Comparison of national and international guidelines relating to treatment with acute NIV
| NIV in acute respiratory failure1 | COPD: NIV with biphasic positive airways pressure in the management of patients with acute type 2 respiratory failure8 | BTS/ICS Guidelines for the ventilatory management of acute hypercapnic respiratory failure in adults11 | Official ERS/ATS clinical practice guidelines: NIV for acute respiratory failure12 | |
| Publication date | 2002 | 2008 | 2016 | 2017 |
| Organisation(s) | BTS | RCP, BTS, ICS | BTS, ICS | ERS, ATS |
| Remit | Use of NIV and CPAP to treat adult patients with ARF. | Use of NIV in emergency and ward areas of acute hospitals to treat patients with AHRF due to COPD. | Assessment and management of adult patients with AHRF, including use of NIV and invasive ventilation. | Use of NIV to treat adults with acute respiratory failure. In this document, NIV refers to bilevel NIV and CPAP. |
| Methodology | SIGN | SIGN | SIGN | Assessment, Development and Evaluation (GRADE) |
| GRADE A OR strong indications for NIV | Acute exacerbation of COPD (AECOPD) pH<7.35 despite controlled O2. | AECOPD with pH<7.35, PaCO2>6 kPa, despite maximal medical therapy and controlled O2 for no more than 1 hour. | AECOPD with pH<7.35 and PaCO2>6.5 kPa that persists or develops despite optimal medical therapy. | AECOPD with pH≤7.35. NIV or CPAP for patients with (ARF) due to cardiogenic pulmonary oedema. |
| Location of NIV care (grade) | HDU/ICU for patients with pH<7.30 or failure to improve after 1–2 hours of NIV on a respiratory ward. (C) | HDU/ICU for patients with<7.26 unless NIV is ceiling of therapy. (A) | A clinical environment with enhanced nursing and monitoring facilities beyond those of a general medical ward. (C) | No recommendation. |
| Staff competency (GRADE) | Training appropriate to baseline knowledge and role. (D) | Staff appropriately trained and experienced. (B) | Regular staff educational updates and training module for new staff. | No recommendation. |
| Staffing levels (GRADE) | No recommendation. | Minimum staffing ratio of 1 nurse to 2 NIV patients for at least the first 24 hours of NIV. (C) | Enhanced nursing and monitoring facilities beyond those of a general medical ward. (C) box 3 in guideline: Essential requirements for NIV; 1 nurse to 2 NIV cases (especially during the first 24 hours of treatment). | No recommendation. |
| Timing | No recommendation. | Consider NIV for all patients with AECOPD and persisting AHRF (<7.35 and PaCO2>6 kPa) despite maximal medical therapy and controlled O2 for no more than 1 hour. | No recommendation. | No recommendation. |
| Physiological monitoring (GRADE) | Respiratory rate. (D) Heart rate. (D) Continuous SaO2 for first 24 hours. (C) | Respiratory rate. (C) Heart rate. (C) Continuous SaO2 and ECG for first 12 hours. (B) | No recommendation, though Good Practice Points (GCP) note; Respiratory rate>25 is a red flag. Continuous SaO2 advised. ECG monitoring advised if pulse rate>120 bpm, dysrhythmia or possible cardiomyopathy. | No recommendation, though supplementary text supports continuous SaO2 and frequent assessment of respiratory and heart rate. |
| Blood gas monitoring (GRADE) | As clinically indicated, plus routinely at 1–2 hours and after 4–6 hours of NIV. (B) | Minimum 1, 4 and 12 hours after NIV. (A) | No recommendation, though a GCP supports intermittent measurement of PaCO2 and pH. | No recommendation. Supplementary text supports routine sampling. though timings differ (text=1–2 hours, table=30–60 min) |
| Documentation of treatment plan (GRADE) | Decision on tracheal intubation before starting NIV. Verified with senior medical staff as soon as possible and documented in the case notes. (D) | Plan in the event of NIV failure should be made at the outset. (C) | Initial care plans should include robust escalation arrangements. (C) Use of NIV may allow time to establish patient preference with regard to escalation to IMV. (D) | No recommendation. |
| Escalation (GRADE) | If no improvement in PaCO2 and pH after 4–6 hours, NIV should be discontinued and IMV considered. (B) | A decision on IMV should normally be made within 4 hours of starting NIV (in the event of failure to improve). (A) | IMV should be considered if there is persistent or deteriorating acidosis despite attempts to optimise delivery of NIV. (A) | No recommendation. |
AECOPD, acute exacerbation of COPD; AHRF, acute hypercapnic respiratory failure; ARF, acute respiratory failure; ATS, American Thoracic Society; BTS, British Thoracic Society; COPD, chronic obstructive pulmonary disease; CPAP, continuous positive airway pressure; ERS, European Respiratory Society; GCP, Good Practice Point; HDU, high dependency unit; ICS, Intensive Care Society; ICU, intensive care unit; IMV, invasive mechanical ventilation; NIV, non-invasive ventilation; RCP, Royal College of Physicians of London; SIGN, Scottish Intercollegiate Guideline Network.