One-Year Outcomes in Patients With Acute Respiratory Distress Syndrome Enrolled in a Randomized Clinical Trial of Helmet Versus Facemask Noninvasive Ventilation

Patel, Bhakti; Wolfe, K.S.; MacKenzie, Erica; Salem, Dhafer; Esbrook, Cheryl L.; Pawlik, Amy J.; Stulberg, M.; Kemple, Crystal; Teele, Megan; Zeleny, Erin; Macleod, Julia; Pohlman, Anne S.; Hall, Jesse B.; Kress, John P.

doi:10.1097/ccm.0000000000003124

Cited by 31 publications

(23 citation statements)

References 21 publications

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“… 7 Use of helmet NIV also had reduced ICU weakness and did not affect functional independence at hospital discharge and less mortality and more functional independence at 1 year compared to NIV with face mask. 8 Increasingly, self-inflicted lung injury (SILI) is being recognized as a reason for increased mortality when endotracheal intubation is delayed in NIV trial for AHRF. 6 Large tidal volumes generated during NIV has been implicated for SILI.…”

Section: Discussionmentioning

confidence: 99%

Voluntary Prone Position for Acute Hypoxemic Respiratory Failure in Unintubated Patients

Rao

Udhayachandar

Rao

et al. 2020

Indian Journal of Critical Care Medicine

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A bstract Severe hypoxemic respiratory failure is frequently managed with invasive mechanical ventilation with or without prone position (PP). We describe 13 cases of nonhypercapnic acute hypoxemic respiratory failure (AHRF) of varied etiology, who were treated successfully in PP without the need for intubation. Noninvasive ventilation (NIV), high-flow oxygen via nasal cannula, supplementary oxygen with venturi face mask, or nasal cannula were used variedly in these patients. Mechanical ventilatory support is offered to patients with AHRF when other methods, such as NIV and oxygen via high-flow nasal cannula, fail. Invasive mechanical ventilation is fraught with complications which could be immediate, ranging from worsening of hypoxemia, worsening hemodynamics, loss of airway, and even death. Late complications could be ventilator-associated pneumonia, biotrauma, tracheal stenosis, etc. Prone position is known to improve oxygenation and outcome in adult respiratory distress syndrome. We postulated that positioning an unintubated patient with AHRF in PP will improve oxygenation and avoid the need for invasive mechanical ventilation and thereby its complications. Here, we describe a series of 13 patients with hypoxemic respiratory of varied etiology, who were successfully treated in the PP without endotracheal intubation. Two patients (15.4%) had mild, nine (69.2%) had moderate, and two (15.4%) had severe hypoxemia. Oxygenation as assessed by PaO 2 /FiO 2 ratio in supine position was 154 ± 52, which improved to 328 ± 65 after PP. Alveolar to arterial (A-a) O 2 gradient improved from a median of 170.5 mm Hg interquartile range (IQR) (127.8, 309.7) in supine position to 49.1 mm Hg IQR (45.0, 56.6) after PP. This improvement in oxygenation took a median of 46 hours, IQR (24, 109). Thus, voluntary PP maneuver improved oxygenation and avoided endotracheal intubation in a select group of patients with hypoxemic respiratory failure. This maneuver may be relevant in the ongoing novel coronavirus disease pandemic by potentially reducing endotracheal intubation and the need for ventilator and therefore better utilization of critical care services. How to cite this article Rao SV, Udhayachandar R, Rao VB, Raju NA, Nesaraj JJJ, Kandasamy S, et al. Voluntary Prone Position for Acute Hypoxemic Respiratory Failure in Unintubated Patients. Indian J Crit Care Med 2020;24(7):557–562.

