Box 1.

Questions to determine whether escalation to invasive mechanical ventilation is appropriate if non-invasive ventilation is failing

Has non-invasive ventilation been delivered optimally (in terms of quality of mask fit, patient–ventilator synchrony, and appropriate escalation of pressures)? If not, adjust or change interface and make appropriate changes to ventilator settings How long has the patient been in hospital? The longer the patient has been in hospital, the less likely a favourable outcome with non-invasive ventilation Are any factors still potentially reversible? If not, there is a risk of prolonging the dying process What was the patient's functional status before admission? A poor functional status is associated with a worse outcome

The more yes answers, the less likely a successful outcome will be reached even with invasive mechanical ventilation. Reproduced with permission from Bourke SC, Piraino T, Pisani L, Brochard L, Elliott MW. Beyond the guidelines for non-invasive ventilation in acute respiratory failure: implications for practice. Lancet Respir Med 2018;6:935–47.¹⁴