Clinical Protocol · November 2025

Chronic Hypercapnic Respiratory Failure

Evaluation and inpatient workflow for home non-invasive ventilation (NIV).

Home NIV protocol · Version: November 2025
Acute problems resolved. Is home NIV indicated?

Restrictive Lung Disease due to Neuromuscular Disease

Discuss with hypoventilation staff. Fellow calls senior staff directly.
  1. To qualify, document at least one of the following:
    1. ABG PaCO2 ≥ 45 mmHg
    2. FVC < 50%
    3. MIP < −60 cm H2O
    4. O2 saturation ≤ 88% for ≥ 5 minutes during a study at least 2 hours in length, on the patient’s home FiO2
  2. Document the neuromuscular diagnosis, such as ALS.
  3. Resident places order: Ventilator — Adult Non-Invasive.
    • Use .NIVORDERRESTNM
    • Obtain pre- and post-treatment ABGs.
  4. Resident documents the final BiPAP ST pressures, with or without oxygen supplementation.

Restrictive Lung Disease due to Chest Wall Deformity

Consider outpatient follow-up unless otherwise indicated by senior staff.
  1. To qualify, document at least one of the following:
    1. ABG PaCO2 ≥ 45 mmHg
    2. O2 saturation ≤ 88% for ≥ 5 minutes during a study at least 2 hours in length, on the patient’s home FiO2
  2. Document the chest wall deformity, such as kyphoscoliosis.
  3. Resident places order: Ventilator — Adult Non-Invasive.
    • Use .NIVORDERRESTCW
    • Obtain pre- and post-treatment ABGs.
  4. Resident documents the final BiPAP ST pressures, with or without oxygen supplementation.

Chronic Obstructive Pulmonary Disease (COPD)

Preference against initiating home NIV during an admission. Follow up as an outpatient unless otherwise indicated by senior staff. Managed by the ICU.
  1. To qualify: ABG PaCO2 ≥ 52 mmHg.
  2. Document: “Hypercapnia is likely not due to sleep apnea.”
  3. Document: “The patient required RAD with backup rate within 24 hours of discharge to avoid rapid symptom exacerbation or a rise in PaCO2.”
  4. Resident places order: Ventilator — Adult Non-Invasive.
    • Place .NIVORDERCOPD in the scheduling instructions.
    • Obtain pre- and post-treatment ABGs until stabilized.
  5. Contact hypoventilation staff for a home mechanical ventilator if any of the following apply:
    • FiO2 requirement ≥ 36% or oxygen requirement ≥ 4 L/min
    • NIV support is required ≥ 8 hours per day
    • The patient requires the alarms and internal battery of a home mechanical ventilator
Care management: Contact HART Medical using the information below.

Obesity Hypoventilation Syndrome (OHS)

As indicated by senior staff.
  1. To qualify: ABG PaCO2 ≥ 45 mmHg.
  2. Resident places order: Ventilator — Adult Non-Invasive.
    • CPAP must be tried first. Use .NIVORDERACPAPOHS
    • Obtain pre- and post-treatment ABGs.
  3. Transition to BiPAP only if CPAP fails because of one or more of the following:
    1. Unable to tolerate CPAP pressure
    2. Clinical worsening
    3. Worsening PaCO2, or no improvement despite auto-CPAP therapy
    4. Worsening hypoxemia
  4. If CPAP fails, place a BiPAP order using .NIVORDERBIPAOHS .
  5. When stable, contact Sleep Medicine for a sleep study. Overnight studies are available Sunday through Thursday only.
  6. Resident documents the final BiPAP pressures, with or without oxygen supplementation.

Discharge, Follow-up, and Contacts

Discharge and hospital follow-up

  1. Discharge order: Attending or fellow places the discharge order using .NIVDISCHARGEORDER .
  2. Hospital follow-up: Resident, fellow, or NP emails sleepaccess@hfhs.org using the Sleep Access template.

Care management contacts

HF Case Manager Monica Miller · mmiller85@hfhs.org
HART Medical Respiratory Therapy Discharge phone: 248-304-4595
Discharge email: RTdischarges@hartmedical.org

COPD Titration Order — NIVORDERCOPD

  1. Use BiPAP ST when PaCO2 ≥ 52 mmHg.
  2. Place an arterial line if possible.
  3. Obtain an ABG at the beginning of titration and again the following morning.
  4. Start manual BiPAP ST titration at IPAP 15 cm H2O, EPAP 5 cm H2O, and backup rate 14/min.
  5. Keep EPAP at 5 cm H2O and increase IPAP up to 25 cm H2O, or to the highest pressure tolerated.
  6. Add oxygen after desaturation to maintain an oxygen saturation of 90%.
Contributors (November 2025): Dr. J. Veljanovski, Dr. H. Jaffrey, Dr. L. Bazan, and Dr. A. K. Uduman.
Hypoventilation staff: Dr. L. Bazan, Dr. A. K. Uduman, and Dr. S. Jaffrey. Fellow calls senior staff directly.

This page reproduces the November 2025 protocol workbook in a mobile-friendly format. Confirm local policy and current order-set requirements before clinical use.

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