Acute heart failure is often characterized by sign and symptoms of acute respiratory distress. Non-invasive ventilatory support is frequently used as a first approach to relieve those symptoms and to improve cardiac and respiratory function. Non-invasive positive pressure ventilation can reduce the rate of endotracheal intubation and improve survival if applied to the appropriate patient at the right moment. The application of a continuous positive airway pressure is a cornerstone in the management of acute cardiogenic pulmonary edema thanks to its ability in reducing respiratory fatigue and improving hemodynamics. Correct implementation of positive pressure ventilation needs an extensive knowledge of cardiocirculatory and pulmonary pathophysiology and the consequent implications of this ventilation mode. The choice of the best available interface and patient’s adaption to it are essential to guarantee the success of non-invasive ventilation. Monitoring patient’s response and respiratory parameters improvement is crucial in order to decide to continue with this approach or promptly shift to invasive mechanical ventilation.