Physiological Comparison of High-Flow Nasal Cannula and Helmet Noninvasive Ventilation in Acute Hypoxemic Respiratory Failure

Domenico Luca Grieco, Luca S Menga, Valeria Raggi, Filippo Bongiovanni, Gian Marco Anzellotti, Eloisa S Tanzarella, Maria Grazia Bocci, Giovanna Mercurio, Antonio M Dell'Anna, Davide Eleuteri, Giuseppe Bello, Riccardo Maviglia, Giorgio Conti, Salvatore Maurizio Maggiore, Massimo Antonelli
American Journal of Respiratory and Critical Care Medicine 2020 February 1, 201 (3): 303-312
Rationale: High-flow nasal cannula (HFNC) and helmet noninvasive ventilation (NIV) are used for the management of acute hypoxemic respiratory failure. Objectives: Physiological comparison of HFNC and helmet NIV in patients with hypoxemia. Methods: Fifteen patients with hypoxemia with PaO2 /FiO2  < 200 mm Hg received helmet NIV (positive end-expiratory pressure ≥ 10 cm H2 O, pressure support = 10-15 cm H2 O) and HFNC (50 L/min) in randomized crossover order. Arterial blood gases, dyspnea, and comfort were recorded. Inspiratory effort was estimated by esophageal pressure (Pes) swings. Pes-simplified pressure-time product and transpulmonary pressure swings were measured. Measurements and Main Results: As compared with HFNC, helmet NIV increased PaO2 /FiO2 (median [interquartile range]: 255 mm Hg [140-299] vs. 138 [101-172]; P  = 0.001) and lowered inspiratory effort (7 cm H2 O [4-11] vs. 15 [8-19]; P  = 0.001) in all patients. Inspiratory effort reduction by NIV was linearly related to inspiratory effort during HFNC ( r  = 0.84; P  < 0.001). Helmet NIV reduced respiratory rate (24 breaths/min [23-31] vs. 29 [26-32]; P  = 0.027), Pes-simplified pressure-time product (93 cm H2 O ⋅ s ⋅ min-1 [43-138] vs. 200 [168-335]; P  = 0.001), and dyspnea (visual analog scale 3 [2-5] vs. 8 [6-9]; P  = 0.002), without affecting PaCO2 ( P  = 0.80) and comfort ( P  = 0.50). In the overall cohort, transpulmonary pressure swings were not different between treatments (NIV = 18 cm H2 O [14-21] vs. HFNC = 15 [8-19]; P  = 0.11), but patients exhibiting lower inspiratory effort on HFNC experienced increases in transpulmonary pressure swings with helmet NIV. Higher transpulmonary pressure swings during NIV were associated with subsequent need for intubation. Conclusions: As compared with HFNC in hypoxemic respiratory failure, helmet NIV improves oxygenation, reduces dyspnea, inspiratory effort, and simplified pressure-time product, with similar transpulmonary pressure swings, PaCO2 , and comfort.

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