This clinical guide provides an overview of non-invasive respiratory support (NIRS) techniques—including High-Flow Nasal Therapy (HFNT), Continuous Positive Airway Pressure (CPAP), and Bilevel Positive Airway Pressure (BiPAP)-for managing acute respiratory failure (ARF).

Both CPAP and BiPAP improve lung volume, reduce shunting, and enhance respiratory mechanics, with BiPAP offering superior CO2 clearance and reduced work of breathing (WOB).

HFNT, which provides humidification and anatomical dead space clearance, is favored for patient comfort and prolonged use. Proper technical optimization is key, requiring adequate gas flow to prevent CO2 rebreathing, especially when using facemasks or helmets, while avoiding both excessive pressure and insufficient flow.

The choice of NIRS modality is tailored to the patient’s condition.

For Cardiogenic Pulmonary Edema (CPE), either CPAP or BiPAP is recommended to support cardiac function.

In de novo ARF (when immediate intubation is not required), HFNT is now considered the first-line therapy. However, BiPAP via facemask is strongly recommended for patients presenting with respiratory acidosis as it is proven to reduce the need for intubation and decrease mortality.

For COVID-19-related ARF, CPAP/BiPAP is preferred over conventional oxygen therapy.

Regardless of the choice, continuous and close monitoring is essential to detect failure, prevent patient self-inflicted lung injury (P-SILI), and ensure timely intubation when necessary.

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