Respiratory Support During the COVID-19 Pandemic: Is It Time to Consider Using a Helmet? | Critical Care Medicine | JAMA | JAMA Network
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March 25, 2021

Respiratory Support During the COVID-19 Pandemic: Is It Time to Consider Using a Helmet?

Author Affiliations
  • 1Interdepartmental Division of Critical Care Medicine, Sinai Health System/University Health Network, University of Toronto, Toronto, Ontario, Canada
  • 2Pritzker School of Medicine, Section of Pulmonary and Critical Care Medicine, Department of Medicine, University of Chicago, Chicago, Illinois
JAMA. 2021;325(17):1723-1725. doi:10.1001/jama.2021.4975
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Acute hypoxemic respiratory failure (AHRF) is the most common organ failure and cause of admission to the intensive care unit (ICU) among patients with COVID-19. As with all forms of AHRF, ICU management is supportive while treating the underlying cause. Because the traditional respiratory support of invasive ventilation, ie, intubation and coupling of the patient to the mechanical ventilator, carries high morbidity and mortality, less invasive respiratory support methods have been studied for decades. The overwhelming demands on ICU resources seen during waves of the SARS-CoV-2 pandemic have accelerated interest in the applicability of alternative respiratory support.

The most commonly used approaches include high-flow nasal oxygen (HFNO) and noninvasive ventilation (NIV). HFNO administers heated humidified oxygen through large bore nasal cannula, typically between 30 and 60 L/min.1 Following a trial among 310 patients that demonstrated a reduction in 90-day mortality with HFNO compared with other noninvasive oxygen therapies (but not helmet NIV), HFNO has gained traction in many ICUs.2 NIV couples the patient to the ventilator with either a face mask or helmet interface. Approximately 15% of patients with severe AHRF were treated with NIV in recent years, with an increase of up to 30% during the COVID-19 pandemic.3,4 Of concern, there has been a high failure rate with face mask interfaces, leading to the need for intubation and invasive mechanical ventilation (approximately 42%-47% across patients with moderate to severe acute respiratory distress syndrome), and a high mortality when intubation is required (approximately 45%).3 These outcomes may be attributable to injurious high tidal volumes generated with NIV, insufficient alveolar recruitment, or high work of breathing.2,5