In a study published online by JAMA, Bhakti K. Patel, M.D., and John P. Kress, M.D., of the University of Chicago, and colleagues examined whether noninvasive ventilation delivered by helmet, compared with a face mask, improves intubation rate among patients with acute respiratory distress syndrome (ARDS). The study is being released to coincide with its presentation at the American Thoracic Society International Conference.
Noninvasive ventilation (NIV) with a face mask is relatively ineffective at preventing endotracheal intubation (placement of a tube into the windpipe [trachea] through the mouth or nose) in patients with ARDS.
Complications of endotracheal intubation include pneumonia, excessive sedation and delirium. An alternative is to deliver NIV via a helmet interface – a transparent hood that covers the entire head of the patient with a soft collar neck seal. This interface offers several advantages over a face mask including improved tolerability and less air leak due to the helmet’s lack of contact with the face and improved seal integrity at the neck. This could reduce intubation rates and extend the benefits of NIV to more patients with ARDS.
Dr. Kress and colleagues randomly assigned patients with ARDS requiring NIV delivered by face mask for at least 8 hours while in the medical intensive care unit to continue face mask NIV or switch to a helmet for NIV support. The final analysis included 44 patients randomly assigned to the helmet group and 39 to the face mask group.
The intubation rate was 61.5 percent for the face mask group and 18.2 percent for the helmet group. The median number of ventilator-free days was significantly higher in the helmet group (28 vs 12.5). At 90 days, 15 patients (34 percent) in the helmet group died compared with 22 patients (56 percent) in the face mask group. Adverse events included 3 interface-related skin ulcers for each group.
“Multicenter studies are needed to replicate these findings,” the authors write.
Article: 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, Bhakti K. Patel, MD; Krysta S. Wolfe, MD; Anne S. Pohlman, MSN; Jesse B. Hall, MD; John P. Kress, MD, doi:10.1001/jama.2016.6338, published online 15 May 2016.
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Editorial: Unmasking a Role for Noninvasive Ventilation in Early Acute Respiratory Distress Syndrome
Several key clinical messages can be gained from this study, writes Jeremy R. Beitler, M.D., M.P.H., of the University of California, San Diego, and colleagues in an accompanying editorial.
“The helmet interface has unique advantages and disadvantages that may influence efficacy of NIV depending on patient and disease characteristics. External validation of the findings by Patel et al and clarification of appropriate eligibility criteria, optimal ventilator settings, and potential mechanisms of effect are needed before clinicians could consider an expanded role for helmet NIV in routine management of select patients with ARDS. Whether helmet NIV affords benefit over high-flow nasal cannula warrants testing in a multicenter trial. Regardless, it is increasingly clear that there may be an important albeit under-investigated role for some form of high-level noninvasive respiratory support to prevent intubation, and perhaps mortality, in acute hypoxemic respiratory failure.”
Editorial: Unmasking a Role for Noninvasive Ventilation in Early Acute Respiratory Distress Syndrom, Jeremy R. Beitler, MD, MPH; Robert L. Owens, MD; Atul Malhotra, MD, JAMA, doi:10.1001/jama.2016.5987, published online 15 May 2016.
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