Respective Effects of Helmet Pressure Support, Continuous Positive Airway Pressure, and Nasal High-Flow in Hypoxemic Respiratory Failure: A Randomized Crossover Clinical Trial

Luca S Menga; Luca Delle Cese; Tommaso Rosà; Melania Cesarano; Roberta Scarascia; Teresa Michi; Daniele G Biasucci; Ersilia Ruggiero; Antonio M Dell'Anna; Salvatore L Cutuli; Eloisa S Tanzarella; Gabriele Pintaudi; Gennaro De Pascale; Claudio Sandroni; Salvatore Maurizio Maggiore; Domenico L Grieco; Massimo Antonelli

doi:10.1164/rccm.202204-0629OC

Respective Effects of Helmet Pressure Support, Continuous Positive Airway Pressure, and Nasal High-Flow in Hypoxemic Respiratory Failure: A Randomized Crossover Clinical Trial

Am J Respir Crit Care Med. 2023 May 15;207(10):1310-1323. doi: 10.1164/rccm.202204-0629OC.

Authors

Luca S Menga^{1

2}, Luca Delle Cese^{1

2}, Tommaso Rosà^{1

2}, Melania Cesarano^{1

2}, Roberta Scarascia^{1

2}, Teresa Michi^{1

2}, Daniele G Biasucci^{1

2}, Ersilia Ruggiero^{1

2}, Antonio M Dell'Anna^{1

2}, Salvatore L Cutuli^{1

2}, Eloisa S Tanzarella^{1

2}, Gabriele Pintaudi^{1

2}, Gennaro De Pascale^{1

2}, Claudio Sandroni^{1

2}, Salvatore Maurizio Maggiore^{3

4}, Domenico L Grieco^{1

2}, Massimo Antonelli^{1

2}

Affiliations

¹ Department of Emergency, Intensive Care Medicine and Anesthesia, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy.
² Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore Rome, Italy.
³ University Department of Innovative Technologies in Medicine and Dentistry, Gabriele d'Annunzio University of Chieti-Pescara, Chieti, Italy; and.
⁴ Department of Anesthesiology, Critical Care Medicine and Emergency, SS. Annunziata Hospital, Chieti, Italy.

Abstract

Rationale: The respective effects of positive end-expiratory pressure (PEEP) and pressure support delivered through the helmet interface in patients with hypoxemia need to be better understood. Objectives: To assess the respective effects of helmet pressure support (noninvasive ventilation [NIV]) and continuous positive airway pressure (CPAP) compared with high-flow nasal oxygen (HFNO) on effort to breathe, lung inflation, and gas exchange in patients with hypoxemia (Pa_O₂/Fi_O₂ ⩽ 200). Methods: Fifteen patients underwent 1-hour phases (constant Fi_O₂) of HFNO (60 L/min), helmet NIV (PEEP = 14 cm H₂O, pressure support = 12 cm H₂O), and CPAP (PEEP = 14 cm H₂O) in randomized sequence. Measurements and Main Results: Inspiratory esophageal (ΔP_ES) and transpulmonary pressure (ΔP_L) swings were used as surrogates for inspiratory effort and lung distension, respectively. Tidal Volume (Vt) and end-expiratory lung volume were assessed with electrical impedance tomography. ΔP_ES was lower during NIV versus CPAP and HFNO (median [interquartile range], 5 [3-9] cm H₂O vs. 13 [10-19] cm H₂O vs. 10 [8-13] cm H₂O; P = 0.001 and P = 0.01). ΔP_L was not statistically different between treatments. Pa_O₂/Fi_O₂ ratio was significantly higher during NIV and CPAP versus HFNO (166 [136-215] and 175 [158-281] vs. 120 [107-149]; P = 0.002 and P = 0.001). NIV and CPAP similarly increased Vt versus HFNO (mean change, 70% [95% confidence interval (CI), 17-122%], P = 0.02; 93% [95% CI, 30-155%], P = 0.002) and end-expiratory lung volume (mean change, 198% [95% CI, 67-330%], P = 0.001; 263% [95% CI, 121-407%], P = 0.001), mostly due to increased aeration/ventilation in dorsal lung regions. During HFNO, 14 of 15 patients had pendelluft involving >10% of Vt; pendelluft was mitigated by CPAP and further by NIV. Conclusions: Compared with HFNO, helmet NIV, but not CPAP, reduced ΔP_ES. CPAP and NIV similarly increased oxygenation, end-expiratory lung volume, and Vt, without affecting ΔP_L. NIV, and to a lesser extent CPAP, mitigated pendelluft. Clinical trial registered with clinicaltrials.gov (NCT04241861).

Keywords: acute hypoxemic respiratory failure; acute respiratory distress syndrome; helmet support; noninvasive ventilation.

Publication types

Randomized Controlled Trial
Research Support, Non-U.S. Gov't

MeSH terms

Continuous Positive Airway Pressure
Humans
Hypoxia / therapy
Lung
Noninvasive Ventilation* / methods
Respiratory Insufficiency* / therapy

Associated data

ClinicalTrials.gov/NCT04241861