Acute hypoxemic respiratory failure in immunocompromised patients: the Efraim multinational prospective cohort study

for the Efraim investigators and the Nine-I study group

Research output: Contribution to journalArticle

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Abstract

Background: In immunocompromised patients with acute hypoxemic respiratory failure (ARF), initial management aims primarily to avoid invasive mechanical ventilation (IMV). Methods: To assess the impact of initial management on IMV and mortality rates, we performed a multinational observational prospective cohort study in 16 countries (68 centers). Results: A total of 1611 patients were enrolled (hematological malignancies 51.9%, solid tumors 35.2%, systemic diseases 17.3%, and solid organ transplantation 8.8%). The main ARF etiologies were bacterial (29.5%), viral (15.4%), and fungal infections (14.7%), or undetermined (13.2%). On admission, 915 (56.8%) patients were not intubated. They received standard oxygen (N = 496, 53.9%), high-flow oxygen (HFNC, N = 187, 20.3%), noninvasive ventilation (NIV, N = 153, 17.2%), and NIV + HFNC (N = 79, 8.6%). Factors associated with IMV included age (hazard ratio = 0.92/year, 95% CI 0.86–0.99), day-1 SOFA (1.09/point, 1.06–1.13), day-1 PaO2/FiO2 (1.47, 1.05–2.07), ARF etiology (Pneumocystis jirovecii pneumonia (2.11, 1.42–3.14), invasive pulmonary aspergillosis (1.85, 1.21–2.85), and undetermined cause (1.46, 1.09–1.98). After propensity score matching, HFNC, but not NIV, had an effect on IMV rate (HR = 0.77, 95% CI 0.59–1.00, p = 0.05). ICU, hospital, and day-90 mortality rates were 32.4, 44.1, and 56.4%, respectively. Factors independently associated with hospital mortality included age (odds ratio = 1.18/year, 1.09–1.27), direct admission to the ICU (0.69, 0.54–0.87), day-1 SOFA excluding respiratory score (1.12/point, 1.08–1.16), PaO2/FiO2 < 100 (1.60, 1.03–2.48), and undetermined ARF etiology (1.43, 1.04–1.97). Initial oxygenation strategy did not affect mortality; however, IMV was associated with mortality, the odds ratio depending on IMV conditions: NIV + HFNC failure (2.31, 1.09–4.91), first-line IMV (2.55, 1.94–3.29), NIV failure (3.65, 2.05–6.53), standard oxygen failure (4.16, 2.91–5.93), and HFNC failure (5.54, 3.27–9.38). Conclusion: HFNC has an effect on intubation but not on mortality rates. Failure to identify ARF etiology is associated with higher rates of both intubation and mortality. This suggests that in addition to selecting the appropriate oxygenation device, clinicians should strive to identify the etiology of ARF.

Original languageEnglish (US)
Pages (from-to)1808-1819
Number of pages12
JournalIntensive Care Medicine
Volume43
Issue number12
DOIs
StatePublished - Dec 1 2017

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Immunocompromised Host
Artificial Respiration
Respiratory Insufficiency
Cohort Studies
Prospective Studies
Mortality
Oxygen
Intubation
Odds Ratio
Invasive Pulmonary Aspergillosis
Pneumocystis carinii
Noninvasive Ventilation
Propensity Score
Pneumocystis Pneumonia
Mycoses
Organ Transplantation
Virus Diseases
Hematologic Neoplasms
Hospital Mortality
Equipment and Supplies

