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Weaning from Non-Invasive Mechanical Ventilation Approaches (NIV-NHF): Insights on How, When and Where

A Special Issue of Journal of Clinical Medicine (ISSN 2077-0383) belonging to the section "Intensive Care".

Deadline for manuscript submissions: closed (25 November 2025) | Viewed by 25602

Editor


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Guest Editor
Intensive Care Unit, Hospital Morales Meseguer, 30007 Murcia, Spain
Interests: mechanical ventilation; critical care medicine; weaning mechanical ventilation; non invasive ventilation
Special Issues, Collections and Topics in MDPI journals

Special Issue Information

Dear Colleagues,

Weaning (withdrawal, escalation, or des-escalation steps) from non-invasive positive pressure ventilation (NIPPV) or nasal high flow oxygen relates to procedures that are put in place to obtain disconnection of the patient from non-invasive nasal high flow devices, and this is crucial in the achievement of best control in respiratory failure. Failure in any of these steps is associated with an increase in mortality and spending a long time in intensive care units or pneumology wards.

However, in terms of pathophysiology, determinant factors, the best tools for early diagnosis and prevention in weaning from NIV nasal high flow, are poorly defined in clinical practice.

In this proposed Special Issue, we aim to define the factors that have an impact on the steps of “how, when and where”, as well as the best escalation-de-escalation (weaning from NIV nasal high flow).

We are considering updating this topic to the following title: Weaning from Non-Invasive Mechanical Ventilation Approaches (NIV nasal high flow), focused on these key major issues:

  1. Withdrawal pathophysiology;
  2. Clinical determinants;
  3. Comorbid conditions;
  4. Equipment-ventilatory modes-setting;
  5. Special determinants in hypercapnic and hypoxemic;
  6. Escalation-de-escalation: determinants’ response;
  7. Recommendations for prevention, safe responses, and effectiveness;
  8. Summary and clinical evidence for withdrawal approach in three key questions: how, when, and where.

Dr. Antonio M. Esquinas
Guest Editor

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Keywords

  • non-invasive positive pressure ventilation (NIPPV)
  • nasal high flow oxygen
  • respiratory failure
  • intensive care units
  • pneumology wards
  • non-invasive mechanical ventilation approaches (NIV nasal high flow)

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Published Papers (3 papers)

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Research

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19 pages, 5191 KB  
Article
Testing the Stable Unit Treatment Variance Assumption (SUTVA) Within Cochrane Reviews of Antimicrobial-Based Pneumonia Prevention Interventions Among Mechanically Ventilated Patients Using Caterpillar Plots
by James C. Hurley
J. Clin. Med. 2025, 14(19), 6841; https://doi.org/10.3390/jcm14196841 - 26 Sep 2025
Cited by 2 | Viewed by 1019
Abstract
Background/Objectives: Causal inference requires validating the stable unit treatment variance assumption (SUTVA). Whilst antimicrobial-based interventions, being topical chlorhexidine and topical antibiotics prophylaxis (TAP), appear effective in preventing ventilator-associated pneumonia (VAP) among ICU patients receiving mechanical ventilation (MV) within randomized concurrent controlled trials [...] Read more.
Background/Objectives: Causal inference requires validating the stable unit treatment variance assumption (SUTVA). Whilst antimicrobial-based interventions, being topical chlorhexidine and topical antibiotics prophylaxis (TAP), appear effective in preventing ventilator-associated pneumonia (VAP) among ICU patients receiving mechanical ventilation (MV) within randomized concurrent controlled trials (RCCT), SUTVA has never been tested for this inference. Methods: Caterpillar plots of the VAP incidence proportions for control and intervention groups within RCCTs obtained from recent Cochrane reviews of antimicrobial-based VAP prevention interventions were derived using random effects methods to enable comparison versus the expert VAP incidence reference range (5 to 40%). Results: The summary VAP prevention effect size derived from three categories of 57 RCCTs of antimicrobial-based interventions was recapitulated. The VAP incidences of 24 control groups and 6 intervention group incidences were above, whereas only 1 and 6, respectively, were below the expert VAP incidence reference range (5 to 40%) (p < 0.001; chi-square = 17.42; df = 2). The results after excluding 18 low-quality studies were similar. Paradoxically, the 90% prediction limits in association with the summary control group incidences are each approximately 20 percentage points wider than for those associated with the intervention group summaries. Conclusions: Control group VAP incidences above and more dispersed versus the expert opinion VAP range are common within the Cochrane reviews of antimicrobial-based VAP prevention interventions. Recognition requires an arms-based analysis using caterpillar plots. The SUTVAs that underlie the inference of prevention from the effect size estimates are not valid. Full article
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Review

