Facemask vs. Helmet | Noninvasive Ventilation

 Published: November 17, 2021

By: Andrew Klein, MS, RRT, RRT-ACCS, RRT-NPS, AE-C and Brady Scott, PhD, RRT-ACCS, FAARC


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We use Noninvasive ventilation (NIV) to treat various disease processes, such as acute hypercapnic and hypoxemic respiratory failure, post-extubation failure, and neuromuscular diseases.1-3 Data supports NIV use in some conditions, like acute exacerbation of COPD and cardiogenic pulmonary edema, and continues to evolve in others.4-7 While proper patient selection is vital to the success of NIV, additional aspects of NIV are crucial to successful implementation and subsequent management of the modality. Ventilator, interface, and mode/setting selections are all critical components to the proper delivery of NIV.8-11

Several NIV interfaces are available, including nasal masks, oronasal masks, mouthpieces, total face masks, and helmets.12 When selecting the best interface, the clinician must consider various factors, such as patient tolerance factors, facial skin breakdown, medication delivery, and device availability. The primary clinical goal in NIV use is to minimize the need for intubation, invasive mechanical ventilation, and the associated adverse effects.13 This article will evaluate device interfaces, helmets, and facemasks (oronasal and total), for NIV delivery in the acute care setting.

Oronasal and Total Face Masks

Oronasal and total face masks are commonly used to deliver NIV for patients in acute respiratory failure.12,14 There is considerable data to support the clinical effectiveness of oronasal and total face masks.12,15 These masks are familiar to most clinicians and are available in many facilities.

There are some notable shortcomings with oronasal and total face masks that respiratory therapists should consider. Oronasal masks might increase the risk for aspiration, and patients may find it challenging to communicate and clear secretions while the mask is in place. The total face mask limits the use of aerosolized medications.12

Facial skin breakdown is also an important consideration with oronasal mask interfaces. The prolonged use of face masks interfaces has caused skin irritation and breakdown. A skin injury can occur after only a few hours, commonly seen on the bridge of the nose.16 Beyond the direct impact on the patient, facial skin breakdown is a significant source of concern with NIV use due to the negative impact that skin-related events have on costs and reimbursement.17,18

To mitigate skin breakdown on the bridge of the nose, total facemasks can be used, at least temporarily, as an alternative to oronasal masks to reduce the risk of skin damage.12 Total face masks help with skin breakdown by offloading the pressure placed on the bridge of the nose associated with the oronasal interface.16 Total face masks are comfortable, and some evidence suggests that switching between multiple different interfaces can minimize skin breakdown.15,16,19



The helmet interface can also be used to deliver NIV. Helmets cover the entire head and seal around the neck, having straps that fit under the arms.12,20,21 Some evidence suggests that helmets may be an alternative to masks at improving arterial blood gases, and many patients tolerate the interface well.10 Helmet NIV can improve oxygenation, inspiratory effort, and shortness of breath compared to high flow nasal oxygen therapy in patients with acute hypoxemic respiratory failure.22 A 2016 systematic review and meta-analysis that included 11 studies and 621 patients found that helmet NIV was associated with a reduction in intubation and hospital mortality when compared to study control strategies. The study authors noted that the helmet was at least as effective as the mask interfaces regarding gas exchange. They also noted that more extensive studies (randomized controlled trials) were needed, as robust scientific evidence was lacking.23 A 2017 systematic review and meta-analysis, in a subgroup analysis, also suggested that helmet NIV could reduce intubation and mortality in some patients. Similar to the 2016 study, the authors conceded that their study findings needed to be confirmed by larger studies.24

Respiratory therapists must know the potential limitations of the helmet. While the helmet does not carry the same risk of facial skin irritation and breakdown as the mask devices, the skin should be monitored around the neck and under the arms where the straps touch the patient.13 Additionally, the increased volume inside of the helmet might increase the likelihood of CO2 rebreathing. Rebreathing of CO2 is dependent on the amount of fresh gas that flushes the device and the amount produced by the patient.12,25 Thus, adequate gas flows and proper safety valves are needed to assure patient safety during helmet NIV.25

Which interface is best?

The choice of interface is an important consideration when delivering NIV. Oronasal and total face masks are common choices to deliver NIV in the acute care setting. Evidence supports using either mask to deliver NIV to treat acute hypoxemic respiratory failure.12 These masks are often readily available in acute care settings, and respiratory therapists are familiar with their uses and limitations. The helmet interface may be a viable alternative to mask interfaces due to the lower risk of facial dermal lesions (compared to masks), patient tolerability, and some positive outcomes. The helmet interface received much attention during the COVID-19 pandemic, as some European organizations recommended it to reduce aerosol dispersion for the safety of healthcare providers.27 Some reports have indeed demonstrated the feasibility of the helmet interface during the pandemic.28,29 That said, a recent randomized clinical trial showed that patients with moderate to severe hypoxemia due to COVID-19 treated with helmet NIV had no difference in days free of respiratory support when compared to high-flow nasal oxygen.30

It is not clear which is superior for the delivery of NIV, mask interfaces or helmets. It is likely that both options play a role and have clinical use in scenarios where their unique attributes make them the best option. However, it is also likely that both have limitations that prevent their use in some clinical situations. More research is needed to help drive decisions regarding the various NIV interfaces’ use and the management strategies unique to each. Regardless of the NIV interface used, respiratory therapists responsible for the initiation and subsequent management of NIV should be well trained on each interface they have available to them in their facility.


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Andrew Klein, MS, RRT, RRT-ACCS, RRT-NPS, AE-C is an adult clinical specialist at Rush University Medical Center. He has been a respiratory therapist for 17 years, with experience in adult critical care. He has been an AARC recognized preceptor for the past 4 years, and has lectured at local, state, and national conferences. Brady Scott, PhD, RRT-ACCS, FAARC is the director of clinical education and associate professor for the respiratory care program at Rush University. He has been a respiratory therapist for more than 20 years, with clinical practice experience in adult emergency/critical respiratory care. In 2007, he was named the Adult Acute Care Specialty Practitioner of the Year by the American Association for Respiratory Care (AARC). He has lectured at regional, state, national and international conferences on topics pertaining to respiratory care. His research interests include simulation-based education and emergency/critical respiratory care.

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