title: Increased mortality in hematological malignancy patients with acute respiratory failure from undetermined etiology: a Groupe de Recherche en Réanimation Respiratoire en Onco-Hématologique (Grrr-OH) study.
abstract: BACKGROUND
  Acute respiratory failure (ARF) is the most frequent complication in patients with hematological malignancies and is associated with high morbidity and mortality. ARF etiologies are numerous, and despite extensive diagnostic workflow, some patients remain with undetermined ARF etiology.
  
  
  METHODS
  This is a post-hoc study of a prospective multicenter cohort performed on 1011 critically ill hematological patients. Relationship between ARF etiology and hospital mortality was assessed using a multivariable regression model adjusting for confounders.
  
  
  RESULTS
  This study included 604 patients with ARF. All patients underwent noninvasive diagnostic tests, and a bronchoscopy and bronchoalveolar lavage (BAL) was performed in 155 (25.6%). Definite diagnoses were classified into four exclusive etiological categories: pneumonia (44.4%), non-infectious diagnoses (32.6%), opportunistic infection (10.1%) and undetermined (12.9%), with corresponding hospital mortality rates of 40, 35, 55 and 59%, respectively. Overall hospital mortality was 42%. By multivariable analysis, factors associated with hospital mortality were invasive pulmonary aspergillosis (OR 7.57 (95% CI 3.06-21.62); p < 0.005), use of invasive mechanical ventilation (OR 1.65 (95% CI 1.07-2.55); p = 0.02), a SOFA score >7 (OR 3.32 (95% CI 2.15-5.15); p < 0.005) and an undetermined ARF etiology (OR 2.92 (95% CI 1.71-5.07); p < 0.005).
  
  
  CONCLUSIONS
  In patients with hematological malignancies and ARF, up to 13% remain with undetermined ARF etiology despite comprehensive diagnostic workup. Undetermined ARF etiology is independently associated with hospital mortality. Studies to guide second-line diagnostic strategies are warranted. ClinicalTrials.Gov NCT01172132.
authors: Réanimation médicale, Hôpital Saint Louis, APHP, Paris, France.
authors: Adrien
authors: A
authors: Contejean
authors: Réanimation médicale, Hôpital Saint Louis, APHP, Paris, France.
authors: Virginie
authors: V
authors: Lemiale
authors: Informatics and biostatistics, Hôpital Saint Louis, APHP, Paris, France.
authors: Matthieu
authors: M
authors: Resche-Rigon
authors: Réanimation, Institut Paoli Calmettes, Marseille, France.|Medical Intensive Care Unit, Hôpital Saint-Louis, ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology And Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Université Paris Diderot Sorbonne, 1, Avenue Claude Vellefaux, 75010, Paris, France.
authors: Djamel
authors: D
authors: Mokart
authors: Réanimation médicale, Hôpital Cochin, APHP, Paris, France.
authors: Frédéric
authors: F
authors: Pène
authors: Service de Reanimation Médicale et Médecine Hyperbare, CHU Angers, Angers, France.
authors: Achille
authors: A
authors: Kouatchet
authors: Service de Pneumologie et Réanimation, Groupe Hospitalier Pitié-Salpêtrière, APHP, Paris, France.
authors: Julien
authors: J
authors: Mayaux
authors: Réanimation polyvalente, Hôpital Avicenne, APHP, Bobigny, France.
authors: François
authors: F
authors: Vincent
authors: Réanimation polyvalente, Hôpital V.Provo, Roubaix, France.
authors: Martine
authors: M
authors: Nyunga
authors: Réanimation polyvalente, Hôpital de Versailles, Le Chesnay, France.
authors: Fabrice
authors: F
authors: Bruneel
authors: Réanimation médicale, Hôpital Cochin, APHP, Paris, France.
authors: Antoine
authors: A
authors: Rabbat
authors: Réanimation médicale, Hôpital Brabois, Nancy, France.
authors: Pierre
authors: P
authors: Perez
authors: Service des Soins Intensifs Medico-Chirurgicaux et Oncologie Thoracique, Institut Jules Bordet, Brussels, Belgium.
authors: Anne-Pascale
authors: AP
authors: Meert
authors: ICU, Ghent University Hospital, Ghent, Belgium.
authors: Dominique
authors: D
authors: Benoit
authors: Réanimation médicale, CHU de Grenoble, Grenoble, France.
authors: Rebecca
authors: R
authors: Hamidfar
authors: Réanimation polyvalente, CHU de Saint-Etienne, Saint-Piest-en-Jarrez, France.
authors: Michael
authors: M
authors: Darmon
authors: Réanimation polyvalente, CHRU de Lille, Lille, France.
authors: Mercé
authors: M
authors: Jourdain
authors: Réanimation et Urgences Médicales, CHU de la Cavale Blanche, Brest, France.
authors: Anne
authors: A
authors: Renault
authors: Réanimation médicale, Hôpital Saint Louis, APHP, Paris, France.
authors: Benoît
authors: B
authors: Schlemmer
authors: Réanimation médicale, Hôpital Saint Louis, APHP, Paris, France. elie.azoulay@aphp.fr.|Medical Intensive Care Unit, Hôpital Saint-Louis, ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology And Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Université Paris Diderot Sorbonne, 1, Avenue Claude Vellefaux, 75010, Paris, France. elie.azoulay@aphp.fr.
authors: Elie
authors: E
authors: Azoulay
keywords: Acute respiratory failure; Bronchoalveolar lavage; Diagnostic strategy; Etiologies; Hematological malignancies; Outcome