Most likely to benefit – COPD or hypercapnic acute cardiogenic pulmonary edema

Caution in severely hypoxemic patients

  • Delay in endotracheal intubation should not occur because of NIPPV
  • Favorable response is usually apparent in the first 2 hours
  • Key is appropriately selecting the right patients for NIPPV


2004 Cochrane database review showed decrease in mortality, decreased intubation, and faster clinical improvement associated with NIPPV.

Dangers of inadequate ventilation

  • Transdiaphragmatic pressure generation is high -> risk of respiratory muscle fatigue

Acute cardiogenic pulmonary edema

Decreases work of breathing and improves cardiovascular function

Cardiovascular function

  • Decreases LV afterload
  • Reduces RV and LV preload

3CPO study showed that in patients with clinical dx of CPE (RR > 30, pH < 7.35, CXR w/ edema) randomized to NIPPV or standard oxygen tx had improved physiologic outcomes with NIPPV, but no difference in intubation rates and 7 and 30 day mortality.

  • Crossover – There was a high incidence of crossover (~15%) from the standard oxygen group. This could make argument that higher rates of intubation could have happened in standard oxygen group.
  • Sick patients excluded – Severely ill patients w/ need for lifesaving intervention were excluded.
  • CPAP vs. PSV+PEEP – Similar outcomes (re: intubation, mortality, clinical changes) between the two modes of NIPPV.

Hypoxemic respiratory failure

Difference between CPAP and PSV+PEEP


  • Early benefit with dyspnea and oxygenation
  • But, no difference with ETI, mortality, or ICU LOS
  • CPAP alone not recommended in mild to severe ARDS


  • Multiple RCTs (Martin 2000, Ferrer 2003) found benefits regarding intubation and mortality. Though importantly these studies had heterogenous patient populations with ARDS from multiple etiologies.
  • Despite some benefit seen in the studies above, there have been high rates of NIPPV failure in PNA and severe hypoxemia patients (Meduri 1996, Jolliet 2001, Domenighetti 2002, Antonelli 2001).


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