Advantages and drawbacks of helmet noninvasive support in acute respiratory failure

ABSTRACT

Introduction

Non-invasive ventilation (NIV) represents an effective strategy for managing acute respiratory failure. Facemask NIV is strongly recommended in acute exacerbation of chronic obstructive pulmonary disease (AECOPD) with hypercapnia and acute cardiogenic pulmonary edema (ACPE). Its role in managing acute hypoxemic respiratory failure (AHRF) remains a debated issue. NIV and continuous positive airway pressure (CPAP) delivered through the helmet are recently receiving growing interest for AHRF management.

Areas covered

In this narrative review, we discuss the clinical applications of helmet support compared to the other available noninvasive strategies in the different phenotypes of acute respiratory failure.

Expert opinion

Helmets enable the use of high positive end-expiratory pressure, which may protect from self-inflicted lung injury: in AHRF, the possible superiority of helmet support over other noninvasive strategies in terms of clinical outcome has been hypothesized in a network metanalysis and a randomized trial, but has not been confirmed by other investigations and warrants confirmation. In AECOPD patients, helmet efficacy may be inferior to that of face masks, and its use prompts caution due to the risk of CO₂ rebreathing. Helmet support can be safely applied in hypoxemic patients with ACPE, with no advantages over facemasks.

KEYWORDS:

• Acute respiratory failure
• helmet support
• mechanical ventilation
• noninvasive ventilation
• positive end-expiratory pressure

Article highlights

• Helmet interface could play a relevant role in managing acute hypoxemic respiratory failure (AHRF) primarily due to the possibility of continuously delivering high PEEP levels for prolonged periods with minimal interruptions. This can also represent an appealing strategy to prevent self-induced lung injury (P-SILI). Due to the narrow physiological window, the key point is to avoid delayed intubation through strict patient monitoring.

• NIV is the mainstay of respiratory support therapy for acute exacerbations of COPD (AECOPD). In AECOPD patients, helmet efficacy may be inferior to that of face masks, and its use prompts caution due to the risk of CO₂ rebreathing. Helmet NIV may play a relevant role in the subset of patients who poorly tolerate the face mask interface, leading to higher tolerability and less discomfort-related intubations.

• The effectiveness of positive pressure in acute cardiogenic pulmonary edema (ACPE) is due mainly to the decrease in both right ventricular preload and left ventricular afterload. No difference between pressure-support/bilevel NIV and CPAP was found, suggesting that the inspiratory support above PEEP may not be warranted in hypoxemic, non-hypercapnic ACPE patients. Helmet support can be safely applied in hypoxemic patients with ACPE, with no advantages over facemasks.

Declaration of interest

F Bongiovanni has received speaking fees from Pfizer and MedicAir. DL Grieco has received speaking fees by Getinge, Fisher and Paykel, GE, Intersurgical, and MSD. M Antonelli has received personal fees by Maquet, and a research grant by Toray. DL Grieco and M Antonelli disclose a research grant by General Electric Healthcare. The authors have no other relevant affiliations or financial involvement with any organization or entity with a financial interest in or financial conflict with the subject matter or materials discussed in the manuscript apart from those disclosed.

Reviewer disclosures

A reviewer on this manuscript has disclosed that they are working part-time at Hamilton Medical AG. Peer reviewers on this manuscript have no other relevant financial relationships or otherwise to disclose.

Abbreviations

AHRF, acute hypoxemic respiratory failure; AECOPD, acute exacerbation of chronic obstructive pulmonary disease; ACPE, acute cardiogenic pulmonary edema; PEEP, positive end-expiratory pressure; P-SILI, patient self-inflicted lung injury

Additional information

Funding

This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors. Outside of the submitted work, DL Grieco is supported by research grants by ESICM and SIAARTI.