Helmets for Patients in the Intensive Care Unit?
Patricia Kritek, MD
Patients with hypoxemic respiratory failure avoided intubation when noninvasive ventilation was delivered via helmet.
Treating patients with acute respiratory distress syndrome (ARDS) usually requires intubation and mechanical ventilation. Although high-flow oxygen can limit these interventions, similar benefits have not been seen with noninvasive positive-pressure ventilation (NPPV; JW Gen Med Aug 1 2015 and N Engl J Med 2015; 372:2185 and JAMA 2015; 313:2331). Often, NPPV fails because of patients’ discomfort from tight-fitting masks and excessive air leak when high levels of pressure are applied.
In an attempt to provide NPPV with greater comfort and efficacy, investigators at the University of Chicago randomized 83 patients with ARDS (who had received traditional facemask NPPV for 8 hours) either to continue facemask NPPV or to switch to an NPPV helmet that covered the patient’s entire head, with a soft collar interface at the neck. The trial was stopped early when interim analysis demonstrated markedly lower intubation rates in the helmet group (18.2% vs. 61.5%). In addition, the helmet group had a lower mean respiratory rate (24.5 vs. 29.1 breaths/minute), spent fewer days in the intensive care unit (ICU; mean, 4.7 vs. 7.8), and were less likely to die by 90 days (hazard ratio, 0.47). No significant differences in skin ulcerations were noted between groups.
Increasingly, we are focusing on keeping ICU patients awake, interactive, and mobile. This study suggests a potential alternative to intubation, but, before we rush to stock all our ICUs with helmets, we need multicenter studies to delineate ideal helmet settings and to determine which patients benefit most from helmet NPPV. Moreover, given the recent positive results attained with high-flow oxygen, I’d like to see a comparison of helmet versus high-flow oxygen.
Patel BK et al. Effect of noninvasive ventilation delivered by helmet vs face mask on the rate of endotracheal intubation in patients with acute respiratory distress syndrome: A randomized clinical trial. JAMA 2016 May 15; [e-pub]. (http://dx.doi.org/10.1001/jama.2016.6338)
Beitler JR et al. Unmasking a roe for noninvasive ventilation in early acute respiratory distress syndrome. JAMA 2016 May 15; [e-pub]. (http://dx.doi.org/10.1001/jama.2016.5987)
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