title: Effect of Noninvasive Ventilation Delivered by Helmet vs Face Mask on the Rate of Endotracheal Intubation in Patients With Acute Respiratory Distress Syndrome: A Randomized Clinical Trial.
abstract: OBJECTIVE
  Noninvasive ventilation (NIV) with a face mask is relatively ineffective at preventing endotracheal intubation in patients with acute respiratory distress syndrome (ARDS). Delivery of NIV with a helmet may be a superior strategy for these patients.
  
  
  OBJECTIVE
  To determine whether NIV delivered by helmet improves intubation rate among patients with ARDS.
  
  
  METHODS
  Single-center randomized clinical trial of 83 patients with ARDS requiring NIV delivered by face mask for at least 8 hours while in the medical intensive care unit at the University of Chicago between October 3, 2012, through September 21, 2015.
  
  
  METHODS
  Patients were randomly assigned to continue face mask NIV or switch to a helmet for NIV support for a planned enrollment of 206 patients (103 patients per group). The helmet is a transparent hood that covers the entire head of the patient and has a rubber collar neck seal. Early trial termination resulted in 44 patients randomized to the helmet group and 39 to the face mask group.
  
  
  METHODS
  The primary outcome was the proportion of patients who required endotracheal intubation. Secondary outcomes included 28-day invasive ventilator-free days (ie, days alive without mechanical ventilation), duration of ICU and hospital length of stay, and hospital and 90-day mortality.
  
  
  RESULTS
  Eighty-three patients (45% women; median age, 59 years; median Acute Physiology and Chronic Health Evaluation [APACHE] II score, 26) were included in the analysis after the trial was stopped early based on predefined criteria for efficacy. The intubation rate was 61.5% (n = 24) for the face mask group and 18.2% (n = 8) for the helmet group (absolute difference, -43.3%; 95% CI, -62.4% to -24.3%; P < .001). The number of ventilator-free days was significantly higher in the helmet group (28 vs 12.5, P < .001). At 90 days, 15 patients (34.1%) in the helmet group died compared with 22 patients (56.4%) in the face mask group (absolute difference, -22.3%; 95% CI, -43.3 to -1.4; P = .02). Adverse events included 3 interface-related skin ulcers for each group (ie, 7.6% in the face mask group had nose ulcers and 6.8% in the helmet group had neck ulcers).
  
  
  CONCLUSIONS
  Among patients with ARDS, treatment with helmet NIV resulted in a significant reduction of intubation rates. There was also a statistically significant reduction in 90-day mortality with helmet NIV. Multicenter studies are needed to replicate these findings.
  
  
  BACKGROUND
  clinicaltrials.gov Identifier: NCT01680783.
authors.affiliation: University of Chicago, Department of Medicine, Section of Pulmonary and Critical Care, Chicago, Illinois.
authors.forename: Bhakti K
authors.initials: BK
authors.lastname: Patel
authors.affiliation: University of Chicago, Department of Medicine, Section of Pulmonary and Critical Care, Chicago, Illinois.
authors.forename: Krysta S
authors.initials: KS
authors.lastname: Wolfe
authors.affiliation: University of Chicago, Department of Medicine, Section of Pulmonary and Critical Care, Chicago, Illinois.
authors.forename: Anne S
authors.initials: AS
authors.lastname: Pohlman
authors.affiliation: University of Chicago, Department of Medicine, Section of Pulmonary and Critical Care, Chicago, Illinois.
authors.forename: Jesse B
authors.initials: JB
authors.lastname: Hall
authors.affiliation: University of Chicago, Department of Medicine, Section of Pulmonary and Critical Care, Chicago, Illinois.
authors.forename: John P
authors.initials: JP
authors.lastname: Kress
mesh_terms: D000368:Aged; D057239:Early Termination of Clinical Trials; D005260:Female; D006260:Head Protective Devices / Q000009:adverse effects; D006801:Humans; D007362:Intensive Care Units / Q000706:statistics & numerical data; D007442:Intubation, Intratracheal / Q000706:statistics & numerical data*; D007902:Length of Stay; D008297:Male; D008397:Masks / Q000009:adverse effects; D008875:Middle Aged; D063087:Noninvasive Ventilation / Q000295:instrumentation* / Q000379:methods; D012128:Respiratory Distress Syndrome / Q000401:mortality / Q000628:therapy*; D012883:Skin Ulcer / Q000209:etiology; D013997:Time Factors