In addition, Gray and colleagues recently published a multicenter randomized trial in the New England Journal of Medicine that showed no benefit in 7-day mortality and intubation rates with noninvasive ventilation versus standard oxygen therapy.

However, per the authors, the difference in intubation rates may be a reflection of the relatively low number of intubations in the trial.²⁴ Also, when comparing supportive ventilation versus standard oxygen therapy, patients showed earlier improvements in resolution of dyspnea, respiratory distress, and metabolic disturbances. Because of the physiological benefits, the authors continue to recommend NIPPV as an adjunctive therapy.

In decompensated heart failure, NIPPV has been shown to be a safe and effective treatment that should be part of emergency medicine’s standard approach.

Asthma. Asthma is another disease that is all too familiar to the emergency physician. NIPPV usage versus standard therapy has shown to be effective in correcting gas exchange abnormalities, decreasing work of breathing, improving peak expiratory flow, and increasing albuterol delivery.^25,26 A prospective, randomized control trial has shown that NIPPV therapy reduces admission rates, improves FEV1, and alleviates an asthma attack faster.²⁷ Currently, the studies are limited to morbidity indicators. However, the data and anecdotal evidence show that NIPPV is effective as a therapeutic option in severe asthma exacerbations. NIPPV, as a therapeutic option, becomes even more pertinent when considering the unique hazards of intubating the asthmatic patient.

Other disease processes. While most data and experience focus on COPD, congestive heart failure, and asthma, NIPPV is certainly not limited to these diseases. Studies with pneumonia patients in respiratory distress have shown that, as long as secretions are controlled, NIPPV decreases intubation rates and respiratory rates.²⁸

Furthermore, very strong arguments for NIPPV versus intubation extend to immunocompromised patients with hypoxemic respiratory failure and pulmonary infiltrates.

In a prospective randomized trial, Hilbert and colleagues found that NIPPV decreased intubation rates and serious complications and increased likelihood of survival to hospital discharge.29 The subsequent decrease in complications is thought to be from the decreased infection rates with NIPPV versus intubation.²⁹

While the mortality benefit may be nonexistent, patients who are DNR/DNI remain an important subset for whom to consider NIPPV. Shortness of breath is often reported as a major source of discomfort, and NIPPV therapy can effectively and comfortably relieve dyspnea.30 Also, there is evidence that NIPPV is effective for pulmonary contusion, and case reports suggest effectiveness in flail chest and cystic fibrosis.^31,32,33,34