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

Abstract

O ver 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 patients [1][2][3][4][5][6][7][8][9][10][11][12][13] led to many randomized controlled trials (RCTs).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.[117][118][119][120][121][122][123][134][135][136][137][138][139][140][141] In addition, noninvasive positive-pressure ventilation has been used to facilitate early liberation from conventional mechanical ventilation [72][73][74][75][76][77][78][79][80][81][82] and to prevent reintubation.70,71,[83][84][85][86][87] These 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 venti lation 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 statements 152,153 and guidelines [154][155][156][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 addi-tion, the first 154 of the two previous guidelines predated the development of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group methodology, [158][159][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. Methods Leadership and scopeAn 18-member guidelines panel of universityaffiliated clinicians, led by two cochairs, was formed in June 2007 as an initiative of the Canadian Critical Care Trials Group / Canadian Critical Care Society Noninvasive Ventilation Guidelines Group.The panel consisted of 15 physicians and 3 respiratory therapists who had a variety of Competing interests: See end of article for competing interests.