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- W2059698506 abstract "Invasive mechanical ventilation, although highly effective in improving gas exchange and reducing the work of breathing, may not only increase the risk of nosocomial infections but can also cause discomfort for the patient and barotrauma.1Mehta S Hill N Noninvasive ventilation.Am J Respir Crit Care Med. 2001; 163: 540-577Crossref PubMed Scopus (897) Google Scholar Most of these complications are related to the endotracheal tube. Conversely, noninvasive positive pressure ventilation (NPPV), defined as any form of ventilatory support applied without the use of an endotracheal tube, offers the potential advantage, in selected patients, of avoiding these drawbacks.NPPV was first applied in the 1930s when Barach and colleagues2Barach AL Martin J Eckman M Positive pressure respiration and its application to the treatment of acute pulmonary edema.Ann Intern Med. 1938; 12: 754-795Crossref Google Scholar showed that continuous positive airway pressure could be useful in the treatment of acute pulmonary edema. Subsequently, NPPV gained popularity as first-line ventilatory treatment of respiratory failure. Two prospective epidemiologic surveys3Esteban A Anzueto A Frutos F et al.Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study.JAMA. 2002; 287: 345-355Crossref PubMed Scopus (1256) Google Scholar, 4Carlucci A Richard JC Wysocki M et al.Noninvasive versus conventional mechanical ventilation. An epidemiologic survey.Am J Respir Crit Care Med. 2001; 163: 874-880Crossref PubMed Scopus (410) Google Scholar found that NPPV was used in 5 to 15% of patients with respiratory failure; however, the percentage of patients treated with NPPV significantly differed between centers, ranging from none in eight ICUs to 67% in one ICU.4Carlucci A Richard JC Wysocki M et al.Noninvasive versus conventional mechanical ventilation. An epidemiologic survey.Am J Respir Crit Care Med. 2001; 163: 874-880Crossref PubMed Scopus (410) Google ScholarNPPV reduced the need for intubation and mortality in patients with acute cardiogenic pulmonary edema,5Masip J Roque M Sanchez B et al.Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and meta-analysis.JAMA. 2005; 294: 3124-3130Crossref PubMed Scopus (458) Google Scholar acute exacerbation of COPD,6Lightowler JV Wedzicha JA Elliott MW et al.Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis.BMJ. 2003; 326: 185-189Crossref PubMed Google Scholar and hypoxemic acute respiratory failure.7Antonelli M Conti G Rocco M et al.A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patient with acute respiratory failure.N Engl J Med. 1998; 339: 429-435Crossref PubMed Scopus (837) Google Scholar However, during NPPV up to 40% of patients may require endotracheal intubation and invasive mechanical ventilation, primarily because of poor patient tolerance and the severity of underlying disease.4Carlucci A Richard JC Wysocki M et al.Noninvasive versus conventional mechanical ventilation. An epidemiologic survey.Am J Respir Crit Care Med. 2001; 163: 874-880Crossref PubMed Scopus (410) Google Scholar Although the face mask is the most common interface used to deliver NPPV, it may be responsible for a certain proportion of NPPV failures. One way of reducing the need for premature termination of NPPV could be to use a different interface to limit the pressure necrosis of the skin, air leaks, and discomfort. A plastic “helmet” that covers the patient’s whole head, originally used to deliver an air mixture during hyperbaric oxygen therapy, has now been developed for NPPV. The helmet makes no contact with the head, so it should be more comfortable than the face mask. In patients with acute hypoxemic respiratory failure and cardiogenic pulmonary edema, the helmet improved gas exchange similarly to the face mask but was more comfortable and permitted longer continuous application.8Antonelli M Conti G Pelosi P et al.New treatment of acute hypoxemic respiratory failure: noninvasive pressure support ventilation delivered by helmet: a pilot controlled trial.Crit Care Med. 2002; 30: 602-608Crossref PubMed Scopus (235) Google Scholar, 9Tonnelier JM Gwenaël P Nowak E et al.Noninvasive continuous positive airway pressure ventilation using a new helmet interface: a case-control prospective pilot study.Intensive Care Med. 2003; 29: 2077-2080Crossref PubMed Scopus (70) Google ScholarOne of the most important drawbacks of the helmet, due to its larger inner volume compared to the face mask (ie, a dead space volume of 8 to 12 L), is carbon dioxide rebreathing, which could limit the efficacy of NPPV.10Taccone P Hess D Bigatello LM et al.Continuous positive airway pressure delivered with a “helmet”: effects on carbon dioxide rebreathing.Crit Care Med. 2004; 32: 2090-2096Crossref PubMed Scopus (140) Google Scholar Antonelli and colleagues,11Antonelli M Pennisi MA Pelosi P et al.Noninvasive positive pressure ventilation using a helmet in patients with acute exacerbation of chronic obstructive pulmonary disease.Anesthesiology. 