173. "As a landing barge noses onto the beach, members of the Negro Seabee Battalion clamber ashore. This assault training is supplemental to the Seabees' chief work as construction crews for the U.S. Navy." Ca. December 1942. National Archives Identifier: 535776, Local Identifier: 208-N-570.
Patients requiring hospitalisation for COVID-19 predominantly present with acute hypoxaemic respiratory failure (AHRF) [1]. Conventional low-flow oxygen therapy will suffice for patients with mild to moderate disease but patients with severe or critical illness will require more advanced support [2]. Endotracheal intubation and mechanical ventilation constitute the highest level of care for patients with AHRF but beds and ventilators in the intensive care unit (ICU) are limited. High-flow oxygen therapy through a nasal cannula (HFNC) is a mainstay of treatment in patients with COVID-19 failing on conventional oxygen therapy in our institution and has recently been endorsed in the surviving sepsis campaign (SSC) guidelines on COVID-19 [3]. HFNC have been shown to improve comfort, oxygenation and 90-day survival, but not intubation rates, compared to standard low-flow oxygen therapy in patients with AHRF [4]. Non-invasive ventilation (NIV) using a continuous positive airway pressure (CPAP) should theoretically improve lung aeration and gas exchange in AHRF compared to HFNC because it enables a higher positive end expiratory pressure (PEEP), similar to that of mechanical ventilation [5]. Yet, NIV is receiving mixed support in relation to COVID-19 [3]. This originates from some observational studies that have reported high failure rates and associated high hospital mortality when using conventional CPAP face masks where tolerance is a well-known issue [6, 7]. In comparison to masks, Helmet CPAP show superior tolerance, significantly reduced intubation rates and improved survival in AHRF and acute respiratory distress syndrome (ARDS) respectively [8, 9]. A systematic review from 2017 found a significant reduction in hospital mortality from using Helmet CPAP in AHRF but stated that there was insufficient evidence to make clear recommendations [10]. The SSC guidelines on COVID-19 make a similar conclusion, positioning the Helmet CPAP as a feasible option for patients with COVID-19 failing on conventional oxygen therapy, but authors were unable to make specific recommendations due to a lack of direct evidence [3]. Helmet CPAP have been used extensively to treat COVID-19 in northern Italy with anecdotally good results [11]. It is our hypothesis that the use of Helmet CPAP will reduce the need for intubation in patients with AHRF from COVID-19 compared to the use of HFNC, without having a negative effect on survival.
LSMagazine Issue 05 Supple 98
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