Correspondence

Heliox in Respiratory Failure from Obstructive Lung Disease

N Engl J Med 1995; 332:192-193January 19, 1995

Article

To the Editor:

There have been sporadic reports of the use of mixtures of helium and oxygen (heliox) as therapy in obstructive lung disease.1-3 We describe a patient with respiratory failure for whom the use of heliox averted the need for intubation.

A 64-year-old woman with obstructive lung disease and episodic bronchospasm was admitted to the hospital after five days of dyspnea and wheezing. The physical examination and chest film supported the diagnosis of an exacerbation of obstructive lung disease. The arterial-blood gas measurements on admission, with the patient breathing 4 liters of oxygen per minute, were as follows: pH, 7.41; partial pressure of carbon dioxide, 43 mm Hg; and partial pressure of oxygen, 110 mm Hg. She was treated with albuterol, ipratropium, and methylprednisolone, and her condition improved over the next three days. The following day, however, acute bronchospasm developed and progressed to respiratory arrest. The patient was intubated. While she was sedated and receiving mechanical ventilation at a rate of 16 breaths per minute and a tidal volume of 10 ml per kilogram of body weight, she had a peak airway pressure of 60 cm of water and auto-PEEP (abnormal gas trapping leading to a positive end-expiratory pressure) of 10 cm of water. Less than 24 hours after intubation, she removed her endotracheal tube. While she was using a mask supplying 40 percent oxygen, progressive hypercapnia and somnolence developed. She was then switched to treatment with heliox provided by a mask that prevented rebreathing; the mixture contained 80 percent helium and 20 percent oxygen, with sufficient additional oxygen to maintain 90 percent oxygen saturation in the patient, as measured by pulse oximetry. The final mixture was 29 percent oxygen. The patient's respiratory rate fell within minutes, and she became alert. The arterial partial pressure of carbon dioxide is shown in Figure 1Figure 1Partial Pressure of Arterial Carbon Dioxide in a Patient Receiving Heliox Treatment.. When this value had fallen to 51 mm Hg, the patient was switched to treatment with 28 percent oxygen in air for 30 minutes, which worsened the hypercapnia. She was again treated with heliox. A standard nasal cannula was inserted 24 hours after the removal of the endotracheal tube, and she was discharged on the 10th day.

Helium is one seventh the density of nitrogen. The drop in pressure across a site of convective acceleration is directly related to the density of the medium. Since convective acceleration occurs at loci of flow limitation, expiratory resistance may be reduced, and maximal expiratory flows have been shown to increase with heliox during induced bronchoconstriction.4,5 We speculate that improved expiratory flows with heliox reduced the extent of dynamic hyperinflation, restoring a mechanical advantage to the inspiratory muscles. That the heliox caused the improvement in this patient's condition is supported by her rapid increase in partial pressure of carbon dioxide during brief trials in which she breathed oxygen-enriched air, both immediately after extubation and again when she was breathing heliox in a stable fashion. Heliox should be considered as an adjuvant therapy for patients with respiratory failure from reversible lower airway obstruction that may avert the need for intubation or allow earlier extubation.

Albert Polito, M.D.
Henry Fessler, M.D.
Johns Hopkins Medical Institutions, Baltimore, MD 21224

5 References

1. 1

   Swidwa DM, Montenegro HD, Goldman MD, Lutchen KR, Saidel GM. Helium-oxygen breathing in severe chronic obstructive pulmonary disease. Chest 1985;87:790-795
   CrossRef | Web of Science | Medline

2. 2

   Shiue S-T, Gluck EH. The use of helium-oxygen mixtures in the support of patients with status asthmaticus and respiratory acidosis. J Asthma 1989;26:177-180
   CrossRef | Web of Science | Medline

3. 3

   Barach AL. The use of helium in the treatment of asthma and obstructive lesions in the larynx and trachea. Ann Intern Med 1935;9:739-765
   Web of Science

4. 4

   Chan-Yeung M, Abboud R, Tsao MS, Maclean L. Effect of helium on maximal expiratory flow in patients with asthma before and during induced bronchoconstriction. Am Rev Respir Dis 1976;113:433-443
   Web of Science | Medline

5. 5

   Despas PJ, Leroux M, Macklem PT. Site of airway obstruction in asthma as determined by measuring maximal expiratory flow breathing air and a helium-oxygen mixture. J Clin Invest 1972;51:3235-3243
   CrossRef | Web of Science | Medline

Citing Articles (9)

Citing Articles

1. 1

   Mostafa Ghanei, Mohsen Rajaeinejad, Rouzbeh Motiei-Langroudi, Farshid Alaeddini, Jafar Aslani. (2011) Helium:oxygen versus air:oxygen noninvasive positive-pressure ventilation in patients exposed to sulfur mustard. Heart & Lung: The Journal of Acute and Critical Care 40:3, e84-e89
   CrossRef

2. 2

   David Lin Lee, Chien-Wei Hsu, Huan Lee, Hsueh-Wen Chang, Yuh-Chin T. Huang. (2005) Beneficial Effects of Albuterol Therapy Driven by Heliox versus by Oxygen in Severe Asthma Exacerbation. Academic Emergency Medicine 12:9, 820-827
   CrossRef

3. 3

   David Lin Lee, Huan Lee, Hsueh-Wen Chang, Alice Y. W. Chang, Shoa-Lin Lin, Yuh-Chin T. Huang. (2005) Heliox improves hemodynamics in mechanically ventilated patients with chronic obstructive pulmonary disease with systolic pressure variations. Critical Care Medicine 33:5, 968-973
   CrossRef

4. 4

   Patrick Gerbeaux, Marc Gainnier, Jean-Michel Arnal, Laurent Papazian, Philippe Jean, Jean-Marie Sainty. (2005) Effects of helium–oxygen mixtures on endotracheal tubes: an in vitro study. Journal of Biomechanics 38:1, 33-37
   CrossRef

5. 5

   Jean-Luc Diehl, Alain Mercat, Emmanuel Guérot, Fethi Aïssa, Jean-Louis Teboul, Christian Richard, Jacques Labrousse. (2003) Helium/oxygen mixture reduces the work of breathing at the end of the weaning process in patients with severe chronic obstructive pulmonary disease. Critical Care Medicine 31:5, 1415-1420
   CrossRef

6. 6

   Patrick Gerbeaux, Marc Gainnier, Alain Boussuges, Joelle Rakotonirina, Pascale Nelh, Dominique Torro, Jean-Michel Arnal, Philippe Jean. (2001) Use of heliox in patients with severe exacerbation of chronic obstructive pulmonary disease. Critical Care Medicine 29:12, 2322-2324
   CrossRef

7. 7

   Gustavo J. Rodrigo, Charles V Pollack, Carlos Rodrigo, Brian H Rowe, E. Haydn Walters, Gustavo J. Rodrigo. 2001. Heliox for treatment of exacerbations of chronic obstructive pulmonary disease. .
   CrossRef

8. 8

   Bennett P. deBoisblanc, Peter DeBleiux, Scott Resweber, Evan E. Fusco, Warren R. Summer. (2000) Randomized trial of the use of heliox as a driving gas for updraft nebulization of bronchodilators in the emergent treatment of acute exacerbations of chronic obstructive pulmonary disease. Critical Care Medicine 28:9, 3177-3180
   CrossRef

9. 9

   Dean Hess, Sunisa Chatmongkolchart. (2000) Techniques to Avoid Intubation: Noninvasive Positive Pressure Ventilation and Heliox Therapy. International Anesthesiology Clinics 38:3, 161-187
   CrossRef