Non-Invasive Positive Pressure Ventilation in the Emergency Department

References

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ACEP Now: October 2025 (Digital)

1. Seeger K. The complete guide to high flow nasal cannula therapy (HFNC) [Internet]. Hamilton Medical. 2024 [cited 2025 Aug 6];Available from: https://www.hamilton-medical.com/en_US/Article-page~knowledge-base~efb4fa6e-cb67-4e7c-ac50-28b9e3472a04~The-complete-guide-to-high-flow-nasal-cannula-therapy–HFNC-~.html
2. Mauri T, Spinelli E, Mariani M, et al. Nasal high flow delivered within the helmet: A new noninvasive respiratory support. Am J Respir Crit Care Med. 2019;199(1):115-117.
3. Tan D, Wang B, Cao P, et al. High flow nasal cannula oxygen therapy versus non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease with acute-moderate hypercapnic respiratory failure: a randomized controlled non-inferiority trial. Crit Care. 2024;28(1).[/sidebar]

Most noninvasive ventilation devices found in the acute care setting also allow you to apply a set (minimum) respiratory rate, in addition to the IPAP, EPAP/CPAP and FiO₂, which is great for patients with an impaired respiratory drive. Conceptually, this is similar to pressure control ventilation, but that is beyond the scope of this article.

Where I have found it to be most helpful, however, is in preparing for intubation. If you are using NIPPV to preoxygenate your patients for intubation (and you probably should be, given the results of the PREOXI trial), setting a minimum respiratory rate allows you to keep the mask on the patient while giving your paralytic, providing ventilation throughout the period where they would otherwise be apneic.⁸

One advanced mode of NIPPV that is worth a mention is average volume-assured pressure support (AVAPS). Just like in BiPAP, you will set the EPAP, FiO₂, and respiratory rate. However, instead of providing a fixed inspiratory pressure, AVAPS targets a set tidal volume (and therefore a target minute ventilation) and varies the inspiratory support necessary to achieve the set target volume. So, for a typical target tidal volume of 8 mL/kg, you can set the allowable range (minimum and maximum) of inspiratory pressure and the machine will dynamically vary the pressure to assure the tidal volume that you are targeting.

AVAPS is contraindicated in the air-hungry patient, since the machine will drop the inspiratory support in response to their large tidal volumes, eliminating the support you intended, potentially making things worse. However, it is perfect for the drowsy patients with COPD, since it will increase the inspiratory pressure (and thus tidal volume) if they fall asleep, making it an auto-titrating mode of NIPPV.⁹ Some patients with severe obesity hypoventilation syndrome or neuromuscular weakness may have AVAPS as a nocturnal ventilation regimen.¹⁰

Using the Ventilator to Deliver NIPPV

Almost all modern ventilators have modes of support that replicate CPAP and BiPAP, typically called pressure support ventilation (PSV). When PSV is selected as the mode of ventilation (regardless of whether they are intubated or still on a non-invasive mask), the terminology changes: instead of using the term CPAP or EPAP, we use the term PEEP (positive end-expiratory pressure). Yes, I know that it’s confusing that CPAP, EPAP, and PEEP are all different names for the same thing.