Skip to main content

Helmet CPAP vs. oxygen therapy in severe hypoxemic respiratory failure due to pneumonia

Intensive Care Medicine volume 40, pages 942–949 (2014)Cite this article

An Erratum to this article was published on 27 May 2014

Abstract

Purpose

The efficacy of noninvasive continuous positive airway pressure (CPAP) to improve outcomes in severe hypoxemic acute respiratory failure (hARF) due to pneumonia has not been clearly established. The aim of this study was to compare CPAP vs. oxygen therapy to reduce the risk of meeting criteria for endotracheal intubation (ETI).

Methods

In a multicenter randomized controlled trial conducted in four Italian centers patients with severe hARF due to pneumonia were randomized to receive helmet CPAP (CPAP group) or oxygen delivered with a Venturi mask (control group). The primary endpoint was the percentage of patients meeting criteria for ETI, including either one or more major criteria (respiratory arrest, respiratory pauses with unconsciousness, severe hemodynamic instability, intolerance) or at least two minor criteria (reduction of at least 30 % of basal PaO2/FiO2 ratio, increase of 20 % of PaCO2, worsening of alertness, respiratory distress, SpO2 less than 90 %, exhaustion).

Results

Between February 2010 and 2013, 40 patients were randomized to CPAP and 41 to Venturi mask. The proportion of patients meeting ETI criteria in the CPAP group was significantly lower compared to those in the control group (6/40 = 15 % vs. 26/41 = 63 %, respectively, p < 0.001; relative risk 0.24, 95 % CI 0.11–0.51; number needed to treat, 2) two patients were intubated in the CPAP group and one in the control group. The CPAP group showed a faster and greater improvement in oxygenation in comparison to controls (p < 0.001). In either study group, no relevant adverse events were detected.

Conclusions

Helmet CPAP reduces the risk of meeting ETI criteria compared to oxygen therapy in patients with severe hARF due to pneumonia.

This is a preview of subscription content, access via your institution.

Access options

Buy single article

Instant access to the full article PDF.

USD 39.95

Price includes VAT (USA)
Tax calculation will be finalised during checkout.

Fig. 1
Fig. 2
Fig. 3

References

  1. Sanz F, Restrepo MI, Fernández E et al (2011) Hypoxemia adds to the CURB-65 pneumonia severity score in hospitalized patients with mild pneumonia. Respir Care 56:612–618

    PubMed  Article  Google Scholar 

  2. Mandell LA, Wunderink RG, Anzueto A (2007) Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis 44(Suppl 2):S27–S72

    CAS  PubMed  Article  Google Scholar 

  3. Woodhead M, Blasi F, Ewig S et al (2011) Guidelines for the management of adult lower respiratory tract infections–full version. Clin Microbiol Infect 17(Suppl 6):E1–E59

    PubMed  Article  Google Scholar 

  4. Keenan SP, Sinuff T, Burns KE et al (2011) Clinical practice guidelines for the use of noninvasive positive-pressure ventilation and noninvasive continuous positive airway pressure in the acute care setting. CMAJ 183:E195–E214

    PubMed Central  PubMed  Article  Google Scholar 

  5. Cosentini R, Brambilla AM, Aliberti S et al (2010) Helmet continuous positive air way pressure vs oxygen therapy to improve oxygenation in community-acquired pneumonia: a randomized, controlled trial. Chest 138:114–120

    PubMed  Article  Google Scholar 

  6. Squadrone V, Coha M, Cerutti E et al (2005) Continuous positive airway pressure for treatment of postoperative hypoxemia: a randomized controlled trial. JAMA 293:589–595

    CAS  PubMed  Article  Google Scholar 

  7. Squadrone V, Massaia M, Bruno B (2010) Early CPAP prevents evolution of acute lung injury in patients with hematologic malignancy. Intensive Care Med 36:1666–1674

    PubMed  Article  Google Scholar 

  8. Delclaux C, L’Her E, Alberti C (2000) Treatment of acute hypoxemic nonhypercapnic respiratory insufficiency with continuous positive airway pressure delivered by a face mask: a randomized controlled trial. JAMA 284:2352–2360

    CAS  PubMed  Article  Google Scholar 

  9. Fine MJ, Auble TE, Yealy DM et al (1997) A prediction rule to identify low-risk patients with community-acquired pneumonia. N Engl J Med 336:243–250

