Immunocompromised patients with acute respiratory distress syndrome: secondary analysis of the LUNG SAFE database

Cortegiani, Andrea; Madotto, Fabiana; Gregoretti, Cesare; Bellani, Giacomo; Laffey, John G.; Pham, Tài; Haren, Frank Van; Giarratano, Antonino; Antonelli, Massimo; Artigas, Antonio

doi:10.1186/s13054-018-2079-9

Cited by 92 publications

(88 citation statements)

References 36 publications

(39 reference statements)

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“…The involvement of immune cells, including neutrophils [6,7] lymphocytes [8], and regulatory T-cell [9,10], has become an active topic of research in ARDS pathogenesis. To date, few clinical studies on the immune status of ARDS patients have focused on aetiology, treatment and prognosis [11]. Immunocompromised individuals represent a significant proportion of ARDS patients [11,12], these patients do not have the ability to respond normally to an infection due to an impaired or weakened immune system.…”

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confidence: 99%

“…To date, few clinical studies on the immune status of ARDS patients have focused on aetiology, treatment and prognosis [11]. Immunocompromised individuals represent a significant proportion of ARDS patients [11,12], these patients do not have the ability to respond normally to an infection due to an impaired or weakened immune system. Some studies have shown that ARDS occurs in patients with previous immunodeficiencies, such as haematologic malignancies, active solid tumours, solid organ transplantation, and acquired immunodeficiency syndrome, as well as in patients taking long-term or high-dose corticosteroids or immunosuppressants, and those who use extra-corporeal membrane oxygenation (ECMO) may have a better prognosis [13].…”

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confidence: 99%

“…Some studies have shown that ARDS occurs in patients with previous immunodeficiencies, such as haematologic malignancies, active solid tumours, solid organ transplantation, and acquired immunodeficiency syndrome, as well as in patients taking long-term or high-dose corticosteroids or immunosuppressants, and those who use extra-corporeal membrane oxygenation (ECMO) may have a better prognosis [13]. Compared with immunocompetent subjects, ARDS patients with typical immunodeficiency have higher mortality regardless of ARDS severity [11]. In addition, atypical immunosuppression is frequently found among ARDS patients, and virus infections are also increasingly being reported in ARDS patients without typical immunosuppression [13].…”

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confidence: 99%

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Prognostic factors for ARDS: clinical, physiological and atypical immunodeficiency

Song

Liu

et al. 2020

BMC Pulm Med

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Background: Risk factors affecting the prognosis of acute respiratory distress syndrome (ARDS) in adults were investigated. The aim was to identify new predictors for ARDS patient prognosis, including those with clinical, pathophysiological, and atypical immunodeficiency. Methods: ARDS patients were retrospectively included. The patients were grouped and analysed according to different oxygenation index grades and prognosis, and factors influencing prognosis and survival were examined. Adolescent patients, patients with typical immunodeficiency and patients who died within 24 h after being diagnosed with ARDS were excluded. The predictive value for mortality was determined by Cox proportional hazard analysis. Results: In total, 201 patients who fulfilled the Berlin definition of ARDS were included. The severity of critical illness on the day of enrolment, as measured by the Acute Physiology and Chronic Health Evaluation (APACHE) II score (P = 0.016), Sequential Organ Failure Assessment (SOFA) score (P = 0.027), and PaO 2 /FiO 2 (P = 0.000), worsened from mild to severe ARDS cases. Compared with survivors, non-survivors were significantly older and had higher APACHE II and SOFA scores. Moreover, significantly lower lymphocyte/neutrophil ratios and leukocyte counts were found among non-survivors than survivors (P = 0.008, P = 0.012). A moderate positive correlation between the lymphocyte/ neutrophil and PaO 2 /FiO 2 ratios (P = 0.023) was observed. In predicting 100-day survival in patients with ARDS, the area under the curve (AUC) for the lymphocyte/neutrophil ratio was significantly higher than those for the PaO 2 / FiO 2 ratio alone, body mass index (BMI) alone, and the lymphocyte count alone (P = 0.0062, 0.0001, and 0.0154). Age (per log 10 years), BMI < 24, SOFA score, leukocyte count, and the lymphocyte/neutrophil ratio were independent predictors of 28-day mortality in ARDS patients. Additionally, ARDS patients with a lymphocyte/ neutrophil ratio < 0.0537 had increased 28-day mortality rates (P = 0.0283). Old age affected both 28-day and 100day mortality rates (P = 0.0064,0.0057).

