Over the past decade, there have been a number of studies of the use of noninvasive ventilation (NIV) in patients with respiratory failure, including that associated with acute congestive heart failure (CHF). Many of these studies have focused on using NIV in an effort to avoid endotracheal intubation, with its associated complications and costs. Most studies have been small, retrospective, and not well focused on the CHF population. As a result, clinical use of NIV in a setting of severe CHF has been controversial and recommendations mixed; however, most studies support a beneficial role for NIV in patients with acute cardiogenic pulmonary edema. Its use is associated with lower endotracheal intubation rates and possibly lower mortality. This article describes two NIV modalities, continuous positive airway pressure (CPAP) and bi-level positive airway pressure (BLPAP), and compares their efficacy. Though BLPAP has theoretical advantages over CPAP, there are questions regarding its safety in a setting of CHF. The key to success in using NIV to treat severe CHF is proper patient selection, close patient monitoring, proper application of the technology, and objective therapeutic goals. When used appropriately, NIV can be a useful adjunct in the treatment of a subset of patients with acute CHF at risk for endotracheal intubation.