Early noninvasive ventilation in general wards for acute respiratory failure: an international, multicentre, open-label, randomised trial.

Summary

In 524 adults with mild acute respiratory failure treated in non-ICU wards, early NIV reduced progression to severe respiratory failure (18.5% vs 28.3%; RR 0.65, 95% CI 0.48–0.90; P=0.008) compared with usual care. There were no differences in hospital length of stay, 28-day mortality, respiratory complications, or adverse events.

Key Findings

• Progression to severe acute respiratory failure was lower with early NIV (18.5%) vs usual care (28.3%); RR 0.65 (95% CI 0.48–0.90), P=0.008.
• No difference in 28-day mortality between groups (1.8% vs 1.8%; RR 1.01, 95% CI 0.87–1.16).
• No significant differences in respiratory complications, hospital length of stay, or adverse events.
• Trial conducted across multiple countries and general wards, enhancing external relevance.

Clinical Implications

Implementing early NIV protocols for mild acute respiratory failure in non-ICU wards may reduce escalation to severe failure and ICU transfers. Ward staffing, monitoring, and standardized criteria for NIV initiation and weaning should be established.

Limitations

• Open-label design may introduce performance bias
• Inclusion limited to mild acute respiratory failure; findings may not generalize to more severe cases

Future Directions

Define optimal patient selection, timing, and NIV settings in ward environments; assess resource utilization and ICU transfer reduction; and evaluate long-term outcomes and patient-centered measures.