Phenotypes of Patients with COVID-19 Who Have a Positive Clinical Response to Helmet Noninvasive Ventilation

Grieco, Domenico Luca; Menga, Luca Salvatore; Cesarano, Melania; Spadaro, Savino; Bitondo, Maria Maddalena; Berardi, Cecilia; Rosà, Tommaso; Bongiovanni, Filippo; Maggiore, Salvatore Maurizio; Antonelli, Massimo

doi:10.1164/rccm.202105-1212le

Cited by 27 publications

(17 citation statements)

References 10 publications

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“…In the study by Ospina-Tascon et al, younger patients (<60 years) and patients with lower IL-6 levels (<100 pg/ml) appeared to benefit more from HFNO than older patients or patients with higher levels of IL-6, while no interaction was detected between HFNO effect and the severity of hypoxemia. In a post-hoc analysis of the HENIVOT trial, patients with low PaCo 2 (<35 mmHg) or severe hypoxemia (PaO 2 /FiO 2 × dyspnea visual analogical scale <30) tended to benefit from helmet ventilation (72). Finally, Crimi et al did not report any interaction between HFNO effect, time to randomization, age, co-morbidities, or severity of hypoxemia.…”

Section: Discussionmentioning

confidence: 97%

High-flow nasal oxygen in acute hypoxemic respiratory failure: A narrative review of the evidence before and after the COVID-19 pandemic

Genecand

Agoritsas²,

Ehrensperger³

et al. 2022

Front. Med.

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High-flow nasal oxygen (HFNO) is a type of non-invasive advanced respiratory support that allows the delivery of high-flow and humidified air through a nasal cannula. It can deliver a higher inspired oxygen fraction than conventional oxygen therapy (COT), improves secretion clearance, has a small positive end-expiratory pressure, and exhibits a washout effect on the upper air space that diminishes dead space ventilation. HFNO has been shown to reduce the work of breathing in acute hypoxemic respiratory failure (AHRF) and has become an interesting option for non-invasive respiratory support. Evidence published before the COVID-19 pandemic suggested a possible reduction of the need for invasive mechanical ventilation compared to COT. The COVID-19 pandemic has resulted in a substantial increase in AHRF worldwide, overwhelming both acute and intensive care unit capacity in most countries. This triggered new trials, adding to the body of evidence on HFNO in AHRF and its possible benefits compared to COT or non-invasive ventilation. We have summarized and discussed this recent evidence to inform the best supportive strategy in AHRF both related and unrelated to COVID-19.

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Section: Discussionmentioning

confidence: 97%

High-flow nasal oxygen in acute hypoxemic respiratory failure: A narrative review of the evidence before and after the COVID-19 pandemic

Genecand

Agoritsas²,

Ehrensperger³

et al. 2022

Front. Med.

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“…Patients in the helmet NIV group experienced less dyspnea, improved gas exchange values, with increased discomfort as compared with high-flow nasal oxygen. The most significant clinical benefit of helmet NIV over high-flow nasal oxygen was observed in patients exhibiting hypocapnia before treatment start, which may identify the sub-population with the most dysregulated inspiratory effort [ 93 ].…”

Section: Discussionmentioning

confidence: 99%

Helmet noninvasive support for acute hypoxemic respiratory failure: rationale, mechanism of action and bedside application

Cesarano

Grieco

Michi

et al. 2022

Ann. Intensive Care

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Introduction Helmet noninvasive support may provide advantages over other noninvasive oxygenation strategies in the management of acute hypoxemic respiratory failure. In this narrative review based on a systematic search of the literature, we summarize the rationale, mechanism of action and technicalities for helmet support in hypoxemic patients. Main results In hypoxemic patients, helmet can facilitate noninvasive application of continuous positive-airway pressure or pressure-support ventilation via a hood interface that seals at the neck and is secured by straps under the arms. Helmet use requires specific settings. Continuous positive-airway pressure is delivered through a high-flow generator or a Venturi system connected to the inspiratory port of the interface, and a positive end-expiratory pressure valve place at the expiratory port of the helmet; alternatively, pressure-support ventilation is delivered by connecting the helmet to a mechanical ventilator through a bi-tube circuit. The helmet interface allows continuous treatments with high positive end-expiratory pressure with good patient comfort. Preliminary data suggest that helmet noninvasive ventilation (NIV) may provide physiological benefits compared to other noninvasive oxygenation strategies (conventional oxygen, facemask NIV, high-flow nasal oxygen) in non-hypercapnic patients with moderate-to-severe hypoxemia (PaO2/FiO2 ≤ 200 mmHg), possibly because higher positive end-expiratory pressure (10–15 cmH2O) can be applied for prolonged periods with good tolerability. This improves oxygenation, limits ventilator inhomogeneities, and may attenuate the potential harm of lung and diaphragm injury caused by vigorous inspiratory effort. The potential superiority of helmet support for reducing the risk of intubation has been hypothesized in small, pilot randomized trials and in a network metanalysis. Conclusions Helmet noninvasive support represents a promising tool for the initial management of patients with severe hypoxemic respiratory failure. Currently, the lack of confidence with this and technique and the absence of conclusive data regarding its efficacy render helmet use limited to specific settings, with expert and trained personnel. As per other noninvasive oxygenation strategies, careful clinical and physiological monitoring during the treatment is essential to early identify treatment failure and avoid delays in intubation.

