Background for Fast Fact #230     Non-invasive positive pressure ventilation (NPPV, often called ‘Bilevel support’ or ‘BiPAP’) is commonly used in patients with acute respiratory failure from asthma, COPD, CHF, and other illnesses such as ALS, sleep apnea, and restrictive lung disease. NPPV decreases the work of breathing during both inhalation and exhalation and provides respiratory assistance for patients with difficulty breathing. This Fast Fact discusses medical decision making around its use at the end of life.  Fast Fact #231 discusses practical aspects of applying and discontinuing NPPV in dying patients.

Goals of NPPV at the end-of-life    NPPV is reserved for patients with dyspnea, low oxygen saturation, and/or elevated CO2 levels. The patient must be able to cooperate with the NPPV which means they must be able to wear the mask and be alert enough to trigger breaths on their own. There are 3 general circumstances in which patients close to death may use NPPV (1):  

1. Patients who desire full, life-prolonging interventions, regardless of prognosis. If the patient’s respiratory status deteriorates while on NPPV, intubation and ventilation are initiated.
2. Patients who want life-prolonging therapy but with limitations (e.g., patients with a ‘Do Not Intubate’ order but otherwise want all attempts at life prolongation). Ideally, NPPV is used only if the etiology for the respiratory failure is thought to be reversible (e.g., COPD flare) and is stopped if it is not producing the desired response or the patient is not tolerating NPPV.
3. Dying patients with respiratory failure or dyspnea for palliative purposes. This category includes dying patients who have decided to forego life-prolonging therapies and wish to focus on comfort measures. NPPV can be used on a trial basis with the intention to ease dyspnea and to help maintain wakefulness by reducing the opioid dosing needed to keep the patient comfortable.  NPPV can also be used to prolong life for a short period to meet a patient’s goals while otherwise providing a comfortable death (e.g., to allow time for family to visit).

Research findings    

• For the first category of patients, several trials have shown that NPPV can reduce mortality, intubation rates, and hospital length of stay (2-5). This research, along with greater availability of more tolerable interfaces (e.g., nasal NPPV) has contributed to a significant increase in NPPV usage recently (6).
• For the second category of patients, there are less robust data. Some observational studies suggest that NPPV can reverse acute respiratory failure and decrease hospital mortality in patients who have ‘Do Not Intubate’ orders (7,8).
• There is growing evidence that NPPV can alleviate dyspnea in dying patients. Among patients with a life expectancy < 6 months, multiple controlled studies (mostly of patients with advanced cancer) showed significant associations between NPPV use and reduced opioid needs and reduced dyspnea compared with high-flow or supplemental oxygen (9-11). However, it is unclear what effect NPPV had on the overall quality of dying and death, a much more complex and subjective clinical question (12).

Drawbacks   NPPV is noisy and can be uncomfortable and frightening. It may interfere with sleep, communication, and family intimacy and it could confuse care goals if not discussed carefully.  Initiating NPPV outside of acute care environments (e.g. at home, nursing home, or hospice facility – see Fast Fact #231) may be challenging if not impossible. Even in the hospital, initiation may require the patient to be transferred to a more monitored setting. Some experts have published concern that NPPV may complicate end of life decision-making for the bereaved and by consequence increase the risk of associated anxiety (13,14).

Medical decision making and counseling 

• Patients in categories #1 & 2, as with all patients nearing the end of life, need ongoing discussions about their realistic prognosis, care goals, and care options (see Fast Fact #164, Fast Fact #165, Fast Fact #222, Fast Fact #223, Fast Fact #224, Fast Fact #225, Fast Fact #226, and Fast Fact #227).
• For dying patients with distressing dyspnea and comfort-only goals of care, opioids are first line agents (see Fast Fact #27). For patients who need sedating doses of opioids to be comfortable, and who articulate a strong preference to be as awake as possible, it is reasonable to offer NPPV if the patient is in an environment which can accommodate it and the risks are acceptable to the patient, including the possibility that the dying process will be prolonged.  Reassure patients that you can alleviate their symptoms even if NPPV is unhelpful or intolerable.
• For dying patients in category #3 who wish to forestall death briefly for a specific goal, it may be reasonable to start a trial of NPPV depending on the patient circumstances. Before initiating NPPV, it is important to discuss withdrawal of NPPV if the patient declined further and lost consciousness or after the above goal has been achieved. The patient/family should also be made aware that NPPV might not be able to forestall death long enough as hoped.

