Portable Ventilator Research Articles

Pregnancy in a Woman with a Congenital Type of Nemaline Myopathy

<i>Introduction</i>: Congenital nemaline myopathy is a genetically heterogeneous disease caused by gene defects in a number of genes: nebulin (2q21-22) alpha-tropomysin (1q21-23), alpha-actin (1q42) and others. Nemaline myopathy can be inherited as an autosomal recessive or dominant trait. <i>Case report</i>: We present a case of the first pregnancy in a woman with a congenital type of nemaline myopathy, with a severe pulmonary involvement, in the Czech Republic. <i>Course of pregnancy</i>: The woman got spontaneously pregnant less than two months after a respiratory failure, when she had to be tracheostomized, remained dependent on portable ventilator support. The patient strictly refused artificial abortion recommended to her. Until the 22^nd gestational week she was stabilized in terms of ventilation and received health care at home. Subsequently, she was repeatedly admitted to the hospital for lung infection to ICU of the Department of Intensive Care. The fetus was developing proportionately, without signs of muscle hypotonia, but after the 23^rd g.w. was diagnosed with slightly progressive polyhydramnios. <i>Childbirth</i>: It was decided to schedule termination of the pregnancy by a caesarean section for the 30^th g.w., during the interval of the patient´s relatively satisfactory clinical respiratory and mental stabilization. A boy was born (1120g) and was transferred to the NICU. The newborn required artificial pulmonary ventilation, from the 3^rd day he was extubated, with intermittent use of nasal CPAP until the 9^th day. <i>Results</i>: The baby prospered, tolerated food and showed no signs of muscle hypotonia. A postoperative course of the mother went without any complications. On the 8^th postoperative day she was discharged from the hospital, ventilator-dependent and with tracheostomy in place. <i>Conclusion</i>: Pregnancy in women with a congenital type of nemaline myopathy with a severe lung involvement is a challenge for physicians. Based on the course of pregnancy it is necessary to decide when its termination will be safe for both the mother and the fetus. The care of the patient requires a multidisciplinary approach.

An Emergency Portable Ventilator for COVID Patients with Acute Breathing Difficulty

In this paper, a design of a ventilator that meets the demand for emergency ventilators required to help patients with acute breathing difficulty during pandemics such as the current COVID-19 pandemic is presented. The AMBU bag based ventilator can be fabricated at low cost and is easily affordable by hospitals. Based on readily available components, the ventilator will cost about INR6000, and can be easily maintained by even non-technical medical personnel. It works on regular AC supply of 220V and runs on 12V DC supply drawing about 1.5A current. The ventilator is light in weight weighing about 2Kg and is easily portable. The use of individually addressable light emitting diodes and a photo- resistor for positioning of the pushrod is an innovative feature of the ventilator. It meets the requirement of emergency ventilators for use during the waiting period before a full fledged ventilator is available to the patient.

Developing Algorithms and Programs for an Artificial Lung Ventilator

Описаны алгоритмы и программы для аппарата искусственной вентиляции легких, которые обеспечивают различные режимы работы аппарата. Работа является актуальной в условиях пандемии COVID-19 в связи с возросшим спросом на данные устройства.Цель исследования – разработка программного комплекса для микроконтроллера STM32L151ZDTx-LQFP144, используемого на переносном аппарате ИВЛ Axion A-IVL-E-03 и обеспечивающего работу в различных режимах вентиляции, графическое отображение динамики дыхания на дисплее и подачу оператору голосовых подсказок и световых сигналов во время работы. Разработанные алгоритмы также предназначены для управления периферийными устройствами и контроля правильности их работы, разрешения аварийных ситуаций с помощью дисплея, голосовых подсказок и световой индикации. Кроме того, в качестве инструмента, который позволяет врачу понять важное взаимодействие между входными параметрами пациента (частота, давление в дыхательных путях и степень вдоха) и клинически важными параметрами (дыхательный объем, средний объем минутной вентиляции), предложены математические модели вентиляции легких с контролируемым давлением. Реализация данных математических моделей показала их применимость для симуляции данных сложных процессов. Разработан удобный и интуитивно понятный графический пользовательский интерфейс.В статье также приводится сравнение существующих аналогов с предложенными разработками.

Design and performance testing of a novel emergency ventilator for in-hospital use.