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“…If we make a correct comparison of the NIV success rate between the COVID-NIV study and the study by Coppadoro et al [ 29 ] (during the helmet phase of the study, where FiO 2 measurements were taken at the helmet inlet), we would see similar results in the moderate-to-severe COVID-19-ARDS category (28.7 vs 22.0%, respectively). Post hoc analysis of the HENIVOT study showed, that more profound stratification of patients using not only PaO 2 /FiO 2 , but in combination with dyspnoea score, and PaCO 2 could predict the efficacy of NIV and HFNO [ 30 ]. The ROX index in our study showed a similar cut-off value for NIV failure as it was in the original study by Roca (< 4.88) [ 18 ] and COVID-19 studies using NIV [ 6 ].…”

Section: Discussionmentioning

confidence: 99%

Breathing pattern, accessory respiratory muscles work, and gas exchange evaluation for prediction of NIV failure in moderate-to-severe COVID-19-associated ARDS after deterioration of respiratory failure outside ICU: the COVID-NIV observational study

et al. 2022

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Background Data on the efficacy of non-invasive ventilation (NIV) after progression of respiratory failure in patients who have already received oxygen therapy, or CPAP outside ICU is limited. The study aimed to find predictors of NIV failure based on breathing pattern, gas exchange, and accessory respiratory muscles evaluation in patients who progressed to moderate-to-severe COVID-19 ARDS. Methods This was a prospective observational study in patients with moderate-to-severe COVID-19-ARDS on NIV (n = 80) admitted to COVID-ICU of Sechenov University. The combined success rate for conventional oxygen and CPAP outside ICU was 78.6% (440 of 560 patients). The primary endpoints were intubation rate and mortality. We measured respiratory rate, exhaled tidal volume (Vte), mean peak inspiratory flow (PIF), inspiratory time (Ti), PaO2, SpO2, end-tidal carbon dioxide (PETCO2), and Patrick score, and calculated ROX index, PaO2/FiO2, ventilatory ratio, and alveolar dead space (Vdalv/Vt) on Days 1, 3, 5, 7, 10, and 14. For all significant differences between NIV success and failure groups in measured data, we performed ROC analysis. Results NIV failure rate in ICU after deterioration of respiratory failure outside ICU was 71.3% (n = 57). Patients with the subsequent NIV failure were older at inclusion, more frail, had longer duration of disease before ICU admission, and higher rate of CPAP use outside ICU. ROC-analysis revealed that the following respiratory parameters after 48 h of NIV can serve as a predictors for NIV failure in moderate-to-severe COVID-19-associated ARDS: PaO2/FiO2 < 112 mmHg (AUROC 0.90 (0.93–0.97), p < 0.0001); PETCO2 < 19.5 mmHg (AUROC 0.84 (0.73–0.94), p < 0.0001); VDalv/VT > 0.43 (AUROC 0.78 (0.68–0.90), p < 0.0001); ROX-index < 5.02 (AUROC 0.89 (0.81–0.97), p < 0.0001); Patrick score > 2 points (AUROC 0.87 (0.78–0.96), p = 0.006). Conclusion In patients who progressed to moderate-to-severe COVID-19-ARDS probability of NIV success rate was about 1/3. Prediction of the NIV failure can be made after 48 h based on ROX index < 5.02, PaO2/FiO2 < 112 mmHg, PETCO2 < 19.5 mmHg, and Patrick score > = 2. Trial registration ClinicalTrials.gov identifier: NCT04667923, registered on 16/12/2020.

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Phenotypes of Patients with COVID-19 Who Have a Positive Clinical Response to Helmet Noninvasive Ventilation

Cited by 27 publications

References 10 publications

High-flow nasal oxygen in acute hypoxemic respiratory failure: A narrative review of the evidence before and after the COVID-19 pandemic

High-flow nasal oxygen in acute hypoxemic respiratory failure: A narrative review of the evidence before and after the COVID-19 pandemic

Helmet noninvasive support for acute hypoxemic respiratory failure: rationale, mechanism of action and bedside application

Breathing pattern, accessory respiratory muscles work, and gas exchange evaluation for prediction of NIV failure in moderate-to-severe COVID-19-associated ARDS after deterioration of respiratory failure outside ICU: the COVID-NIV observational study

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