2004; 100: 16-24Crossref PubMed Scopus (156) Google Scholar comparing NPPV using the helmet and face mask in patients with acute exacerbation of COPD, found that after 1 h of NPPV both groups had a significant reduction in arterial carbon dioxide levels. However, the decrease in arterial carbon dioxide was smaller in the helmet group, and this difference was greater in the subgroups of patients who failed NPPV.11Antonelli M Pennisi MA Pelosi P et al.Noninvasive positive pressure ventilation using a helmet in patients with acute exacerbation of chronic obstructive pulmonary disease.Anesthesiology. 2004; 100: 16-24Crossref PubMed Scopus (156) Google ScholarThe helmet comprises a plastic hood with a soft collar, making for better comfort than the face mask, although it may dissipate the inspiratory pressure delivered by the ventilator. Two studies12Chiumello D Pelosi P Gattinoni L et al.Noninvasive positive pressure ventilation delivered by helmet vs.standard face mask. Intensive Care Med. 2003; 29: 1671-1679Crossref PubMed Scopus (102) Google Scholar, 13Rocca F Appendini L Ranieri M et al.Effectiveness of mask and helmet interfaces to deliver non-invasive ventilation in a human model of resistive breathing.J Appl Physiol. 2005; 99: 1262-1271Crossref Scopus (86) Google Scholar in humans that evaluated the helmet and face mask in healthy subjects during pressure support ventilation found a similar breathing pattern, but the helmet required greater inspiratory muscle effort and took a longer time to reach the selected level of airway pressure.In this issue of CHEST (see page 1424), Dr. Moerer and colleagues14Moerer O Fisher S Quintel M et al.Influence of two interfaces for noninvasive ventilation compared to invasive ventilation on the mechanical properties and performance of a respiratory system: a lung model study.Chest. 2006; 129: 1424-1431Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar report a bench study of ventilatory performance by simulating spontaneous breathing at the beginning of an inspiratory effort, and compared a helmet and face mask during NPPV at different levels of pressure support ventilation and positive end-expiratory pressure (PEEP). They measured the time delay to activate the ventilatory trigger, the time between the initiation of an inspiratory effort until the preset PEEP level is reached, and the inspiratory pressure time product (ie, the muscle inspiratory effort) during these two periods. The helmet, although presenting a significantly longer time delay, caused a lower pressure time product compared to the face mask. In addition, by increasing the level of pressure support or PEEP, the helmet furthermore significantly reduced the delay times and pressure time product.During NPPV, the ventilator must first pressurize the interface (face mask or helmet) and then the respiratory system.12Chiumello D Pelosi P Gattinoni L et al.Noninvasive positive pressure ventilation delivered by helmet vs.standard face mask. Intensive Care Med. 2003; 29: 1671-1679Crossref PubMed Scopus (102) Google Scholar The actual design of the helmet (high compliance) means that it needs higher inspiratory volumes than the face mask to reach the same airway pressure, causing a longer delay times. However, the patient can use the higher gas volume inside the helmet at the beginning of an inspiration, thus reducing the initial inspiratory muscle effort.A practical clinical message from the current14Moerer O Fisher S Quintel M et al.Influence of two interfaces for noninvasive ventilation compared to invasive ventilation on the mechanical properties and performance of a respiratory system: a lung model study.Chest. 2006; 129: 1424-1431Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar and previous studies12Chiumello D Pelosi P Gattinoni L et al.Noninvasive positive pressure ventilation delivered by helmet vs.standard face mask. Intensive Care Med. 2003; 29: 1671-1679Crossref PubMed Scopus (102) Google Scholar, 13Rocca F Appendini L Ranieri M et al.Effectiveness of mask and helmet interfaces to deliver non-invasive ventilation in a human model of resistive breathing.J Appl Physiol. 