Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting

Over the past two decades, the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure by mask has increased substantially for acutely ill patients. Initial case series and uncontrolled cohort studies that suggested benefit in selected patients1–13 led to many randomized controlled trials (RCTs).14–151 Both methods of ventilation have been used in the setting of acute respiratory failure to avoid endotracheal intubation in different patient populations and settings, with variable success.14–69,117–123,134–141 In addition, noninvasive positive-pressure ventilation has been used to facilitate early liberation from conventional mechanical ventilation72–82 and to prevent reintubation.70,71,83–87These guidelines were developed to answer the following questions: What evidence is available in the literature to support recommendations for the use of noninvasive positive-pressure ventilation and continuous positive airway pressure for patients who are at risk of or who have acute respiratory distress or failure, patients who have undergone surgery and patients who are being weaned from mechanical ventilation or have recently undergone extubation? In addition, how can these two modes of noninvasive ventilation be optimally applied in these settings?Consensus conference statements152,153 and guidelines154–157 exist for the use of noninvasive ventiliation (the term used throughout this paper to refer to both noninvasive positive-pressure ventilation and continuous positive airway pressure) in the acute care setting. However, since publication of the two English guidelines addressing use in the acute care setting,154,156 many new RCTs have been published. In addition, the first154 of the two previous guidelines predated the development of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group methodology,158–160 and a less rigorous methodology was used in the second.156 Accordingly, we conducted a comprehensive search and appraisal of the current literature, using the GRADE methodology to assess the quality of the research and to generate clinical recommendations