Noninvasive positive pressure ventilation (NIPPV) is the administration of ventilatory support without the use of an invasive artificial airway such as an endotracheal tube, tracheostomy tube, or laryngeal mask airway. Its use has been rapidly growing since its introduction in the late 1980s and early 1990s¹,² and it is now utilized as an adjunct to existing medical therapies or even as an alternative to endotracheal intubation for selected conditions. The main advantages of NIPPV are the ability to provide ventilatory support to a patient without the need for sedation and without bypassing airway defenses, both of which are necessary with invasive ventilation. Perhaps the most familiar use of NIPPV is for patients suffering from obstructive sleep apnea for which it is considered the standard of care³ and is provided by portable home devices (Fig. 3-1). However, in other groups of patients, most notably those suffering from exacerbations of chronic obstructive pulmonary disease (COPD) and cardiogenic pulmonary edema, NIPPV has been shown to decrease intubation rates and in-hospital mortality.⁴,⁵ As experience with NIPPV grows, it is being evaluated in a growing number of scenarios, including postextubation respiratory failure (Fig. 3-2), as a component of ventilator weaning in the ICU and as a method to provide ventilatory support to patients with do-not-intubate status.⁶,⁷,⁸ Although the range of conditions responsive to NIPPV is expanding, patient selection is still key to its successful implementation.

Successful use of NIPPV requires correct selection of both patient and equipment. Although the two acute conditions most likely to respond to NIPPV are exacerbations of COPD and congestive heart failure, patients must be evaluated on an individual basis for suitability for NIPPV.
Tables 3-1 and 3-2 list criteria to consider when evaluating a patient for NIPPV.

NIPPV can be provided via a variety of different interfaces. The characteristic that they all share is the ability to provide positive pressure. Oronasal masks were among the earliest interfaces and are still the most commonly used (Figs. 3-3 and 3-4).⁹ These masks cover both the nose and the mouth. They may be particularly effective for an acutely dyspneic patient as these patients tend to breathe through their mouths rather than their noses.¹⁰ However, these masks increase the risk of aspiration in a vomiting patient because they interfere with the expectoration of gastric contents. Quick-release mechanisms on newer oronasal masks decrease this risk but require the patient to be awake and alert in order to release their mask. Nasal masks decrease the aspiration risk and allow the patient to speak while receiving NIPPV, but they increase the risk of air leaks through the mouth (Figs. 3-5 and 3-6). Mouthpieces, nasal pillows (Fig. 3-7), total face masks, and helmets may also be used to provide NIPPV. Each interface has its own set of advantages and disadvantages (Table 3-3).