Complications of noninvasive ventilation in acute care.

The use of noninvasive ventilation (NIV) for acute respiratory failure has become widespread, but with the newfound beneficial treatments come complications. There is credible although somewhat disparate evidence to support the concept that, compared to invasive ventilation, NIV can reduce the incidence of infectious complications. In selected populations, nosocomial pneumonia appears to be significantly less common with NIV than with endotracheal intubation. NIV complications range from minor (eg, mask-related difficulties) to serious (eg, aspiration and hemodynamic effects). Evidence shows that if NIV is inappropriately applied for too long, the consequences may lead to death, presumably due to excessive delay of intubation. Despite apparently similar costs of treatment for patients with equivalent severity of illness, there is substantially less reimbursement for NIV than for intubation. The use of sedation in NIV patients has not been systematically studied, and sedation is generally underutilized, to avoid complications. Do-not-intubate patients pose a special ethical dilemma with regard to NIV, because NIV may conflict with a preexisting directive not to use life-support measures in the terminally ill patient.