Choosing between high-flow nasal cannula, noninvasive ventilation (NIV), CPAP, and conventional oxygen is one of the most common decisions in critical care. The new 2026 American Thoracic Society (ATS) Clinical Practice Guideline provides updated, evidence-based recommendations across the spectrum of acute respiratory failure.

In Season 1, Episode 62 of PRISM Rounds, we examine the guideline published in the American Journal of Respiratory and Critical Care Medicine and explore what its recommendations mean for bedside practice.

We discuss four critical clinical questions:

  1. Acute hypoxemic respiratory failure: Why is high-flow nasal cannula strongly recommended over conventional oxygen, and when should clinicians consider NIV or CPAP?

  2. Acute hypercapnic respiratory failure: Why does NIV remain first-line therapy, and when might high-flow oxygen be a reasonable alternative?

  3. Preoxygenation before intubation: How can HFNC and NIV reduce peri-intubation hypoxemia?

  4. Postextubation respiratory support: Which patients benefit from preventive NIV or HFNC, and how can we reduce reintubation?

We also examine the strength and certainty of the evidence, important limitations of network meta-analyses, and the distinction between reducing intubation and improving survival.

The central clinical question: Are we choosing the right respiratory support strategy for the right patient, and recognizing early enough when that strategy is failing?

This episode is designed for intensivists, pulmonologists, emergency physicians, respiratory therapists, critical care fellows, and other clinicians managing acute respiratory failure.

Primary Reference:
Goel NN, Ferreyro BL, et al. Noninvasive respiratory support for adult patients with acute respiratory failure: An official American Thoracic Society Clinical Practice Guideline. American Journal of Respiratory and Critical Care Medicine. 2026;212(9):2135–2158.

https://doi.org/10.1093/ajrccm/aamag302

Listen and subscribe to PRISM Rounds on Apple Podcasts, Spotify, Youtube or visit https://www.prismrounds.com.

Evidence reviewed. Clinical decisions informed.


Tags

ritical Care

Pulmonary Medicine

ATS Guidelines

Noninvasive Ventilation

NIV

High-Flow Nasal Cannula

HFNC

CPAP

Acute Respiratory Failure

Hypoxemic Respiratory Failure

Hypercapnic Respiratory Failure

COPD Exacerbation

Mechanical Ventilation

Preoxygenation

Extubation

Intensive Care Medicine

Evidence-Based Medicine

Clinical Practice Guidelines

Respiratory Therapy

PRISM Rounds

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