Considering the high failure rate of NIV therapy in patients with PIAH1N1 virus infection and ALI/ARDS, the treatment of ARDS associated with the PIAH1N1 virus infection should be based upon published, evidence-based guidelines for sepsis-associated ARDS. Standard lung-protective ventilation strategies are appropriate initially [2, 5] . We appreciate the interest of Dr Ñamendys-Silva and colleagues in our article [1] and their insightful observations regarding ventilator management of severe PIAH1N1 virus infection. We agree that NIV is not recommended for patients with respiratory failure due to PIAH1N1 virus infection. However, several points should be clarifi ed. Use of NIV in ARDS remains controversial and the etiology of hypoxemia seems to be an important determinant of successful outcome. Our results describe our national clinical practice in the current pandemic and it is consistent with other reports [3, 6] . Other authors have recently reported that, in centers with expertise on NIV, 30% of patients with ARDS were treated with NIV as a fi rst-line intervention and 30 to 50% of these avoided orotracheal intubation [1, 3, 6] . Th us, only a small number of patients with ARDS benefi ted from NIV in expert centers, always needing close monitoring in the ICU setting. In selected patients with milder presentation a conservative ventilator approach should be considered until additional data from 2009 PIAH1N1 is obtained.