For a patient suffering from ARF, the point in time of NIV application may have more to do with study enrollment and study group assignment (NIV or intubation) than the underlying pathology. Specifically, in some cases if NIV had been initiated hours prior, a clear benefit may have been demonstrated. One must also remember that at many institutions, the threshold for intubation (or intensive care unit admission) may be different, as well as the treating provider’s expertise and experience with NIV. In addition, well-established and consistent criteria for NIV failure have not been clearly defined and vary significantly study to study, making generalizations difficult. A comparison of patient groups with equal possible clinical outcomes is necessary to compare the findings “on a level playing field” and determine external validity.
Conclusion
Noninvasive ventilation represents a critically important intervention—one that should be applied early and aggressively in the ED to patients presenting with ARD in whom there are no contraindications to treatment. The EP should recognize the patient at high risk and, at the time of application, continue to closely monitor him or her for signs of improvement or deterioration.
As NIV use continues to increase, it is important that the clinician have a good working knowledge of its setup, modes of operation, and potential complications. A comfort level should exist for troubleshooting at the bedside. As provider competence increases, standardized quality of care is improved.
Dr Burns is an associate professor, residency director, and vice chair of academic affairs, department of emergency medicine, The University of Oklahoma School of Community Medicine, Tulsa.