title: Noninvasive Ventilation in Patients With Hematologic Malignancy.
abstract: BACKGROUND
  Noninvasive ventilation (NIV) is commonly used as first-line therapy for immunocompromised patients with acute respiratory failure. However, it may not be appropriate for all patients, as failure of NIV and delayed endotracheal intubation (ETI) may increase mortality. We report our center's experience and outcomes for patients with active hematologic malignancy (HM) treated with NIV.
  
  
  METHODS
  We conducted a retrospective study of consecutive patients with HM who were admitted to the intensive care unit (ICU) of Mount Sinai Hospital for acute respiratory failure between January 1, 2010, and May 31, 2015, and were initially treated with NIV. We compared the characteristics of patients who were successfully treated with NIV and avoided intubation and those who failed NIV.
  
  
  RESULTS
  Seventy-nine patients (mean age 56 ± 14 years, mean Acute Physiology and Chronic Health Evaluation II score 27 ± 5) with HM were treated with NIV for acute respiratory failure. The etiology of respiratory failure was multifactorial in 31 (39%) patients, with features of pneumonia in 61 (77%) patients, severe sepsis or septic shock in 33 (42%) patients, and pulmonary edema in 24 (30%) patients. The majority of patients were admitted with acute leukemia (n = 60, 76%), 8 (10%) with lymphoma, and 11 (14%) with chronic leukemia, multiple myeloma, or myelodysplastic syndrome. Of the 79 patients treated with NIV, 44 (56%) failed NIV and required ETI, 7 (9%) had a do-not-intubate (DNI) order and died, and 28 (35%) avoided ETI. Compared with patients who avoided ETI, those who failed NIV or had a DNI order and died were more likely to have acute leukemia (84% vs 61%; P = .02) and at baseline had higher Paco2(39 vs 30; P = .038), higher fraction of inspired oxygen (Fio2) requirements (0.6 vs 0.4; P = .002), and more vasopressor use (31% vs 11%; P = .059). The ICU mortality was 42%; 3-month mortality was 57% overall and was significantly lower in the NIV success patients compared with the NIV failure group (21% vs 74%; P < .001).
  
  
  CONCLUSIONS
  Two-thirds of patients with HM and respiratory failure failed NIV and required ETI, and had high subsequent mortality. Patients who failed NIV had higher Paco2, higher Fio2, and a trend toward more vasopressor use.
authors.affiliation: 1 Department of Medicine, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Jiajia
authors.initials: J
authors.lastname: Liu
authors.affiliation: 2 National University of Ireland, Galway, Ireland.
authors.forename: Conor
authors.initials: C
authors.lastname: Bell
authors.affiliation: 3 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Vagia
authors.initials: V
authors.lastname: Campbell
authors.affiliation: 3 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Julian
authors.initials: J
authors.lastname: DeBacker
authors.affiliation: 3 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Erik
authors.initials: E
authors.lastname: Tamberg
authors.affiliation: 3 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Christie
authors.initials: C
authors.lastname: Lee
authors.affiliation: 3 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada.
authors.forename: Sangeeta
authors.initials: S
authors.lastname: Mehta
keywords: endotracheal intubation; hematologic malignancy; noninvasive ventilation; respiratory failure; risk factor