Copyright #ERS Journals Ltd 2003

Eur Respir J 2003; 22: Suppl. 47, 31s–37s European Respiratory Journal
DOI: 10.1183/09031936.03.00050403 ISSN 0904-1850
Printed in UK – all rights reserved

Mechanical ventilation: invasive versus noninvasive

L. Brochard

Mechanical ventilation: invasive versus noninvasive. L. Brochard. #ERS Journals Ltd Correspondence: L. Brochard
2003. Service de Réanimation Médicale
ABSTRACT: Mechanical ventilation is the most widely used supportive technique in Hôpital Henri Mondor
intensive care units. Several forms of external support for respiration have long been 94010 Créteil Cedex
described to assist the failing ventilatory pump, and access to lower airways through France
Fax: 33 142079943
tracheostomy or endotracheal tubes had constituted a major advance in the manage- E-mail: [email protected]
ment of patients with respiratory distress. More recently, however, new "noninvasive"
ventilation (NIV) techniques, using patient/ventilator interfaces in the form of facial Keywords: Acute exacerbation of chronic
masks, have been designed. obstructive pulmonary disease
The reasons for promoting NIV include a better understanding of the role of endotracheal intubation
ventilatory pump failure in the indications for mechanical ventilation, the development mechanical ventilation
of ventilatory modalities able to work in synchrony with the patient, and the extensive pulmonary oedema
recognition of complications associated with endotracheal intubation and standard
Received: May 6 2003
mechanical ventilation. Accepted after revision: July 29 2003
NIV has been used primarily for patients with acute hypercapnic ventilatory failure,
and especially for acute exacerbation of chronic obstructive pulmonary disease. In this
population, the use of NIV is associated with a marked reduction in the need for
endotracheal intubation, a decrease in complication rate, a reduced duration of hospital
stay and a substantial reduction in hospital mortality. Similar benefits have also been
demonstrated in patients with asphyxic forms of acute cardiogenic pulmonary oedema.
In patients with primarily hypoxemic forms of respiratory failure, the level of success of
NIV is more variable, but major benefits have also been demonstrated in selected
populations with no contraindications such as multiple organ failure, loss of
consciousness or haemodynamic instability.
One important factor in success seems to be the early delivery of noninvasive
ventilation during the course of respiratory failure. Noninvasive ventilation allows many
of the complications associated with mechanical ventilation to be avoided, especially the
occurrence of nosocomial infections. The current use of noninvasive ventilation is
growing up, and is becoming a major therapeutic tool in the intensive care unit.
Eur Respir J 2003; 22: Suppl. 47, 31s–37s.

Without mechanical support for respiration, many patients in which every breath is supported by the ventilator. Rarely,
would die within hours to days due to acute hypoxaemic and controlled mechanical ventilation is used.
hypercapnic respiratory failure. Observational, physiological
and case/control studies form a large body of evidence
demonstrating that noninvasive ventilation (NIV) can be Acute exacerbation of chronic respiratory failure
used in many situations to decrease a patient9s dyspnoea and
work of breathing, improve gas exchange and ultimately Patients with hypercapnic forms of acute respiratory failure
avoid the need for endotracheal intubation (ETI) [1–3]. are most likely to benefit from NIV [1–3]. Their respiratory
Randomised controlled trials have confirmed this and muscles become unable to generate adequate alveolar
helped delineate when NIV should be used as a first-line ventilation despite large pressure swings because of the
treatment. Studies conducted outside the context of clinical presence of severe abnormalities in respiratory mechanics
trials are also of great importance in ensuring that the results (intrinsic positive end-expiratory pressure (PEEP) and high
of these trials can be obtained in real life [4–6]. Indeed, the inspiratory resistances) [9]. Stimulation of the respiratory
success of NIV may follow a learning curve, and early results centres and the large negative intrathoracic pressure swings
may not be as good as those obtained later. In addition, it generated do not permit compensation for these abnor-
must be clear to clinicians that NIV is a complementary malities; rapid shallow breathing ensues, associated with
technique and cannot replace ETI in all instances. carbon dioxide retention and respiratory acidosis, and a risk
In theory, the modes and settings for the delivery of NIV of respiratory muscle fatigue. Dyspnoea, right ventricular
could be very similar to those for traditional mechanical failure and encephalopathy characterise the severe acute
ventilation through an endotracheal tube or tracheotomy exacerbation. Delivery of NIV allows the patient to take
cannula. In practice, because the circumstances of ventilation deeper breaths with less effort. NIV at two levels of pressure
are different, the population of patients more selected and the (pressure support [10] and PEEP [11]) delivers a positive
equipment available sometimes more limited, this is not the inspiratory pressure swing in synchrony with the patient9s
case. In addition, leaks are a quasiconstant feature of NIV [7, inspiratory effort. A low level of pressure during expiration
8]. NIV is usually delivered in the form of assisted ventilation, counterbalances the effects of dynamic hyperinflation, which
32s L. BROCHARD