BackgroundThe rapidly evolving COVID-19 pandemic has led to increased use of critical care resources, particularly mechanical ventilators. Amidst growing concerns that the health care system could face a shortage of ventilators in the future, there is a need for an affordable, simple, easy to use, emergency stockpile ventilator.MethodsOur team of engineers and clinicians designed and tested an emergency ventilator that uses a single limb portable ventilator circuit. The circuit is controlled by a pneumatic signal with electronic microcontroller input, using air and oxygen sources found in standard patient rooms. Ventilator performance was assessed using an IngMar ASL 5000 breathing simulator, and it was compared with a commercially available mechanical ventilator.ResultsThe emergency ventilator provides volume control mode, intermittent mandatory ventilation and continuous positive airway pressure. It can generate tidal volumes between 300 and 800 mL with <10% error, with pressure, volume, and waveforms substantially equivalent to existing commercial ventilators.ConclusionsWe describe a cost effective, safe, and easy to use ventilator that can be rapidly manufactured to address ventilator shortages in a pandemic setting. It meets basic clinical needs and can be provided for emergency use in cases requiring mechanical ventilation because of complications due to respiratory failure from infectious diseases.

Case 2: Unusual Cause of Abdominal Distention and Abdominal Wall Erythema in a Preterm Infant

A female infant is born at 24 weeks’ gestational age via normal spontaneous vaginal delivery to a 36-year-old gravida 5, para 2+2+0 woman with no known medical problems. The pregnancy is uncomplicated, and prenatal laboratory results and her fetal survey are all unremarkable. The mother presents at 24 weeks with spontaneous rupture of membranes and she receives 1 dose of dexamethasone just before delivery. Apgar scores are 3 and 8 at 1 and 5 minutes, respectively. The infant undergoes immediate intubation within the first minutes after birth; because of respiratory distress, she receives 1 dose of surfactant replacement therapy through the endotracheal tube and is transferred to the NICU in a portable ventilator after initial stabilization. Initial newborn examination findings are within normal parameters. The infant is born with a birthweight of 620 g, head circumference of 22 cm, and length of 32 cm, with all measurements plotted to be appropriate for gestational age. An umbilical arterial catheter and umbilical venous catheter are inserted, partial sepsis evaluation undertaken, and antibiotic treatment started. The infant is maintained on endotracheal intubation and mechanical ventilation on volume control–assist control mode, with volume guarantee of 2.8 mL, maximum ventilation pressure 20 cm H2O, positive end expiratory pressure 6 cm H2O, inspiratory time 0.3 seconds, and heart rate 60 beats/min. She is given a second dose of surfactant …

A Gas-Powered, Patient-Responsive Automatic Resuscitator for Use in Acute Respiratory Failure: A Bench and Experimental Study.

During the COVID-19 pandemic, a need for innovative, inexpensive, and simple ventilator devices for mass use has emerged. The Oxylator (CPR Medical Devices, Markham, Ontario, Canada) is an FDA-approved, fist-size, portable ventilation device developed for out-of-hospital emergency ventilation. It has not been tested in conditions of severe lung injury or with added PEEP. We aimed to assess the performance and reliability of the device in simulated and experimental conditions of severe lung injury, and to derive monitoring methods to allow the delivery of safe, individualized ventilation during situations of surge. We bench-tested the functioning of the device with an added PEEP valve extensively, mimicking adult patients with various respiratory mechanics during controlled ventilation, spontaneous breathing, and prolonged unstable conditions where mechanics or breathing effort was changed at every breath. The device was further tested on a porcine model (4 animals) after inducing lung injury, and these results were compared with conventional ventilation modes. The device was stable and predictable, delivering a constant flow (30 L/min) and cycling automatically at the inspiratory pressure set (minimum of 20 cm H2O) above auto-PEEP. Changes in respiratory mechanics manifested as changes in respiratory timing, allowing prediction of tidal volumes from breathing frequency. Simulating lung injury resulted in relatively low tidal volumes (330 mL with compliance of 20 mL/cm H2O). In the porcine model, arterial oxygenation, CO2, and pH were comparable to conventional modes of ventilation. The Oxylator is a simple device that delivered stable ventilation with tidal volumes within a clinically acceptable range in bench and porcine lung models with low compliance. External monitoring of respiratory timing is advisable, allowing tidal volume estimation and recognition of changes in respiratory mechanics. The device can be an efficient, low-cost, and practical rescue solution for providing short-term ventilatory support as a temporary bridge, but it requires a caregiver at the bedside.

