LAUSR

We describe the exceptional use of a paediatric helmet to deliver noninvasive respiratory support in a neonate with facial malformation, where more usual interfaces were not suitable. This use was completely safe and helped in managing its respiratory failure. A male neonate (38 weeks, 2690 g) with severe face malformation (bilateral cleft lip, nose and palate, Fig. 1a) had milk aspiration and presented with signs of ab ingestis pneumonia at day 2 of life. He needed continuous positive airway pressure (CPAP) for dyspnoea (Silverman’s score 5) and increasing oxygen need (30% to have arterial saturation >90%). We tried to deliver CPAP with different types of nasal prongs, masks and pharyngeal tubes but, due to his malformation, we were unsuccessful. He was uncomfortable (Echelle Douleur et Inconfort du Nouveau-né (EDIN) score 3) and CPAP transmission was always poor. We then started helmet-delivered CPAP using a small-sized paediatric helmet (Infant CaStar; Intersurgical, Mirandola, Italy) connected to BabyLog 8000+ ventilator with flow and CPAP set at 20 L/min and 5 cm H2O, respectively. In a second phase, we also ventilated the patient though the helmet using neutrally adjusted ventilator assist (NAVA). This was provided connecting the helmet to a Servo-Iventilator (Maquet, Solna, Sweden) and placing the oesophageal NAVA probe, using the specific ventilator software. Pressurisation rate was set at the maximum, positive end expiratory pressure at 6 cm H2O, NAVA level and trigger at 3 cm H2O/μV and 0.5 μV, respectively. Pression transmission was satisfactory and dyspnoea quickly disappeared. Transcutaneous blood gases were continuously monitored and arterialised capillary blood samples were drawn every 24 h to detect signs of CO2 rebreathing due to helmet dead space. Oxygen requirements decreased and arterial saturation was ≥95%; blood gas, perfusion index, heart rate and mean arterial pressure were always good. Since the helmet may increase the noise due to the gas flow, we used ear protections (Natus Medical Inc., Seattle, WA, USA; Fig. 1b) and the baby always showed adequate comfort (EDIN score ≤1). This case is consistent with the literature showing safe and efficacious non-invasive respiratory support using helmets in bigger infants and children. Although non-invasive respiratory support in neonates is usually provided with nasal mask or prongs, this case demonstrates that using the helmet is safe and feasible. Consent for publication was signed by parents: to the best of our knowledge, this is the first case of a neonate with facial malformation treated using helmet-delivered non-invasive respiratory support.