Oxygen therapy, HFNC and NIV

NIV and CPAP beyond COPD

Reviewed Nov 2026·4 references
New· views rounded down, updated weekly

CPAP or bilevel NIV is strongly indicated for cardiogenic pulmonary oedema, useful in immunocompromised and post-operative respiratory failure, can prevent post-extubation failure in high-risk patients, but should not be used to rescue established post-extubation failure.

At the bedside

Timed steps
  1. 1

    CPAP or bilevel

    Cardiogenic pulmonary oedema

    CPAP 8-10 cmH2O (or bilevel) with FiO2 to target; plus nitrates if BP allows and diuretics. Strong recommendation.

  2. 2

    Early NIV or HFNC

    Immunocompromised

    Conditional recommendation for NIV in ERS/ATS; HFNC is often preferred now.

  3. 3

    Abdominal or thoracic surgery

    Post-operative

    NIV for post-operative acute respiratory failure (conditional).

  4. 4

    Prevention in high risk

    After extubation

    Prophylactic NIV (alternating with HFNC) reduces reintubation in high-risk patients (HIGH-WEAN). Do NOT use NIV to rescue established post-extubation respiratory failure.

  5. 5

    Early NIV

    Chest trauma

    Conditional recommendation in hypoxaemic chest trauma with adequate analgesia.

  6. 6

    Caution

    De novo hypoxaemia (pneumonia, ARDS)

    No recommendation for NIV over HFNC (ESICM 2023); if used, avoid large tidal volumes (> 9.5 mL/kg PBW) and intubate promptly if failing.

  7. 7

    Dyspnoea relief

    Palliative

    NIV may be offered for dyspnoea in palliative care if it improves comfort.

ERS/ATS 2017 NIV recommendations

ConditionRecommendation
COPD with acute respiratory acidosisStrong for bilevel NIV
Cardiogenic pulmonary oedemaStrong for bilevel or CPAP
Immunocompromised with ARFConditional for early NIV
Post-operative ARFConditional for NIV
Prevention of post-extubation ARF in high riskConditional for NIV
Established post-extubation ARFConditional against NIV
Chest traumaConditional for NIV
Palliation of dyspnoeaConditional for NIV
De novo hypoxaemic ARFNo recommendation
Red flag · call your senior now
Expired tidal volume > 9.5 mL/kg PBW on NIV in hypoxaemic failure predicts failure (patient self-inflicted lung injury risk).
Pitfall
Continuing NIV for hours in pneumonia while the patient tires: delayed intubation.
Pearl
Helmet NIV allows higher PEEP with less leak and is better tolerated for long periods.

References

  1. 1

    Rochwerg B, Brochard L, Elliott MW, et al. Official ERS/ATS clinical practice guidelines: noninvasive ventilation for acute respiratory failure. Eur Respir J. 2017;50(2):1602426

  2. 2

    Grasselli G, Calfee CS, Camporota L, et al. ESICM guidelines on acute respiratory distress syndrome: definition, phenotyping and respiratory support strategies. Intensive Care Med. 2023;49(7):727-759

  3. 3

    Thille AW, Muller G, Gacouin A, et al. Effect of postextubation high-flow nasal oxygen with noninvasive ventilation vs high-flow nasal oxygen alone on reintubation among patients at high risk of extubation failure (HIGH-WEAN). JAMA. 2019;322(15):1465-1475

  4. 4

    Hernández G, Vaquero C, Colinas L, et al. Effect of postextubation high-flow nasal cannula vs noninvasive ventilation on reintubation and postextubation respiratory failure in high-risk patients. JAMA. 2016;316(15):1565-1574

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