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Early release, published at www.cmaj.ca on February 14, 2011. Subject to revision.

CMAJ

Review

Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting

Sean P. Keenan MD MSc, Tasnim Sinuff MD PhD, Karen E.A. Burns MD MSc, John Muscedere MD, Jim Kutsogiannis MD, Sangeeta Mehta MD,Deborah J. Cook MD MSc, Najib Ayas MD, Neill K.J. Adhikari MD CM MSc, Lori Hand BSc RRT, Damon C. Scales MD PhD, Rose Pagnotta RRT, Lynda Lazosky RRT, Graeme Rocker MD, Sandra Dial MD, Kevin Laupland MD MSc, Kevin Sanders MD, Peter Dodek MD MHSc, as the Canadian Critical Care Trials Group / Canadian Critical Care Society Noninvasive Ventilation Guidelines Group
An abridged version of thisarticle and a related commentary by Bersten are available at www.cmaj.ca

O

ver the past two decades, the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure by mask has increased substantially for acutely ill patients. Initial case series and uncontrolled cohort studies that suggested benefit in selected patients1–13 led to many randomizedcontrolled trials (RCTs).14–151 Both methods of ventilation have been used in the setting of acute respiratory failure to avoid endotracheal intubation in different patient populations and settings, with variable success.14−69,117−123,134−141 In addition, noninvasive positive-pressure ventilation has been used to facilitate early liberation from conventional mechanical ventilation72−82 and to preventreintubation.70,71,83−87 These guidelines were developed to answer the following questions: What evidence is available in the literature to support recommendations for the use of noninvasive positive-pressure ventilation and continuous positive airway pressure for patients who are at risk of or who have acute respiratory distress or failure, patients who have undergone surgery and patients who arebeing weaned from mechanical ventilation or have recently undergone extubation? In addition, how can these two modes of noninvasive ventilation be optimally applied in these settings? Consensus conference statements152,153 and guidelines154–157 exist for the use of noninvasive ventiliation (the term used throughout this paper to refer to both noninvasive positive-pressure ventilation and continuouspositive airway pressure) in the acute care setting. However, since publication of the two English guidelines addressing use in the acute care setting,154,156 many new RCTs have been published. In addi-

tion, the first154 of the two previous guidelines predated the development of the Grading of Recommendations Assessment, Development and Evaluation (GRADE) Working Group methodology,158–160 and aless rigorous methodology was used in the second.156 Accordingly, we conducted a comprehensive search and appraisal of the current literature, using the GRADE methodology to assess the quality of the research and to generate clinical recommendations.

Competing interests: See end of article for competing interests. This article has been peer reviewed. Correspondence to: Dr. Sean P. Keenan;sean_keenan@telus.net CMAJ 2011.DOI:10.1503 /cmaj.100071

Methods
Leadership and scope An 18-member guidelines panel of universityaffiliated clinicians, led by two cochairs, was formed in June 2007 as an initiative of the Canadian Critical Care Trials Group / Canadian Critical Care Society Noninvasive Ventilation Guidelines Group. The panel consisted of 15 physicians and 3 respiratory therapists whohad a variety of

Key points
• Noninvasive positive-pressure ventilation should be the first option for ventilatory support for patients with either a severe exacerbation of chronic obstructive pulmonary disease (COPD) or cardiogenic pulmonary edema. Continuous positive airway pressure delivered by mask appears to be just as effective as noninvasive positive-pressure ventilation for patients...