Noninvasive ventilation in acute hypoxemic respiratory failure: What is the future?

De novo acute hypoxemic respiratory failure (AHRF) remains one of the leading causes of intensive care unit (ICU) admission and is still associated with high rates of intubation and mortality. Developing effective strategies to prevent intubation and its associated complications remains a critical objective in this population. Noninvasive ventilation (NIV) has been proposed as a potential alternative to invasive ventilation in AHRF. However, no clear clinical benefit has been consistently demonstrated to date. The lack of definitive evidence has left experts unable to provide recommendations for the use of NIV in AHRF. Several factors may account for the inconsistencies in the literature and merit further investigation. Identifying early predictive criteria for NIV failure could be essential in determining which patients are most likely to benefit from this intervention. In addition, the approach to NIV settings may require reconsideration, particularly regarding the level of assistance. Efforts to reduce tidal volume, while aiming to minimize ventilator-induced lung injury, may have inadvertently resulted in insufficient support, amplifying the harmful effects of excessive inspiratory effort. The choice of interface may also significantly influence the physiological effects and outcomes and warrants further exploration. Finally, the frugal nature of noninvasive techniques makes them well-suited for the universal management of AHRF, regardless of constraints. This highlights the need for future developments aimed at optimizing oxygen and energy efficiency, enhancing the ease of use and robustness of NIV devices, and evaluating the effectiveness of NIV under high-constraint conditions, such as in low- and middle-income countries. This review addresses these critical questions.