2005; 99: 1262-1271Crossref Scopus (86) Google Scholar is that the physician should set higher levels of PEEP and pressure support to reduce inspiratory muscle effort closer to that with the face mask. Although the patient tolerates the helmet better, it needs careful clinical monitoring and setting. Invasive mechanical ventilation, although highly effective in improving gas exchange and reducing the work of breathing, may not only increase the risk of nosocomial infections but can also cause discomfort for the patient and barotrauma.1Mehta S Hill N Noninvasive ventilation.Am J Respir Crit Care Med. 2001; 163: 540-577Crossref PubMed Scopus (897) Google Scholar Most of these complications are related to the endotracheal tube. Conversely, noninvasive positive pressure ventilation (NPPV), defined as any form of ventilatory support applied without the use of an endotracheal tube, offers the potential advantage, in selected patients, of avoiding these drawbacks. NPPV was first applied in the 1930s when Barach and colleagues2Barach AL Martin J Eckman M Positive pressure respiration and its application to the treatment of acute pulmonary edema.Ann Intern Med. 1938; 12: 754-795Crossref Google Scholar showed that continuous positive airway pressure could be useful in the treatment of acute pulmonary edema. Subsequently, NPPV gained popularity as first-line ventilatory treatment of respiratory failure. Two prospective epidemiologic surveys3Esteban A Anzueto A Frutos F et al.Characteristics and outcomes in adult patients receiving mechanical ventilation: a 28-day international study.JAMA. 2002; 287: 345-355Crossref PubMed Scopus (1256) Google Scholar, 4Carlucci A Richard JC Wysocki M et al.Noninvasive versus conventional mechanical ventilation. An epidemiologic survey.Am J Respir Crit Care Med. 2001; 163: 874-880Crossref PubMed Scopus (410) Google Scholar found that NPPV was used in 5 to 15% of patients with respiratory failure; however, the percentage of patients treated with NPPV significantly differed between centers, ranging from none in eight ICUs to 67% in one ICU.4Carlucci A Richard JC Wysocki M et al.Noninvasive versus conventional mechanical ventilation. An epidemiologic survey.Am J Respir Crit Care Med. 2001; 163: 874-880Crossref PubMed Scopus (410) Google Scholar NPPV reduced the need for intubation and mortality in patients with acute cardiogenic pulmonary edema,5Masip J Roque M Sanchez B et al.Noninvasive ventilation in acute cardiogenic pulmonary edema: systematic review and meta-analysis.JAMA. 2005; 294: 3124-3130Crossref PubMed Scopus (458) Google Scholar acute exacerbation of COPD,6Lightowler JV Wedzicha JA Elliott MW et al.Non-invasive positive pressure ventilation to treat respiratory failure resulting from exacerbations of chronic obstructive pulmonary disease: Cochrane systematic review and meta-analysis.BMJ. 2003; 326: 185-189Crossref PubMed Google Scholar and hypoxemic acute respiratory failure.7Antonelli M Conti G Rocco M et al.A comparison of noninvasive positive-pressure ventilation and conventional mechanical ventilation in patient with acute respiratory failure.N Engl J Med. 1998; 339: 429-435Crossref PubMed Scopus (837) Google Scholar However, during NPPV up to 40% of patients may require endotracheal intubation and invasive mechanical ventilation, primarily because of poor patient tolerance and the severity of underlying disease.4Carlucci A Richard JC Wysocki M et al.Noninvasive versus conventional mechanical ventilation. An epidemiologic survey.Am J Respir Crit Care Med. 2001; 163: 874-880Crossref PubMed Scopus (410) Google Scholar Although the face mask is the most common interface used to deliver NPPV, it may be responsible for a certain proportion of NPPV failures. One way of reducing the need for premature termination of NPPV could be to use a different interface to limit the pressure necrosis of the skin, air leaks, and discomfort. A plastic “helmet” that covers the patient’s whole head, originally used to deliver an air mixture during hyperbaric oxygen therapy, has now been developed for NPPV. The helmet makes no contact with the head, so it should be more comfortable than the face mask. In patients with acute hypoxemic respiratory failure and cardiogenic pulmonary edema, the helmet improved gas exchange similarly to the face mask but was more comfortable and permitted longer continuous application.8Antonelli M Conti G Pelosi P et al.New treatment of acute hypoxemic respiratory failure: noninvasive pressure support ventilation delivered by helmet: a pilot controlled trial.Crit Care Med. 2002; 30: 602-608Crossref PubMed Scopus (235) Google Scholar, 9Tonnelier JM Gwenaël P Nowak E et al.Noninvasive continuous positive airway pressure ventilation using a new helmet interface: a case-control prospective pilot study.Intensive Care Med. 2003; 29: 2077-2080Crossref PubMed Scopus (70) Google Scholar One of the most important drawbacks of the helmet, due to its larger inner volume compared to the face mask (ie, a dead space volume of 8 to 12 L), is carbon dioxide rebreathing, which could limit the efficacy of NPPV.10Taccone P Hess D Bigatello LM et al.Continuous positive airway pressure delivered with a “helmet”: effects on carbon dioxide rebreathing.Crit Care Med. 2004; 32: 2090-2096Crossref PubMed Scopus (140) Google Scholar Antonelli and colleagues,11Antonelli M Pennisi MA Pelosi P et al.Noninvasive positive pressure ventilation using a helmet in patients with acute exacerbation of chronic obstructive pulmonary disease.Anesthesiology. 