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Section: Discussionmentioning

confidence: 99%

Voluntary Prone Position for Acute Hypoxemic Respiratory Failure in Unintubated Patients

Rao

Udhayachandar

Rao

et al. 2020

Indian Journal of Critical Care Medicine

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“…Such improvement may mainly be due to the applied interface (ie, the helmet); in fact, the helmet has been largely recognized to be comfortable 5,9,10 and to reduce intubation rates 6 and in-hospital 90-d and 1-y mortality compared with the mask. 6,21 In particular, the a new-generation helmet used in the present study was characterized by improved pressurization and triggering performance, 8,9 which also allowed its use in more-challenging patients such as those with a COPD exacerbation. 10 Use in these patients is frequently problematic due to a less-efficient reduction in inspiratory effort and poorer patient-ventilator interaction compared with a mask.…”

Section: Discussionmentioning

confidence: 99%

Neurally-Adjusted Ventilatory Assist for Noninvasive Ventilation via a Helmet in Subjects With COPD Exacerbation: A Physiologic Study

et al. 2019

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BACKGROUND: In patients with COPD exacerbation, noninvasive ventilation (NIV) is strongly recommended. NIV is generally delivered by using patient triggered and flow-cycled pressure support through a face mask. A specific method to generate neurally-controlled pressure support has been shown to improve comfort and patient-ventilator interaction. In addition, the helmet interface was better tolerated by patients compared with a face mask. Herein, we compared neurally-controlled pressure support through a helmet with pressure support through a face mask with respect to subject comfort, breathing pattern, gas exchange, pressurization and triggering performance, and patientventilator synchrony. METHODS: Two 30-min trials of NIV were randomly delivered to 10 subjects with COPD exacerbation redundant: (1) pressure support through a face mask with inspiratory pressure support of >8 cm H 2 O to obtain a tidal volume of 6-8 mL/kg of ideal body weight; and (2) NAVA through a helmet, setting the neurally-adjusted ventilatory assist level at 15 cm H 2 O/V, with an upper airway pressure limit to obtain the same overall airway pressure applied during pressure support through a face mask. We assessed subject comfort, breathing frequency, respiratory drive, arterial blood gases, pressure-time product (PTP) of the first 300 ms and 500ms after initiation of subject effort, inspiratory trigger delay, and rate of asynchrony determined as the asynchrony index. RESULTS: Median and interquartile range NAVA through a helmet improved comfort (7.0 [6.0-8.0]) compared with pressure support through a face mask (5.0 [4.7-5.2], P ‫؍‬ .005). The breathing pattern was not different between the methods. Respiratory drive was slightly, although not significantly, reduced (P ‫؍‬ .19) during NAVA through a helmet in comparison with pressure support through a face mask. Gas exchange was also not different between the trials. The PTP of the first 300 ms (P ‫؍‬ .92) and PTP of the first 500 ms (P ‫؍‬ .08) were not statistically different between trials, whereas triggering performance, patient-ventilator interaction, and synchrony were all improved by NAVA through a helmet compared with pressure support through a face mask. CONCLUSIONS: In the subjects with COPD with exacerbation, NAVA through a helmet improved comfort, triggering performance, and patient-ventilator synchrony compared with pressure support through a face mask.

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“…[ 17 ] Consider helmet-based ventilation as it is less likely to leak and with it, one can increase air pressure to deliver NIV. [ 41 ]…”

Section: Respiratory Managementmentioning

confidence: 99%

Respiratory and cardiovascular effects of COVID-19 infection and their management

Kapoor

2020

J Anaesthesiol Clin Pharmacol

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One-Year Outcomes in Patients With Acute Respiratory Distress Syndrome Enrolled in a Randomized Clinical Trial of Helmet Versus Facemask Noninvasive Ventilation

Cited by 31 publications

References 21 publications

Voluntary Prone Position for Acute Hypoxemic Respiratory Failure in Unintubated Patients

Voluntary Prone Position for Acute Hypoxemic Respiratory Failure in Unintubated Patients

Neurally-Adjusted Ventilatory Assist for Noninvasive Ventilation via a Helmet in Subjects With COPD Exacerbation: A Physiologic Study

Respiratory and cardiovascular effects of COVID-19 infection and their management

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