    CAS  PubMed  Article  Google Scholar 

  10. Lim WS, Baudouin SV, George RC et al (2009) Pneumonia Guidelines Committee of the BTS standards of care committee. BTS guidelines for the management of community acquired pneumonia in adults: ed 2009. Thorax 64(Suppl 3):iii1–iii55

  11. Le Gall JR, Lemeshow S, Saulnier F (1993) A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. JAMA 270:2957–2963 (Erratum in JAMA 271:1321, 1994)

    CAS  PubMed  Article  Google Scholar 

  12. Jaber S, Michelet P, Chanques G (2010) Role of non-invasive ventilation (NIV) in the perioperative period. Best Pract Res Clin Anaesthesiol 24:253–265

    PubMed  Article  Google Scholar 

  13. American Thoracic Society; Infectious Diseases Society of America (2005) Guidelines for the management of adults with hospital-acquired, ventilator-associated, and healthcare-associated pneumonia. Am J Respir Crit Care Med 171:388–416

    Article  Google Scholar 

  14. Ramirez JA, Srinath L, Ahkee S, Huang A, Raff MJ (1995) Early switch from intravenous to oral cephalosporins in the treatment of hospitalized patients with community-acquired pneumonia. Arch Intern Med 155:1273–1276

    CAS  PubMed  Article  Google Scholar 

  15. Ferrer M, Esquinas A, Leon M et al (2003) Noninvasive ventilation in severe hypoxemic respiratory failure: a randomized clinical trial. Am J Respir Crit Care Med 168:1438–1444

    PubMed  Article  Google Scholar 

  16. Navalesi P, Fanfulla F, Frigerio P et al (2000) Physiologic evaluation of noninvasive mechanical ventilation delivered with three types of mask in patients with chronic hypercapnic respiratory failure. Crit Care Med 28:1785–1790

    CAS  PubMed  Article  Google Scholar 

  17. Prinianakis G, Delmastro M, Carlucci A et al (2004) Effect of varying the pressurisation rate during noninvasive pressure support ventilation. Eur Respir J 23:314–320

    CAS  PubMed  Article  Google Scholar 

  18. Plant PK, Owen JL, Elliott MW (2000) Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial. Lancet 355:1931–1935

    CAS  PubMed  Article  Google Scholar 

  19. Kelly BJ, Matthay MA (1993) Prevalence and severity of neurologic dysfunction in critically ill patients. Influence on need for continued mechanical ventilation. Chest 104:1818–1824

    CAS  PubMed  Article  Google Scholar 

  20. Confalonieri M, Potena A, Carbone G et al (1999) Acute respiratory failure in patients with severe community-acquired pneumonia. A prospective randomized evaluation of noninvasive ventilation. Am J Respir Crit Care Med 160:1585–1591

    CAS  PubMed  Article  Google Scholar 

  21. L’Her E, Deye N, Lellouche F et al (2005) Physiologic effects of noninvasive ventilation during acute lung injury. Am J Respir Crit Care Med 172:1112–1118

    PubMed  Article  Google Scholar 

  22. Mariani J, Macchia A, Belziti C et al (2011) Noninvasive ventilation in acute cardiogenic pulmonary edema: a meta-analysis of randomized controlled trials. J Card Fail 17:850–859

    PubMed  Article  Google Scholar 

  23. Principi T, Pantanetti S, Catani F et al (2004) Noninvasive continuous positive airway pressure delivered by helmet in hematological malignancy patients with hypoxemic acute respiratory failure. Intensive Care Med 30:147–150

    PubMed  Article  Google Scholar 

  24. Corrado A, Roussos C, Ambrosino N et al (2002) European Respiratory Society Task Force on epidemiology of respiratory intermediate care in Europe. Respiratory intermediate care units: a European survey. Eur Respir J 20(5):1343–1350

    CAS  PubMed  Article  Google Scholar 

  25. Dellinger RP, Levy MM, Rhodes A et al (2012) Surviving Sepsis Campaign Guidelines Committee including The Pediatric Subgroup. Surviving Sepsis Campaign: international guidelines for management of severe sepsis and septic shock, 2012. Intensive Care Med 39:165–228

    Article  Google Scholar 

Download references

Acknowledgments

The authors acknowledge the assistance of Tommaso Maraffi, MD (Emergency Medicine Department, IRCCS Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy). RC takes responsibility for the content of the manuscript, including the data and analysis. Conception and design: RC, AMB, SA, AB, PP; analysis and interpretation: RC, AMB, SA, AB, EP, SN, GF, PP, PT; drafting the manuscript for important intellectual content: RC, AMB, SA, AB, EP, SN, GF, PP, FN, MDF, FC, PT. Funding: Research grant from the IRCCS Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy.