result in a positive residual alveolar pressure at the end of effects of using NIV in asthmatic patients deteriorating
expiration. The combination of the two levels of pressure has despite medical therapy [27, 28].
the greatest efficacy in reducing patient effort [12]. NIV can
reverse the clinical abnormalities related to hypoxaemia,
hypercapnia and acidosis [9, 13].
Where to perform noninvasive ventilation

Clinical trials An early randomised trial in 60 patients performed by BOTT

et al. [14] found major benefits of NIV performed in the
The efficacy of NIV in the case of acute exacerbation of emergency department or ward on dyspnoea and outcome,
chronic obstructive pulmonary disease (COPD) has been especially when the four patients who did not tolerate NIV
extensively studied (table 1). A recent international consensus were excluded from the analysis. A more recent prospective
conference recommended that NIV be considered a first-line multicentric randomised trial conducted in the UK by PLANT
treatment in these patients [24], and British Thoracic Society et al. [20] compared standard therapy alone (control group)
guidelines recommend that every hospital should be able to and with NIV in 236 COPD patients admitted to general
deliver NIV on a round-the-clock basis in this indication [25]. respiratory wards due to acute respiratory failure. The failure
In 1990, a case/control study first demonstrated that NIV (reaching criteria for ETI) rate was higher in the control
could markedly reduce the need for ETI [9]. Subsequently, group (27 versus 15%), and NIV was associated with a lower
several prospective randomised trials confirmed that NIV in-hospital mortality rate. Two specific aspects of this study
reduces the need for ETI and the rate of complications, need to be emphasised in order to explain the results. Owing
shortens the duration of hospital stay and improves survival to admission policy in the UK, all patients who failed NIV
in patients with COPD [14–16, 18–20, 26]. In a prospective were not transferred to an ICU, and, for this reason, the
randomised trial, KRAMER et al. [15] found a major reduction results may not be extrapolated to all kinds of medical
in the need for ETI. In this study, 74% of patients had COPD institution because the control group might have benefited
and the reduction in ETI rate in this group was from 67 to from a more intensive approach in other institutions. The
9%. Two studies, conducted in the UK, demonstrated the authors stressed the fact that, for the most severe patients
efficacy of NIV outside the intensive care unit (ICU) [14, 20]. (arterial blood pH of v7.30 on admission), the benefit of
In the largest study in the ICU, in which 85 patients with delivering NIV outside the ICU became marginal, with a high
COPD were randomised to treatment with or without face mortality rate. These patients would probably have benefited
mask pressure support ventilation [16], the ETI rate was 74% from early ICU admission for NIV delivery. The other aspect
for controls receiving standard medical treatment compared is the specific teaching and training of personnel before and
to only 26% in the NIV group. This reduction was associated during the course of the study. A strict protocol was followed
with fewer complications during the ICU stay, a reduced during the study, with no individual titration. Very probably,
duration of hospital stay and, more importantly, a significant this is a key element in explaining the benefits observed in the
reduction in mortality rate (from 29 to 9%). The overall study. Other studies performed in emergency departments did
decrease in mortality was ascribable to reductions in the need not show similar benefits [17, 29], and, in one study, the
for ETI and various ICU-related complications. results even suggested that ETI could have been delayed by
Two open studies also described the beneficial short-term inappropriate or inadequate use of NIV [29].

