UMEM Educational Pearls

Category: Critical Care

Title: Non-invasive Ventilation (NIV): What s the Evidence?

Keywords: bilevel ventilation, bipap, cpap, respiratory failure, respiratory distress, copd, acute pulmonary edema (PubMed Search)

Posted: 3/29/2011 by Haney Mallemat, MD
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Emergency Medicine physicians are gaining experience with non-invasive ventilation (i.e., Bi-level ventilation and continuous positive-pressure ventilation) in managing respiratory distress and failure. Although NIV is commonly used across a variety of pathologies, the best data exists for use with COPD exacerbation and cardiogenic pulmonary edema (CHF, not an acute MI) 


Although other indications for NIV have been studied, the data is less robust (eg., smaller study size, weak control groups, etc.). If there are no contraindications, however, many experts still support a trial of NIV in the following populations:

  • Asthma
  • Severe community acquired pneumonia
  • Acute lung injury / Acute Respiratory Distress Syndrome
  • Chest trauma (lung contusion, rib fractures, flail chest,etc)
  • Immunosuppression with acute respiratory failure
  • Neuromuscular respiratory failure (eg., Myesthenia Gravis)
  • Cystic Fibrosis
  • Pneumocystis Jiroveci Pneumonia
  • “Do not intubate” status


Failure to clinically improve during a NIV trial should prompt invasive mechanical ventilation.


Keenan, S. et al. Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. CMAJ. 2011 Feb 22;183(3):E195-214. Epub 2011 Feb 14.