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BTS/ICS guideline for the ventilatory management
of acute hypercapnic respiratory failure in adults
ACraigDavidson,
1
Stephen Banham,
1
Mark Elliott,
2
Daniel Kennedy ,
3
C olin Gelder,
4
Alas tair Glossop,
5
Alis tair C olin Church,
6
Ben Creagh-Brown,
7
James W illiam Dodd,
8,9
Tim F elton,
10
Bernard Foëx,
11
Leigh Mansfield,
12
Lynn McDonnell,
13
R obert Parker,
14
Car oline Marie P atterson,
15
Milind So vani,
16
Lynn Thomas,
17
BTS Standards of
Car e C ommittee Member, British Thor a cic Society/Intensive Care Society Acute
Hyper capnic R espiratory Failure Guideline Dev elopment Group, On behalf of the
British Thor a cic Society Standards of Care Committee
▸ Additional material is
published online only. To view
please visit the journal online
(http://dx.doi.org/10.1136/
thoraxjnl-2015-208209).
For numbered affiliations see
end of article.
Correspondence to
Dr A C Davidson,
BTS, 17 Doughty Street,
London WC1N 2PL, UK;
craigdavidson@doctors.org.uk
Healthcare providers need to
use clinical judgement,
knowledge and expertise when
deciding whether it is
appropriate to apply
recommendations for the
management of patients. The
recommendations cited here
are a guide and may not be
appropriate for use in all
situations. The guidance
provided does not override the
responsibility of healthcare
professionals to make decisions
appropriate to the
circumstances of each patient,
in consultation with the patient
and/or their guardian or carer.
Received 17 December 2015
Accepted 10 January 2016
▸ http://dx.doi.org/10.1136/
thoraxjnl-2016-208281
To cite: Davidson AC,
Banham S, Elliott M, et al.
Thorax 2016;71:ii1–ii35.
SUMMARY OF RECOMMENDATIONS
Principles of mechanical ventilation
Modes of mechanical ventilation
Recommendation
1. Pressure-targeted ventilators are the devices of
choice for acute NIV (Grade B).
Good practice points
▸ Both pressure support (PS) and pressure control
modes are effective.
▸ Only ventilators designed specifically to deliver
NIV should be used.
Choice of interface for NIV
Recommendation
2. A full face mask (FFM) should usually be the
first type of interface used (Grade D).
Good practice points
▸ A range of masks and sizes is required and staff
involved in delivering NIV need training in and
experience of using them.
▸ NIV circuits must allow adequate clearance of
exhaled air through an exhalation valve or an
integral exhalation port on the mask.
Indications for and contra-indications to NIV in
AHRF
Recommendation
3. The presence of adverse features increase the
risk of NIV failure and should prompt consider-
ation of placement in high dependency unit
(HDU)/intensive care unit (ICU) (Grade C).
Good practice points
▸ Adverse features should not, on their own, lead
to withholding a trial of NIV.
▸ The presence of relative contra-indications
necessitates a higher level of supervision, consid-
eration of placement in HDU/ICU and an early
appraisal of whether to continue NIV or to
convert to invasive mechanical ventilation
(IMV).
Monitoring during NIV
Good practice points
▸ Oxygen saturation should be continuously
monitored.
▸ Intermittent measurement of pCO
2
and pH is
required.
▸ ECG monitoring is advised if the patient has a
pulse rate >120 bpm or if there is dysrhythmia
or possible cardiomyopathy.
Supplemental oxygen therapy with NIV
Recommendations
4. Oxygen enrichment should be adjusted to
achieve SaO
2
88–92% in all causes of acute hyper-
capnic respiratory failure (AHRF) treated by NIV
(Grade A).
5. Oxygen should be entrained as close to the
patient as possible (Grade C).
Good practice points
▸ As gas exchange will improve with increased
alveolar ventilation, NIV settings should be opti-
mised before increasing the FiO2.
▸ The flo w rate of supplemental oxygen ma y need to
be increased when ventilatory pressur e is increased
to maintain the same SaO2 target.
▸ Mask leak and delayed triggering may be caused
by oxygen flow rates >4 L/min, which risks pro-
moting or exacerbating patient-ventilator asyn-
chrony. The requirement for high flow rates
should prompt a careful check for patient-
ventilator asynchrony.
▸ A ventilator with an integral oxygen blender is
recommended if oxygen at 4 L/min fails to
maintain SaO2 >88%.
Humidification with NIV
Recommendation
6. Humidification is not routinely required
(Grade D).
Good practice point
Heated humidification should be considered if the
patient reports mucosal dryness or if respiratory
secretions are thick and tenacious.
Bronchodilator therapy with NIV
Good practice points
▸ Nebulised drugs should normally be adminis-
tered during breaks from NIV.
▸ If the patient is dependent on NIV, bronchodila-
tor drugs can be given via a nebuliser inserted
into the ventilator tubing.
Davidson AC, et al. Thorax 2016;71:ii1–ii35. doi:10.1136/thoraxjnl-2015-208209 ii1
BTS guidelines
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