Background: Prolonged application time of helmet continuous positive airway pressure (CPAP) leads to better outcomes, but its timing can be influenced by the patient's tolerance. Aims and objectives: To investigate patients' pain and tolerance experience related to different options of helmet fixing system: 'armpits strap' versus 'counterweights system'. Design: This was a non-randomized crossover study performed in a 10-bed intensive care unit and referral extra corporeal membrane oxigenation (ECMO) centre of an Italian university hospital. Results: Twenty patients were enrolled. For helmet-CPAP cycles performed with the armpit straps option, the mean pain numerical rate on a 0-10 scale was: 0⋅5 ± 1⋅4 at T 0 (baseline) , 1⋅5 ± 2⋅0 at T 1 (after 1 h) and 2⋅6 ± 2⋅5 at T 2 (end of cycle) (p = 0⋅023). The same analysis was performed for the counterweights fixing option. The mean score was 0⋅3 ± 0⋅6 at T 0 , 0⋅3 ± 0⋅2 at T 1 and 0⋅5 ± 0⋅7 at T 2 (p = 0⋅069). The mean duration for CPAP cycles performed with armpits strap and counterweights system was 3⋅0 ± 1⋅0 and 3⋅9 ± 2⋅3 h, respectively (p < 0⋅001). The mean section of the Basilic vein that was investigated before wearing the helmet was equal to 0⋅23 ± 0⋅20 cm 2 . After 1 h of therapy with the counterweight option and armpit straps, the mean increase of the vein's section was 0⋅27 ± 0⋅21(p = 0⋅099) and 0⋅30 ± 0⋅25, respectively (p = 0⋅080). Conclusions: The fixing system options in use to anchor the helmet during CPAP could worsen the pain experience level and cause device-related pressure ulcers. When compared with the armpit straps option, the counterweights system appears to be a suitable approach to minimize the risks of pressure sores and pain during the treatment. Relevance to practice: The helmet CPAP is a reliable therapy to manage acute respiratory failure. Major improvements regarding pulmonary alveolar recruitment and oxygen levels are strictly related to a prolonged time of helmet CPAP cycles. Using a counterweight fixing system, where the armpits straps are not necessary, could be helpful in reducing patients' pain experience. Squadrone et al., 2004), but it also depends on the ventilator settings, the interfaces available (Navalesi et al., 2000) and the quality of interaction between the pulmonary ventilator and the patient's spontaneous breathing (Vignaux et al., 2009).According to Taccone et al. (2004), non-invasive CPAP should be delivered by continuous gas flow in order to avoid or minimize the mismatch of patient/ventilator interaction. Currently, in Europe, the mask interface is still the main choice, even if new trends in several countries of south Europe demonstrated that the helmet is the alternative first choice to delivering CPAP (Crimi et al., 2010).

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