New Guideline on Noninvasive Respiratory Support for Acute Respiratory Failure (Part 1)

Starting with what wasn't said

A major American thoracic society has released a new official clinical practice guideline for the use of noninvasive respiratory support in adults with respiratory failure—both in the ICU and medical ward. (PulmCCM is not affiliated with any specialty society.)

It’s a significant framework shift that, for the first time, considers the indications and use of noninvasive support not only for discrete disease states but across the spectrum of respiratory failure (hypoxemic, hypercapnic, preoxygenation, and post-extubation support).

At the same time, the guideline update avoids any residual controversies that remain in the decisions whether and when to use conventional oxygen, high-flow oxygen, or noninvasive ventilation, endorsing standard practice rather than seeking to change it.

As such, we’ll first consider the new guideline in terms of what it doesn’t say.

What the New Guideline for the Use of Noninvasive Respiratory Support Doesn’t Say

1. No Strong Advice to Avoid Noninvasive Ventilation in Patients with Acute Lung Injury/ARDS

For more than a decade, prominent researchers and authors have made the case that spontaneously breathing patients with respiratory failure add further self-induced injury to their injured lungs by generating high transpulmonary pressure swings through forceful breathing.

“[T]hese patients may develop lung injury that is similar to the ventilator-induced lung injury observed in mechanically ventilated patients,” argued a seminal 2017 paper in this genre. The term P-SILI (patient self-induced lung injury) gained currency.

Placing such patients on noninvasive ventilation (e.g., BiPAP™) would add fuel to the fire, boosting the struggling patients’ tidal volumes to dangerous heights, and was therefore inadvisable, adherents claimed.

Instead of stretching lungs further with noninvasive ventilation, intubation with mechanical ventilation and sedation could be considered a lung-saving, prophylactic measure “rather than just a supportive therapy, to minimize the progression of lung injury from a form of patient self-inflicted lung injury.”

There have been no compelling real-world outcome data to support this perspective, which nevertheless gained significant traction in the late 2010s. This had major implications during the Covid-19 pandemic, when many thousands of patients were indeed “prophylactically” intubated very early in their course, straining resources and producing real or threatened ventilator shortages, without any clear differences in outcomes compared to a delayed strategy (during which noninvasive ventilation was commonly used).

In 2026, three authors anchored by the ventilator guru Martin Tobin marked the distance of the pendulum’s swing with an editorial titled, “Patient Self-Inflicted Lung Injury—Does It Really Exist?”:

“Claims for the existence of P-SILI are based on the shakiest of circumstantial evidence. Six decades of research on how to prudently select settings and remove/wean the ventilator at the earliest time were abrogated during a pandemic on the warrant of an unproven hypothetical entity.”

The Recommendation

For hypoxemic respiratory failure, the society guideline strongly recommends high-flow nasal oxygen over conventional oxygen. They only weakly (“conditionally”) recommended noninvasive ventilation over conventional oxygen.

Both NIV and HFNO have been shown to delay or prevent the need for intubation in closely monitored patients with hypoxemic respiratory failure. The evidence for HFNO appears slightly stronger.

Continuous positive airway pressure (CPAP) was also weakly/conditionally endorsed over conventional oxygen, for hypoxemic respiratory failure.

Although HFNO could not be recommended over NIV overall, in their distinction (strong vs conditional), the preference for high-flow oxygen over NIV/CPAP seems clear, especially in light of the suggestion that noninvasive ventilation has a greater theoretical risk for patients with high respiratory efforts, “resulting in persistently high transpulmonary pressures and tidal volumes that may increase the risk of lung injury and contribute to treatment failure.”

The European 2023 guidelines also do not explicitly advise against NIV for ARDS, but they all but do so by endorsing the P-SILI concept and warning that:

the application of additional positive pressure assistance during inspiration could lead to higher transpulmonary pressures and total stress applied to the lung, particularly when respiratory drive is high.

2. No Definition or Advised Method to Avoid “Delayed Intubation”

When to intubate a patient who appears to be failing noninvasive respiratory support is one of the most difficult decisions in clinical practice.

Although the guideline emphasizes the need for close monitoring and prompt escalation of therapy, including timely intubation, it provides no guidance to help make this decision.

Awake proning—the most noninvasive form of respiratory support—is never mentioned. Among 1,121 patients with respiratory failure due to Covid-19, the number needed to treat with awake proning to prevent an intubation was 14.

In part two, we’ll cover what the guideline did say, which was largely an endorsement of and a catching-up-with what has become standard practice.

Reference

Goel NN, Ferreyro BL, Pitre T, Lewis K, Homer-Bouthiette C, Angriman F, Kawano Dourado L, Drake M, Eaton TL, Esbrook CL, Frat JP, Grieco DL, LeTourneau W, Mosier J, Patel BK, Qadir N, Riviello E, Roca O, Twagirumugabe T, Vranas KC, Munshi L, Rochwerg B; American Thoracic Society Assembly on Critical Care. Noninvasive Respiratory Support for Adult Patients with Acute Respiratory Failure. An Official American Thoracic Society Clinical Practice Guideline. Am J Respir Crit Care Med. 2026 Jun 29:aamag302. doi: 10.1093/ajrccm/aamag302. Epub ahead of print. PMID: 42371750.