References 

1. Curtis JR, Cook DJ, Sinuff T, et al; Society of Critical Care Medicine Palliative Noninvasive Positive VentilationTask Force. Noninvasive positive pressure ventilation in critical and palliative care settings: understanding the goals of therapy. Crit Care Med. 2007; 35(3):932-9.
2. Peter JV, Moran JL. Noninvasive ventilation in exacerbations of chronic obstructive pulmonary disease: implications of different meta-analytic strategies. Ann Intern Med. 2004; 141(5):W78-9.
3. Keenan SP, Sinuff T, Cook DJ, Hill NS. Does noninvasive positive pressure ventilation improve outcome in acute hypoxemic respiratory failure? A systematic review. Crit Care Med. 2004; 32(12):2516-23.
4. Lindenauer PK, Stefan MS, Shieh MS, et al.  Outcomes associated with invasive and noninvasive ventilation among patients hospitalized with exacerbations of chronic obstructive pulmonary disease.  JAMA Intern Med. 2014;174(12):1982-1993.
5. Tallman  TA, Peacock  WF, Emerman  CL,  et al; ADHERE Registry.  Noninvasive ventilation outcomes in 2,430 acute decompensated heart failure patients: an ADHERE Registry Analysis.   Acad Emerg Med. 2008;15(4):355-362.
6. Sullivan DR, Kim H, Gozalo PL, et al.  Trends in noninvasive and invasive mechanical ventilation among Medicare beneficiaries at the end of life. JAMA Intern Med 2021;181(1):93-102.
7. Schettino G, Altobelli N, Kacmarek RM. Noninvasive positive pressure ventilation reverses acute respiratory failure in select “do-not-intubate” patients. Crit Care Med. 2005; 33(9):1976-82.
8. Levy M, Tanios MA, Nelson D, et al. Outcomes of patients with do-not-intubate orders treated with noninvasive ventilation. Crit Care Med. 2004; 32(10):2002-7.
9. Nava  S, Ferrer  M, Esquinas  A,  et al.  Palliative use of non-invasive ventilation in end-of-life patients with solid tumours: a randomised feasibility trial.   Lancet Oncol. 2013;14(3):219-227. 
10. Hui  D, Morgado  M, Chisholm  G,  et al.  High-flow oxygen and bilevel positive airway pressure for persistent dyspnea in patients with advanced cancer: a phase II randomized trial.   J Pain Symptom Manage. 2013;46(4):463-473.
11. Sinuff T, Cook DJ, Keenan SP, et al. Noninvasive ventilation for acute respiratory failure near the end of life. Crit Care Med. 2008; 36(3):789-94.
12. Azoulay  E, Kouatchet  A, Jaber  S,  et al.  Noninvasive mechanical ventilation in patients having declined tracheal intubation.   Intensive Care Med. 2013;39(2):292-301.
13. Nava S, Evangelisti I, et al.  Human and financial costs of non-invasive mechanical ventilation in patients affected by chronic obstructive pulmonary disease and acute respiratory failure. Chest 1997; 111:1631-1638.
14. Azoulay E, Kouatchet A, et al. Non-invasive ventilation for end-of-life oncology patients. The Lancet Oncology, 2013; 14:e200-e201. 

Author Affiliations:  Northwestern Memorial Hospital, Chicago, IL (MEY, ES); University of Pittsburgh Medical Center, Pittsburgh, PA (RSM, DBW).
Version History:   Originally published April 2010; copy-edited August 2015 by Sean Marks MD; copy-edited again in February 2025.
Conflicts of Interest: None to report.