Calculating AMBU Bag Dimensions for Use in Portable Ventilators

Based on the design of non-portable ventilators, this project examines and analyzes the primary individual component used within a motorized AMBU bag ventilator - the AMBU bag. Calculations are conducted to assess the minimum volume for an AMBU bag to provide sufficient oxygen for average total lung capacity. It allows to determine the feasibility and effectiveness of an electrical, portable AMBU bag ventilator under the reduced size requirements. A calculus-based formula, known as the Disk Method, is utilized for these calculations. It is shown that the Disk method can be reversed to find a shape of an AMBU bag given a predetermined volume and desired dimensions. Thus an affordable, motorized, portable AMBU bag ventilator with full functionality and effectiveness can be developed. It will contribute to fulfilling the need for more ventilators due the current COVID-19 pandemic.

Weaning by Surgical Tracheostomy and Portable Ventilators Released ICU Ventilators During Coronavirus Disease 2019 Surge in London

Weaning by Surgical Tracheostomy and Portable Ventilators Released ICU Ventilators During Coronavirus Disease 2019 Surge in London

How “Maximizing Shareholder Value” Minimized the Strategic National Stockpile: The $5.3 Trillion Question for Pandemic Preparedness Raised by the Ventilator Fiasco

With just 4.2 percent of the world’s population, the United States had, as of July 21, 2020, 26.0 percent of its confirmed Covid-19 cases and 23.1 percent of its deaths. The magnitude of the tragedy raises the critically important counterfactual question of how the United States as a nation would have fared had there been competent and committed political leadership in place when, during January 2020, intelligence indicating the severity of the unfolding pandemic became available. A partial answer to this question lies in identifying the organizational and technological capabilities to develop, produce, and deliver “countermeasures”—personal protective equipment (PPE), ventilators, diagnostic tests, therapies, and vaccines—that a prepared federal administration would have been able to mobilize to respond to the pandemic. Main repositories of the necessary capabilities are government agencies and business firms, with the development, production, and delivery of countermeasures heavily reliant on government-business collaborations (GBCs). We contend that the success of projects for pandemic preparedness and response depends on the strength of GBCs. In this essay, we focus on the particular case of ventilators for the Strategic National Stockpile (SNS). We trace the historical evolution within the federal government of the current system of pandemic preparedness for and response through the end of the Obama administration. We then analyze the particular GBCs to develop ventilators for the SNS initiated and implemented by the Biomedical Research and Development Authority (BARDA), under the Assistant Secretary for Preparedness and Response (ASPR) within the U.S. Department of Health and Human Services (HHS). BARDA initiated two successive GBCs, one beginning in 2010 and the second in 2014, with two different business firms, for the purpose of developing portable, easy-to-use, and affordable ventilators for the SNS. We show that the strength of these collaborations lay with the innovative ventilator manufacturers with which BARDA contracted. The weakness of these GBCs appeared when these innovative manufacturers fell under the control of business corporations committed to the ideology of “maximizing shareholder value” (MSV). In each case, the financialized business corporation undermined development and delivery of ventilators to the SNS. We then explain why, in general, we should expect that business firms driven by MSV will be unreliable partners in GBCs—at the expense of the nation’s preparedness for and response to an emergency such as the Covid-19 pandemic. This lack of reliability is rooted in the strategic orientation of corporations which have put stock-market valuation of the company ahead of its innovative performance in producing goods and services. The Covid-19 crisis has already revealed the extent to which, in the U.S. economy, the stock market functions not to support value creation but rather as the prime means of value extraction. The most overt form of value extraction is the corporate practice of open-market repurchases of the company’s own shares—aka stock buybacks—typically done in addition to copious distributions to shareholders in the form of cash dividends. In the decade 2010-2019, companies in the S&amp;P 500 Index spent $5.3 trillion on buybacks, representing 54 percent of net income, in addition to $3.8 trillion (39 percent of net income) distributed to shareholders as dividends. In view of this “predatory value extraction,” we conclude this essay with the “$5.3 trillion” question for executives and directors of corporations who, in their embrace of MSV ideology, must bear significant responsibility for the failure of the United States to respond to not only the Covid-19 pandemic but also climate change and income inequity. The question: Why does the company that you head do stock buybacks? In particular, we direct this question to the executives and directors of three corporations that, as of the year 2020, are the biggest repurchasers of their own stock in history: Microsoft at number three, ExxonMobil at number two, and Apple at number one. We also pose this question to the senior executives and board members of any company engaged in the practice who, in August 2019, signed the Business Roundtable (BRT) Statement of the Purpose of a Corporation, which explicitly rejected the BRT’s 1997 pronouncement that “corporations exist principally to serve shareholders,” replacing it with a redefinition of “the purpose of the corporation to promote ‘an economy that serves all Americans’.”

