surgery: a matched-control study. Respir Care. 2007;52(11):1463-1471. (Matched case
control; 25 patients)
45.* Rocco M, DellUtri D, Morelli A, et al. Noninvasive ventilation by helmet or face mask in immunocompromised
patients: a case-control study. Chest. 2004;126(5):1508-1515.
46.* Gillies ID, Morgan M, Sykes MK, et al. The nature and
incidence of complications of peripheral arterial puncture.
Anaesthesia. 1979;34(5):506-509. (Observational; 839 patients)
47.* Lim BL, Kelly AM. A meta-analysis on the utility of peripheral venous blood gas analyses in exacerbations of chronic
obstructive pulmonary disease in the emergency department. Eur J Emerg Med. 2010;17(5):246-248. (Meta-analysis; 6
studies)
48.* Kelly AM, Klim S. Agreement between arterial and transcutaneous PCO2 in patients undergoing non-invasive ventilation. Respir Med. 2011;105(2):226-229. (Clinical trial; 46
patients)
49. Gay PC. Complications of noninvasive ventilation in acute
care. Respir Care. 2009;54(2):246-257. (Review; 56 references)
50. 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. (Meta-analysis; 13 studies, 540
patients)
51. Levy M, Tanios MA, Nelson D, et al. Outcomes of patients
with do-not-intubate orders treated with noninvasive ven-
EMCC 2011
52.
53.
54.*
55.*
56.
57.
58.
59.
60.
61.
62.
63.
64.
18
tilation. Crit Care Med. 2004;32(10):2002-2007. (Multi-center

cohort; 114 patients)
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2009;53(9):1153-1157. (Retrospective; 38 patients)
Curtis JR, Cook DJ, Sinuff T, et al. Noninvasive positive pressure ventilation in critical and palliative care settings: understanding the goals of therapy. Crit Care Med. 2007;35(3):932939. (Consensus document, Task Force recommendation)
Bourke SC, Tomlinson M, Williams TL, et al. Effects of noninvasive 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 trial; 92
patients)
Seneviratne J, Mandrekar J, Wijdicks EF, et al. Noninvasive
ventilation in myasthenic crisis. Arch Neurol. 2008;65(1):5458. (Retrospective cohort; 52 patients)
Fartoukh M, Lefort Y, Habibi A, et al. Early intermittent
noninvasive ventilation for acute chest syndrome in adults
with sickle cell disease: a pilot study. Intensive Care Med.
2010;36(8):1355-1362. (Randomized trial; 67 patients)
Hernandez G, Fernandez R, Lopez-Reina P, et al. Noninvasive ventilation reduces intubation in chest trauma-related
hypoxemia. Chest. 2010;137(1):74-80. (Randomized trial; 50
patients with early termination)
Moran F, Bradley JM, Piper AJ. Non-invasive ventilation for cystic fibrosis. Cochrane Database Syst Rev.
2009;21(1):CD002769. (Cochrane meta-analysis; 15 trials, 106
patients)
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. (Clinical trial; 36 patients)
Constantin JM, Schneider E, Cayot-Constanti S, et al.
Remifentanil-based sedation to treat noninvasive ventilation
failure: apreliminary study. Intensive Care Med. 2007;33(1):8287. (Clinical trial; 13 patients)
Akada S, Takeda S, Yoshida Y, et al. The efficacy of dexmedetomidine in patients with noninvasive ventilation: a preliminary study. Anesth Analg. 2008;107(1):167-170. (Clinical
trial; 10 patients)
Futier E, Constantin JM, Pelosi P, et al. Noninvasive Ventilation and Alveolar Recruitment Maneuver Improve Respiratory Function during and after Intubation of Morbidly Obese
Patients: A Randomized Controlled Study. Anesthesiology.
2011;114(6):1354-1363. (Randomized trial; 66 patients)
Jaber S, Jung B, Corne P, et al. An intervention to decrease
complications related to endotracheal intubation in the
intensive care unit: a prospective, multiple-center study.
Intensive Care Med. 2010;36(2):248-255. (Clinical trial; 244
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Weingart SD. Preoxygenation, Reoxygenation, and Delayed
Sequence Intubation in the Emergency Department. J Emerg
Med. 2010. [Epub ahead of print]. (Review; 5 references)
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1. Which of the following patients has an absolute contraindication to NIV?

