Effect of non-invasive oxygenation strategies in immunocompromised patients with severe acute respiratory failure: a post-hoc analysis of a randomised trial

Frat, Jean‐Pierre; Ragot, Stéphanie; Girault, Christophe; Parratte, Sébastien; Prat, Gwénaël; Boulain, Thierry; Demoule, Alexandre; Ricard, Jean‐Damien; Coudroy, Rémi; Robert, René; Mercat, Alain; Brochard, Laurent; Thille, Arnaud W.

doi:10.1016/s2213-2600(16)30093-5

Cited by 203 publications

(194 citation statements)

References 21 publications

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“…A multicentre randomized trial conducted in hypoxemic ARF patients has shown that NIV, compared with standard oxygen therapy and HFNO, was related to higher intubation and mortality rates, particularly in more severely hypoxemic patients [11]. Similar results were confirmed whatever the underlying severity of hypoxemia in a post hoc analysis of immunocompromised patients of the previous study [12]. In the same way, another multicentre randomized trial did not show any benefit of NIV compared with oxygen therapy (standard or HFNO) in immunocompromised patients with hypoxemic ARF [13].…”

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confidence: 55%

“…These observations have to be interpreted cautiously, since NIV in these trials was used for short median periods of time in patients allocated to this treatment [11,13]. An additional explanation for these adverse outcomes in hypoxemic ARF could be, as for invasive mechanical ventilation, the potential promotion of ventilator-induced lung injuries, because of a higher expired tidal volume and transpulmonary pressure than expected under NIV [11,12,14]. In fact, if not applied in an optimal way, NIV could lead to deleterious effects.…”

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confidence: 99%

“…Finally, applying NIV in hypoxemic ARF is probably still possible in well-selected patients and experienced centres [18], provided ICU clinicians pay particular attention to the ventilator settings (expired tidal volume) [9,10,12] or, if experienced, possibly use a helmet as interface [15]. Under these conditions, the new HACOR score could be very useful to avoid unduly delaying the intubation time and increasing mortality, particularly in more severe patients.…”

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confidence: 99%

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Non-invasive ventilation in hypoxemic acute respiratory failure: is it still possible?

2017

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Non-invasive ventilation in hypoxemic acute respiratory failure: is it still possible?

2017

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“…In two studies, the effects of NHF and NIV were assessed in immunocompromised patients admitted to the ICU for ARF [69,70]. In both studies, the rates of intubation and mortality were lower in patients treated with NHF than in those randomly assigned to NIV.…”

Section: Acute Hypoxaemic Respiratory Failure In Immunocompromised Pamentioning

confidence: 99%

“…In both studies, the rates of intubation and mortality were lower in patients treated with NHF than in those randomly assigned to NIV. Moreover, NIV remained independently associated with increased rate of intubation and mortality [69,70]. The results could be attributed to the better tolerance of NHF and the potential harmful effects of NIV through increasing tidal volumes, thus leading to high transpulmonary pressure and ventilator-induced lung injury [70].…”

Section: Acute Hypoxaemic Respiratory Failure In Immunocompromised Pamentioning

confidence: 99%

Nasal high flow therapy: a novel treatment rather than a more expensive oxygen device

2017

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Nasal high flow is a promising novel oxygen delivery device, whose mechanisms of action offer some beneficial effects over conventional oxygen systems. The administration of a high flow of heated and humidified gas mixture promotes higher and more stable inspiratory oxygen fraction values, decreases anatomical dead space and generates a positive airway pressure that can reduce the work of breathing and enhance patient comfort and tolerance. Nasal high flow has been used as a prophylactic tool or as a treatment device mostly in patients with acute hypoxaemic respiratory failure, with the majority of studies showing positive results. Recently, its clinical indications have been expanded to post-extubated patients in intensive care or following surgery, for pre-and peri-oxygenation during intubation, during bronchoscopy, in immunocompromised patients and in patients with "do not intubate" status. In the present review, we differentiate studies that suggest an advantage (benefit) from other studies that do not suggest an advantage (no benefit) compared to conventional oxygen devices or noninvasive ventilation, and propose an algorithm in cases of nasal high flow application in patients with acute hypoxaemic respiratory failure of almost any cause.