Table 1. – Randomised controlled clinical trials assessing the efficacy of noninvasive ventilation (NIV) in patients with chronic
obstructive pulmonary disease (COPD)
First author [Ref.] Patients n Location/study Impact of NIV

BOTT [14] 60 Ward Improvement in ABGs, dyspnoea

Reduction in ETI criteria
Reduction in mortality (excluding 4 patients not on NIV)
KRAMER [15] 31 (74% COPD) ICU Improvement in ABGs, dyspnoea
Reduction in ETI (67 to 9% in COPD)
BROCHARD [16] 84 ICU Improvement in ABGs
Reduction in ETI (74 to 26%), complications, LOS
Reduction in mortality
BARBÉ [17] 24 Emergency ward No benefit; no ETI required
ANGUS [18] 17 NIV versus doxapram Improvement in ABGs
CELIKEL [19] 30 – Improvement in ABGs
Reduction in criteria for ETI, LOS
PLANT [20] 236 Ward Improvement in ABGs
Reduction in criteria for ETI
Reduction in mortality
CONTI [21] 49 Late ICU admission and NIV Reduction in ETI (48 to 100%)
Similar ICU outcome
Fewer long-term readmissions (65 versus 100%)
NAVA [22] 50 MV curtailment after 48 h Improvement in weaning success
Reduction of LOS, complications
Reduction in mortality
GIRAULT [23] 33 MV curtailment after 4–5 days Shorter duration of ETI
No change in outcome
Longer duration of ventilation

ABGs: arterial blood gases; ETI: endotracheal intubation; ICU: intensive care unit; LOS: length of stay; MV: mechanical ventilation.
 MECHANICAL VENTILATION: INVASIVE/NONINVASIVE 33s

