title: Effect of non-invasive oxygenation strategies in immunocompromised patients with severe acute respiratory failure: a post-hoc analysis of a randomised trial.
abstract: The use of non-invasive ventilation is controversial in immunocompromised patients with acute respiratory failure, whereas the use of high-flow nasal cannula oxygen therapy is growing as an alternative to standard oxygen. We aimed to compare outcomes of immunocompromised patients with acute respiratory failure treated with standard oxygen with those treated with high-flow nasal cannula oxygen alone or high-flow nasal cannula oxygen associated with non-invasive ventilation.
  
  
  
  We did a post-hoc subgroup analysis in a subset of immunocompromised patients with non-hypercapnic acute respiratory failure from a multicentre, randomised, controlled trial. In the trial, patients from 23 intensive care units in France and Belgium were randomly assigned (1:1:1) to receive either standard oxygen, high-flow nasal cannula alone, or non-invasive ventilation interspaced with high-flow nasal cannula between non-invasive ventilation sessions (non-invasive ventilation group). Patients with profound neutropenia, acute-on-chronic respiratory failure, cardiogenic pulmonary oedema, shock, or altered consciousness were excluded. The primary outcome was the proportion of patients who required endotracheal intubation within 28 days after randomisation.
  
  
  
  Of the 82 immunocompromised patients, 30 were treated with standard oxygen, 26 with high-flow nasal cannula alone, and 26 with non-invasive ventilation plus interspaced high-flow nasal cannula. 8 (31%) of 26 patients treated with high-flow nasal cannula alone, 13 (43%) of 30 patients treated with standard oxygen, and 17 (65%) of 26 patients treated with non-invasive ventilation required intubation at 28 days (p=0·04). Odds ratios (ORs) for intubation were higher in patients treated with non-invasive ventilation than in those treated with high-flow nasal cannula: OR 4·25 (95% CI 1·33-13·56). ORs were not significantly different between patients treated with high-flow nasal cannula alone and standard oxygen: OR 1·72 (0·57-5·18). After multivariable logistic regression, the two factors independently associated with endotracheal intubation and mortality were age and use of non-invasive ventilation as first-line therapy.
  
  
  
  Non-invasive ventilation might be associated with an increased risk of intubation and mortality and should be used cautiously in immunocompromised patients with acute hypoxaemic respiratory failure.
  
  
  
  French Ministry of Health, the French societies of intensive care (Société de Réanimation de Langue Française, SRLF) and pneumology (Société de Pneumologie de Langue Française, SPLF), La Mutuelle de Poitiers, AADAIRC (Association pour l'Assistance à Domicile Aux Insuffisants Respiratoires Chroniques), and Fisher&Paykel Healthcare.
authors.affiliation: CHU de Poitiers, Service de Réanimation Médicale, Poitiers, France; équipe 5 ALIVE, INSERM, CIC-1402, Poitiers, France; Faculté de Médecine et de Pharmacie de Poitiers, Universite de Poitiers, Poitiers, France. Electronic address: jean-pierre.frat@chu-poitiers.fr.
authors.forename: Jean-Pierre
authors.initials: JP
authors.lastname: Frat
authors.affiliation: Biostatistics, INSERM, CIC-1402, Poitiers, France; Faculté de Médecine et de Pharmacie de Poitiers, Universite de Poitiers, Poitiers, France.
authors.forename: Stéphanie
authors.initials: S
authors.lastname: Ragot
authors.affiliation: Department of Medical Intensive Care, Rouen University Hospital, Rouen, France; UPRES EA 3830-IRIB, Institute for Biomedical Research, Rouen University, Rouen, France.
authors.forename: Christophe
authors.initials: C
authors.lastname: Girault
authors.affiliation: CHU Clermont-Ferrand, Pôle de Médecine Périopératoire, Clermont-Ferrand, France; R2D2, EA-7281, Auvergne University, Clermont-Ferrand, France.
authors.forename: Sébastien
authors.initials: S
authors.lastname: Perbet
authors.affiliation: CHU de la Cavale Blanche, Service de Réanimation Médicale, Brest, France.
authors.forename: Gwénael
authors.initials: G
authors.lastname: Prat
authors.affiliation: Centre Hospitalier Régional d'Orléans, Réanimation médico-chirurgicale, Orléans, France.
authors.forename: Thierry
authors.initials: T
authors.lastname: Boulain
authors.affiliation: Groupe Hospitalier Universitaire Pitié Salpêtrieère, Service de Pneumologie et Réanimation Médicale, Paris, France; Université Pierre et Marie Curie, Paris, France.
authors.forename: Alexandre
authors.initials: A
authors.lastname: Demoule
authors.affiliation: Assistance Publique des Hôpitaux de Paris, Hôpital Louis Mourier, Service de Réanimation Médico-Chirurgicale, Colombes, France; Universite Paris Diderot, UMR IAME 1137, Sorbonne Paris Cité, Paris, France.
authors.forename: Jean-Damien
authors.initials: JD
authors.lastname: Ricard
authors.affiliation: CHU de Poitiers, Service de Réanimation Médicale, Poitiers, France; équipe 5 ALIVE, INSERM, CIC-1402, Poitiers, France; Faculté de Médecine et de Pharmacie de Poitiers, Universite de Poitiers, Poitiers, France.
authors.forename: Rémi
authors.initials: R
authors.lastname: Coudroy
authors.affiliation: CHU de Poitiers, Service de Réanimation Médicale, Poitiers, France; équipe 5 ALIVE, INSERM, CIC-1402, Poitiers, France; Faculté de Médecine et de Pharmacie de Poitiers, Universite de Poitiers, Poitiers, France.
authors.forename: René
authors.initials: R
authors.lastname: Robert
authors.affiliation: CHU Angers, Département de Réanimation Médicale et Médecine Hyperbare, Angers, France.
authors.forename: Alain
authors.initials: A
authors.lastname: Mercat
authors.affiliation: Keenan Research Centre and Critical Care Department, St Michael's Hospital, Toronto, ON, Canada; Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, ON, Canada.
authors.forename: Laurent
authors.initials: L
authors.lastname: Brochard
authors.affiliation: CHU de Poitiers, Service de Réanimation Médicale, Poitiers, France; équipe 5 ALIVE, INSERM, CIC-1402, Poitiers, France; Faculté de Médecine et de Pharmacie de Poitiers, Universite de Poitiers, Poitiers, France.
authors.forename: Arnaud W
authors.initials: AW
authors.lastname: Thille
mesh_terms: D000208:Acute Disease; D000368:Aged; D001530:Belgium; D000072601:Cannula / Q000706:statistics & numerical data; D005260:Female; D005602:France; D006801:Humans; D000860:Hypoxia / Q000209:etiology / Q000401:mortality / Q000628:therapy*; D007362:Intensive Care Units / Q000706:statistics & numerical data; D007442:Intubation, Intratracheal / Q000706:statistics & numerical data; D008297:Male; D008875:Middle Aged; D063087:Noninvasive Ventilation / Q000009:adverse effects* / Q000379:methods; D010102:Oxygen Inhalation Therapy / Q000379:methods*; D012131:Respiratory Insufficiency / Q000150:complications / Q000401:mortality / Q000628:therapy*; D016896:Treatment Outcome