The role of noninvasive ventilation in the ventilator discontinuation process

In recent years, there has been increasing interest in the use of noninvasive ventilation (NIV) in the post-extubation period to shorten the length of invasive ventilation, to prevent extubation failure, and to rescue a failed extubation. The purpose of this review is to summarize the evidence related to the use of NIV in these settings. NIV can be used to allow earlier extubation in selected patients who do not successfully complete a spontaneous breathing trial (SBT). Its use in this setting should be restricted to patients who are intubated during an exacerbation of COPD or patients with neuromuscular disease. This category of patients should be good candidates for NIV and should be extubated directly to NIV. In patients who successfully complete an SBT, but are at risk for extubation failure, NIV can be used to prevent extubation failure. These patients should also be good candidates for NIV and should be extubated directly to NIV. NIV should be used cautiously in patients who successfully complete an SBT, but develop respiratory failure within 48 hours post-extubation. In this setting, NIV is indicated only in patients with hypercapnic respiratory failure. Reintubation should not be delayed if NIV is not immediately successful in reversing the post-extubation respiratory failure. Evidence does not support routine use of NIV post-extubation.