Noninvasive mechanical ventilation in early acute respiratory distress syndrome

Noninvasive ventilation (NIV) has a well­‑established role in the treatment of acute­‑on­‑chronic respiratory failure and cardiogenic pulmonary edema. Its role in acute hypoxemic respiratory failure has been increasingly investigated, but its impact on the management and outcome of the subset of patients with acute respiratory distress syndrome (ARDS) is still to be determined. ARDS could be a risk factor for NIV failure, and in these patients, delayed endotracheal intubation can lead to an increased mortality. On the other hand, in a subset of patients with ARDS, endotracheal intubation can be avoided when NIV is applied. This review summarizes the current practice of NIV use in patients with ARDS and underlines the importance of proper patient selection before an NIV trial as well as criteria that should be used to predict failure early enough. A brief overview of high­‑flow nasal cannula is also provided. The use of NIV in ARDS is still debated, and it is important to be aware of the potential limitations and pitfalls of this treatment, which, when properly applied, could reduce the incidence of endotracheal intubation.