Use of positive airway pressure without endotracheal intubation

Continuous positive airway pressure (CPAP) and expiratory positive airway pressure (E-PAP) may be used safely without endotracheal intubation in patients with acute respiratory failure when strict selection criteria are adhered to. The therapy should be titrated to reduce intrapulmonary shunting, improve PaO2, and reduce FIO2. Other considerations include balancing oxygen consumption against cardiac output and oxygen transport. Absolute or relative indications for abandoning the technique and using endotracheal intubation with mechanical ventilatory support include unrelenting hypoxia, patient exhaustion, rising Paco2, development of metabolic acidosis, presence of ventricular arrhythmias, and inability to protect the airway.