Non-invasive Ventilation and Dexmedetomidine in Critically Ill Adults

Inclusion Criteria: 1. Age ≥18 years 2. Patient receiving any NIV modality for acute respiratory failure of any etiology 3. Admitted to ICU, PACU, step-down unit (surgical or medical), or emergency department(with planned admission to a monitored setting) or equivalent unit where hemodynamics and respiratory status can be monitored, and NIV is permitted; and 4. Presence of one or more of the following after optimized NIV treatment: 1. Agitation (Defined as a Richmond Agitation and Sedation Scale \[RASS\] score of ≥+2 or a Riker Sedation-Agitation Scale \[SAS\] score of ≥5) (Appendix 1 Table 2 and Table 3) 2. Patient expresses intolerance or requests removal of NIV secondary to self-reported discomfort, anxiety, or claustrophobia 3. Other reason that the physician judges the patient to be intolerant of NIV or agitated, not captured above, or feels that the patient would benefit from titrated sedation for other reasons. Exclusion Criteria: 1. Absence of a functioning pacemaker with one of the following: a-Persistent bradycardia defined as a heart rate (HR) ≤60bpm; b-Second or third-degree heart block; or c- Tachybrady syndrome 2. Persistent hypotension, defined as a mean arterial pressure (MAP) ≤65mmHg despite volume resuscitation and vasopressors 3. Imminent need for endotracheal intubation as determined by healthcare team 4. Patient's goals of care do not include intubation and IMV 5. Patient is not for vasopressors or inotropic support 6. Death is deemed imminent and inevitable 7. Patient is currently on a dexmedetomidine infusion for a duration of \> 12 hours 8. Previously enrolled in the inDEX trial 9. Acute liver failure with hepatic encephalopathy INR \> 3 and/or bilirubin \> 300 10. Current pregnancy or breast feeding 11. Known allergy to dexmedetomidine 12. Patients receiving Amphotericin B or Diazepam 13. Treating physician does not believe that participation in the trial is in the best interest of the patient (reasons for refusal will be captured)