Managing asthma with noninvasive ventilation (NIV)

Can you use noninvasive ventilation for asthmatic patients in respiratory distress? Get an expert's opinion here.
Last update2nd Aug 2022

Imagine during your next clinical shift you’re called to evaluate a patient with a history of asthma. She is in severe respiratory distress. Since you recently had good success with using noninvasive ventilation (NIV) in a patient with chronic obstructive pulmonary disease (COPD), you consider using NIV in this patient with asthma.

Asthma is similar to COPD—in both, there is airway obstruction, particularly during expiration. And while the obstruction is somewhat different in its pathology—asthma has inflammation due to an accumulation of mucus and thickening of the bronchial walls whereas COPD has the loss of elasticity to the walls—you wouldn’t be alone to think that the treatment should provide similar beneficial results.

Figure 1. Both asthma and chronic obstructive pulmonary disease (COPD) are obstructive airway diseases, however, the pathophysiology is different. In COPD the airway obstruction is caused by a loss of elasticity. While in asthma the obstruction is due to an accumulation of mucus and thickening of the bronchial walls.

However, there is a lack of literature on the use of NIV in acute asthma exacerbations. A 2011 clinical practice guideline from the Canadian Critical Care Trials Group “make(s) no recommendation about the use of noninvasive positive-pressure ventilation in patients who have an exacerbation of asthma, because of insufficient evidence.” 1

In fact, no studies have demonstrated improved morbidity or mortality rates from the use of NIV in patients with asthma.

For these same reasons, a 2012 Cochrane Review on NIV for acute asthma exacerbations states that “this course of treatment remains controversial.” 2

Figure 2. Based on the literature, the treatment of asthma with noninvasive ventilation (NIV) remains controversial.

No large randomized trial has evaluated the use of continuous positive airway pressure (CPAP) in asthma patients. In the literature that exists, the small trials looking at CPAP in asthma concluded there was no harm to its use, but reported no conclusive mortality or intubation benefit. The physiologic benefits of improved airflow and improved deposition of nebulized bronchodilators have not translated into a measurable change in clinical outcomes.

So, despite the lack of support from guidelines and medical literature, I hope I have still convinced you to consider a trial of NIV for your patient in asthma.

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  1. Keenan, SP, Sinuff, T, Burns, KEA, et al. 2011. Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. CMAJ. 183: E195–E214. PMID: 21324867
  2. Lim, WJ, Akram, RM, Carson, KV, et al. 2012. Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma. Cochrane Database Syst Rev. 12: CD004360. PMID: 23235608

Recommended reading

  • Holley, MT, Morrissey TK, Seaberg, DC, et al. 2001. Ethical dilemmas in a randomized trial of asthma treatment: can Bayesian statistical analysis explain the results? Acad Emerg Med. 8: 1128–1135. PMID: 11733289
  • Soma, T, Hino, M, Kida, K, et al. 2008. A prospective and randomized study for improvement of acute asthma by non-invasive positive pressure ventilation (NPPV). Intern Med. 47: 493–501. PMID: 18344635
  • Soroksky, A, Stav, D, and Shpirer, I. 2003. A pilot prospective, randomized, placebo-controlled trial of bilevel positive airway pressure in acute asthmatic attack. Chest. 123: 1018–1025. PMID: 12684289


About the author

Michael Allison, MD
Chief of Critical Care Medicine at the University of Maryland St. Joseph Medical Center, USA.
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