Conflicts of interest

On behalf of all authors, the corresponding author states that there is no conflict of interest.

Author information

Authors and Affiliations

  1. Emergency Medicine Department, IRCCS Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy

    Anna Maria Brambilla, Elena Prina, Francesco Nicoli & Roberto Cosentini

  2. Department of Health Science, University of Milan Bicocca, Clinica Pneumologica, AO San Gerardo, Monza, Italy

    Stefano Aliberti

  3. Department of Specialistic, Diagnostic and Experimental Medicine, Respiratory and Critical Care Unit, Alma Mater Studiorum, University of Bologna, Sant’Orsola Malpighi Hospital, Bologna, Italy

    Manuela Del Forno & Stefano Nava

  4. High Dependency Unit, San Giovanni Bosco Hospital, Piazza Donatore del Sangue 3, 10154, Turin, Italy

    Giovanni Ferrari

  5. IRCCS AOU San Martino IST, Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genova, Italy

    Francesco Corradi & Paolo Pelosi

  6. School of Specialization in Hospital Pharmacy, University of Milan, Via Colombo, 71, Milan, Italy

    Angelo Bignamini

  7. Department of Pathophysiology and Transplantation, University of Milan IRCCS Fondazione Ca’ Granda, Ospedale Maggiore Policlinico, Milan, Italy

    Paolo Tarsia

Authors
  1. Anna Maria Brambilla
    View author publications

    You can also search for this author in PubMed Google Scholar

  2. Stefano Aliberti
    View author publications

    You can also search for this author in PubMed Google Scholar

  3. Elena Prina
    View author publications

    You can also search for this author in PubMed Google Scholar

  4. Francesco Nicoli
    View author publications

    You can also search for this author in PubMed Google Scholar

  5. Manuela Del Forno
    View author publications

    You can also search for this author in PubMed Google Scholar

  6. Stefano Nava
    View author publications

    You can also search for this author in PubMed Google Scholar

  7. Giovanni Ferrari
    View author publications

    You can also search for this author in PubMed Google Scholar

  8. Francesco Corradi
    View author publications

    You can also search for this author in PubMed Google Scholar

  9. Paolo Pelosi
    View author publications

    You can also search for this author in PubMed Google Scholar

  10. Angelo Bignamini
    View author publications

    You can also search for this author in PubMed Google Scholar

  11. Paolo Tarsia
    View author publications

    You can also search for this author in PubMed Google Scholar

  12. Roberto Cosentini
    View author publications

    You can also search for this author in PubMed Google Scholar

Corresponding author

Correspondence to Roberto Cosentini.

Additional information

Take-home message: Our results show a reduction of the risk of meeting criteria for intubation with helmet CPAP in comparison to oxygen therapy in severe hARF due to pneumonia. Helmet CPAP also promotes a faster and greater improvement in oxygenation, with no relevant adverse events during treatment.

Electronic supplementary material

Below is the link to the electronic supplementary material.

Supplementary material 1 (DOC 694 kb)

Rights and permissions

Reprints and Permissions

About this article

Verify currency and authenticity via CrossMark

Cite this article

Brambilla, A.M., Aliberti, S., Prina, E. et al. Helmet CPAP vs. oxygen therapy in severe hypoxemic respiratory failure due to pneumonia. Intensive Care Med 40, 942–949 (2014). https://doi.org/10.1007/s00134-014-3325-5

Download citation

  • Received:

  • Accepted:

  • Published:

  • Issue Date:

  • DOI: https://doi.org/10.1007/s00134-014-3325-5

Keywords

  • Continuous positive airway pressure
  • Pneumonia
  • Respiratory failure
  • Intubation