The FLARE Four
- The role of noninvasive positive pressure ventilation (NIPPV) in the treatment of acute respiratory distress syndrome (ARDS) has yet to be substantiated in large randomized, controlled trials
- It's unclear whether helmet ventilation provides substantial benefit over other NIPPV methods in ARDS
- In the Surviving Sepsis Campaign guidelines for treatment of critically ill COVID-19 patients, a trial of NIPPV is weakly recommended for those without an urgent need for intubation
- Major concerns remain about masking worsening ARDS or providing suboptimal ventilation with NIPPV
- Studies of face mask and helmet NIPPV indicate the risk of aerosolization of SARS-CoV-2 cannot be dismissed
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In light of feared ventilator shortages, or to provide care aligned with a patient's goals and preferences, some clinicians have advocated the use of helmet ventilation in COVID-19. Camille Petri, MD, a fellow in Pulmonary and Critical Care Medicine at Massachusetts General Hospital, discussed this strategy in a fast literature update posted on May 7, 2020.
As an alternative to noninvasive positive pressure ventilation (NIPPV) with a face mask, helmet ventilation might mitigate issues such as poor seal and eye irritation, allowing longer continuous use. Expertise in helmet ventilation is limited, and no helmets are approved in the U.S.
Some considerations about helmet ventilation:
- Need for high flow rate
- Slower changes in inspiratory flow or tidal volume, which can lead to patient–ventilator dyssynchrony
- Heightened concern for rebreathing of CO2
- Noise exposure and pressure on the tympanic membranes
Helmet Ventilation and ARDS
NIPPV has been used in acute respiratory distress syndrome (ARDS) for decades, showing benefits for some specific, limited patient populations. No large randomized, controlled trial has demonstrated noninferiority or improved outcomes with NIPPV in ARDS.
Helmet ventilation has not been studied in a large, multicenter trial for patients with ARDS or compared with invasive mechanical ventilation. It's unclear whether helmet ventilation provides substantial benefit over other NIPPV methods in ARDS.
Helmet Ventilation and COVID-19
In the Surviving Sepsis Campaign guidelines for the treatment of critically ill COVID-19 patients, a trial of NIPPV with close monitoring and frequent reassessment is weakly recommended for those without an urgent need for intubation. There is no recommendation for or against helmet NIPPV.
Studies of face mask and helmet NIPPV suggest a trial of NIPPV may be reasonable in selected patients with mild ARDS, though this has not yet been studied in COVID-19. If NIPPV is used, close monitoring is advised as major concerns remain about masking worsening ARDS or providing suboptimal ventilation support.
One rationale for helmet ventilation is the perception that it's associated with a lower risk of aerosolization of SARS-CoV-2. However, studies of face mask and helmet ventilation indicate the risk can't be dismissed. The availability of personal protective equipment should be considered before using NIPPV.
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