Reintubation due to ventilatory failure is associated with high mortality, mainly because of its association with infectious events, which increases prophylactic use of NIV in patients at risk of reintubation. We do not provide concrete evidence in LT, but there are several studies on intubated patients at risk of post-extubation ventilatory failure in comparable circumstances to lung transplant patients’ conditions that have shown a decrease in post-extubation ventilatory failure rate in patients using NIV after extubation, trying to maintain NIV as long as possible in the first 24 h, compared with patients who received standard treatment [7].

Along with this, early use of NIV could be considered in lung transplant patients who do not pass a T-piece trial or have hypercapnia during this trial, looking for a protective effect on further development of ventilatory failure.

In post-extubation ventilatory failure, the use of NIV seems attractive as a way to avoid the need for reintubation. However, in this case, there are dissenting opinions about its safety and usefulness. Once ventilatory failure is established, NIV may not be as useful as we think; it can even have a deleterious effect on survival because it may delay a needed intubation, increasing the overall mortality. However, in some studies performed in ventilatory failure in the postoperative period in thoracic surgery, NIV allowed a reduction in the rate of respiratory complications and its associated mortality in a relevant way.

A major cause of readmission to the ICU in the late postoperative period of LT is respiratory failure. This might be due to many circumstances, most commonly infection, cardiogenic acute pulmonary edema, drug side effects, and acute rejection. These situations with higher ventilatory requirements are often worsened by different circumstances related to LT: myopathy due to steroid use and ventilatory mechanics alterations due to surgery. Thus, it is known that lung transplant patients who require invasive mechanical ventilation have a worse prognosis than patients admitted to the ICU due to diseases not derived from surgery [8].

Moreover, NIV has demonstrated its usefulness in treating patients with hypoxemic respiratory failure of different etiologies, reducing the need for ETI and thereby decreasing infectious complications from it (nosocomial pneumonia and septic shock) and decreasing global mortality [9].

Along with the evidence that NIV is safe and may be beneficial in hypoxemic failure, this technique also has utility in ventilatory failure management in immunosuppressed patients. In these patients, when ventilatory failure requires ETI, mortality increases significantly, but NIV use enables to reduce reintubation rate and mortality, compared with reintubated patients. Particularly in lung transplant patients it has demonstrated an improvement in physiological parameters (arterial blood gases analysis, breathing rate, etc.) after introducing NIV as acute respiratory failure treatment. However, these results derive from a descriptive study without a control group, so we can only conclude that the NIV option is safe and may be beneficial to these patients [10].