Non-invasive ventilation guidelines for adult patients with acute respiratory failure
Over the past three decades the application of non-invasive ventilation has emerged as a core therapy in the management of patients with acute and chronic respiratory failure. While the use of NIV in acute respiratory failure was initially confined to the critical care setting it is now well accepted that some patients can be effectively managed in alternative settings where appropriate resources, expertise and staffing are available.
With a rapidly emerging evidence base and the availability of constantly improving ventilator technology, keeping up to date with NIV can be a challenge for many clinicians. In NSW, there is considerable clinical variation between facilities and within facilities for utilisation of NIV and patient outcomes (NSW ICU Practice Audit, 2012). Evidence suggests the use of NIV in the management of acute respiratory failure may:
- reduce the need for invasive ventilation
- decrease the need for prolonged mechanical ventilation
- improve patient outcomes
- reduce hospital and ICU length of stay
- reduce mortality and morbidity in those with acute on chronic respiratory failure (1, 2).
Initiation and Titration
Interface and Comfort
The purpose of this guideline is to provide a consistent level of support and guidance to clinicians in adult critical care areas and specialist respiratory care units about the care required for patients receiving NIV. This guideline draws on current best evidence and clinical expertise and describes key aspects of care including: 1) clinical assessment; 2) NIV management; and 3) and patient care. The guideline does not include recommendations regarding other treatments that patients may require including bronchodilators, cortocosteroids or antibiotics.
The degree to which an adult patient is compliant with NIV not only relates to his or her presenting physiological condition, it also involves a combination of issues associated with the therapy. Primary among these issues is the care required to ensure patient comfort, and thus, compliance. The development of this guideline is to formulate recommendations about best practice (based on evidence and clinical expertise) for the care to be provided to a person receiving NIV. The recommendations apply to patients receiving NIV in rural, regional or urban setting and in any adult critical care or specialised respiratory unit, irrespective of the level of Medical Officer and/or allied health professional support.
The scope of this guideline is for critically ill adult patients who, following medical assessment, require non-invasive positive pressure ventilation as an adjunct to standard medical therapy. This may occur in intensive care, high dependency and dedicated specialist respiratory units with a higher level of clinical support. It should be noted that this guideline was developed using evidence of best practice relating to adult patients only. The concepts and recommendations may be considered when providing NIV to children.
This guideline has been developed for all healthcare professionals who provide care for patients with acute respiratory failure who are treated with NIV including nurses, doctors, physiotherapists and other allied health professionals.
How the guideline was developed
A systematic guideline development method (3) was used, based on NHMRC processes and the AGREE tool. A guideline development network (GDN) was formed. This network developed the guideline template that outlined the clinical question and specific areas to be addressed within the guideline. Following this a systematic review was undertaken (for more details see below). The practice review was restricted to a review of local practices from all NSW ICUs. Of the 39 ICUs reviewed, there was a large variance in policies, protocols and practices related to the use of NIV. A technical report was developed from the systematic review and this document was used to inform discussions and recommendation development at the consensus meeting (November 27, 2012).
NHMRC evidence statement forms were used. Following the meeting the guideline document was written and circulated among group members. Consensus development and organisational consultation was undertaken over three stages:
- Guideline group consensus - two intensive care doctors were recruited. This larger guideline group received the guideline and technical report. Agreement on recommendations was undertaken using an online survey (Survey Monkey) and a 1-9 Likert scale. Consensus was set as a median of ≥ 7 (see Table 9).
- The external validation group received the guideline and technical report. Agreement on recommendations was undertaken using an online survey
- Organisational consultation was undertaken by distributing the guideline via ACI network consultation.
- Following each stage the guideline was revised to reflect the feedback received.
Recommendations for practice
|Section||Recommendation||Grade of recommendation|
Prior to commencement of NIV patients are to be assessed for:
Failure to meet any one of these criteria renders the patient ineligible for NIV and review of alternate care or escalation of therapy should be undertaken (4, 5).
All patients receiving NIV are to have a documented plan of care. This plan is to be developed on commencement of NIV, reviewed on a regular basis (at least every 24 hours and with a change in the patient’s condition) and updated as required. Where available, the care plan is to be developed by a critical care or respiratory Medical Officer or designated clinically qualified respiratory proxy.
All patients receiving NIV are to have a formal assessment and documentation of full body skin integrity at least daily. This includes the skin under the interface i.e. nose, face and neck.
Assessment of mask fit, interface type, head strap tightness, skin integrity of mask contact point, ventilation synchrony and degree of mask leak are to be completed each time the interface is adjusted and at least second hourly (6, 7).
Interventions to prevent pressure injury secondary to the interface are to be implemented on commencement of NIV.
