Invasive and non-invasive mechanical ventilation

Early recognition of patients who might potentially require ventilatory support is a key goal of critical care outreach programmes and an important skill for all hospital medical staff. Decisions about the initiation and timing of invasive ventilation can be difficult, and early discussion with critical care colleagues is essential. Appropriateness of invasive ventilatory support can also require advanced discussion with patients and families. In the past 10–15 years, the role of non-invasive ventilation (NIV) has expanded, not least in an attempt to minimize the complications inherent in invasive ventilation. Indeed, NIV is now considered first-line therapy in some conditions (chronic obstructive pulmonary disease, pulmonary oedema, mild to moderate hypoxaemic respiratory failure in immunocompromised patients), and a ‘trial of NIV’ is often considered in respiratory failure resulting from an increasingly wide range of causes. With NIV, the importance of the environment (setting, monitoring, experience of staff) and forward planning cannot be overemphasized. When used for other than the standard indications, NIV should be employed in a high-dependency or intensive care setting in patients for whom invasive ventilation would be considered.