Workload for the personnel Cardiogenic pulmonary oedema

In the study of PLANT et al. [20], the training period Pathophysiology

comprised 8 h over the 3 months preceding the study and 1 h
monthly during the trial. Three studies specifically studied the Continuous positive airway pressure (CPAP) has the
workload for the personnel associated with the use of NIV. ability, by raising intrathoracic pressure, to decrease shunting
They found a different distribution of workload compared to and improve arterial oxygenation and dyspnoea in patients
a more traditional approach towards patients with respiratory with acute cardiogenic pulmonary oedema [42–47]. CPAP can
failure [15, 20, 30]. The first 6–8 h of NIV are usually both lessen the work of breathing substantially and improve
associated with a high level of workload, reflecting the need cardiovascular function by decreasing the left ventricular
for personnel to remain at the bedside. afterload in nonpreload-dependent patients [46]. Pressure
support plus PEEP induces similar pathophysiological
benefits.
When to perform noninvasive ventilation Most patients with cardiogenic pulmonary oedema
improve rapidly with medical therapy. A few, however,
Early NIV to prevent further deterioration must become an develop acute asphyxic respiratory distress and require
important part of the first-line therapy of acute exacerbation ventilatory support until the medical treatment starts to
of COPD [31]. A very low arterial blood pH, marked alter- work. This may be particularly common in elderly patients
ation in mental status when NIV is started, and the presence with heart disease and patients with concomitant chronic lung
of comorbid conditions or a high severity score characterise disease [48]. Several NIV modalities have been tried success-
patients who experience NIV failure [1, 32]. The presence of fully, the goal being to avoid ETI.
several of these factors seems to indicate that late delivery of
NIV during the course of the exacerbation reduces the likeli-
hood of success. Every effort should be made to deliver NIV Continuous positive airway pressure or pressure support
early, and close monitoring is therefore in order when NIV is plus positive end-expiratory pressure
started late. In addition, a recent randomised controlled trial
indicates that the efficacy of NIV diminishes when this Randomised trials comparing either CPAP or pressure
therapy is applied late in the course of the exacerbation. support plus PEEP to standard medical therapy found similar
Indeed, CONTI et al. [21] studied patients at a very late stage, results with the two techniques in terms of improvement in
and showed a reduction in ETI from 100 to 52%, which was arterial blood gas levels and respiratory frequency. Both
associated with only marginal short-term benefits. NIV was CPAP and pressure support plus PEEP significantly reduced
applied to patients with COPD who had stayed a mean of the ETI rate [43, 44, 47, 49, 50]. Two studies, however,
14 h in the emergency ward before being admitted to the ICU, indicate a need for caution. One compared pressure support
when, before the advent of NIV, ETI and mechanical plus PEEP and CPAP [51]. Acute myocardial infarction was
ventilation would have been the usual treatment. Interest- more common in the pressure support group than in the
ingly, there were still significant long-term benefits associated CPAP group and it remains unclear whether this should be
with the use of NIV, such as a decrease in the readmission rate ascribed to a randomisation bias or to a deleterious effect of
and the need for long-term oxygen therapy. pressure support plus PEEP itself. A high rate of acute
myocardial infarction was not found in the NIV arm of a
randomised controlled trial with pressure support and PEEP,
Long-term survival nor in observational studies [47, 49, 50]. The second study
compared intravenous bolus therapy with high-dose nitrates
Three studies have suggested that the use of NIV is to conventional medical therapy (a different medical therapy)
associated with a better 1-yr survival compared to standard and pressure support plus PEEP. The first of these two
ICU therapy [33, 34] or invasive mechanical ventilation [35]. treatments was far more clinically effective than NIV and
The recent study of CONTI et al. [21] confirms these findings. resulted in a better outcome [52]. These two studies draw
attention to the vulnerability of patients with cardiogenic
pulmonary oedema, particularly those with ischaemic heart
Negative pressure ventilation disease. They indicate that both appropriate drug therapy and
close monitoring are in order when using any form of NIV,
Nowadays, the technique of negative pressure ventilation is especially in patients with ischaemic heart disease.
only available in very few centres in the world. It should be
mentioned, however, that negative pressure ventilation was
the first mode of delivering noninvasive ventilation, before Hypoxaemic respiratory failure
positive pressure ventilation became the rule in the 1950s [36,
37]. Its efficacy in the treatment of acute exacerbations of Positive pressure ventilation was reintroduced during the
COPD may be superior, in experienced hands, to a traditional first half of the twentieth century, for support of patients
approach with invasive mechanical ventilation, and similar to requiring general anaesthesia for surgery, especially thoracic
noninvasive ventilation via a face mask [38, 39]. procedures. When the earliest case series of patients with
adult respiratory distress syndrome were reported in the late
1960s [53], positive pressure ventilation was used with
Helium-oxygen mixture increasing frequency for nonsurgical patients with acute
respiratory failure of various causes, including obstructive
The use of a helium/oxygen mixture during NIV seems very airways disease and severe pneumonia. NIV was proposed, in
promising for further reducing dyspnoea and work of the early 1990s, for treating these patients, but initial studies
breathing in patients with COPD [40, 41]. Several randomised have not all been successful [27, 54, 55]. More recently, new
controlled trials are in progress to test the hypothesis that this trials with careful selection of patients have demonstrated
gas mixture could increase the success rate of this technique. clear benefits of NIV [56–58].
34s L. BROCHARD

