Noninvasive Positive Pressure Ventilation Use in the Prehospital Setting: A Preliminary Cross-Sectional Analysis of State Protocols and Nationwide Clinical Practice.
The Journal of emergency medicine · 2026-01-04 · Registry study
Abstract
BACKGROUND: Prehospital respiratory distress is a common and high-risk condition that often requires critical interventions, including noninvasive positive pressure ventilation (NIPPV). OBJECTIVE: We aimed to describe U.S. emergency medical services (EMS) state protocols and nationwide practice patterns related to the prehospital use of NIPPV. METHODS: We completed a cross-sectional analysis of all publicly available, active state-level EMS protocols in the United States related to the prehospital use of NIPPV. Second, we completed a cross-sectional analysis of nationwide EMS practice patterns related to NIPPV use in 2023. We included EMS patient care reports filed by the unit that treated and transported the patient in which NIPPV was administered during a 9-1-1 scene response. Descriptive statistics were computed, stratified by suspected diagnostic indication. RESULTS: Among 30 states with an NIPPV protocol, early use of NIPPV was recommended in eight protocols for suspected pulmonary edema, compared with two for bronchospasm. Among an analytic sample of 30,358,677 EMS encounters, 133,768 (0.6%) included NIPPV use. Bronchospasm was suspected in 44.0% of encounters, 16.2% pulmonary edema, 7.1% mixed (i.e., bronchospasm and pulmonary edema), and 32.8% either other or unspecified indication. CONCLUSION: State EMS protocols tended to recommend NIPPV use as first-line for pulmonary edema and only a salvage measure for bronchospasm; however, NIPPV was used nearly three times more often for bronchospasm. Further research is encouraged to enable an evidence-based approach to achieving improved alignment between protocols and practice to better support EMS when administering critical care for respiratory distress.