Noninvasive Ventilation Procedures

Updated: Jul 18, 2022
  • Author: Suneel Kumar Pooboni, MD, , FRCPCH, FRCP(Edin), FCCP; Chief Editor: Zab Mosenifar, MD, FACP, FCCP  more...
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Noninvasive ventilation (NIV) can be defined as a ventilation modality that supports breathing by delivering mechanically assisted breaths without the need for intubation or surgical airway. [1] It is a popular method of adult respiratory management in both the emergency department (ED) and the intensive care unit (ICU), and it is increasingly used in the care of pediatric patients. [2]  Besides avoiding the adverse effects of invasive ventilation, NIV has the added advantage of patient comfort. It has become an important mechanism of ventilator support both inside and outside the ICU. [3, 4, 5]

NIV is divided into two main types, negative-pressure ventilation (NPV) and noninvasive positive-pressure ventilation (NIPPV); the latter is further subdivided into several subtypes, including continuous positive airway pressure (CPAP), bilevel positive airway pressure (BiPAP), and volume-assured pressure support (VAPS). This article addresses these methods and briefly discusses heliox adjunct therapy.



NIV is indicated in neonates and infants as follows:

  • Weaning from the ventilator
  • Preventing collapse of the lung
  • Minimal need for respiratory support, with good respiratory drive

NIV is indicated in children as follows:

NIV is indicated in adults as follows:

  • Bilateral pneumonia
  • Acute congestive heart failure with pulmonary edema
  • Neuromuscular disorders
  • Acute lung injury
  • Weaning from ventilator - A 2009 meta-analysis indicated that NIV, as a method of weaning critically ill adults from invasive ventilation, was significantly associated with reduced mortality and ventilator-associated pneumonia [7] ; although NIV is currently employed for weaning from invasive ventilation in the acute setting, its use for weaning from prolonged ventilation is still occasional and has not been standardized [8]

A systematic review and meta-analysis by Glenardi et al compared NIV with high-flow nasal oxygen therapy in COVID-19 patients with acute respiratory failure (ARF). [9]  NIV was found to have a higher success rate but also a significantly higher mortality. The authors suggested that high-flow nasal oxygen therapy should be considered before NIV in ARF associated with COVID-19 but noted that larger studies would be needed for better definition of the benefits of the former in this setting.



Absolute contraindications for NIV are as follows:

  • Respiratory arrest or unstable cardiorespiratory status
  • Uncooperative patients
  • Inability to protect airway (impaired swallowing and cough)
  • Trauma or burns involving the face
  • Facial, esophageal, or gastric surgery
  • Apnea (poor respiratory drive)
  • Reduced consciousness

Relative contraindications for NIV are as follows:

  • Extreme anxiety
  • Morbid obesity
  • Copious secretions
  • Need for continuous or nearly continuous ventilatory assistance
  • Lack of respiratory drive
  • Diseases with air trapping (eg, asthma) - In a child on CPAP, periodic monitoring is required; if the clinical condition and arterial blood gases deteriorate despite CPAP support, intubation should be considered


A large retrospective cohort study by Lindenauer et al found that patients with severe COPD exacerbations who were treated with NIV at the time of hospitalization had lower inpatient mortality, shorter length of stay, and lower costs than patients who were treated with invasive mechanical ventilation. [10]

Another large retrospective cohort study found that in 1254 patients hospitalized with asthma exacerbation and receiving ventilatory support in the form of NIV or invasive mechanical ventilation, those successfully treated with NIV appeared to have better outcomes than those treated with invasive mechanic ventilation. [11]  However, it is possible that NIV may have been used selectively in a lower-risk group.