Noninvasive ventilation in acute lung injury: caution is good, more evidence is better.

Noninvasive ventilation (NIV) has emerged over the last 2 decades to become the clear choice in the management of patients presenting with respiratory distress secondary to cardiogenic pulmonary edema1 and exacerbations of COPD.2 For these patient groups NIV clearly improves symptoms and, for the latter group at least, NIV is associated with less need for invasive mechanical ventilation and less hospital mortality. NIV has been used in other patient groups presenting with respiratory distress, with the objective of decreasing the need for invasive mechanical ventilation and improving hospital survival.3-7 The evidence in the literature supporting NIV’s use beyond patients with cardiogenic pulmonary edema and COPD, however, is much weaker, especially for those patients presenting with acute lung injury (ALI).8 In this issue of the Journal, Agarwal and colleagues report their systematic analysis of the literature on NIV in ALI.9 They