Table 2.
Potential Benefits and Disadvantages of Different Breathing Support Strategies in Acute Respiratory Failure
| Type of breathing support | Benefits | Disadvantages |
|---|---|---|
| NIPPV (CPAP or BiPAP) | Less invasive than intubation. (A proportion of patients will survive without requiring intubation.) Avoids sedation, inability to communicate, potential delirium, and post-traumatic stress disorder associated with intubation, if intubation can be avoided. May better alleviate dyspnea, work of breathing, hypoxia, or hypercapnia compared with HFNC and standard oxygen. May be used outside of the intensive care unit (eg, in a dedicated respiratory ward). Provides a treatment option in patients with “do-not-intubate” orders. |
Compared with intubation (and sedation), patients on NIPPV may take larger tidal volumes and have an increased risk of subsequent lung injury. If NIPPV fails and intubation is required, the “delayed” intubation may be associated with a higher risk of complications due to a rushed procedure. Requires specialist nursing care compared with HFNC and standard oxygen. NIPPV might be more aerosol-producing (compared with HFNC, standard oxygen, and invasive mechanical ventilation, apart from the high risk during intubation), although this risk can be reduced with viral filters, etc. A tight-fitting mask may be uncomfortable for patients, especially when used continuously for extended length of time; some patients cannot tolerate NIPPV. May not allow for adequate mucociliary clearance. |
| Early intubation | Enables increased control of hypoxia, hypercapnia, and work of breathing compared with NIPPV, HFNC, and standard oxygen. Potentially avoids rushed intubation associated with risk of complications later compared with a failed trial of NIPPV. Once intubated with a closed respiratory circuit, the aerosol-generating risk may be lower compared with NIPPV. Treatment of choice when patient has significant inability to protect airway (eg, due to severe encephalopathy). Compared with NIPPV or HFNC, intubation with sedation may better facilitate patient undergoing certain procedures or transporting to a different medical facility (eg, patient cannot lie flat for a computed tomography scan). |
Requires specialist care in the intensive care unit (physician, nurses, and respiratory therapists). Often requires sedation, inability for patient to communicate, and may have increased association with delirium and post-traumatic stress disorder. May be associated with longer hospitalization and higher mortality compared with patients who have avoided intubation on NIPPV. Risk of vocal cord damage, procedural hypotension, and other adverse effects directly associated with placement of an endotracheal tube. Potential for lung injury associated with positive end-expiratory pressure. High risk of viral transmission during intubation (can be limited by techniques of apneic oxygenation and rapid sequence intubation with paralysis) and also during procedures which require opening the circuit such as bronchoscopy or suctioning. Compared with NIPPV, it is unclear if early intubation is associated with improved patient outcomes. |
| HFNC | Compared with standard oxygen, HFNC may be associated with improved hypoxia, improved hypercapnia (minor positive end-expiratory pressure support), and dyspnea. Compared with NIPPV (and intubation), HFNC is generally better tolerated and more comfortable, especially for extended continuous use. Enables patient to speak, eat, and drink. May even be more comfortable than high-flow standard oxygen (HFNC has heated humidifier). Compared with NIPPV, HFNC may allow for improved mucociliary clearance. Provides a treatment option in patients with “do-not-intubate” orders. May be used outside of the intensive care unit (eg, in a dedicated respiratory ward). |
May require special nursing competency. Provides only minimal positive end-expiratory pressure compared with NIPPV and invasive ventilation. Aerosol-producing procedure and risk of viral transmission, especially on high flow rates. |
| Standard oxygen via nasal prongs | Does not require specialist nursing competency. Does not require a bed in the intensive care unit. More widely available than ventilators or BiPAP machines. Provides a treatment option in patients with “do-not-intubate” orders. Compared with NIPPV, may be less aerosol producing. |
Is often less efficacious in improving hypoxia, hypercapnia, dyspnea, and work of breathing compared with HFNC, NIPPV, and intubation. May cause iatrogenic hypercapnic respiratory failure if the oxygen is not titrated and the patient is at risk of hypercapnia. High flow rates are aerosol producing. |
BiPAP = bilevel positive airway pressure; CPAP = continuous positive airway pressure; HFNC = high-flow nasal cannula; NIPPV = noninvasive positive pressure ventilation.