COMMENTARY

Noninvasive Ventilation in the Immunocompromised Patient: Superior to Oxygen Alone?

Greg Martin, MD

Disclosures

January 19, 2016

Effect of Noninvasive Ventilation vs Oxygen Therapy on Mortality Among Immunocompromised Patients With Acute Respiratory Failure: A Randomized Clinical Trial

Lemiale V, Mokart D, Resche-Rigon M, et al; Groupe de Recherche en Réanimation Respiratoire du patient d'Onco-Hématologie (GRRR-OH)
JAMA. 2015;314:1711-1719

Study Summary

The use of noninvasive ventilation (NIV) has expanded in recent years. This ventilation strategy is now recommended for use in various acutely and critically ill patients. NIV is commonly used in immunocompromised patients, although without strong evidence of efficacy in reducing mortality. Lemiale and colleagues sought to determine whether NIV would benefit immunocompromised patients in nonhypercapnic respiratory failure.

This study was a multicenter, randomized controlled trial, conducted in 28 intensive care units (ICUs) in France. A total of 374 immunocompromised adult patients were randomly assigned to receive NIV or oxygen therapy alone, with a primary outcome of 28-day mortality. The 28-day mortality was 24.1% in the NIV group and 27.3% in the oxygen group (P = .47), and oxygenation failure occurred in 38.2% of the NIV group and 44.8% of the oxygen therapy group (P = .20). There were no significant between-group differences in rate of ICU-acquired infections, duration of mechanical ventilation, or length of ICU or hospital stay. The investigators concluded that for the management of immunocompromised ICU patients with acute hypoxemic respiratory failure, NIV is not superior to oxygen therapy alone.

Viewpoint

Immunocompromised patients are at high risk for critical illness, and especially acute respiratory failure. Mortality rates in these patients have ranged from 40% to 90%. Mortality is strongly predicted by the use of invasive mechanical ventilation, possibly because of the risks associated with this mode of ventilation. This has prompted clinicians to seek alternative ventilation strategies, such as NIV. In fact, use of NIV for immunocompromised patients with acute respiratory failure has been incorporated into some clinical practice guidelines.

A significant limitation of this study is the fact that nearly 85% of the study subjects were immunocompromised as a result of cancer therapy, as opposed to innate conditions or such acquired immunodeficiencies as HIV. Furthermore, the care of ICU patients continues to improve, and lower-than-expected mortality rates may have reduced the likelihood of reaching expected conclusions about the benefits of NIV. Those issues aside, this study examines an important question, although the results do not change clinical practice.

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