Acute Respiratory Failure
Patient with respiratory distress requiring ventilatory support
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Pulmonary MedicineManagement
Non-Invasive Ventilation for Acute Respiratory Failure
Non-Invasive Ventilation for Acute Respiratory Failure: Acute Respiratory Failure → Type of Respiratory Failure? → NIV Indicated? → ⚠️ NIV Contraindicat...
Pathway Overview
15 steps
Algorithm Steps
15 total
01Start 02Decision Type of Respiratory Failure?
Hypoxemic vs Hypercapnic
- Type 1 (Hypoxemic): PaO2 <60mmHg, normal/low CO2
- Type 2 (Hypercapnic): PaO2 <60 + PaCO2 >45 + pH <7.35
- Mixed: Features of both
03Decision NIV Indicated?
Check indications and contraindications
- INDICATIONS:
- • AECOPD with respiratory acidosis (pH 7.25-7.35)
- • Cardiogenic pulmonary edema
- • Immunocompromised with respiratory failure
- • Post-extubation support
- • Chest wall deformity/neuromuscular disease
04Warning ⚠️ NIV Contraindicated
Consider immediate intubation
- Cardiac/respiratory arrest
- Unable to protect airway
- Facial trauma/burns/surgery
- Fixed upper airway obstruction
- Vomiting/high aspiration risk
- Undrained pneumothorax
- Severely impaired consciousness
05Outcome Proceed to Intubation
NIV has failed
- Do not delay if deteriorating
- RSI with appropriate induction
- Lung-protective ventilation
- ICU admission
06Decision Select NIV Mode
Based on clinical indication
- CPAP: For Type 1 failure, cardiogenic pulmonary edema
- BiPAP: For Type 2 failure, COPD, hypoventilation
07Action CPAP Setup
For cardiogenic pulmonary edema
- Starting pressure: 5-10 cmH2O
- Titrate to 10-12 cmH2O as tolerated
- Add FiO2 to maintain SpO2 ≥94%
- Use full face mask
- Monitor for improvement in work of breathing
08Action Interface Selection
Choose appropriate mask
- Full face mask: Most common, effective
- Nasal mask: If claustrophobia, better tolerated
- Total face mask: Edentulous, facial hair
- Helmet: Prolonged use, less leak
09Action Titrate Settings
Optimize ventilation
- Increase IPAP to improve ventilation (↓PaCO2)
- Increase EPAP to improve oxygenation
- Aim for: Tidal volume 6-8 mL/kg
- Target: RR <25, patient-ventilator synchrony
- Reduce leak to <40 L/min
10Action Close Monitoring
Assess response to NIV
- ABG at 1-2 hours, then 4-6 hourly
- Target: pH improving toward >7.35
- Monitor: RR, HR, SpO2, comfort
- Watch for: Distension, mask leak, skin breakdown
11Decision Response at 1-2 Hours?
Assess clinical and ABG improvement
- Good: pH improving, RR decreasing, comfortable
- Poor: pH worsening, RR not improving, agitation
12Action Continue NIV
Maintain as long as needed
- Use for as much of first 24h as possible
- Allow breaks for eating, nebulizers
- Wean over 48-72h as pH normalizes
- Transition to nocturnal NIV if needed
13Outcome Wean from NIV
When clinically stable
- pH >7.35 on minimal support
- Reduce IPAP gradually
- Increase time off NIV
- Consider domiciliary NIV if recurrent
14Warning ⚠️ NIV Failure
Consider intubation
- pH not improving or worsening after 1-2h
- Decreasing level of consciousness
- Hemodynamic instability
- Intolerance despite optimization
- Prepare for intubation
- Path rejoins step 05Shared downstream outcome
15Action BiPAP Setup
For hypercapnic respiratory failure
- IPAP: Start 10-12 cmH2O, titrate to 20-25
- EPAP: Start 4-5 cmH2O
- Backup rate: 12-16 breaths/min
- Inspiratory time: 0.8-1.2 seconds
- FiO2: Target SpO2 88-92%
- Path rejoins step 08Shared downstream outcome
Guideline Source
BTS/ICS Guideline for NIV in Acute Respiratory Failure
Clinical Safety Information
Clinical Decision Support — Not a Substitute for Clinical Judgment
Individual patient factors may require deviation from these recommendations.
Known Limitations
- Settings require individual titration
- Does not cover chronic NIV initiation
- Interface selection based on availability
- Staff training essential for safe delivery
Applicable Regions
UKEUGlobal
Global: Principles universal; device availability varies
Version 1Next review: 2027-01-01
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Related Resources
Frequently Asked Questions
What is the Non-Invasive Ventilation for Acute Respiratory Failure?
The Non-Invasive Ventilation for Acute Respiratory Failure is a management clinical algorithm for Pulmonary Medicine. It provides a structured decision tree to guide clinical decision-making, based on BTS/ICS Guideline for NIV in Acute Respiratory Failure.
What guideline is the Non-Invasive Ventilation for Acute Respiratory Failure based on?
This algorithm is based on BTS/ICS Guideline for NIV in Acute Respiratory Failure (DOI: 10.1136/thoraxjnl-2016-208678).
What are the limitations of the Non-Invasive Ventilation for Acute Respiratory Failure?
Known limitations include: Settings require individual titration; Does not cover chronic NIV initiation; Interface selection based on availability; Staff training essential for safe delivery. Individual patient factors may require deviation from these recommendations.
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