2004; 100: 16-24Crossref PubMed Scopus (156) Google Scholar comparing NPPV using the helmet and face mask in patients with acute exacerbation of COPD, found that after 1 h of NPPV both groups had a significant reduction in arterial carbon dioxide levels. However, the decrease in arterial carbon dioxide was smaller in the helmet group, and this difference was greater in the subgroups of patients who failed NPPV.11Antonelli M Pennisi MA Pelosi P et al.Noninvasive positive pressure ventilation using a helmet in patients with acute exacerbation of chronic obstructive pulmonary disease.Anesthesiology. 2004; 100: 16-24Crossref PubMed Scopus (156) Google Scholar The helmet comprises a plastic hood with a soft collar, making for better comfort than the face mask, although it may dissipate the inspiratory pressure delivered by the ventilator. Two studies12Chiumello D Pelosi P Gattinoni L et al.Noninvasive positive pressure ventilation delivered by helmet vs.standard face mask. Intensive Care Med. 2003; 29: 1671-1679Crossref PubMed Scopus (102) Google Scholar, 13Rocca F Appendini L Ranieri M et al.Effectiveness of mask and helmet interfaces to deliver non-invasive ventilation in a human model of resistive breathing.J Appl Physiol. 2005; 99: 1262-1271Crossref Scopus (86) Google Scholar in humans that evaluated the helmet and face mask in healthy subjects during pressure support ventilation found a similar breathing pattern, but the helmet required greater inspiratory muscle effort and took a longer time to reach the selected level of airway pressure. In this issue of CHEST (see page 1424), Dr. Moerer and colleagues14Moerer O Fisher S Quintel M et al.Influence of two interfaces for noninvasive ventilation compared to invasive ventilation on the mechanical properties and performance of a respiratory system: a lung model study.Chest. 2006; 129: 1424-1431Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar report a bench study of ventilatory performance by simulating spontaneous breathing at the beginning of an inspiratory effort, and compared a helmet and face mask during NPPV at different levels of pressure support ventilation and positive end-expiratory pressure (PEEP). They measured the time delay to activate the ventilatory trigger, the time between the initiation of an inspiratory effort until the preset PEEP level is reached, and the inspiratory pressure time product (ie, the muscle inspiratory effort) during these two periods. The helmet, although presenting a significantly longer time delay, caused a lower pressure time product compared to the face mask. In addition, by increasing the level of pressure support or PEEP, the helmet furthermore significantly reduced the delay times and pressure time product. During NPPV, the ventilator must first pressurize the interface (face mask or helmet) and then the respiratory system.12Chiumello D Pelosi P Gattinoni L et al.Noninvasive positive pressure ventilation delivered by helmet vs.standard face mask. Intensive Care Med. 2003; 29: 1671-1679Crossref PubMed Scopus (102) Google Scholar The actual design of the helmet (high compliance) means that it needs higher inspiratory volumes than the face mask to reach the same airway pressure, causing a longer delay times. However, the patient can use the higher gas volume inside the helmet at the beginning of an inspiration, thus reducing the initial inspiratory muscle effort. A practical clinical message from the current14Moerer O Fisher S Quintel M et al.Influence of two interfaces for noninvasive ventilation compared to invasive ventilation on the mechanical properties and performance of a respiratory system: a lung model study.Chest. 2006; 129: 1424-1431Abstract Full Text Full Text PDF PubMed Scopus (46) Google Scholar and previous studies12Chiumello D Pelosi P Gattinoni L et al.Noninvasive positive pressure ventilation delivered by helmet vs.standard face mask. Intensive Care Med. 2003; 29: 1671-1679Crossref PubMed Scopus (102) Google Scholar, 13Rocca F Appendini L Ranieri M et al.Effectiveness of mask and helmet interfaces to deliver non-invasive ventilation in a human model of resistive breathing.J Appl Physiol. 2005; 99: 1262-1271Crossref Scopus (86) Google Scholar is that the physician should set higher levels of PEEP and pressure support to reduce inspiratory muscle effort closer to that with the face mask. 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- W2059698506 title "Is the Helmet Different Than the Face Mask in Delivering Noninvasive Ventilation?" @default.
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