Continuous positive airway pressure controlled trial in patients who experienced respiratory
distress after lung resection. The reason why ETI should be
A recent investigation evaluated whether CPAP via a face avoided is the very poor outcome of patients, who usually
mask produced physiological benefits and reduced the need require reintubation shortly after lung surgery. A reduction
for ETI in patients with acute lung injury [59]. CPAP was in ETI rate and a clear benefit in terms of hospital survival
associated with an early favourable physiological response in was observed with NIV. A noncontrolled study suggested
terms of comfort and oxygenation during the first hour. interesting results using NIV after bilateral lung transplanta-
However, no differences were found in the need for ETI, in- tion [65].
hospital mortality or duration of ICU stay. In addition, use of
CPAP was associated with more complications, including
stress ulcer bleeding and cardiac arrest at the time of ETI. Community-acquired pneumonia
These results suggest that CPAP alone cannot be recom-
mended for avoiding ETI in patients with acute lung injury.
CONFALONIERI et al. [26], in a randomised controlled trial,
Its use should be limited to a short initial period if no other
showed major benefit of NIV in patients with community-
method is available.
acquired pneumonia, by reducing the rate of ETI and
complications and duration of stay. This benefit, however,
was almost entirely explained by the subgroup of patients
Pressure support and positive end-expiratory pressure with COPD. Other studies with severely hypoxaemic patients
with pneumonia have shown a high rate of failure in this
Until the late 1990s, the most convincing successes with subgroup [27, 32, 67]. NIV cannot be recommended for all
NIV were obtained in patients with acute respiratory acidosis patients with severe community-acquired pneumonia.
in whom hypoxaemia was not the main reason for respiratory
failure. One randomised controlled trial, of WYSOCKI et al.
[55], found no benefit of NIV in patients with no previous
history of chronic lung disease, except in the subgroup of Noninvasive ventilation in the postextubation period
patients who developed acute hypercapnia. However, the
beneficial effects of NIV have now been extended to different The physiological rationale for this approach was recently
forms of hypoxaemic respiratory failure with carefully demonstrated by VITACCA et al. [68]. HILBERT et al. [69]
selected patients, showing that NIV may reduce the need suggested favourable effects of NIV on preventing reintuba-
for ETI and improve outcomes [26, 56–58, 60, 61]. tion in patients with COPD in a case/control study. A recent
ANTONELLI et al. [56] showed marked benefits of NIV using prospective randomised trial by KEENAN et al. [70] was
pressure support and PEEP in hypoxaemic patients free from performed in all patients experiencing postextubation respira-
COPD, haemodynamic instability or neurological impair- tory distress. This study did not show any benefit of NIV.
ment, who were randomised when they reached predefined Two other prospective randomised trials did not find any
criteria for ETI. Improvements in oxygenation were similar preventive effect of NIV [71, 72]. The benefits of this tech-
with both the noninvasive and the invasive approach. Despite nique may thus be observed only in patients with COPD, and
a 30% failure rate, patients treated with NIV showed a shorter the efficacy of NIV in preventing reintubation in all patients
duration of ventilation and ICU stay and experienced fewer remains unproven.
complications. Thus NIV can be effective in selected patients A number of patients with COPD still require ETI because
with hypoxaemic respiratory failure but with no haemody- they fail NIV, show a contraindication to NIV (such as a need
namic or mental impairment. for surgery) or exhibit criteria requiring immediate ETI.
However, when there is a need for prolonged ventilatory
assistance, these patients may be switched to NIV after a few
Immunosuppressed patients days of ETI, as a means of deliberately reducing the duration
of invasive ventilation [22, 23]. This approach was shown, in
One of the main benefits of NIV may be a reduction in the two randomised controlled trials, to reduce the duration of
risk of infectious complications [5, 6]. Therefore, patients at ETI [22, 23]. In one study only, complications were reduced
high risk of nosocomial infection when mechanically venti- and survival rate was higher at day 60 with this approach [22].
lated may be particularly likely to benefit from NIV. Several Lastly, NIV can also be proposed in persistent weaning
recent trials have shown major benefits of NIV as a preventive failure. FERRER et al. [73] recently reported the results of a
measure during episodes of acute hypoxaemic respiratory prospective randomised controlled trial in 43 mechanically
failure in solid organ transplant patients or patients with ventilated patients who had failed a weaning trial for 3
severe immunosuppression, particularly related to haemato- consecutive days and were randomly extubated, receiving
logical malignancies and neutropenia [57, 60, 62]. The rates of NIV, or remained intubated following a conventional
ETI and infectious complication, duration of stay, and weaning approach. Earlier extubation with NIV resulted in
mortality were significantly reduced by use of NIV. Early a shorter duration of mechanical ventilation and stay, less
initiation of NIV seems necessary to avoid ETI and provide need for tracheotomy, a lower incidence of complications and
benefit to patients. improved survival in these patients.
Patients suffering from Pneumocystis carinii pneumonia
during the course of human immunodeficiency virus infection
may also benefit from NIV, as shown in the case/control study Patients not to be intubated
of CONFALONIERI et al. [63]
Several reports have described the effects of NIV in patients
with acute respiratory failure who were poor candidates for
Lung surgery ETI because of advanced age, debilitation or a "do not
resuscitate" order [74, 75]. The overall success rate in these
Several studies looked at the use of NIV after lung sur- reports was y60–70%. Gas exchange improved rapidly in
gery [64–66]. AURIANT et al. [64] conducted a randomised successfully treated patients. Even when respiratory failure
 MECHANICAL VENTILATION: INVASIVE/NONINVASIVE 35s

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