Effect of Helmet Noninvasive Ventilation vs High-Flow Nasal Oxygen on Days Free of Respiratory Support in Patients With COVID-19 and Moderate to Severe Hypoxemic Respiratory Failure
Authors: Domenico Luca Grieco, Luca S. Menga, Melania Cesarano, Tommaso Rosà, Savino Spadaro, Maria Maddalena Bitondo, Jonathan Montomoli, Giulia Falò, Tommaso Tonetti, Salvatore L. Cutuli, Gabriele Pintaudi, Eloisa S. Tanzarella, Edoardo Piervincenzi, Filippo Bongiovanni, Antonio M. Dell’Anna, Luca Delle Cese, Cecilia Berardi, Simone Carelli, Maria Grazia Bocci, Luca Montini, Giuseppe Bello, Daniele Natalini, Gennaro De Pascale, Matteo Velardo, Carlo Alberto Volta, V. Marco Ranieri, Giorgio Conti, Salvatore Maurizio Maggiore, Massimo Antonelli, Gian Marco Anzellotti, Laura Cascarano, Francesca Ceccaroni, Paolo De Santis, Mariangela Di Muro, Miriana Durante, Nicoletta Filetici, Veronica Gennenzi, Antonio Gullì, Gianmarco Lombardi, Alessio Maccaglia, Riccardo Maviglia, Alessandro Mele, Giovanna Mercurio, Teresa Michi, Tony C. Morena, Martina Murdolo, Mariano Alberto Pennisi, Stefania Postorino, Antonella Potalivo, Francesca Pozzana, Carlotta Rubino, Martina Savino, Roberta Scarascia, Angela Scavone, Donatella Settanni, Serena Silva, Flavia Torrini, Joel Vargas, Carmelina Zaccone
Journal: JAMA (2021)

<h3>Importance</h3> High-flow nasal oxygen is recommended as initial treatment for acute hypoxemic respiratory failure and is widely applied in patients with COVID-19. <h3>Objective</h3> To assess whether helmet noninvasive ventilation can increase the days free of respiratory support in patients with COVID-19 compared with high-flow nasal oxygen alone. <h3>Design, Setting, and Participants</h3> Multicenter randomized clinical trial in 4 intensive care units (ICUs) in Italy between October and December 2020, end of follow-up February 11, 2021, including 109 patients with COVID-19 and moderate to severe hypoxemic respiratory failure (ratio of partial pressure of arterial oxygen to fraction of inspired oxygen ≤200). <h3>Interventions</h3> Participants were randomly assigned to receive continuous treatment with helmet noninvasive ventilation (positive end-expiratory pressure, 10-12 cm H<sub>2</sub>O; pressure support, 10-12 cm H<sub>2</sub>O) for at least 48 hours eventually followed by high-flow nasal oxygen (n = 54) or high-flow oxygen alone (60 L/min) (n = 55). <h3>Main Outcomes and Measures</h3> The primary outcome was the number of days free of respiratory support within 28 days after enrollment. Secondary outcomes included the proportion of patients who required endotracheal intubation within 28 days from study enrollment, the number of days free of invasive mechanical ventilation at day 28, the number of days free of invasive mechanical ventilation at day 60, in-ICU mortality, in-hospital mortality, 28-day mortality, 60-day mortality, ICU length of stay, and hospital length of stay. <h3>Results</h3> Among 110 patients who were randomized, 109 (99%) completed the trial (median age, 65 years [interquartile range {IQR}, 55-70]; 21 women [19%]). The median days free of respiratory support within 28 days after randomization were 20 (IQR, 0-25) in the helmet group and 18 (IQR, 0-22) in the high-flow nasal oxygen group, a difference that was not statistically significant (mean difference, 2 days [95% CI, −2 to 6];<i>P</i> = .26). Of 9 prespecified secondary outcomes reported, 7 showed no significant difference. The rate of endotracheal intubation was significantly lower in the helmet group than in the high-flow nasal oxygen group (30% vs 51%; difference, −21% [95% CI, −38% to −3%];<i>P</i> = .03). The median number of days free of invasive mechanical ventilation within 28 days was significantly higher in the helmet group than in the high-flow nasal oxygen group (28 [IQR, 13-28] vs 25 [IQR 4-28]; mean difference, 3 days [95% CI, 0-7];<i>P</i> = .04). The rate of in-hospital mortality was 24% in the helmet group and 25% in the high-flow nasal oxygen group (absolute difference, −1% [95% CI, −17% to 15%];<i>P</i> &gt; .99). <h3>Conclusions and Relevance</h3> Among patients with COVID-19 and moderate to severe hypoxemia, treatment with helmet noninvasive ventilation, compared with high-flow nasal oxygen, resulted in no significant difference in the number of days free of respiratory support within 28 days. Further research is warranted to determine effects on other outcomes, including the need for endotracheal intubation. <h3>Trial Registration</h3> ClinicalTrials.gov Identifier:NCT04502576