Speaker's Highlight

• Don Sin University of British Columbia, St. Paul Hospital (Canada)
  Kenneth R. Chapman Toronto General Hospital Research Institute (Canada)
• Parameswaran Nair McMaster University (Canada)
  Carolyn Calfee UCSF (U.S.A.)
• Gregory P. Downey University of Colorado School of Medicine (U.S.A.)
  David A. Schwartz University of Colorado School of Medicine (U.S.A.)
• Neil Schluger Tuberculosis Control Branch, California Department of Public Health (U.S.A.)
  Nick Kim Critical Care & Sleep Medicine, University of California San Diego (U.S.A.)
• Nicola Hananiah Baylor College of Medicine (U.S.A.)
  Jae-Joon Yim Seoul National University College of Medicine (Republic of Korea)
• Koichiro Asano Tokai University School of Medicine (Japan)
  Diahn-Warng Perng Taipei Veterans General Hospital (Taiwan)
• Konstantinos Kostikas University of Ioannina (Greece)
  Karin Klooster University Medical Center Groningen (Kingdom of the Netherlands)

• Noninvasive Ventilation For Acute Respiratory Failure In The Emergency Department

  Acute respiratory failure can deteriorate within minutes, yet invasive ventilation is not always the first or best option. Noninvasive ventilation (NIV), delivered through a well-fitted mask, can improve oxygenation, reduce work of breathing and avoid complications associated with endotracheal intubation when used in carefully selected patients.

  In Australian emergency departments, NIV is most often considered for acute exacerbations of chronic obstructive pulmonary disease (COPD) with hypercapnic acidosis, acute cardiogenic pulmonary oedema and selected cases of hypoxaemic respiratory failure. It requires more than a machine: success depends on patient selection, staff expertise, close observation and a clear plan for escalation.

  Recognising Patients Who May Benefit

  Bi-level positive airway pressure, commonly called BiPAP, provides higher inspiratory pressure and lower expiratory pressure. This supports ventilation and can reduce carbon dioxide retention in patients with COPD exacerbations. Continuous positive airway pressure (CPAP) provides a constant level of pressure and is particularly useful when alveolar recruitment and reduced cardiac preload are needed, such as in acute pulmonary oedema.

  The strongest indications are increased work of breathing, respiratory acidosis caused by ventilatory failure and severe distress that persists after initial treatment. NIV should complement treatment of the underlying cause, including bronchodilators, corticosteroids, antibiotics when indicated, diuresis or vasodilators. It is not a substitute for prompt management of sepsis, myocardial infarction, pulmonary embolism or an obstructed airway.

  A patient who is vomiting, unable to protect the airway, severely agitated, haemodynamically unstable or rapidly deteriorating may require intubation instead. Facial trauma, recent upper-airway surgery and an inability to cooperate can make mask ventilation unsafe or ineffective. A treatment limitation plan should be clarified early, particularly for frail patients or those with advanced disease.

  Starting NIV Safely In The ED

  Before applying the mask, position the patient upright, attach continuous pulse oximetry and cardiac monitoring, and obtain baseline observations. Blood gas analysis helps identify hypercapnia and acidosis, while chest imaging, electrocardiography and bedside ultrasound may clarify the cause. Oxygen should be titrated to the clinical target rather than delivered at an unnecessarily high concentration.

  Explain the mask and allow the patient to hold it briefly if possible. Begin with a comfortable interface and modest pressures, then adjust according to respiratory rate, tidal volume, synchrony, distress and gas results. A tight seal is important, but excessive strap tension causes pressure injury and leaks around the eyes. Heated humidification may improve comfort during prolonged treatment, although it can complicate circuit management.

  The first hour is critical. Review the patient frequently for reduced accessory muscle use, improving alertness, falling respiratory rate and better blood gas values. Worsening acidosis, persistent hypoxaemia, exhaustion, declining consciousness or inability to tolerate the interface should trigger senior review and preparation for invasive ventilation.

  Avoiding Common Complications

  Mask leak is one of the most frequent causes of NIV failure. Staff should check the mask size, head position, tubing connections and synchrony before simply increasing pressure. Reassurance, coaching and short breaks may help an anxious patient, but sedatives can suppress airway reflexes and respiratory drive. If medication is considered, it requires senior input, continuous monitoring and a setting equipped for immediate airway rescue.

  Pressure areas can develop on the nasal bridge, cheeks and behind the ears, especially during long treatment. Alternate interfaces when clinically suitable, use protective dressings and inspect the skin regularly. Gastric insufflation, dry mucous membranes, eye irritation and aspiration are additional risks. Oral care and the ability to remove the mask quickly are important practical safeguards.

  In Australia, local protocols may differ between metropolitan hospitals in Sydney, Melbourne, Brisbane, Perth or Adelaide and smaller regional services. Remote and rural teams may need to coordinate early with retrieval services, including the Royal Flying Doctor Service, when a patient is failing NIV. Transfer should never be delayed while waiting for a late blood gas result or an ideal mask.

  Coordinating Care Across Australian Services

  Emergency clinicians should involve respiratory, intensive care or anaesthetic teams early when NIV is likely to continue beyond the initial stabilisation period. Clear documentation should include the indication, settings, oxygen target, mask type, blood gas results, response and escalation threshold. This is especially important during busy winter periods, when respiratory viruses increase demand in Australian hospitals.

  Smoke exposure from bushfires and prescribed burns can worsen respiratory symptoms, while seasonal influenza, COVID-19 and respiratory syncytial virus may increase presentations. Standard infection prevention procedures, appropriate room ventilation and equipment decontamination are essential. Devices and consumables should be sourced through approved hospital channels and used according to Therapeutic Goods Administration requirements and manufacturer instructions.

  Consent and treatment refusal must be handled within the relevant Australian state or territory framework. Privacy obligations under the Privacy Act 1988 and applicable state health-record legislation also apply when sharing information with family, paramedics, retrieval teams or receiving hospitals. In an emergency, clinicians should document the clinical basis for urgent treatment and any advance care directive or substitute decision-making information available.

  Practical Recommendations For Better NIV Delivery

  • Select NIV for a defined physiological problem, especially hypercapnic COPD exacerbation or acute cardiogenic pulmonary oedema.
  • Treat the underlying cause immediately rather than relying on positive pressure alone.
  • Record baseline respiratory rate, work of breathing, mental state, oxygen requirement and blood gas results.
  • Reassess continuously at the bedside during initiation and repeat blood gases when the clinical response is uncertain.
  • Use a comfortable, correctly sized mask and inspect the skin, eyes and mouth at regular intervals.
  • Define failure criteria before starting, including worsening acidosis, exhaustion, reduced consciousness or refractory hypoxaemia.
  • Escalate early to intensive care, anaesthesia or retrieval services when invasive ventilation may be needed.

  NIV works best as a monitored clinical process rather than a standalone device intervention. A calm explanation, suitable interface, targeted settings and rapid recognition of failure can improve tolerance while protecting the patient from delayed intubation. For Australian emergency teams, the practical standard is simple: start with a clear indication, review the response closely and keep the airway escalation plan ready from the first minute.

  Richard Russell Nuffield Department of Clinical Medicine, University of Oxford (United Kingdom)
• Mona Bafadhel King’s College London (United Kingdom)
  David Jackson Guy’s and St Thomas’ Hospital, King’s College London (United Kingdom)
• James Chalmers University of Dundee (United Kingdom)
  David Price University of Aberdeen (United Kingdom)