Modes, settings, and the place where ventilation should be initiated

Home non-invasive ventilation (NIV) has evolved from a hospital-based supportive therapy into a sophisticated, technology-driven treatment with advanced monitoring, telemedicine, and automated ventilatory modes. Despite these advances, key controversies remain regarding optimal ventilatory mode selection, parameter personalization, and the best setting for NIV initiation. Pressure-targeted ventilation has become the predominant strategy because of its adaptability and leak compensation, although conventional volume-targeted ventilation remains a valid option in selected patients. Hybrid automated modes, including volume-assured pressure support and automatic EPAP systems, offer physiological advantages and modest benefits in comfort or adherence, but have not consistently demonstrated superiority over carefully optimized conventional NIV. Across disease phenotypes, clinical success depends less on mode selection than on individualized physiological titration of pressures, backup rate, triggering, and cycling. Finally, outpatient and home initiation supported by telemonitoring are increasingly feasible, supporting a more patient-centered and cost-effective model of NIV care.