Helmet CPAP in 1,685 Patients With COVID-19

Background Helmet CPAP was adopted widely as a noninvasive ventilatory support strategy during the COVID-19 pandemic, aiding the management of patients with acute hypoxemic respiratory failure (AHRF) both inside and outside ICUs. However, large-scale data from resource-limited settings remain limited. Research Question What are the predictors of success, defined as the avoidance of endotracheal intubation (ETI), and mortality among patients with COVID-19-related AHRF treated with helmet CPAP? Study Design and Methods This was a multicenter, retrospective observational cohort study including 1,685 adults with confirmed COVID-19 and AHRF who received helmet CPAP between November 2020 and November 2021 at 1 public and 1 private hospital in a large urban center. The intervention involved the use of a novel helmet CPAP interface. The primary outcome was the need for ETI; the secondary outcome was in-hospital mortality. Variables were analyzed using Poisson regression and were grouped into 4 domains: (1) intrinsic patient characteristics, (2) extent of respiratory involvement, (3) systemic extrapulmonary manifestations of COVID-19, and (4) early respiratory response to helmet CPAP. Results Of the 1,685 patients, 63% avoided ETI. In-hospital mortality was 24%, with nearly all deaths occurring in intubated patients. Protective factors against ETI included younger age, higher Pao 2 to Fio 2 ratio, higher serum bicarbonate, lower Sequential Organ Failure Assessment (SOFA) scores, fewer adverse events, and treatment in a public hospital. Risk factors for both ETI and mortality included older age; elevated SOFA scores; higher lactate dehydrogenase, urea, and creatinine levels; and adverse events related to helmet CPAP use. Interpretation Our results show that helmet CPAP was feasible and effective for managing COVID-19-related AHRF in a resource-limited setting. The identified clinical and laboratory predictors of ETI and mortality may guide patient selection and monitoring and may support helmet CPAP as a scalable noninvasive strategy in future respiratory pandemics. Clinical Trial Registration ClinicalTrials.gov; No.: NCT05375799; URL: www.clinicaltrials.gov