BACKGROUND: Acute hypoxemic and hypercapnic respiratory failure are among the most common reasons for ICU admission and need for invasive mechanical ventilation. Noninvasive respiratory support (NIRS) strategies-including high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and continuous positive airway pressure (CPAP)-may prevent intubation, improve outcomes, and reduce ICU utilization. However, there is uncertainty regarding optimal patient and modality selection, resulting in variable implementation. There are no clinical practice guidelines comprehensively addressing the use of the different NIRS strategies across the spectrum of acute respiratory failure.
OBJECTIVE: To update and develop new evidence-based clinical practice recommendations informing NIRS use, including HFNC, NIV and CPAP, in adults with acute respiratory failure.
METHODS: A multidisciplinary panel used the Grading of Recommendations, Assessment, Development, and Evaluation approach to address four PICO (Population, Intervention, Comparator, Outcome) questions related to the use of NIRS for hypoxemic and hypercapnic respiratory failure, preoxygenation for intubation, and postextubation respiratory support. Recommendations were informed by several systematic reviews and network meta-analyses.
RESULTS: The panel made a strong recommendation for HFNC and a conditional recommendation for NIV or CPAP for adults with acute hypoxemic respiratory failure with close monitoring for the need for escalation of respiratory support, based primarily on effects on need for intubation. For acute hypercapnic respiratory failure, the panel made a strong recommendation for NIV to reduce mortality and need for invasive mechanical ventilation, and a conditional recommendation for HFNC only in patients with less severe hypercapnia and with mild acidemia (eg, pH > 7.25), provided that close monitoring and prompt escalation to NIV are available. The panel made a strong recommendation for HFNC or NIV for preoxygenation prior to endotracheal intubation to prevent peri-intubation hypoxemia. The panel also issued a risk-based recommendation, suggesting HFNC for low-risk patients and NIV for high-risk patients to reduce the need for re-intubation following extubation after critical illness.
CONCLUSIONS: Noninvasive respiratory support strategies are effective in improving outcomes in a range of clinical scenarios. We provide evidence-based recommendations, which can be further informed by patient risk, institutional capacity, and interface tolerance.
| Discipline Area | Score |
|---|---|
| Emergency Medicine |  |
| Intensivist/Critical Care |  |
| Respirology/Pulmonology | Coming Soon... |
| Hospital Doctor/Hospitalists | Coming Soon... |
| Internal Medicine | Coming Soon... |
NIRS has become increasingly sophisticated and complex to apply optimally in various scenarios. This guideline helps parse the indications in a more practical and useful manner.
This guideline from the ATS provides important recommendations on using noninvasive respiratory support. They make a strong recommendation for HFNC and conditional recommendation for NIV or CPAP for adults with acute hypoxemic respiratory failure with close monitoring for escalation of respiratory support. For acute hypercapnic respiratory failure, they made a strong recommendation for NIV to reduce mortality and need for mechanical ventilation, and a conditional recommendation for HFNC only in patients with less severe hypercapnia and with mild acidemia (pH > 7.25), although close monitoring and prompt escalation to NIV should be available. There was a strong recommendation for HFNC or NIV for preoxygenation prior to endotracheal intubation to prevent peri-intubation hypoxemia. The panel also issued a risk-based recommendation, suggesting HFNC for low-risk patients and NIV for high-risk patients to reduce the need for re-intubation following extubation after critical illness.
This guideline on HFNC/NIV for oxygenation in respiratory failure, peri-intubation, and post-intubation makes a lot of sense and also provides a practical approach weighing the costs/benefits to each therapy compared with standard oxygen therapy. Even in the recommendations for peri-intubation, using NIV vs HFNC is left open even with data suggesting less complications with NIV, but in the setting of HFNC being potentially easier to use. Future research emphasizes many of the issues surrounding these questions.
Comprehensive summary relevant to emergency physicians managing critical care patients.
Superb example of a GRADE-adherent clinical practice guideline with crossover relevance for emergency medicine, critical care, and hospital internal medicine. The recommendations are likely to standardize practice for respiratory failure patients while aligning shared decision-making discussions with anticipated outcomes.
A consensus statement about advanced respiratory support in acute respiratory failure. I was disappointed by their position on NIV vs HFNC in preoxygenation.
Strong guidelines based on solid data; should be implemented quickly.
This is an evidence-based guideline for using non-invasive ventilation modalities, which makes it highly important for practitioners. Most of the evidence is already known to clinicians but not integrated in this type of format with recommendations.
Nice summary of data with clear recommendations for managing various forms of respiratory failure. Also highlights areas for further study. This can be applied universally.
