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Background: Noninvasive ventilation (NIV) still has high failure rate when used for acute respiratory failure (ARF). Delirium may impact the outcome, however data regarding its incidence, timing of occurrence and clinical predictors are lacking. Methods: Consecutive patients with ARF subjected to NIV were recruited in 9 Respiratory Intensive Care Units (July 2019-January 2020). Individuals with neurological impairment, established psychiatric or neurological disease, need for immediate intubation, and use of home-NIV were excluded. Demographics and clinical features, including tolerance to interface and NIV setting were recorded on admission, whereas delirium was assessed by the CAM-ICU7 Scale twice/per day up to a week. The impact of baseline variables on the occurrence of delirium and its influence on NIV outcome were analysed. Results: Thirty-two out of 92 enrolled patients (34,7%) developed delirium over 7 days upon admission; time to onset was 32.6 hours (SD=12.6). Sepsis (OR=2.9[1.2-14.5] p=0.01), SOFA score>7 (OR= 3.5[1.6-19.4] p=0.002), low tolerance to interface (OR=1.9[1.1-21.4] p=0.002), use of helmet (OR=4.2[1.7-29] p=0.001), and higher pre-DELIRIC (OR=1.8 [1.1-14]p=0.03) and BORG (OR=2.6[1.4-11.6]p=0.002] scores were significantly associated with delirium. Delirium was highly related with NIV failure (HR=3.5[1.4-8.5] p=0.01). Conclusion: The occurrence of delirium in patients undergoing acute NIV is relevant and negatively affects the outcome. Multiple related clinical factors should be addressed early on admission to prevent the risk of NIV failure in these patients.