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Effect of High-Flow Nasal Oxygen vs Standard Oxygen on 28-Day Mortality in Immunocompromised Patients With Acute Respiratory Failure

Azoulay

Lemiale

Mokart

et al. 2018

JAMA

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IMPORTANCE High-flow nasal oxygen therapy is increasingly used for acute hypoxemic respiratory failure (AHRF). OBJECTIVE To determine whether high-flow oxygen therapy decreases mortality among immunocompromised patients with AHRF compared with standard oxygen therapy. DESIGN, SETTING, AND PARTICIPANTS The HIGH randomized clinical trial enrolled 776 adult immunocompromised patients with AHRF (PaO 2 <60 mm Hg or SpO 2 <90% on room air, or tachypnea >30/min or labored breathing or respiratory distress, and need for oxygen Ն6 L/min) at 32 intensive care units (ICUs) in France between May 19, 2016, and December 31, 2017. INTERVENTIONS Patients were randomized 1:1 to continuous high-flow oxygen therapy (n = 388) or to standard oxygen therapy (n = 388). MAIN OUTCOMES AND MEASURES The primary outcome was day-28 mortality. Secondary outcomes included intubation and mechanical ventilation by day 28, PaO 2 :FIO 2 ratio over the 3 days after intubation, respiratory rate, ICU and hospital lengths of stay, ICU-acquired infections, and patient comfort and dyspnea. RESULTS Of 778 randomized patients (median age, 64 [IQR, 54-71] years; 259 [33.3%] women), 776 (99.7%) completed the trial. At randomization, median respiratory rate was 33/min (IQR, 28-39) vs 32 (IQR, 27-38) and PaO 2 :FIO 2 was 136 (IQR, 96-187) vs 128 (IQR, 92-164) in the intervention and control groups, respectively. Median SOFA score was 6 (IQR, 4-8) in both groups. Mortality on day 28 was not significantly different between groups (35.6% vs 36.1%; difference, −0.5% [95% CI, −7.3% to +6.3%]; hazard ratio, 0.98 [95% CI, 0.77 to 1.24]; P = .94). Intubation rate was not significantly different between groups (38.7% vs 43.8%; difference, −5.1% [95% CI, −12.3% to +2.0%]). Compared with controls, patients randomized to high-flow oxygen therapy had a higher PaO 2 :FIO 2 (150 vs 119; difference, 19.5 [95% CI, 4.4 to 34.6]) and lower respiratory rate after 6 hours (25/min vs 26/min; difference, −1.8/min [95% CI, −3.2 to −0.2]). No significant difference was observed in ICU length of stay (8 vs 6 days; difference, 0.6 [95% CI, −1.0 to +2.2]), ICU-acquired infections (10.0% vs 10.6%; difference, −0.6% [95% CI, −4.6 to +4.1]), hospital length of stay (24 vs 27 days; difference, −2 days [95% CI, −7.3 to +3.3]), or patient comfort and dyspnea scores. CONCLUSIONS AND RELEVANCE Among critically ill immunocompromised patients with acute respiratory failure, high-flow oxygen therapy did not significantly decrease day-28 mortality compared with standard oxygen therapy. TRIAL REGISTRATION clinicaltrials.gov Identifier: NCT02739451.

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Effect of non-invasive oxygenation strategies in immunocompromised patients with severe acute respiratory failure: a post-hoc analysis of a randomised trial

Cited by 203 publications

References 21 publications

Non-invasive ventilation in hypoxemic acute respiratory failure: is it still possible?

Non-invasive ventilation in hypoxemic acute respiratory failure: is it still possible?

Nasal high flow therapy: a novel treatment rather than a more expensive oxygen device

Effect of High-Flow Nasal Oxygen vs Standard Oxygen on 28-Day Mortality in Immunocompromised Patients With Acute Respiratory Failure

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