Tailoring noninvasive ventilation management in non-ICU settings and the cardiac surgery context.

Most respiratory therapists agree that noninvasive ventilation (NIV) has brought a revolution in respiratory failure.1 This rapidly expanding treatment strategy supports gas exchange and improves functional status of patients, shortens ICU and hospital stay, reduces mortality, and decreases costs.2 NIV is now the accepted standard of care for high-risk patients with exacerbation of COPD or acute cardiogenic pulmonary edema.1 The use of NIV has also increased in other acute respiratory failure etiologies, such as acute lung injury and ARDS, severe communityacquired pneumonia, chest trauma, and in immunocompromised patients.3 During the past decade, therapeutic applications of NIV have been reported in postoperative respiratory failure4,5 and in acute respiratory distress after extubation, as a first-line intervention, though with controversial effectiveness.6 Indisputably, the effectiveness of NIV commencement depends on the establishment of a successful institutional NIV program. Training in NIV is of utmost importance and must be thorough. Identifying appropriate patients and understanding the goals and the risks of NIV can be reached only with continuing education. Improved knowledge among clinicians increases its successful and efficient use. Other important factors include the available respiratory equipment and the acceptance of a proper protocol.2 Moreover, choosing the appropriate location for applying NIV can be a significant part of a flexible NIV program, although that may contain risks. Establishing an NIV program in a non-ICU setting can be safely performed, but the setting selection requires consideration of several factors: staff education and skills, the unit’s monitoring capabilities, and identifying the more stable patients are the keys to success.7 Given the considerable pressure for ICU beds, this option is quite attractive and promising in many hospitals. An ideal place for NIV would seem to be the stepdown unit, which offers lower cost and a less distressful environment than the ICU. Additionally, the staff’s NIV experience and the monitoring available in a step-down unit ensure the efficiency of NIV management. In some circumstances, and in the lack of an available high-dependence-unit bed, physicians are forced to initiate NIV on the general wards. However, both technical and personnel resources are required. In the absence of an experienced NIV team, and if the ward is not suitably monitored, there should be concern about patient safety and NIV failure. In this issue of RESPIRATORY CARE, Khalid et al evaluate the outcomes of NIV delivered on general wards by a medical emergency team. According to their results, NIV can be safely initiated by specialized and educated personnel outside the ICU.8