A high failure rate of the initial non-invasive positive pressure ventilation (NIPPV) therapy has been observed in medical critically ill patients with acute lung injury (ALI).

Unless the underlying shock, metabolic acidosis and severe hypoxemia are rapidly resolved, a trial of NIPPV is unlikely to be successful.

Given the higher than expected mortality in patients who failed a trial of NIPPV, it should be instituted with extreme caution in ALI patients who have shock, metabolic acidosis or severe hypoxemia.

This study was performed at a single tertiary care center and the findings may not be generalizable.

The observational nature of the study does not allow estimation of the cause and effect relationship between the predictors and outcome as unmeasured confounding factors may not have been accounted for.

The decision to intubate was left to treating physicians and was not uniform or prospectively defined.

Of 79 consecutive patients who met the inclusion criteria, 23 were excluded because of a do not resuscitate order and two did not give research authorization. Of the remaining 54 patients, 38 (70.3%) failed NIPPV, among them all 19 patients with shock.

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