Examination of two therapies for critically ill immunocompromised patients with respiratory failure

Among immunocompromised patients admitted to the intensive care unit with hypoxemic (inadequate oxygenation of the blood) acute respiratory failure, early noninvasive ventilation compared with oxygen therapy alone did not reduce the risk of death at 28 days, according to a study appearing in JAMA. The study is being released to coincide with its presentation at the 28th annual congress of the European Society of Intensive Care Medicine.

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 percent to 90 percent and remains high, despite improvements in recent years. Noninvasive ventilation has been recommended to decrease mortality among immunocompromised patients with hypoxemic acute respiratory failure. However, its effectiveness has been unclear, according to background information in the article.

Elie Azoulay, M.D., Ph.D., of Saint-Louis University Hospital, Paris, and colleagues had 374 critically ill immunocompromised patients randomly assigned to early noninvasive ventilation (n = 191) or oxygen therapy alone (n = 183). Of these patients, 317 (85 percent) were receiving treatment for hematologic malignancies or solid tumors. The trial was conducted at 28 ICUs in France and Belgium.

On day 28 after randomization, 46 deaths (24 percent) had occurred in the noninvasive ventilation group vs 50 (27 percent) in the oxygen group. Oxygenation failure occurred in 155 patients overall (41 percent), 38 percent in the noninvasive ventilation group and 45 percent 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 multicenter randomized trial enrolling critically ill immunocompromised patients with acute respiratory failure, early noninvasive 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 prespecified subgroups," the authors write. "However, study power was limited."

Editorial: The Changing Landscape of Noninvasive Ventilation in the Intensive Care Unit

Bhakti K. Patel, M.D., and John P. Kress, M.D., of the University of Chicago, comment on this subject in an accompanying editorial.

"With additional efforts to continue to reduce the percentage of critically ill patients who require invasive mechanical ventilation, alternative strategies for noninvasive ventilation that minimize face mask leak, improve oxygenation, and decrease work of breathing with alternative interfaces such as high-flow nasal cannula will need further investigation."