How to initiate a noninvasive ventilation program: bringing the evidence to the bedside

Noninvasive ventilation (NIV) is under-utilized, despite robust evidence supporting its use in appropriately selected patients with acute respiratory failure. Diffusion of NIV into practice requires that clinicians view it as better than invasive ventilation, that it is perceived as compatible with existing approaches to mechanical ventilation, that it is not too difficult to apply, that it is trialable, and that its results are visible. Barriers to NIV use include lack of awareness of the evidence, lack of agreement with the evidence, lack of self-efficacy, unrealistic outcome expectations, and the inertia of previous practice. A flexible, tireless, enthusiastic, and knowledgeable clinical champion is important when initiating an NIV program. Knowledge and training are also important; ideally the training should be one-on-one and hands-on to the extent possible. Adequate personnel and equipment resources are necessary when implementing the program. Guidelines and protocols may be useful as educational resources, to avoid clinical conflict and consolidate authority. When initiating an NIV program it is important to recognize that NIV does not avoid intubation in all cases. Success often improves with experience. The available evidence suggests that NIV is cost-effective. For optimum success the multidisciplinary nature of NIV application must be recognized. The NIV program should be a quality-improvement initiative. Following these principles, a successful program can be initiated in any acute-care setting.