All Science Journal Classification (ASJC) codes

  • Critical Care and Intensive Care Medicine

Cite this

for the Efraim investigators and the Nine-I study group. / Acute hypoxemic respiratory failure in immunocompromised patients : the Efraim multinational prospective cohort study. In: Intensive Care Medicine. 2017 ; Vol. 43, No. 12. pp. 1808-1819.
@article{aeb3a74fe6014087abc140d9bf59ac8b,
title = "Acute hypoxemic respiratory failure in immunocompromised patients: the Efraim multinational prospective cohort study",
abstract = "Background: In immunocompromised patients with acute hypoxemic respiratory failure (ARF), initial management aims primarily to avoid invasive mechanical ventilation (IMV). Methods: To assess the impact of initial management on IMV and mortality rates, we performed a multinational observational prospective cohort study in 16 countries (68 centers). Results: A total of 1611 patients were enrolled (hematological malignancies 51.9{\%}, solid tumors 35.2{\%}, systemic diseases 17.3{\%}, and solid organ transplantation 8.8{\%}). The main ARF etiologies were bacterial (29.5{\%}), viral (15.4{\%}), and fungal infections (14.7{\%}), or undetermined (13.2{\%}). On admission, 915 (56.8{\%}) patients were not intubated. They received standard oxygen (N = 496, 53.9{\%}), high-flow oxygen (HFNC, N = 187, 20.3{\%}), noninvasive ventilation (NIV, N = 153, 17.2{\%}), and NIV + HFNC (N = 79, 8.6{\%}). Factors associated with IMV included age (hazard ratio = 0.92/year, 95{\%} CI 0.86–0.99), day-1 SOFA (1.09/point, 1.06–1.13), day-1 PaO2/FiO2 (1.47, 1.05–2.07), ARF etiology (Pneumocystis jirovecii pneumonia (2.11, 1.42–3.14), invasive pulmonary aspergillosis (1.85, 1.21–2.85), and undetermined cause (1.46, 1.09–1.98). After propensity score matching, HFNC, but not NIV, had an effect on IMV rate (HR = 0.77, 95{\%} CI 0.59–1.00, p = 0.05). ICU, hospital, and day-90 mortality rates were 32.4, 44.1, and 56.4{\%}, respectively. Factors independently associated with hospital mortality included age (odds ratio = 1.18/year, 1.09–1.27), direct admission to the ICU (0.69, 0.54–0.87), day-1 SOFA excluding respiratory score (1.12/point, 1.08–1.16), PaO2/FiO2 < 100 (1.60, 1.03–2.48), and undetermined ARF etiology (1.43, 1.04–1.97). Initial oxygenation strategy did not affect mortality; however, IMV was associated with mortality, the odds ratio depending on IMV conditions: NIV + HFNC failure (2.31, 1.09–4.91), first-line IMV (2.55, 1.94–3.29), NIV failure (3.65, 2.05–6.53), standard oxygen failure (4.16, 2.91–5.93), and HFNC failure (5.54, 3.27–9.38). Conclusion: HFNC has an effect on intubation but not on mortality rates. Failure to identify ARF etiology is associated with higher rates of both intubation and mortality. This suggests that in addition to selecting the appropriate oxygenation device, clinicians should strive to identify the etiology of ARF.",
author = "{for the Efraim investigators and the Nine-I study group} and Elie Azoulay and Peter Pickkers and Marcio Soares and Anders Perner and Jordi Rello and Bauer, {Philippe R.} and {van de Louw}, Andry and Pleun Hemelaar and Virginie Lemiale and Taccone, {Fabio Silvio} and {Martin Loeches}, Ignacio and Meyhoff, {Tine Sylvest} and Jorge Salluh and Peter Schellongowski and Katerina Rusinova and Nicolas Terzi and Sangeeta Mehta and Massimo Antonelli and Achille Kouatchet and Andreas Barratt-Due and Miia Valkonen and Landburg, {Precious Pearl} and Fabrice Bruneel and Bukan, {Ramin Brandt} and Fr{\'e}d{\'e}ric P{\`e}ne and Victoria Metaxa and Moreau, {Anne Sophie} and Virginie Souppart and Gaston Burghi and Christophe Girault and Silva, {Ulysses V.A.} and Luca Montini and Fran{\cc}ois Barbier and Nielsen, {Lene B.} and Benjamin Gaborit and Djamel Mokart and Sylvie Chevret and Antoine Rabbat and Isabelle Vinatier and Michael Darmon and Kada Klouche and Laura Platon and Alexandre Demoule and Julien Mayaux and Florent Wallet and Akli Chermak and Caroline Lemaitre and Elise Artaud-Macari and Jonas Nelsen and Moeller, {Ann M.}",
year = "2017",
month = "12",
day = "1",
doi = "10.1007/s00134-017-4947-1",
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}

