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The rational of mechanical ventilation is to support gas exchange and unload respiratory muscle until the pathophysiology leading to respiratory failure improves. Intubation maintains patent airways, allows high working pressure but significantly increases the risk to develop severe respiratory infections and is poorly tolerated by the patients. Over the last two decades devices have been produced to consent a non-invasive interface between patient and ventilator. Today it is thus possible to ventilate patients with highly performing and well tolerated face masks of different shapes or with helmets. Moreover, ventilators have been implemented with modalities of ventilation aimed at a non-invasive ventilation (NIV). In NIV several ventilator modalities can be used. The most used are: continuous positive airway pressure (CPAP) that delivers constant pressure during both inspiration and expiration, and that does not actively assist inspiration; and differently delivered forms of bi-level ventilation (NiPPV) which provide two levels of airway pressure that actively assist inspiration while providing end expiratory pressure. These implementations have challenged the way NIV can be used and have open new approaches. Today NIV can be used to prevent intubation, as an alternative to conventional invasive ventilation