Complications following pulmonary lobectomy: the role of helmet noninvasive ventilation.

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.