Non-Invasive Ventilation (NIV)

This page brings together guidance and resources aimed at those involved in the delivery of acute NIV. 

BTS Guidelines

The BTS/ICS Guidelines for the Ventilatory Management of Acute Hypercapnic Respiratory Failure in Adults were published in Thorax in March 2016 and replace the 2008 Guidelines on NIV for COPD patients.

NCEPOD Report: Inspiring Change - A review of the quality of care provided to patients receiving acute non-invasive ventilation

The primary aim of the study was to identify and explore avoidable and remediable factors in the process of care for patients treated with acute non-invasive ventilation (NIV). The study was proposed by BTS after successive BTS national audits identified suboptimal outcomes in patients treated with acute NIV, including high mortality rates (34%), increasing across audit periods, which compared unfavourably to UK trial data and international audit outcomes. The audits also found significant variation in outcome, both at institutional level and according to location of care. 

An NCEPOD study was the ideal mechanism to disentangle the factors involved in poorer outcomes and also to identify and champion areas of good practice. The study report, which was published in July 2017, includes robust recommendations that can be used to improve NIV services. 

BTS Quality Standards

Following the 2016 Guidelines and 2017 NCEPOD report, BTS has developed Quality Standards for acute non-invasive ventilation in adults, which were published in BMJ Open Respiratory Research in April 2018. These identify six key indicators of quality care and provide information on how to measure attainment against these standards. 

  1. Acute non-invasive ventilation (NIV) should be offered to all patients who meet evidence-based criteria. Hospitals must ensure there is adequate capacity to provide NIV to all eligible patients.
  2. All staff who prescribe, initiate or make changes to acute NIV treatment should have evidence of training and maintenance of competencies appropriate for their role.
  3. Acute NIV should only be carried out in specified clinical areas designated for the delivery of acute NIV.
  4. Patients who meet evidence-based criteria for acute NIV should start NIV within 60min of the blood gas result associated with the clinical decision to provide NIV and within 120min of hospital arrival for patients who present acutely.
  5. All patients should have a documented escalation plan before starting treatment with acute NIV. Clinical progress should be reviewed by a healthcare professional with appropriate training and competence within 4hours and by a consultant with training and competence in acute NIV within 14hours of starting acute NIV.
  6. All patients treated with acute NIV should have blood gas analysis performed within 2hours of starting acute NIV; failure of these blood gas measurements to improve should trigger specialist healthcare professional review within 30min.


National audits of acute NIV took place in 2010, 2011, 2012 and 2013 but have been on hold pending the outcome of the NCEPOD study. The next BTS National NIV Audit will run in Feb-Mar 2019 and has been included in the NHS England Quality Accounts List for 2018/19. 

BTS audits are available for local use outside of national audit periods for local use, and the NIV audit is being updated to reflect the recommendations from the NCEPOD Inspiring Change report and new Quality Standards. The updated audit will be available from 1 June 2018 to allow services to assess their performance against these standards ahead of the next national audit.  

For further details, please log in or register for the BTS audit system


A BTS Short Course on Acute Non Invasive Ventilation & Home Mechanical Ventilation will take place in London on 11-12 October 2018. Further details are available here


May 2018