Noninvasive Ventilation in Immunosuppressed Patients with Pulmonary Infiltrates, Fever, and Acute Respiratory Failure

Abstract

In selected immunosuppressed patients with pneumonitis and acute respiratory failure, early initiation of noninvasive ventilation is associated with significant reductions in the rates of endotracheal intubation and serious complications and an improved likelihood of survival to hospital discharge.

Early warning and prevention of pneumonia in acute leukemia by patient education, spirometry, and positive expiratory pressure: A randomized controlled trial

“…Effects are documented on morbidity and survival compared with endotracheal mechanical ventilation 38 and conventional oxygen delivery 39, 40; however conflicting results exist 41, 42, 43, 44. An RCT among hematological patients admitted to the ICU, showed that comprehensive 45‐minute noninvasive ventilation every 3 hr with face mask connected to a ventilator (CPAP/PEEP), in addition to oxygen therapy, can reduce the number of intubation cases and increase survival compared to initial oxygen therapy alone 45. The present study suggests that assisted breathing in a markedly lower volume may be beneficial in preventing pneumonia in this at‐risk population of AML during the pancytopenic phase of induction chemotherapy.…”

Non-invasive ventilation in patients with hematological malignancies: the saga continues, but where is the finale?

“…First, it should be kept in mind that interventional trials, even with correct randomization, may be flawed by imbalances in unmeasured, known or unknown, confounders between the treatment and control arm. This is of more concern when the study is smaller and the population under study more heterogeneous, as is the case in the study by Squadrone et al [9] and the two previous randomized trials [6,7]. In this light, the etiology of the underlying ARF is poorly defined in the present study population, although it is a major predictor of outcome [3-5, 10, 11] and is such an important potential confounder.…”

“…For instance, in the aforementioned study by Hilbert et al, patients in the NIV-treated arm tended to have a final diagnosis made by bronchoalveolar lavage more often compared to patients receiving oxygen support only (p = 0.09). Given the small sample size and an associated mortality of 38% in patients with final diagnosis as compared to 73% (p = 0.007) in those without, this imbalance may have in part favored the NIV-treated arm in this study [7]. By design, Squadrone et al excluded some known etiologies of ARF, such as COPD, cardiac failure, and evident infection, arriving at a study population consisting primarily of patients with ARF without a clear underlying cause [9].…”

“…Since noninvasive mechanical ventilation (NIV) has been shown to effectively reverse ARF without the need for intubation, and consequently improve survival, in that other category of patients with poor prognosis once intubated, i.e., the patient with chronic obstructive pulmonary disease (COPD) exacerbation, noninvasive modes of mechanical ventilatory support have been increasingly used in hematological patients with ARF. Two small interventional trials [6,7] randomizing immunocompromized patients (including hematological patients in one study [7]) with hypoxemia and diffuse pulmonary infiltrates between therapy with NIV and supportive oxygen only found reduced rates of intubation and better survival in the NIV-treated arm, and thus founded the main scientific rationale for the use of NIV in hematological patients with ARF. Observational studies provided more conflicting results, as some of these found an association between better survival and the use of NIV as compared with invasive ventilation [2], while others identified no such protective effect of NIV [4,5].…”

“…Similarly to two previous randomized controlled trials [6,7], this study compares a noninvasive mode of ventilator support, in this case continuous positive airway pressure (CPAP) delivered by the helmet interface, with standard supplemental oxygen in acute hypoxemic respiratory failure. The study population consisted exclusively of hematological patients, was performed at the hematological ward, and recruited patients in an even earlier, or less severe, phase of ARF as before, with PaO 2 /FiO 2 levels between 200 and 300 instead of below 200.…”