Should we carry out noninvasive ventilation using a helmet in acute respiratory distress syndrome?

In a recent issue of the Journal of American Medical Association, Patel and colleagues compared two different interfaces to carry out noninvasive ventilation (NIV) in patients admitted to ICU for acute hypoxemic respiratory failure (1). Among them, only those who met the criteria for acute respiratory distress syndrome (ARDS) according to the Berlin definition (2) could be included, i.e., those having had worsening of respiratory symptoms within the previous week, a PaO₂/FiO₂ ≤300 mmHg with positive end-expiratory pressure (PEEP) at least 5 cmH₂O, and bilateral pulmonary infiltrates, after excluding those with cardiogenic pulmonary edema. However, patients were included after at least 8 hours of NIV as first-line therapy with a standard face mask.