When deterioration in skin integrity is identified, immediate strategies are to be employed to reduce further injury (6).
a) Initial settings for bi-level positive airway pressure (BPAP): inspiratory positive airway pressure (IPAP) of 10cmH2O and expiratory positive airway pressure (EPAP) of 4-5cmH2O= pressure support (PS) level of 5-6cm H2O (6, 8).
b) Initial settings for continuous positive airway pressure (CPAP): 5cm H20 (6, 8)
Increases to IPAP of 2-5cmH2O can be undertaken every 10 minutes or as clinically indicated until therapeutic response is achieved. The maximum IPAP should not exceed 20 – 23 cmH2O (6).
The target tidal volume of 6-8mls/kg (ideal body weight) is the target for all adult patients (7).
Optimal non-invasive positive pressure ventilation (NIV) is the lowest pressure and lowest Fi02 that achieve Sa02 of 90% or Pa02 of 60mmHg without further clinical deterioration (9).
All NIV circuits are to be actively humidified (10).
Heat moisture exchangers (HMEs) are not recommended for NIV (10).
Gas temperatures during NIV are to be based on patient comfort (10).
Assessment of patient comfort and pain is to be completed at least second hourly and documented (11).
Assessment of patient tolerance for higher levels of NIV is to be completed at least hourly until highest level of compliance reached (11, 12).
Patients receiving NIV are to be positioned to achieve maximal chest wall movement and prevent upper airway obstruction (6).
A total face or oronasal mask provide a similar clinical outcome and are preferred over the nasal mask in the acute setting (4).
The choice of mask is influenced by:
The total face mask could be considered; however due to the limited use in Australia and limited evidence of greater efficacy it is not the first line therapy.
A clear plan for the parameters indicating escalation to intubation and ventilation in the event of NIV failure is to be documented on clinical presentation or initiation of therapy (6).
If the patient does not clinically improve within four hours of starting NIV the decision to intubate and ventilate is to be made (6).
Intubation and ventilation is to be implemented rather than NIV continued for late failure (where late failure is defined as failure after 48 hours of NIV) (6).
A clear plan for the parameters indicating the decision not to intubate and ventilate in the event of NIV failure is to be documented on clinical presentation or initiation of therapy. This decision is to be discussed between the patient (or enduring guardian) and treating medical specialist and documented in the clinical records (6).
An advanced health directive is to be completed for any future presentations if one has not previously been completed (13).
Palliation for symptom relief, in combination with opioids and benzodiazepines, to treat breathlessness is to be documented on clinical presentation or initiation of therapy by medical staff. Such plans are to be implemented by nursing staff in response to assessment of patient comfort as required (6).
Patients with acute respiratory presentations associated with chronic medical conditions are:
A clear plan for the nursing care to be provided while the patient is receiving NIV is to be documented within 24 hours of initiation of therapy. This plan is to include the psychosocial support including (but not limited to) cultural safety, spiritual needs, family needs and financial concerns.
Oral hygiene is to be attended every two hours as long as the patient’s tolerance to ceasation of NIV is longer than five minutes. Refer to the Oral Care Clinical Practice Guideline for further information.
Eye care is to be attended every two hours. Refer to the Eye Care Clinical Practice Guideline for further information.
Eye Care Clinical Practice Guideline
A full body wash, including facial shave, is to be attended daily or more often as required in response to patient diaphoresis and the patient’s level of tolerance..
Patients are to receive pressure injury prevention management as per the Pressure Injury Prevention Guideline.
Pressure Injury Prevention Guideline
Patients are to be encouraged to sit out of bed as tolerated. When in bed they are to be positioned in an upright position to facilitate chest wall expansion.
Pressure Injury Prevention Guideline
The Physical Activity and Movement Guideline provides a graded mobility schedule. Patients are to be assessed and managed as per this guideline.
Physical Activity and Movement Guideline
Pharmacotherapies (i.e. anti-anxiolytics) are to be documented by medical staff on clinical presentation or initiation of therapy and implemented by nursing staff as required in response to patient assessment (6).
Referrals to allied health professionals are to be implemented where services are available in the clinical setting to support the patient and his or her significant other/s psychosocial wellbeing.
Oral feeding is to be initiated if the patient is able to tolerate small periods off NIV.
No oral intake is to be implemented if the patient has a decreased LOC or the patient is in respiratory distress with an increased work of breathing (i.e. R.R > 30/min). Intravenous fluids are to be commenced in these circumstances.
Patients receiving NIV are to have daily UECs and CMP blood samples taken for the duration of their NIV therapy to assess fluid and electrolyte status (6).
Patients receiving NIV are to have a strict fluid balance and stool chart implemented for the duration of their NIV therapy to assess elimination and fluid status.
