Helmet CPAP linked to less intubation in patients with COVID-19 respiratory failure

Key takeaways:

• Patients with COVID-19 respiratory failure using helmet CPAP vs. facemask CPAP had decreased intubation rates.
• Further, fewer patients using helmet CPAP died in the hospital.

Fewer patients with respiratory failure related to COVID-19 using helmet CPAP experienced intubation compared with facemask CPAP, according to study results published in CHEST.

“The results of the present study suggest that CPAP delivered via the helmet interface, as compared with a facemask, may prevent endotracheal intubation in patients with COVID-19 with moderate to severe respiratory failure,” Nicolás Colaianni-Alfonso, PhD, of the respiratory intermediate care unit at the Hospital General de Agudos Juan A. Fernández, and colleagues wrote.

“Use of high positive end-expiratory pressure (PEEP) for longer-term treatments with good patient comfort is the most relevant advantage of using the helmet interface,” they added.

In a prospective single-center cohort study, Colaianni-Alfonso and colleagues analyzed 112 ICU patients with acute hypoxemic respiratory failure related to COVID-19 from June 2020 to September 2021 to evaluate the difference in endotracheal intubation rates between helmet CPAP and facemask CPAP use.

Researchers additionally looked at how mortality rates and physiological parameters differed based on the method of CPAP delivery.

To be included, patients had to have a failed response to high-flow nasal oxygen that was initially given for 12 hours at 60 L per minute along with fraction of inspired oxygen (FIO₂) to keep oxygen saturation (SpO₂) at 92% to 96%, according to researchers. After the 12 hours, these patients did not have a respiratory rate under 30 breaths per minute or SpO₂ greater than 94% with FIO₂ less than 0.6%, so they were given CPAP.

Of the total cohort, 55 patients (median age, 57 years; 22% women) chose to receive helmet CPAP and 57 patients (median age, 57 years; 35% women) chose facemask CPAP. Regardless of the method of CPAP delivery, every patient first received continuous CPAP for 24 hours at 10 cm H₂O and FIO₂ to keep SpO₂ at 92% to 96%. Following this period, researchers wrote that patients received rotation therapy involving CPAP and high-flow nasal oxygen.

Both sets of patients had similar baseline demographics and levels of clinical severity.

Notably, researchers found that those using helmet option had an extended median length of time on CPAP than those using the facemask option (211 hours vs. 151 hours; P = .009), as well as elevated median PEEP (14 cm H₂O vs. 10 cm H₂O; P < .001) and median SpO₂/FIO₂ after CPAP (251 vs. 187; P = .001).

Additionally, after CPAP, patients who received it through a facemask had a higher median respiratory rate compared with patients who received it through a helmet (25 vs. 22; P = .002).

For the main outcome, researchers observed that less patients using helmet CPAP experienced endotracheal intubation compared with patients using facemask CPAP (29% vs. 49%; P = .029). Following adjustment for Sequential Organ Failure Assessment score (SOFA) and baseline PaO₂/FIO₂, they found a hazard ratio (HR) of 0.47 (95% CI, 0.25-0.87).

Further, more patients receiving facemask CPAP had hypoxemia as their reason for intubation than those receiving helmet CPAP (10 [18%] vs. 3 [5%]; P = .005).

In terms of secondary outcomes, researchers observed fewer deaths of those using helmet CPAP (18% vs. 35%; P = .049) and an adjusted hazard ratio of 0.38 (95% CI, 0.18-0.83; P = .015) after accounting for baseline sex, SOFA score and Acute Physiology and Chronic Health Evaluation II score.

“Despite the nonrandomized design of this investigation and the small sample analyzed, these findings suggest a possible clinical benefit of helmet over facemask CPAP in patients with COVID-19 respiratory failure,” Colaianni-Alfonso and colleagues wrote. “Further randomized studies systematically assessing the clinical effects of helmet CPAP in COVID-19 and in other hypoxemic patients appear warranted to foster its use in other ICUs.”