Acute hypoxemic respiratory failure in immunocompromised patients : the Efraim multinational prospective cohort study. / for the Efraim investigators and the Nine-I study group.

In: Intensive Care Medicine, Vol. 43, No. 12, 01.12.2017, p. 1808-1819.

Research output: Contribution to journalArticle

TY - JOUR

T1 - Acute hypoxemic respiratory failure in immunocompromised patients

T2 - the Efraim multinational prospective cohort study

AU - for the Efraim investigators and the Nine-I study group

AU - Azoulay, Elie

AU - Pickkers, Peter

AU - Soares, Marcio

AU - Perner, Anders

AU - Rello, Jordi

AU - Bauer, Philippe R.

AU - van de Louw, Andry

AU - Hemelaar, Pleun

AU - Lemiale, Virginie

AU - Taccone, Fabio Silvio

AU - Martin Loeches, Ignacio

AU - Meyhoff, Tine Sylvest

AU - Salluh, Jorge

AU - Schellongowski, Peter

AU - Rusinova, Katerina

AU - Terzi, Nicolas

AU - Mehta, Sangeeta

AU - Antonelli, Massimo

AU - Kouatchet, Achille

AU - Barratt-Due, Andreas

AU - Valkonen, Miia

AU - Landburg, Precious Pearl

AU - Bruneel, Fabrice

AU - Bukan, Ramin Brandt

AU - Pène, Frédéric

AU - Metaxa, Victoria

AU - Moreau, Anne Sophie

AU - Souppart, Virginie

AU - Burghi, Gaston

AU - Girault, Christophe

AU - Silva, Ulysses V.A.

AU - Montini, Luca

AU - Barbier, François

AU - Nielsen, Lene B.

AU - Gaborit, Benjamin

AU - Mokart, Djamel

AU - Chevret, Sylvie

AU - Rabbat, Antoine

AU - Vinatier, Isabelle

AU - Darmon, Michael

AU - Klouche, Kada

AU - Platon, Laura

AU - Demoule, Alexandre

AU - Mayaux, Julien

AU - Wallet, Florent

AU - Chermak, Akli

AU - Lemaitre, Caroline

AU - Artaud-Macari, Elise

AU - Nelsen, Jonas

AU - Moeller, Ann M.

