The where-to-do-it of noninvasive ventilation revisited.

Noninvasive ventilation (NIV) represents the standard of care in acute respiratory failure.1 In acute hypercapnic ventilatory failure due to COPD exacerbations and acute cardiogenic pulmonary edema, NIV is without doubt highly effective in terms of reduced intubation rates and mortality.2,3 As a consequence of the growing amount of evidence for these benefits, NIV use has been ever increasing during the past decade.4,5 The rising number of patients treated with NIV applies not only to the aforementioned, well-proven indications but also to other conditions leading to acute respiratory failure: NIV use extended into the prehospital setting,6 postextubation respiratory failure,7 acute hypoxemic failure due to pneumonia or ARDS,8 and support during bronchoscopy in acute hypoxemic respiratory failure.9 Besides the question of which conditions can be effectively treated with NIV, the question of where to perform NIV is nearly as old as the technique itself.10,11 Before the advent of NIV, nearly all patients in need of mechanical ventilation had to be transferred to an ICU. In this setting, optimal monitoring equipment is present, and the 24/7 presence of respiratory therapists, nurses, and physicians ensures competent and uninterrupted care of these vulnerable patients. The German national guidelines recommend that NIV be initiated in the setting of intermediate care units or ICUs.12 This high level of care is desirable to achieve optimal results regarding patient safety. However, as significant shortages of ICU beds are a constant problem in many countries around the world, such recommendations appear to be impractical for many situations. Furthermore, the chance for reduced ICU resource utilization is one of the many benefits of NIV in the management of acute respiratory failure. Hence, most national and international guidelines on NIV do not specify exactly where to initiate NIV for acute respiratory failure.13-16 Instead, they describe a range of different scenarios: from high-level ICUs, emergency departments, and respiratory intermediate care units to general wards, all settings may be appropriate under certain conditions. The recommendation is to analyze the available resources at an institutional level and match them with the group of patients who need care. The importance of formal and continuous training is emphasized. A randomized multi-center study investigated whether initiating NIV in COPD subjects with acute hypercapnic ventilatory failure (average pH 7.32, range of 7.25–7.35) in the general ward is safe and effective.17 Intubation rates and mortality were reduced in comparison with standard therapy by 44% and 50%, respectively. It should be emphasized that in this study, NIV was initiated by nurses and physiotherapists. Success was felt to be dependent on the quality of the medical staff’s formal training, protocolbased procedures, and focusing on specialized NIV wards. Regarding the difference in work load, the authors found an average increase of only 26 min used for the NIV group