How “Maximizing Shareholder Value” Minimized the Strategic National Stockpile: The $5.3 Trillion Question for Pandemic Preparedness Raised by the Ventilator Fiasco

With just 4.2 percent of the world’s population, the United States had, as of July 21, 2020, 26.0 percent of its confirmed Covid-19 cases and 23.1 percent of its deaths. The magnitude of the tragedy raises the critically important counterfactual question of how the United States as a nation would have fared had there been competent and committed political leadership in place when, during January 2020, intelligence indicating the severity of the unfolding pandemic became available. A partial answer to this question lies in identifying the organizational and technological capabilities to develop, produce, and deliver “countermeasures”—personal protective equipment (PPE), ventilators, diagnostic tests, therapies, and vaccines—that a prepared federal administration would have been able to mobilize to respond to the pandemic. Main repositories of the necessary capabilities are government agencies and business firms, with the development, production, and delivery of countermeasures heavily reliant on government-business collaborations (GBCs). We contend that the success of projects for pandemic preparedness and response depends on the strength of GBCs. In this essay, we focus on the particular case of ventilators for the Strategic National Stockpile (SNS). We trace the historical evolution within the federal government of the current system of pandemic preparedness for and response through the end of the Obama administration. We then analyze the particular GBCs to develop ventilators for the SNS initiated and implemented by the Biomedical Research and Development Authority (BARDA), under the Assistant Secretary for Preparedness and Response (ASPR) within the U.S. Department of Health and Human Services (HHS). BARDA initiated two successive GBCs, one beginning in 2010 and the second in 2014, with two different business firms, for the purpose of developing portable, easy-to-use, and affordable ventilators for the SNS. We show that the strength of these collaborations lay with the innovative ventilator manufacturers with which BARDA contracted. The weakness of these GBCs appeared when these innovative manufacturers fell under the control of business corporations committed to the ideology of “maximizing shareholder value” (MSV). In each case, the financialized business corporation undermined development and delivery of ventilators to the SNS. We then explain why, in general, we should expect that business firms driven by MSV will be unreliable partners in GBCs—at the expense of the nation’s preparedness for and response to an emergency such as the Covid-19 pandemic. This lack of reliability is rooted in the strategic orientation of corporations which have put stock-market valuation of the company ahead of its innovative performance in producing goods and services. The Covid-19 crisis has already revealed the extent to which, in the U.S. economy, the stock market functions not to support value creation but rather as the prime means of value extraction. The most overt form of value extraction is the corporate practice of open-market repurchases of the company’s own shares—aka stock buybacks—typically done in addition to copious distributions to shareholders in the form of cash dividends. In the decade 2010-2019, companies in the S&amp;P 500 Index spent $5.3 trillion on buybacks, representing 54 percent of net income, in addition to $3.8 trillion (39 percent of net income) distributed to shareholders as dividends. In view of this “predatory value extraction,” we conclude this essay with the “$5.3 trillion” question for executives and directors of corporations who, in their embrace of MSV ideology, must bear significant responsibility for the failure of the United States to respond to not only the Covid-19 pandemic but also climate change and income inequity. The question: Why does the company that you head do stock buybacks? In particular, we direct this question to the executives and directors of three corporations that, as of the year 2020, are the biggest repurchasers of their own stock in history: Microsoft at number three, ExxonMobil at number two, and Apple at number one. We also pose this question to the senior executives and board members of any company engaged in the practice who, in August 2019, signed the Business Roundtable (BRT) Statement of the Purpose of a Corporation, which explicitly rejected the BRT’s 1997 pronouncement that “corporations exist principally to serve shareholders,” replacing it with a redefinition of “the purpose of the corporation to promote ‘an economy that serves all Americans’.”

