Article Title

Elements of Effective Noninvasive Ventilation Use in Patients With Chronic Obstructive Pulmonary Disease Among High-Performing Hospitals

Publication Date



chronic obstructive pulmonary disease, implementation science


Background/Aims: Noninvasive ventilation (NIV) is an important component of treatment for patients with respiratory failure due to exacerbations of chronic obstructive pulmonary disease (COPD). Proven benefits include reduced need for invasive ventilation, complications, mortality and hospital length of stay. Despite these well-established benefits and strong recommendations in clinical guidelines, utilization of NIV varies widely across hospitals. The purpose of this study was to identify approaches used by hospitals that have been successful in implementing NIV to treat respiratory failure among patients with COPD.

Methods: In-depth interviews were conducted with key stakeholders from a sample of high-performing hospitals selected from a large and representative network of 386 U.S. hospitals. High performers were defined as hospitals in which a high proportion of patients with COPD requiring mechanical ventilation were treated with NIV, and that achieved low risk-adjusted mortality. Interviews were audio-recorded and transcribed verbatim. Themes and subthemes were identified through iterative readings of the transcripts, generation of preliminary lists of themes and discussion among team members until the team reached consensus that all important themes and subthemes present in the first sample of 25 interviews had been identified.

Results: Interviews have been conducted with 25 participants from five hospitals, including respiratory therapists (n = 12), physicians (n = 8) and nurses (n = 5). Preliminary analyses reveal three domains related to effective NIV use: 1) processes, 2) structural elements, and 3) contextual factors. Key processes included timely identification of appropriate patients and early initiation of NIV, frequent assessment of patient status and attention to patient comfort on NIV. Necessary structural elements included adequate equipment, sufficient numbers of qualified respiratory therapists and flexibility in staffing. Important contextual factors included achieving “buy-in” from key stakeholders, respiratory therapist autonomy, interdisciplinary teamwork and ongoing staff education. Hospital leaders, policies and protocols were identified as playing a supporting role in promoting essential elements.

Conclusion: These preliminary findings suggest elements of effective NIV use that characterize the experience of high-performing hospitals. By describing strategies to promote these elements, this study advances the understanding of how to successfully implement a complex intervention like NIV.