Heliox – Part of the Kitchen Sick
From the first party where we had balloons that floated, I think we have all had a fascination with the most Noble of the Noble Gases – Helium!
While it is fun to make your kids think that you are in fact the voice of Mickey Mouse, does Helium have any utility in our ED?
- It is the second most abundant element in the universe (that’s cool)!
- It is an inert gas that is odorless and tasteless.
- It has a lower molecular weight and is less dense than Oxygen.
- It has been used in medicine since the 1930’s, yet has limited supporting evidence.
- It is a mixture of oxygen and Helium resulting in a gas less dense than air (essentially Helium replaces Nitrogen in the air).
- In conditions where there is increased airway resistance (asthma, croup, upper airway masses, etc) there is turbulent airflow, which increases the work of breathing.
- Heliox can reduce airway resistance by increasing laminar airflow and decrease work of breathing.
- It is generally administered in mixtures of 70:30 or 80:20 (Helium:Oxygen).
- Better lung mechanics
- Improved delivery of albuterol or other nebulized medications
- Few known side-effects/complications (it is inert after all)
- Contraindicated in hypoxemic patients (if your patient needs 50% oxygen, you can’t use Heliox)
- Paucity of large prospective randomized trials to support its use
- It doesn’t treat the causative issue
- Currently systematic reviews and guidelines state that Heliox should NOT be used in ALL patients with acute asthma in the ED and that it doesn’t play a role in the initial treatment.
- FORTUNATELY, those are not the patients that we would likely use Heliox in. There are studies that point toward its benefit in selected patients with severe obstructive disease.
Personally, this is what I (humbly) think:
- I consider Heliox in any patient that has severe increased work of breathing and who hasn’t improved with 1st and 2nd line therapies. The patient who comes in looking like the need to be intubated emergently is not the patient that gets Heliox first… they get intubated. But the kid who is still in severe respiratory distress after your 1st line meds and maneuvers and is still looking like they have some residual fight let in them, then Heliox may give them the edge they need to get through this without a big piece of plastic in their airway. It is in the Kitchen Sick with other fun things like Magnesium and BiPap.
- Particularly with those conditions that the process of intubating may not be super easy (ex, Croup [difficult to pass the ETT] and Asthma [potential for complications with hypoxia and acidosis leading to arrest]) or in those who being mechanically ventilated is potentially hazardous (Asthma – difficult to optimize their lung mechanics and avoid acidosis).
- A trial of Heliox will either help the patient and save them from intubation or it won’t and then you know what needs to be done. So I don’t appreciate that it has a significant down-side. AS LONG AS THE PATIENT DOESN’T NEED HIGH OXYGEN CONCENTRATIONS.
Cincinnati Children’s Hospital Medical Center. Evidence-based care guideline for management of acute asthma exacerbation in children. Cincinnati (OH): Cincinnati Children’s Hospital Medical Center; INFO@GUIDELINES.GOV 2011
Rodrigo GV, Pollack CV, Rodrigo C, Rowe BH. Heliox for non-intubated acute asthma patients. Cochrane Collaboration 2010.
Liet JM, Ducruet T, Gupta V, Cambonie G. Heliox inhalation therapy for bronchiolitis in infants. Cochrane Collaboration 2010.
Vorwerk C, Coats T. Heliox for croup in children. Cochrane Collaboration 2010.
Rivera M L, Kim T Y, Stewart G M, et al., – Albuterol nebulized in heliox in the initial ED treatment of pediatric asthma: a blinded, randomized controlled trial; , Am J Emer Med (2006);24: pp. 38 42.
Kim I K, Phrampus E,Venkataraman S, et al., Helium/Oxygen-Driven Albuterol Nebulization in the Treatment of Children With Moderate to Severe Asthma Exacerbations:A Randomized, Controlled Trial; Pediatrics (2005);116(5): pp. 1,127 1,133.
Martion-Torres F, Rodriguez-Nunez A, Martinon-Sanchez J. Heliox Therapy in Infants with Acute Bronchiolitis. Pediatrics (2002); 109 (1); 68-73.