Transition From an ICU Ventilator to a Portable Home Ventilator in Children.

The transition from an ICU ventilator to a portable home ventilator (PHV) for children requiring long-term mechanical ventilation is a crucial step in preparing for discharge home and may not be successful on the first attempt. A review of this process at our institution revealed that some children required multiple trials before they were able to tolerate a PHV. A protocol was developed to standardize the transition process and reduce the number of failed attempts. Key features of the protocol included a transition readiness assessment and criteria for changing to the PHV. A retrospective chart review was completed to evaluate the process of changing to a PHV before and after the protocol was in place during the time period of 2011-2018. Primary outcome measures included the number of transition attempts and the length of time to achieve successful transition. A successful transition attempt was defined as the ability to tolerate a PHV for 14 d. The study included 56 children ≤ 3 y old with a tracheostomy who required long-term ventilator support. The majority of subjects were from the neonatal ICU and had a diagnosis of bronchopulmonary dysplasia. There was a significant decrease in the number of attempts (P = .005) and in the length of time (P = .01) to successfully transition to a PHV for those who underwent the protocol. The process of changing from an ICU ventilator to a PHV in children requiring long-term mechanical ventilation was improved through the use of a standardized protocol. Both the number of failed attempts and the length of time to achieve successful transition were reduced when the protocol was applied. Further study is needed to evaluate other medical and nonmedical factors that may affect successful transition to a PHV.

MADVent: A low-cost ventilator for patients with COVID-19.

The COVID‐19 pandemic has produced critical shortages of ventilators worldwide. There is an unmet need for rapidly deployable, emergency‐use ventilators with sufficient functionality to manage COVID‐19 patients with severe acute respiratory distress syndrome. Here, we show the development and validation of a simple, portable and low‐cost ventilator that may be rapidly manufactured with minimal susceptibility to supply chain disruptions. This single‐mode continuous, mandatory, closed‐loop, pressure‐controlled, time‐terminated emergency ventilator offers robust safety and functionality absent in existing solutions to the ventilator shortage. Validated using certified test lungs over a wide range of compliances, pressures, volumes and resistances to meet U.S. Food and Drug Administration standards of safety and efficacy, an Emergency Use Authorization is in review for this system. This emergency ventilator could eliminate controversial ventilator rationing or splitting to serve multiple patients. All design and validation information is provided to facilitate ventilator production even in resource‐limited settings.

DRDO's Portable Low-Cost Ventilator: "DEVEN".

A reliable, portable and low-cost ventilator named “DEVEN” is designed and developed by scientists of Dr. APJ Abdul Kalam Missile Complex, RCI, DRDO-Hyderabad. This Ventilator is named as DEVEN—DRDO’s Economical Ventilator. DEVEN has features comparable to high-end ventilators and would serve the requirements of a large number of ventilators under the present COVID-19 pandemic situation. Also, DEVEN being a portable ventilator can be used in field application using a portable air compressor and reservoir. Hence, it can be used in an ambulance, any mobile vehicle or for application in any remote/rural area. DEVEN has a micro-controller-operated solenoid valve-based design and is developed by tweaking existing technology being used for hot gas reaction control systems (HRCS), employed in attitude control of exo-atmospheric missiles. HRCS is achieved by actuating solenoid valves through a micro-controller to control the flow of oxidizer as well as fuel. Existing controllers being used for control of electro-mechanical actuators are tweaked for control of the above-mentioned solenoid valves for inspiratory as well as expiratory lines of DEVEN.Graphic abstract

The Perioperative Services Response at a Major Children's Hospital During the Peak of the COVID-19 Pandemic in New York City.

The Perioperative Services Response at a Major Children's Hospital During the Peak of the COVID-19 Pandemic in New York City.

Efficacy of Amflow®, a Real-Time-Portable Feedback Device for Delivering Appropriate Ventilation in Critically Ill Patients: A Randomised, Controlled, Cross-Over Simulation Study.