a. Patient with acute exacerbation of COPD

with respiratory acidosis

b. Dyspneic patient with productive cough

and CAP

c. Severe asthmatic patient with accessory

muscle use

d. Obtunded patient with excess respiratory

secretions

e. Patient with blunt chest trauma, pulmonary

contusion, and hypoxemia
2. The most appropriate NIV modality for suspected ACPE is:

a. CPAP

b. Tracheal intubation with 5 cm H2O of PEEP

c. 100% nonrebreather mask

d. 15 cm H2O IPAP and 5 cm H2O EPAP

e. The Boussignac mask
3. The following clinical assessment may be dangerously inaccurate:

a. Arterial PCO2
b. Venous pH

c. PtCO2
d. PaO2/FiO2 ratio
4. Complications of NIV include all of the following EXCEPT:

a. Barotrauma

b. Gastric insufflation

c. Severe hypoxemia

d. Mucus plugging
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EM Critical Care

UNDERSTANDING AND CARING FOR

Robert T. Arntfield, MD, FRCPC

Jose Dionisio Torres, Jr., MD

Clinical Instructor in Emergency Medicine, New York Hospital

Michael S. Radeos, MD, MPH

Research Director, Department of Emergency Medicine,

oninvasive ventilation (NIV) is a method of delivering

Lillian L. Emlet, MD, MS, FACEP

Thomas J. Abramo, MD, FAAP, FACEP

Professor of Pediatrics & Emergency Medicine, Division Chief,

Chief Fellow, Division of Pulmonary and Critical Care Medicine,

Ryan G. K. Mihata, MD, MPH, FAAEM

Clinical Assistant Professor of Emergency Medicine, Wright

Describe the potential advantages of NIV over

Describe techniques for initiation of NIV in the ED.

Summarize the current evidence relating to the use of

Date of original release: August 1, 2011

Andy Jagoda, MD, FACEP

Emanuel P. Rivers, MD, MPH, IOM

needs immediate tracheal intubation. In this issue of

The triage nurse calls you to the resuscitation room where

Indications For Noninvasive Ventilation In

There is no clear consensus on the indications for

Table 1. Noninvasive Ventilation Glossary

Acute cardiogenic pulmonary edema

Acute respiratory failure

Bi-level positive airway pressure, in which the

Expiratory positive airway pressure

Hypoxemic acute respiratory failure

Inspiratory positive airway pressure

Ventilation delivered without an orotracheal or

Noninvasive positive pressure ventilation; this

Positive end-expiratory pressure

The difference between inspiratory and expiratory

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Critical Appraisal Of The Literature

blood gases. Finally, is the timing of NIV important?

Ovid MEDLINE and PubMed were searched for

Going Deeper: How Noninvasive

Table 2. Absolute And Relative

Lack of trained or experienced staff

Used with permission from European Respiratory Society 2010.

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cardiography in 15 patients; 4 patients (21%) showed

Noninvasive Ventilation In The Prehospital

American College of Emergency Physicians (ACEP) Clinical

Clinical Policy: Critical

Use 5 to 10 cm H2O CPAP by nasal or face mask as therapy for

British Thoracic Society9

Update of 2002 British

NIV should be considered in all patients with an acute exacerbation

Quality Standards Subcommittee of the American Academy

NIV should be considered to treat respiratory insufficiency in ALS,

American College of Physicians American Society of

Bi-level NIV is a beneficial support strategy that decreases the

Global Initiative for Chronic

Global Strategy for the

NIV improves respiratory acidosis (increases pH and decreases

American College of Critical

A patient who has specifically refused intubation but desires other

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with ACPE.15 Their results suggest that prehospital

Acute Exacerbation Of Chronic Obstructive