Introduction
In the early 2000's, two randomized controlled trials have shown that non-invasive ventilation (NIV) could decrease mortality of immunocompromised patients admitted to ICU for acute respiratory failure (ARF) as compared to standard oxygen therapy (O2) [1, 2]. However, the benefits of NIV in immunocompetent patients with ARF failure are debated. High flow nasal cannula oxygen therapy (High-Flow Oxygen) may offer an alternative in hypoxemic patients. We recently found in a randomized controlled trial including 310 patients with ARF that High-Flow Oxygen decreased mortality as compared to NIV [3]. Immunocompromised patients could be also included in this study, except those with profound neutropenia. Therefore, we assessed the benefits of High-Flow Oxygen or NIV in this subgroup of patients.
Objectives
To compare intubation and mortality rates in the subset of immunocompromised patients admitted to ICU for ARF.
Methods
We performed a subgroup analysis of the FLORALI study. This study included all patients with non-hypercapnic (PaCO2 ≤ 45 mm Hg) ARF excluding patients with cardiogenic pulmonary edema and those with underlying chronic lung disease. Patients were assigned to three groups according to treatment: High-Flow Oxygen, O2 or NIV. The primary outcome was the intubation rate and secondary outcome included 90-day mortality. We focused on the subset of immunocompromised patients included in this study, knowing that patients with profound neutropenia were excluded.
Results
Among the 310 patients with ARF, 82 (26%) were immunocompromised including 26 patients in the High-Flow Oxygen group, 30 in the O2 group, and 26 in the NIV group. Intubation rates were 31%, 43% and 55% in the High-Flow Oxygen, O2 and NIV groups, respectively (p = 0.04). The 90-day mortality rates were 15%, 27% and 46% in the High-Flow Oxygen, O2 and NIV groups (p = 0.046). Ventilator-free days at day 28 were 26 ± 6, 23 ± 10 and 14 ± 13 days in the High-Flow Oxygen, O2 and NIV groups, respectively (p < 0.0001).
Conclusions
In immunocompromised patients admitted to ICU for acute hypoxemic respiratory failure, High-Flow Oxygen was associated with lower intubation and mortality rates, and a reduced duration of invasive mechanical ventilation as compared to O2 or NIV.
References
Antonelli M, Conti G, Bufi M, Costa MG, Lappa A, Rocco M, et al: Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: a randomized trial. JAMA. 2000, 283 (2): 235-241. 10.1001/jama.283.2.235.
Hilbert G, Gruson D, Vargas F, Valentino R, Gbikpi-Benissan G, Dupon M, et al: Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. N Engl J Med. 2001, 344 (7): 481-487. 10.1056/NEJM200102153440703.
Frat JP, Thille AW, Mercat A, Girault C, Ragot S, Perbet S, et al: High-Flow Nasal Cannulae Oxygen Therapy in Acute Hypoxemic Respiratory Failure. N Engl J Med. 2015, 372: 2185-2196. 10.1056/NEJMoa1503326.
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Frat, JP., Ragot, S., Girault, C. et al. High flow nasal cannula oxygen therapy in immunocompromised patients with acute hypoxemic respiratory failure. ICMx 3 (Suppl 1), A425 (2015). https://doi.org/10.1186/2197-425X-3-S1-A425
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DOI: https://doi.org/10.1186/2197-425X-3-S1-A425