Mask-Free NIV® in the Emergency Department — ED Doctors Discuss Their Experience

Vapotherm’s high velocity therapy is a tool for can treating respiratory distress.  Vapotherm does not practice medicine or provide medical services or advice, any clinical recommendations provided herein are solely those of the speakers. Practitioners should refer to the full indications for use and operating instructions of any products referenced before use. All participants are paid consultants of Vapotherm.

The VP of Medical Education at Vapotherm®, Michael McQueen, MD, MBA, had a conversation with a group of Emergency Department physicians on their use of high velocity therapy. High velocity therapy is Mask-Free NIV for spontaneously breathing patients and has been found to have equivalent outcomes to Non-Invasive Positive Pressure Ventilation (NiPPV) in adults presenting in the ED in undifferentiated respiratory distress.[1]

Here are a few quick highlights from this conversation:


  • Kirk S. Hinkley, MD, FACEP—Commonwealth Health EMS & One Air Ambulance, Medical Director, and Cayuga Medical Center, Emergency Physician
  • Adam Hennessey, DO, FACEP—Taylor Hospital, Assistant Medical Director, and Our Lady of Lourdes Medical Center, Emergency Physician
  • Aditya Ahlawat, MD—Putnam County Hospital, Chief of Medicine & Hospitalist

Why Use High Velocity Therapy

Dr. Hennessey admits to loving Bi-PAP® as well as intubations, but the group agrees that high velocity therapy is an additional tool that is user-friendly, easy-to-titrate, effective and safe for patients. Patients can eat, drink, and talk which is often advantageous for communicating not just with family, but with the attending physician. Another benefit they emphasize is that it can be used from “cradle-to-grave” on a wide variety of patients.

“I have a four-year old. I would much rather see him on Vapotherm if he is bronchiolitic than progressing to needing intubation.” – Dr. Hennessey

Outcomes of High Velocity Therapy on CHF Patients

High velocity therapy is well-suited for treating undifferentiated respiratory distress, including hypercapnia, in spontaneously breathing patients. Twenty percent of the patients in the multi-center, randomized, controlled trial conducted by Doshi and colleagues had CHF1 either as a primary or co-diagnosis and the high velocity therapy arm of the study demonstrated equivalent outcomes to NiPPV. The group notes that these results gave them a sort of permission to try high velocity therapy on CHF patients. Furthermore, it is not always clear what diagnosis a patient has when they arrive in the Emergency Department, which is another reason the doctors name it as a useful tool.

“I’ve not seen a particular subgroup of patients that’s not done well on [Hi-VNI Technology]. I’m not sure even what the theory is as to why a CHF patient would benefit from the technology, but the fact is that they do and so I continue to use it with good results.” – Dr. Hinkley

Potentially Reducing ICU Admissions and Intubations with High Velocity Therapy

Although not all the doctors have specific numbers, anecdotally they have experienced a drop in intubations, in ICU admissions, as well as in PICU transfers. One of the reasons, not directly discussed by them, that physicians and hospitals may potentially see these outcomes is in part due to the mask-free interface. Studies have shown that more than 30% of NiPPV failure is attributed to mask-intolerance.[2] Once a patient fails on NiPPV, many physicians intubate, but given that high velocity therapy is easy to tolerate, it is a viable alternative for the patients who can’t or won’t wear a mask.

“We have actually noticed, particularly in our ICU, less intubations per month for the last six months. And that has coincidentally or uncoincidentally coincided with Vapotherm’s application at Putnam County Hospital.” – Dr. Ahlawat

High velocity therapy for Transnasal Humidified Rapid Insufflation Ventilatory Exchange (THRIVE) pre-intubation

The group discussed the benefits of pre-oxygenation before intubation to mitigate risk for those patients who are too sick for non-invasive respiratory treatment. Although high velocity therapy offers ventilatory support, it can also oxygenate and these physicians did use it for THRIVE.

“Easy setup, easy application, and it’s almost a no-brainer to have it next to your patient and it’s another tool in your toolbox.” – Dr. Ahlawat

Proper Mask-Free Interface Selection for High Velocity Therapy

High velocity therapy is an open system that requires CO2 to be flushed out of the upper airway, which is why the interface should never occlude more than 50% of the patient’s nares. Hi-VNI Cannulas come in eight different sizes to accommodate all patients, from premature neonates to adults.

“Because the technology is high velocity, and not positive pressure, you don’t want to occlude the nares, you want … fifty percent of the nares open and you want the mouth ideally open, too.” – Dr. Hennessey

You can view the full discussion here.

For spontaneously breathing patients

No Mask. No Problem. Mask-Free NIV

[1] Doshi, Pratik et al. High-Velocity Nasal Insufflation in the Treatment of Respiratory Failure: A Randomized Clinical Trial. Annals of Emergency Medicine, 2018.
[2] Carron M. et al. Complications of non-invasive ventilation techniques: a comprehensive qualitative review of randomized trials. British Journal of Anaesthesia. 110(6):896-914. (2013)