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17 pages, 1320 KB  
Review
Liberation from Non-Invasive Ventilation in Complex Intensive Care Unit Patients
by Hafsa Safdar and Joseph B. Barney
J. Clin. Med. 2026, 15(6), 2148; https://doi.org/10.3390/jcm15062148 - 11 Mar 2026
Viewed by 2477
Abstract
The evolution of non-invasive mechanical ventilation (NIV) from the iron lung of the 1950s to the use of sophisticated ventilators with mask apparatus has allowed for the optimal management of a wide range of respiratory disorders. NIV is now a mainstay in the [...] Read more.
The evolution of non-invasive mechanical ventilation (NIV) from the iron lung of the 1950s to the use of sophisticated ventilators with mask apparatus has allowed for the optimal management of a wide range of respiratory disorders. NIV is now a mainstay in the management of acute, chronic and acute-on-chronic hypoxemic and hypercapnic respiratory failure from diverse etiologies. While NIV offers an effective approach to avoid invasive mechanical ventilation with its inherent risks of lung injury and sedation-related harms, it is a complex modality that requires a nuanced approach to management As the use of NIV has become ubiquitous, complex challenges are faced in the initiation, management and discontinuation of the treatment. We review complex clinical scenarios that present during liberation from non-invasive mechanical ventilation and an approach to successful weaning and liberation in these patient populations. Full article
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21 pages, 854 KB  
Review
Non-Invasive Ventilation: When, Where, How to Start, and How to Stop
by Mary Zimnoch, David Eldeiry, Oluwabunmi Aruleba, Jacob Schwartz, Michael Avaricio, Oki Ishikawa, Bushra Mina and Antonio Esquinas
J. Clin. Med. 2025, 14(14), 5033; https://doi.org/10.3390/jcm14145033 - 16 Jul 2025
Cited by 8 | Viewed by 20706
Abstract
Non-invasive ventilation (NIV) is a cornerstone in the management of acute and chronic respiratory failure, offering critical support without the risks of intubation. However, successful weaning from NIV remains a complex, high-stakes process. Poorly timed or improperly executed weaning significantly increases morbidity and [...] Read more.
Non-invasive ventilation (NIV) is a cornerstone in the management of acute and chronic respiratory failure, offering critical support without the risks of intubation. However, successful weaning from NIV remains a complex, high-stakes process. Poorly timed or improperly executed weaning significantly increases morbidity and mortality, yet current clinical practice often relies on subjective judgment rather than evidence-based protocols. This manuscript reviews the current landscape of NIV weaning, emphasizing structured approaches, objective monitoring, and predictors of weaning success or failure. It examines guideline-based indications, monitoring strategies, and various weaning techniques—gradual and abrupt—with evidence of their efficacy across different patient populations. Predictive tools such as the Rapid Shallow Breathing Index, Lung Ultrasound Score, Diaphragm Thickening Fraction, ROX index, and HACOR score are analyzed for their diagnostic value. Additionally, this review underscores the importance of care setting—ICU, step-down unit, or general ward—and how it influences outcomes. Finally, it highlights critical gaps in research, especially around weaning in non-ICU environments. By consolidating current evidence and identifying predictors and pitfalls, this article aims to support clinicians in making safe, timely, and patient-specific NIV weaning decisions. In the current literature, there are gaps regarding patient selection and lack of universal protocolization for initiation and de-escalation of NIV as the data has been scattered. This review aims to consolidate the relevant information to be utilized by clinicians throughout multiple levels of care in all hospital systems. Full article
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