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

option in the management of patients who are at risk of or have respiratory failure in the acute care setting. Over the past two decades, the use of noninvasive positivepressure ventilation and of noninvasive continuous positive airway pressure by mask has in creased tremendously among acutely ill patients. Initial case series and uncontrolled cohort studies that suggested benefit in selected patients led to many randomized controlled trials (RCTs). Both methods of ventilation have been used to avoid endotracheal intubation in different patient populations with variable success. In addition, noninvasive positive-pressure ventilation has been used to facilitate early liberation from conventional mechanical ventilation and to prevent reintubation. Comprehensive guidelines on the use of noninvasive ventilation have been published previously. Since then, the growing body of literature and variation in practice have underscored the need for new clinical practice guidelines for the management of patients who have acute respiratory distress or failure. To develop these guidelines, we conducted a systematic and comprehensive review of RCTs in this area. We considered more recent literature (an additional 58 trials), included only evidence from RCTs and used GRADE methodology (Grading of Recommendations Assessment, Development and Evaluation) to formulate the recommendations. Moreover, we have addressed the use of noninvasive ventilation in additional clinical settings: the postoperative setting, use for immunocompromised patients, weaning from conventional mechanical ventilation, transition to spontaneous breathing and the use for patients at high risk of respiratory failure after extubation. Although these guidelines were developed in the context of the Canadian health care system, we considered RCTs from any country. Therefore, we believe that these recommendations are generalizable and useful to all clinicians who care for patients who are at risk of or who have acute respiratory distress or failure in an acute care setting. Throughout this article, we include respiratory distress that is manifested by increased work of breathing but that does not meet traditional criteria for respiratory failure in our definition of acute respiratory failure. When we use the term “noninvasive ventilation,” we are referring to noninvasive positive-pressure ventilation and continuous positive airway pressure. Finally, when we use the term “continuous positive airway pressure,” the mode of delivery is understood to be by mask. Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting