Helmet continuous positive airway pressure vs. high flow nasal cannula oxygen in acute cardiogenic pulmonary oedema: a randomized controlled trial

Abstract

Aims Non-invasive ventilation represents an established treatment for acute cardiogenic pulmonary oedema (ACPO) although no data regarding the best ventilatory strategy are available. We aimed to compare the effectiveness of helmet CPAP (hCPAP) and high flow nasal cannula (HFNC) in the early treatment of ACPO. Methods and results Single-centre randomized controlled trial of patients admitted to the emergency department due to ACPO with hypoxemia and dyspnoea on face mask oxygen therapy. Patients were randomly assigned with a 1:1 ratio to receive hCPAP or HFNC and FiO2 set to achieve an arterial oxygen saturation >94%. The primary outcome was a reduction in respiratory rate; secondary outcomes included changes in heart rate, PaO2/FiO2 ratio, Heart rate, Acidosis, Consciousness, Oxygenation, and Respiratory rate (HACOR) score, Dyspnoea Scale, and intubation rate. Data were collected before hCPAP/HFNC placement and after 1 h of treatment. Amongst 188 patients randomized, hCPAP was more effective than HFNC in reducing respiratory rate [−12 (95% CI; 11–13) vs. −9 (95% CI; 8–10), P < 0.001] and was associated with greater heart rate reduction [−20 (95% CI; 17–23) vs. −15 (95% CI; 12–18), P = 0.042], P/F ratio improvement [+149 (95% CI; 135–163) vs. +120 (95% CI; 107–132), P = 0.003] as well as in HACOR scores [6 (0–12) vs. 4 (2–9), P < 0.001] and Dyspnoea Scale [4 (1–7) vs. 3.5 (1–6), P = 0.003]. No differences in intubation rate were noted (P = 0.321). Conclusion Amongst patients with ACPO, hCPAP resulted in a greater short-term improvement in respiratory and hemodynamic parameters as compared with HFNC. Trial registration Clinical trial submission: NMRR-17-1839-36966 (IIR). Registry name: Medical Research and Ethics Committee of Malaysia Ministry of Health. Clinicaltrials.gov identifier: NCT04005092. URL registry: https://clinicaltrials.gov/ct2/show/NCT04005092.

Noninvasive respiratory support in the emergency department: Controversies and state‐of‐the‐art recommendations

“…One prospective study in hypercapnic patients with cardiogenic pulmonary edema found no difference in CO 2 clearance or work of breathing, 17 whereas a retrospective study showed increased odds of failure with patients with cardiogenic pulmonary edema or hypercapnia when treated with NHF. 18 The only published trial comparing the NHF with NIPPV showed helmet CPAP had a greater improvement in respiratory failure at 1 h. 19 Little is known about the physiologic effects of NHF on acute cardiogenic pulmonary edema. However, given that NHF increases end-expiratory lung volume without the required positive intrathoracic pressure, the benefit for ADHF patients is likely from improved lung mechanics and gas exchange rather than myocardial performance.…”

Clinical review of high-flow nasal oxygen therapy in human and veterinary patients

“…Osman et al conducted a randomized controlled trial comparing HFNOT to non-invasive ventilation (helmet CPAP) in adult patients presenting the emergency room with acute cardiogenic pulmonary oedema ( 90 ). They found CPAP to be more effective in the very short term in improving dyspnoea, hemodynamics and respiratory parameters.…”

Acute dyspnea in the emergency department: a clinical review

“…Only recently the use of HFNO has been investigated in patients with cardiogenic pulmonary edema and, to date, a limited number of studies is available. Two randomized trials found that, compared to oxygen therapy, HFNO reduced respiratory rate without any significant effect on the need for intubation or mortality [ 107 , 123 ]. However, when HFNO was compared to helmet CPAP, although both systems improved the respiratory rate and PaO 2 /FiO 2 , greater improvements were observed in the helmet CPAP group, possibly related to the lower level of positive end-expiratory pressure (PEEP) actually applied by HFNO relative to CPAP [ 107 , 124 ].…”