Ventilation fails immuno-compromised patients

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Among immuno-compromised patients admitted to the intensive care unit with hypoxemic (inadequate oxygenation of the blood) acute respiratory failure, early non-invasive ventilation compared with oxygen therapy alone did not reduce the risk of death at 28 days, according to a study.

The number of patients living with immune deficiencies is increasing steadily. These patients are at high risk for life-threatening complications, including acute respiratory failure warranting admission to the intensive care unit (ICU). Mortality in this situation has ranged from 40% to 90% and remains high, despite improvements in recent years. Non-invasive ventilation has been recommended to decrease mortality among immuno-compromised patients with hypoxemic acute respiratory failure. However, its effectiveness has been unclear, according to background information in the article.

Dr Elie Azoulay, of Saint-Louis University Hospital, Paris, and colleagues had 374 critically ill immuno-compromised patients randomly assigned to early non-invasive ventilation (n = 191) or oxygen therapy alone (n = 183). Of these patients, 317 (85 percent) were receiving treatment for haematologic malignancies or solid tumours. The trial was conducted at 28 ICUs in France and Belgium.

On day 28 after randomisation, 46 deaths (24%) had occurred in the non-invasive ventilation group vs 50 (27%) in the oxygen group. Oxygenation failure occurred in 155 patients overall (41%), 38% in the non-invasive ventilation group and 45% in the oxygen group. There were no significant differences in ICU-acquired infections, duration of mechanical ventilation, or lengths of ICU or hospital stays.

“In this multi-centre randomised trial enrolling critically ill immuno-compromised patients with acute respiratory failure, early non-invasive ventilation, compared with oxygen therapy alone, did not reduce the primary outcome of day-28 all-cause mortality, either overall or in any of the pre-specified subgroups,” the authors write. “However, study power was limited.”

Abstract
Importance: Noninvasive ventilation has been recommended to decrease mortality among immunocompromised patients with hypoxemic acute respiratory failure. However, its effectiveness for this indication remains unclear.
Objective: To determine whether early noninvasive ventilation improved survival in immunocompromised patients with nonhypercapnic acute hypoxemic respiratory failure.
Design, Setting, and Participants: Multicenter randomized trial conducted among 374 critically ill immunocompromised patients, of whom 317 (84.7%) were receiving treatment for hematologic malignancies or solid tumors, at 28 intensive care units (ICUs) in France and Belgium between August 12, 2013, and January 2, 2015.
Interventions: Patients were randomly assigned to early noninvasive ventilation (n = 191) or oxygen therapy alone (n = 183).
Main Outcomes and Measures: The primary outcome was day-28 mortality. Secondary outcomes were intubation, Sequential Organ Failure Assessment score on day 3, ICU-acquired infections, duration of mechanical ventilation, and ICU length of stay.
Results: At randomization, median oxygen flow was 9 L/min (interquartile range, 5-15) in the noninvasive ventilation group and 9 L/min (interquartile range, 6-15) in the oxygen group. All patients in the noninvasive ventilation group received the first noninvasive ventilation session immediately after randomization. On day 28 after randomization, 46 deaths (24.1%) had occurred in the noninvasive ventilation group vs 50 (27.3%) in the oxygen group (absolute difference, −3.2 [95% CI, −12.1 to 5.6]; P = .47). Oxygenation failure occurred in 155 patients overall (41.4%), 73 (38.2%) in the noninvasive ventilation group and 82 (44.8%) in the oxygen group (absolute difference, −6.6 [95% CI, −16.6 to 3.4]; P = .20). There were no significant differences in ICU-acquired infections, duration of mechanical ventilation, or lengths of ICU or hospital stays.
Conclusions and Relevance: Among immunocompromised patients admitted to the ICU with hypoxemic acute respiratory failure, early noninvasive ventilation compared with oxygen therapy alone did not reduce 28-day mortality. However, study power was limited.

JAMA material
JAMA abstract
JAMA editorial


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