Noninvasive Ventilation and Mortality During COVID-19: What Could Have Been Wrong?

We read with interest the article by Botsch et al titled “Noninvasive Ventilation for Moderate to Severe Acute Respiratory Distress Syndrome Due to COVID-19” recently published in the American Journal of Critical Care.¹  The high rates of intubation and mortality among patients receiving noninvasive ventilation (NIV) give us the chance to share some reflections on the management of patients with acute respiratory distress syndrome (ARDS) undergoing NIV during the first 2 waves of the COVID-19 pandemic.

Reasons for the failure of NIV at such high rates in patients with moderate to severe ARDS, beyond their clinical conditions, could also be found in the modes of ventilation and their settings, the equipment used to deliver NIV, and the “double-edged sword” represented by the precautions to prevent the SARS-CoV-2 aerosol from spreading via the breathing circuits of ventilators. All these issues could have influenced the phenomenon called patient self-inflicted lung...