LetterCorrespondence

Complications Following Pulmonary Lobectomy: The Role of Helmet Noninvasive VentilationThe authors respond to: Complications Following Pulmonary Lobectomy: The Role of Helmet Noninvasive Ventilation

Ramesh Unnikrishnan, Luca Ampollini, Praveen Jacob John, Anitha Shenoy, Maria Barbagallo, Stefanie Ziegler and Andrea Ortu
Respiratory Care May 2013, 58 (5) e64-e65; DOI: https://doi.org/10.4187/respcare.02248

To the Editor:

We read with great interest the paper by Barbagallo et al on prophylactic use of helmet CPAP after pulmonary lobectomy: a randomized control trial.1

Noninvasive ventilation (NIV) is a type of ventilation that does not require placement of an artificial airway. Selection of ventilation interfaces and the type of ventilator are the most important and influencing factors. Different types of interfaces have been developed over the years, but none have been clearly proven superior to another.2 Only a little attention has been paid to the type of interface used. Data on NIV in the postoperative setting are selective. The results published by Aguilo et al3 and Perrin et al4 prove the aspects of improvement in oxygenation and pulmonary function postoperatively. The paper by Barbagallo et al has enlightened the short duration of beneficial effects of NIV on oxygenation.

The objective of the study was to understand the effects of helmet NIV in patients post pulmonary lobectomy. The helmet interface, which is a recent introduction, has some important advantages in terms of improved tolerance, allows acceptable interaction with the environment, and can be used in different anatomic situations, such as edentulous and facial trauma patients. It also does not cause skin lesions. The helmet improves comfort, which permits longer periods of NIV delivery. However, because helmets are larger than facial masks, the pressure within the system during ventilation may be dissipated against the high compliance of the helmet, thus interfering with correct pressurization and ventilator function.5–8

We did not understand why the authors chose to compare helmet interface over oxygen therapy via face mask. We would like to ask the authors why they did not consider comparing helmet interface versus commonly used interfaces like facial interface. This type of comparison will provide a better insight on the beneficial effects of helmet interface in terms of tolerance and patient-ventilator synchrony.9 Age > 60 years and COPD may have caused some amount of confounding in the study.10 The authors could have studied the number of ventilator alarms, disconnection, complications (eg, nasal breakdown),11 and total number of trouble-shootings that would provide insight on additional benefits of the helmet interface.

Overall, it is doubtful whether the beneficial effect obtained was due to CPAP or helmet interface.

Footnotes

  • The authors have disclosed no conflicts of interest.

References

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    . Prophylactic use of helmet CPAP after pulmonary lobectomy: a prospective randomized controlled study. Respir Care 2012;57(9):1418-1424.
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The authors respond to: Complications Following Pulmonary Lobectomy: The Role of Helmet Noninvasive Ventilation

We thank Unnikrishnan and colleagues for their interest in and comments regarding our recently published paper, outlining the benefit of the prophylactic use of helmet CPAP (hCPAP), in comparison to air-entrainment mask after pulmonary lobectomy.1 Our standard postoperative protocol after pulmonary lobectomy considers the use of air-entrainment mask with FIO2 of 0.4 in air. It is reported that postoperative pulmonary complications can reach an incidence of 15-18%.2,3 In particular, acute respiratory failure after lung surgery is fatal in up to 40% to more than 60%.2 In these circumstances, we conducted a prospective randomized controlled study with the aim to evaluate the effectiveness of the prophylactic application of CPAP delivered by hCPAP to improve oxygenation (PaO2/FIO2), in comparison to oxygen therapy over an air-entrainment mask (FIO2 0.4).

We found a significantly better PaO2/FIO2 after hCPAP, compared to the control group (P = .001) after the second cycle of CPAP; however, this improvement was not long lasting and PaO2/FIO2 values were not significantly different in either group after 24 hours, 48 hours, and 1 week.

Additionally, postoperative complications were not statistically different in either groups. Finally, patients receiving postoperative hCPAP had a significantly shorter hospital stay, in comparison to the control group (P = .042).

Dr Unnikrishnan and colleagues reported their indecision about the comparison of helmet interface over oxygen therapy via commonly used face mask. The authors' interest was to compare the standard institutional method of oxygen delivery after pulmonary lobectomy to a noninvasive method of ventilation, and not to compare 2 different ways (helmet and mask) of positive pressure oxygen supply. As described in the paper, the choice of the helmet interface was made by a definitely better acceptance, as compared to an oronasal mask.4,5

Comparing helmet interface versus facial interface, as proposed by Unnikrishnan et al, could certainly be the aim of a subsequent study.

Footnotes

  • The authors have disclosed no conflicts of interest.

References

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    1. Barbagallo M,
    2. Ortu A,
    3. Spadini E,
    4. Salvadori A,
    5. Ampollini L,
    6. Internullo E,
    7. et al
    . Prophylactic use of helmet CPAP after pulmonary lobectomy: a prospective randomized controlled study. Respir Care 2012;57(9):1418-1424.
    OpenUrlAbstract/FREE Full Text
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    4. Carlucci A,
    5. Prinianakis GG,
    6. Antonelli M,
    7. et al
    . Non-invasive ventilation in chronic obstructive pulmonary disease patients: helmet versus facial mask. Intensive Care Med 2007;33(1):74-81.
    OpenUrlCrossRefPubMed
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