ATS Addresses NIV Strategies for Adults with Acute Respiratory Failure

Knowing which noninvasive ventilation (NIV) strategy to employ for which patient in the ICU has been a challenge, but a new clinical practice guideline (CPG) published by the American Thoracic Society (ATS) may help guide clinicians as they attempt to make the best decisions for their patients.

Developed by the ATS Assembly on Critical Care, the CPG addresses noninvasive respiratory support (NIRS) strategies for patients with acute hypoxemic respiratory failure, acute hypercapnic respiratory failure, preoxygenation of patients, and postextubation.

The expert panel compared three NIRS strategies – HFNC, NIV, and CPAP – to standard oxygen in these patients.

For patients with acute hypoxemic respiratory failure, the recommendations call for the use of:

• HFNC as compared to standard oxygen therapy.
• NIV via facemask or helmet as compared to standard oxygen therapy.
• CPAP via facemask or helmet as compared to standard oxygen therapy.

For patients with acute hypercapnic respiratory failure, the recommendations call for the use of:

• NIV via facemask as compared to standard oxygen therapy.
• HFNC as an alternative to NIV as compared to standard oxygen therapy for patients with acute hypercapnic respiratory failure and mild acidemia, provided that monitoring and escalation to NIV are promptly available.

For the preoxygenation of patients undergoing endotracheal intubation, the recommendations include: 

• The use of HFNC or NIV via facemask as compared to standard oxygen therapy.
• No recommendation was made for or against HFNC compared with NIV for preoxygenation in these patients.

For postextubation patients, the recommendations call for the use of:

• HFNC or NIV via facemask as compared to standard oxygen therapy.
• NIV via facemask as compared to standard oxygen therapy or HFNC in patients at high risk of extubation failure, such as those age 65 or older, and those with obesity, hypercapnia, prolonged mechanical ventilation, or severe illness.

The authors believe these recommendations are consistent with prior international guidelines that have established NIRS as an essential component of evidence-based care for patients with acute respiratory failure. However, they also emphasize that implementation should be tailored to the individual patient and clinicians must remain vigilant to changing patient needs.

“Together, these recommendations emphasize that the success of NIRS depends on appropriate patient selection, careful monitoring, and defined escalation thresholds rather than a single preferred device or interface,” they wrote.

The CPG was published in the September edition of the American Journal of Respiratory and Critical Care Medicine. 

Highlighted in RC Buzz, October 12, 2026