Objective The aim of this study was to test whether Amflow® (a newly designed portable ventilation feedback device) can assist rescuers in delivering target tidal volume (VT) and respiration rate (RR) during self-inflating bag (SB) ventilations in various clinical scenarios. Method This was a simulation study with a prospective cross-over design. A total of 40 trained participants who underwent training for SB ventilation were recruited. Using a SB with or without Amflow® alternately, participants delivered ventilations to test lungs connected to a gas flow analyser in each of three different scenarios: acute respiratory distress syndrome (ARDS; 315–385 ml ranges for 350 ml target VT, with 20 breaths/min); cardiopulmonary resuscitation (CPR; 450–550 ml ranges for 500 ml target VT with 10 breaths/min); and adult head trauma (630–770 ml ranges for 700 ml target VT with 15 breaths/min). Results The feedback group (SB with Amflow®) demonstrated a significantly higher percentage of delivering the appropriate VT ranges than the no-feedback group for both ARDS (58.6% versus 23.5%, respectively) and CPR (85.4% versus 41.0%, respectively) (all p < 0.05). However, there was no significant difference between the two groups in the percentage of delivering the appropriate VT ranges in head trauma patients (65.9% versus 68.3%, respectively; p=0.092). In all three scenarios, a higher percentage of target RR delivered was achieved in the feedback group (88.3%, 99.2%, and 96.3%, respectively) compared with the no-feedback group (5.8%, 12.5%, and 10.0%, respectively) (all p < 0.05). Conclusion The Amflow® device could be useful for rescuers in delivering SB ventilation with appropriate VT and RR simultaneously in various critical situations, except for clinical cases that demand greater delivered VT.

Special Risk of Using Portable Emergency Ventilator Based on Clinical Application

Risk management of medical devices covers the whole life cycle of medical devices, which is of great significance to the life safety and health condition of patients. The existing risk management of medical devices, especially the risk analysis in the research and development stage, often becomes a mere formality. The special risks faced by the research and development products in the clinical application scenarios are not well addressed. This study proves the necessity and importance of the combination of risk analysis and clinical application in the research and development stage of medical devices by the analysis of several special hazard sources in the process of clinical application of portable emergency ventilator.

Effect of portable non-invasive ventilation on exercise tolerance in COPD: One size does not fit all

In a cross-over RCT, portable NIV (pNIV) reduced dynamic hyperinflation (DH) compared to pursed lip breathing (PLB) during recovery from intermittent exercise in COPD, but not consistently in all subjects. In this post-hoc analysis, DH response was defined as a reduction ≥4.5 % of predicted resting inspiratory capacity with pNIV compared to PLB.At exercise iso-time (where work completed was consistent between pNIV and PLB), 8/24 patients were DH non-responders (DH: 240 ± 40 mL, p = 0.001 greater using pNIV). 16/24 were DH responders (DH: 220 ± 50 mL, p = 0.001 lower using pNIV). Compared to DH responders, DH non-responders exhibited greater resting DH (RV/TLC: 65 ± 4% versus 56 ± 2%; p = 0.028) and did not improve exercise tolerance (pNIV: 30.9 ± 3.4 versus PLB: 29.9 ± 3.3 min; p = 0.603). DH responders increased exercise tolerance (pNIV: 34.9 ± 2.4 versus PLB: 27.1 ± 2.3 min; p = 0.001). Resting RV/TLC% was negatively associated with the magnitude of DH when using pNIV compared to PLB (r=-0.42; p = 0.043).Patients with profound DH were less likely to improve exercise tolerance with pNIV. Further studies using auto-adjusted ventilators are warranted.

Pragmatic recommendations for intubating critically ill patients with suspected COVID-19.

Pragmatic recommendations for intubating critically ill patients with suspected COVID-19.

可搬型局所換気装置による介護空間の空気環境改善に関する研究 （その2）CFD解析による各種局所換気システムの捕集率

可搬型局所換気装置による介護空間の空気環境改善に関する研究 （その2）CFD解析による各種局所換気システムの捕集率

ISCCM Guidelines for the Use of Non-invasive Ventilation in Acute Respiratory Failure in Adult ICUs.