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confidence: 99%

Section: (Continued From Previous Page)mentioning

confidence: 99%

Section: (Continued From Previous Page)mentioning

confidence: 99%

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Prognostic factors for ARDS: clinical, physiological and atypical immunodeficiency

Song

Liu

et al. 2020

BMC Pulm Med

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“…Non-invasive ventilation (NIV) is frequently used as firstline respiratory support in HSCT patients [46]. However, early studies which showed a mortality benefit in immunosuppressed patients with using NIV compared to invasive mechanical ventilation were limited by relatively few numbers of HSCT patients and extremely high mortality in the control groups [47,48].…”

Section: Respiratory Viral Infection Is Common Aftermentioning

confidence: 99%

ICU Complications of Hematopoietic Stem Cell Transplant, Including Graft vs Host Disease

Stephens

2020

Evidence-Based Critical Care

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A 44 year-old woman with a history of acute myeloid leukemia (AML) underwent a non-myeloablative haploidentical peripheral blood hematopoietic stem cell transplant (HSCT) 10 days ago. She was admitted to the hospital with fevers to 39 °C. On examination, she is anxious-appearing, with a temperature of 38.9 °C, a heart rate of 120 beats/min, a respiratory rate of 28 breaths/min, a blood pressure of 98/64 mmHg, and an oxygen saturation of 94% on 4 L/min oxygen via nasal cannula. A tunneled central venous catheter is in situ in her right internal jugular vein. Her total white blood cell (WBC) count is <0.5 cells/mm 3 and platelet count is 8000 cells/mm 3 . A chest CT scan shows diffuse patchy bilateral infiltrates (Figure). She is started on empiric antibiotic coverage with piperacillin/tazobactam, and 3 L of crystalloid are administered. Several hours later, she is more hypotensive, with nadir systolic pressures of 80-88 mmHg, and is more hypoxic, now saturating 85% on 6 L/min nasal cannula oxygen. QuestionHow should this patient be managed?Answer Broad spectrum antibiotics and lung-protective respiratory support.All patients after HSCT are immunosuppressed, profoundly so in the early post-transplant period before engraftment has occurred. This patient is likely to have a pneumonia with secondary septic shock, but a central line-associated infection from her tunneled central line is possible, as are non-infectious complications of HSCT. Respiratory failure is the most frequent cause of intensive care unit (ICU) admission after HSCT, most frequently from an infectious cause. The patient was placed on high-flow nasal cannula (HFNC) for oxygenation support and started on a norepinephrine infusion for hemodynamic support. Antibacterial coverage was changed to meropenem, levofloxacin, and vancomycin, and voriconazole was added for antifungal coverage. Her central line was removed. Her respiratory status continued to decline, and endotracheal intubation and mechanical ventilation were required 24 h after admission. She was placed on volume assist-control with a tidal volume of 6 mL/kg predicted body weight, and bronchoscopy with bronchoalveolar lavage (BAL) was performed. The BAL fluid was initially bloody, but cleared with sequential aliquots. Microbiologic studies of the BAL fluid were positive for respiratory syncytial virus and Pseudomonas aeruginosa. She was maintained on low tidal-volume ventilation and vasopressors were weaned off. Her white blood cell count slowly began to recover, and her respiratory status began to improve. She was extubated on hospital day 12 and was discharged from the ICU on hospital day 14. Principles of ManagementHematopoietic stem cell transplant (HSCT) has become an essential therapeutic modality in the treatment of malignant and non-malignant hematologic disease. In 2016, more than 23,000 HSCTs were performed in the United States, including approximately 15,000 autologous HSCTs and more than 8500 allogeneic transplants [1]. Allogeneic transplants are associated with more morbidity and m...

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“…In this patient the pattern of infection by Pneumocystis jiroveci, Staphylococcus aureus/MSSA, Candida dubliniensis, Cytomegalovirus and Legionella pneumophila reflecst the compromised immune function. The mortality of immunosuppressed patients suffering ARDS is increased [1] regardless of the severity of the disease. Polimicrobial infections are seen regularly in immunocompromised critically ill patients.…”

Section: Introductionmentioning

confidence: 99%

A case report of fatal disseminated fungal sepsis in a patient with ARDS and extracorporeal membrane oxygenation

et al. 2020

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Background: With the following report we want to present an unusual case of a patient suffering from acute respiratory distress syndrome with early discovery of bacterial pathogens in bronchoalveolar liquid samples that developed a fatal undiscovered disseminated fungal infection. Case presentation: A 67-year-old man was admitted to our university hospital with dyspnea. Progressive respiratory failure developed leading to admission to the intensive care unit, intubation and prone positioning was necessary. To ensure adequate oxygenation and lung protective ventilation veno-venous extracorporeal membrane oxygenation was established. Despite maximal therapy and adequate antiinfective therapy of all discovered pathogens the condition of the patient declined further and he deceased. Postmortem autopsy revealed Mucor and Aspergillus mycelium in multiple organs such as lung, heart and pancreas as the underlying cause of his deterioration and death. Conclusion: Routine screening re-evaluation of every infection is essential for adequate initiation and discontinuation of every antiinfective therapy. In cases with unexplained deterioration and unsuccessful sampling the possibility for diagnostic biopsies should be considered.

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Immunocompromised patients with acute respiratory distress syndrome: secondary analysis of the LUNG SAFE database

Cited by 92 publications

References 36 publications

Prognostic factors for ARDS: clinical, physiological and atypical immunodeficiency

Prognostic factors for ARDS: clinical, physiological and atypical immunodeficiency

ICU Complications of Hematopoietic Stem Cell Transplant, Including Graft vs Host Disease

A case report of fatal disseminated fungal sepsis in a patient with ARDS and extracorporeal membrane oxygenation

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