Noninvasive respiratory support for adult patients with acute respiratory failure: an official American Thoracic Society Clinical Practice Guideline

BACKGROUND: Acute hypoxemic and hypercapnic respiratory failure are among the most common reasons for ICU admission and need for invasive mechanical ventilation. Noninvasive respiratory support (NIRS) strategies-including high-flow nasal cannula (HFNC), noninvasive ventilation (NIV), and continuous positive airway pressure (CPAP)-may prevent intubation, improve outcomes, and reduce ICU utilization. However, there is uncertainty regarding optimal patient and modality selection, resulting in variable implementation. There are no clinical practice guidelines comprehensively addressing the use of the different NIRS strategies across the spectrum of acute respiratory failure. OBJECTIVE: To update and develop new evidence-based clinical practice recommendations informing NIRS use, including HFNC, NIV and CPAP, in adults with acute respiratory failure. METHODS: A multidisciplinary panel used the Grading of Recommendations, Assessment, Development, and Evaluation approach to address four PICO (Population, Intervention, Comparator, Outcome) questions related to the use of NIRS for hypoxemic and hypercapnic respiratory failure, preoxygenation for intubation, and postextubation respiratory support. Recommendations were informed by several systematic reviews and network meta-analyses. RESULTS: The panel made a strong recommendation for HFNC and a conditional recommendation for NIV or CPAP for adults with acute hypoxemic respiratory failure with close monitoring for the need for escalation of respiratory support, based primarily on effects on need for intubation. For acute hypercapnic respiratory failure, the panel made a strong recommendation for NIV to reduce mortality and need for invasive mechanical ventilation, and a conditional recommendation for HFNC only in patients with less severe hypercapnia and with mild acidemia (eg, pH > 7.25), provided that close monitoring and prompt escalation to NIV are available. The panel made a strong recommendation for HFNC or NIV for preoxygenation prior to endotracheal intubation to prevent peri-intubation hypoxemia. The panel also issued a risk-based recommendation, suggesting HFNC for low-risk patients and NIV for high-risk patients to reduce the need for re-intubation following extubation after critical illness. CONCLUSIONS: Noninvasive respiratory support strategies are effective in improving outcomes in a range of clinical scenarios. We provide evidence-based recommendations, which can be further informed by patient risk, institutional capacity, and interface tolerance.