Dietetics and nutritionist assessments are to be undertaken and documented for the patient receiving NIV 24 hours after initiation of therapy.
Clinicians are to undertake a risk assessment to identity the risk of contamination and mucosal or conjunctival splash injuries when caring for a patient being treated with NIV. PPE (including goggles/face shield/gloves and gown/apron) as per NSW 2007 Infection Prevention Control Policy should be worn according to the risk assessment (14, 15).
PD2007_036 Australian Guidelines for Prevention & Control of Infection in Healthcare.
Clinicians must adhere to the Five Moments of Hand Hygiene (16).
To reduce the risk of microbial transmission, equipment utilised for each patient must be cleaned as per the NSW Infection Control Policy and ASA Standard 4187 prior to and following use (14, 17).
AS 4187 2003
Items labeled single patient use are intended to be used in the care of one patient only and are to be discarded when the patient no longer requires the item (14).
NSW Policy PD 2007_036
Reuse of an NIV circuit/face mask may be possible only if the items are marked as reuse and cleaning instructions are supplied; the manufacturer’s recommendations are to be followed. The NSW Infection Control Policy (PD2007_036) states that the circuit and face mask are classified as a semi-critical item and require cleaning and disinfection before reuse (14).
NSW Policy PD 2007_036
Any health facility that provides NIV should have a policy/procedure stating patient selection criteria and management plan/s for patients recovery, NIV including initial settings and escalation strategies (18).
The frequency of documentation for NIV is to be at least hourly in the acute phase and then may be reduced to 2-4 hourly once the patient is stable or is in a specialised respiratory unit.
Patients receiving NIV must be located in a ward area where there are appropriate numbers of competent staff able to provide monitoring and titration of therapy consistent with all aspects of patient care required.
Organisations providing NIV are to have formal education processes relating to NIV and a competency assessment package for new graduates and staff working in these areas.
Where hospitals wish to monitor the outcomes of patients receiving NIV, minimum data for collection could include:
The evidence review for these recommendations was current to December 2012. Clinicians are advised to check the literature as research may have been published that change these recommendations.
Grade of recommendation
Body of evidence can be trusted to guide evidence
Body of evidence can be trusted to guide practice in most situations
Body of evidence provides some support for recommendation/s but care should be taken in its application
Body of evidence is weak and recommendation must be applied with caution
Consensus was set as a median of ≥ 7
Grades A–D are based on NHMRC grades (15)
|ABG||Arterial blood gas|
|ABHR||Alcohol-based hand rub|
|ACPO||Acute cardiogenic pulmonary oedema|
|ARF||Acute respiratory failure|
|AVPU||“alert, voice, pain unresponsive” – measure of level of consciousness|
|BMI||Body mass index|
|BPAP||Bilevel positive airway pressure|
|BSA||Body surface area|
|CPAP||Continuous positive airway pressure|
|GDN||Guideline development network|
|GCS||Glasgow Coma Scale|
|HDU||High dependency unit|
|HME||Heat and moisture exchange|
|ICU||Intensive care units|
|IDUC||Indwelling urinary catheter|
|NIV||Non-invasive positive pressure ventilation|
|TFM||Total face mask|
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- Holanda MA, Reis RC, Winkeler GF, Fortaleza SC, Lima JW, Pereira ED. Influence of total face, facial and nasal masks on short-term adverse effects during noninvasive ventilation. J Bras Pneumol. 2009;35(2):164-73.
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- Officer OotCH. Advanced Care Directives NSW. Sydney: Ministry of Health; 2005.
- Clinical Safety QaG. Infection Control Policy. In: Health Do, editor. Sydney: NSW Health 2007.
- NHMRC. Australian Guidelines for the Prevention and Control of Infection in Healthcare. Canberra: Commonwealth of Australia; 2010.
- Clinical Safety QaG. Hand Hygiene Policy. In: Health Do, editor. Sydney: NSW Department of Health; 2010.
- Association AS. Cleaning, disinfection and sterilizing resusable medical and surgical instruments and equipment, and maintenance of associated environments in health care facilities. Australian Standards Association; 2003.
- McCurdy B. Noninvasive Positive Pressure Ventilation for Acute Respiratory Failure Patients With Chronic Obstructive Pulmonary Disease (COPD): An Evidence-Based Analysis. Ontario Health Technology Assessment Series. Ontario2012. p. 1-108.
The information on this page is general in nature and cannot reflect individual patient variation. It reflects Australian intensive care practice, which may differ from that in other countries. It is intended as a supplement to the more specific information provided by the doctors and nurses caring for your loved one. ICNSW attests to the accuracy of the information contained here but takes no responsibility for how it may apply to an individual patient. Please refer to the full disclaimer.