The Importance of Non-Invasive Mechanical Ventilation: Current Status in Iran


Saeid Safari 1 , 2 , Amir Hossein Lotfi 2 , Mitra Hekmatafshar 3 , *

1 Pain Research Center, Iran University of Medical Sciences, Tehran, IR Iran

2 Department of Intensive Care, Laleh Hospital, Tehran, IR Iran

3 School of Nursing and Midwifery, Shahid Beheshti University of Medical Sciences, Tehran, IR Iran

How to Cite: Safari S, Lotfi A H, Hekmatafshar M. The Importance of Non-Invasive Mechanical Ventilation: Current Status in Iran, Ann Anesth Crit Care . 2017 ; 2(1):e10570. doi: 10.5812/aacc.10570.


Annals of Anesthesiology and Critical Care: 2 (1); e10570
Published Online: December 31, 2016
Article Type: Editorial
Received: October 10, 2016
Revised: November 21, 2016
Accepted: December 15, 2016

Over the past two decades, the use of non-invasive positive pressure ventilation (NIPPV) has increased in many ICUs around the world (1). According to a study conducted in French, the use of non-invasive ventilation during 1994 to 2001 increased from 20 to 90% (2). The result of serial survey from more than 40 countries indicated that the overall use of NIPPV increased from 4.4% in 1998 to 14% in 2010 (3, 4).

NIPPV is used in wide variety conditions. It is a well-recognized approach in the management of acute respiratory failure, acute exacerbations of chronic obstructive pulmonary disease (COPD), hypoxemic respiratory failure, community-acquired pneumonia, cardiogenic pulmonary edema, and after solid organ transplants (5). It is also considered as the most effective treatment available for motor neuron disease when respiratory symptoms appear (6).

Non-invasive ventilation is a well-known strategy to avoid endotracheal intubation and its complications (7).

Endotracheal intubation in critically ill patients is accompanied by high risk and life threatening complications such as severe hypoxemia and hypotension, even in intensive care units (8). NIPPV reduces endotracheal intubation rate, mortality, and length of stay in the intensive care unit and it is a life-saving intervention (9-11).

NIPPV is also a cost-effective intervention (9). Results of a prospective observational study in India indicated that NIPPV can be a cost-effective intervention in countries with limited resources due to the decreased need for invasive mechanical ventilation (12). Use of NIPPV is not limited to intensive care unit. It is applicable in alternative settings with necessary recourses consisted of appropriate ventilator and mask, expert physicians, and other professional caregivers (13). The use of NIPPV outside the intensive care unit is an opportunity for reduction of the cost of care. Given the benefits of NIV, applying this approach to eligible patients who did not receive it is another opportunity which can reduce the cost of care and complications of invasive mechanical ventilation (14-16).

There is a lot of attention paid to NIPPV in international database. An electronic search without any limitation in time was conducted in PubMed and ScienceDirect databases. The search terms employed were “NIPPV” OR “non-invasive positive pressure ventilation” OR “non-invasive ventilation”. Also, an evidence-based medicine database, the Cochrane library, was searched with keywords mentioned above. The number of retrieved articles is shown in Table 1. Persian databases such as “SID”, “Magiran” and “Barekat knowledge network system” were also searched using related keywords, and a few research papers about NIPPV were found in Iran (Table 1).

Table 1. The Number of Articles Retrieved from International Databases Based on Keywords
International DatabasesIranian Databases
Search StrategyPubMedScienceDirectCochrane LibrarySID
Barekat knowledge network system
Number of articles retrieveda
“Non-invasive positive pressure ventilation”OR14531294903 trialsLess than 30
“Non-invasive ventilation”14 Systematic

aSearch without any limitation in time.

Using NIPPV requires a professional teamwork. As the same as anesthesiologists and intensivists, literature review of published articles indicates that nurses play an important role in the management of patients undergoing NIPPV (17-19). Also, in the research area, faculty nurses are interested to investigate NIPPV as an author (18, 20).

In recent years, an academic education course in critical care nursing master’s degree has established in Iran. This course will provide expert nurses with the specific knowledge and skills to provide better nursing care for patients requiring NIPPV.

In spite of the importance of using NIPPV in the management of respiratory failure, there are some barriers which limit applying this method of treatment. Systematic use of NIPPV is limited to some educational centers and it has not been established in non-specialized hospitals. Lack of national guideline about the use of NIPPV could contribute to lack of use. Also, there is not any systematic knowledge about NIPPV indication, selection of appropriate patients, and necessary equipment and ventilator for appropriate utilization of this approach. Most specialists and other professional members also need to pass more educational courses about non-invasive mechanical ventilation. Another limitation in applying NIPPV is poor compliance. Enhancing patient compliance and comfort are key factors for successful use of NIV.

Choice of suitable interface, levels of pressure applied, position of the patient, synchrony of ventilation, pharmacotherapy for dyspnea, treatment of anxiety and pain, humidification of air flow, and palliation of symptoms are some factors that can enhance patient compliance and comfort (21).

Given the importance of systematic use of NIV for eligible patients, paying attention to this well-known approach by health policy-makers and intensivists is necessary. Designing a national and context based guideline by forming an expert panel of intensivists, anesthesiologists, pulmonologists, and other related health care providers is crucial. Successful implementation of such guideline is just possible with collaboration and support of health care policy makers.


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