B1. NIV in Acute Cardiogenic Pulmonary Oedema: Recommendations: NIV is recommended in hospital patients with ARF, due to Cardiogenic pulmonary edema. (1A). NIV should be used in patients with acute heart failure/ cardiogenic pulmonary edema, right from emergency department itself. (1B) Both CPAP and BiPAP modes are safe and effective in patients with cardiogenic pulmonary edema. (1A). However, BPAP (NIV-PS) should be preferred in cardiogenic pulmonary edema with hypercapnia. (3A) B2. NIV in acute hypoxemic respiratory failure: Recommendations: NIV may be used over conventional oxygen therapy in mild early acute hypoxemic respiratory failure (P/F ratio <300 and >200 mmHg), under close supervision. (2B) We strongly recommend against a trial of NIV in patients with acute hypoxemic failure with P/F ratio <150. (2A) B3. NIV in ARF due to Chest Trauma: Recommendations: NIV may be used in traumatic flail chest along with adequate pain relief. (3B) B4. NIV in Immunocompromised Host: Recommendations: In Immunocompromised patients with early ARF, we may consider NIV over conventional oxygen. (2B). B5. NIV in Palliative Care: Recommendations: We strongly recommend use of NIV for reducing dyspnea in palliative care setting. (2A) B6. NIV in post-operative cases: Recommendations: NIV should be used in patients with post-operative acute respiratory failure. (2A) B6a. NIV in abdominal surgery: Recommendations: NIV may be used in patients with ARF following abdominal surgeries. (2A) B6b. NIV in bariatric surgery: Recommendations: NIV may be used in post-bariatric surgery patients with pre-existent OSA or OHS. (3A) B6c. NIV in Thoracic surgery: Recommendations: In cardiothoracic surgeries, use of NIV is recommended post operatively for acute respiratory failure to improve oxygenation and reduce chance of reintubation. (2A) NIV should not be used in patients undergoing esophageal surgery. (UPP) B6d. NIV in post lung transplant: Recommendations: NIV may be used for shortening weaning time and to avoid re-intubation following lung transplantation. (2B) B7. NIV during Procedures (ETI/Bronchoscopy/TEE/Endoscopy): Recommendations: NIV may be used for pre-oxygenation before intubation. (2B) NIV with appropriate interface may be used in patients of ARF during Bronchoscopy/Endoscopy to improve oxygenation. (3B) B8. NIV in Viral Pneumonitis ARDS: Recommendations: NIV cannot be considered as a treatment of choice for patients with acute respiratory failure with H1N1 pneumonia. However, it may be reasonable to use NIV in selected patients with single organ involvement, in a strictly controlled environment with close monitoring. (2B) B9. NIV and Acute exacerbation of Pulmonary Tuberculosis: Recommendations: Careful use of NIV in patients with acute Tuberculosis may be considered, with effective infection control precautions to prevent air-borne transmission. (3B) B10. NIV after planned extubation in high risk patients: Recommendation: We recommend that NIV may be used to wean high risk patients from invasive mechanical ventilation as it reduces re-intubation rate. (2B) B11. NIV for respiratory distress post extubation: Recommendations: We recommend that NIV therapy should not be used to manage respiratory distress post-extubation in high risk patients. (2B) C. Recommendation: Choice of mode should be mainly decided by factors like disease etiology and severity, the breathing effort by the patient and the operator familiarity and experience. (UPP) We suggest using flow trigger over pressure triggering in assisted modes, as it provides better patient ventilator synchrony. Especially in COPD patients, flow triggering has been found to benefit auto PEEP. (3B) D. D1. Sedation: Recommendations: A non-pharmacological approach to calm the patient (Reassuring the patient, proper environment) should always be tried before administrating sedatives. (UPP) In patients on NIV, sedation may be used with extremely close monitoring and only in an ICU setting with lookout for signs of NIV failure. (UPP) E. Recommendations: We recommend that portable bilevel ventilators or specifically designed ICU ventilators with non-invasive mode should be used for delivering Non-invasive ventilation in critically ill patients. (UPP) Both critical care ventilators with leak compensation and bi-level ventilators have been equally effective in decreasing the WOB, RR, and PaCO2. (3B) Currently, Oronasal mask is the most preferred interface for non-invasive ventilation for acute respiratory failure. (3B) F. Recommendations: We recommend that weaning from NIV may be done by a standardized protocol driven approach of the unit. (2B) How to cite this article: Chawla R, Dixit SB, Zirpe KG, Chaudhry D, Khilnani GC, Mehta Y, et al. ISCCM Guidelines for the Use of Non-invasive Ventilation in Acute Respiratory Failure in Adult ICUs. Indian J Crit Care Med 2020;24(Suppl 1):S61-S81.