PY - 2017/12/1

Y1 - 2017/12/1

N2 - Background: In immunocompromised patients with acute hypoxemic respiratory failure (ARF), initial management aims primarily to avoid invasive mechanical ventilation (IMV). Methods: To assess the impact of initial management on IMV and mortality rates, we performed a multinational observational prospective cohort study in 16 countries (68 centers). Results: A total of 1611 patients were enrolled (hematological malignancies 51.9%, solid tumors 35.2%, systemic diseases 17.3%, and solid organ transplantation 8.8%). The main ARF etiologies were bacterial (29.5%), viral (15.4%), and fungal infections (14.7%), or undetermined (13.2%). On admission, 915 (56.8%) patients were not intubated. They received standard oxygen (N = 496, 53.9%), high-flow oxygen (HFNC, N = 187, 20.3%), noninvasive ventilation (NIV, N = 153, 17.2%), and NIV + HFNC (N = 79, 8.6%). Factors associated with IMV included age (hazard ratio = 0.92/year, 95% CI 0.86–0.99), day-1 SOFA (1.09/point, 1.06–1.13), day-1 PaO2/FiO2 (1.47, 1.05–2.07), ARF etiology (Pneumocystis jirovecii pneumonia (2.11, 1.42–3.14), invasive pulmonary aspergillosis (1.85, 1.21–2.85), and undetermined cause (1.46, 1.09–1.98). After propensity score matching, HFNC, but not NIV, had an effect on IMV rate (HR = 0.77, 95% CI 0.59–1.00, p = 0.05). ICU, hospital, and day-90 mortality rates were 32.4, 44.1, and 56.4%, respectively. Factors independently associated with hospital mortality included age (odds ratio = 1.18/year, 1.09–1.27), direct admission to the ICU (0.69, 0.54–0.87), day-1 SOFA excluding respiratory score (1.12/point, 1.08–1.16), PaO2/FiO2 < 100 (1.60, 1.03–2.48), and undetermined ARF etiology (1.43, 1.04–1.97). Initial oxygenation strategy did not affect mortality; however, IMV was associated with mortality, the odds ratio depending on IMV conditions: NIV + HFNC failure (2.31, 1.09–4.91), first-line IMV (2.55, 1.94–3.29), NIV failure (3.65, 2.05–6.53), standard oxygen failure (4.16, 2.91–5.93), and HFNC failure (5.54, 3.27–9.38). Conclusion: HFNC has an effect on intubation but not on mortality rates. Failure to identify ARF etiology is associated with higher rates of both intubation and mortality. This suggests that in addition to selecting the appropriate oxygenation device, clinicians should strive to identify the etiology of ARF.

AB - Background: In immunocompromised patients with acute hypoxemic respiratory failure (ARF), initial management aims primarily to avoid invasive mechanical ventilation (IMV). Methods: To assess the impact of initial management on IMV and mortality rates, we performed a multinational observational prospective cohort study in 16 countries (68 centers). Results: A total of 1611 patients were enrolled (hematological malignancies 51.9%, solid tumors 35.2%, systemic diseases 17.3%, and solid organ transplantation 8.8%). The main ARF etiologies were bacterial (29.5%), viral (15.4%), and fungal infections (14.7%), or undetermined (13.2%). On admission, 915 (56.8%) patients were not intubated. They received standard oxygen (N = 496, 53.9%), high-flow oxygen (HFNC, N = 187, 20.3%), noninvasive ventilation (NIV, N = 153, 17.2%), and NIV + HFNC (N = 79, 8.6%). Factors associated with IMV included age (hazard ratio = 0.92/year, 95% CI 0.86–0.99), day-1 SOFA (1.09/point, 1.06–1.13), day-1 PaO2/FiO2 (1.47, 1.05–2.07), ARF etiology (Pneumocystis jirovecii pneumonia (2.11, 1.42–3.14), invasive pulmonary aspergillosis (1.85, 1.21–2.85), and undetermined cause (1.46, 1.09–1.98). After propensity score matching, HFNC, but not NIV, had an effect on IMV rate (HR = 0.77, 95% CI 0.59–1.00, p = 0.05). ICU, hospital, and day-90 mortality rates were 32.4, 44.1, and 56.4%, respectively. Factors independently associated with hospital mortality included age (odds ratio = 1.18/year, 1.09–1.27), direct admission to the ICU (0.69, 0.54–0.87), day-1 SOFA excluding respiratory score (1.12/point, 1.08–1.16), PaO2/FiO2 < 100 (1.60, 1.03–2.48), and undetermined ARF etiology (1.43, 1.04–1.97). Initial oxygenation strategy did not affect mortality; however, IMV was associated with mortality, the odds ratio depending on IMV conditions: NIV + HFNC failure (2.31, 1.09–4.91), first-line IMV (2.55, 1.94–3.29), NIV failure (3.65, 2.05–6.53), standard oxygen failure (4.16, 2.91–5.93), and HFNC failure (5.54, 3.27–9.38). Conclusion: HFNC has an effect on intubation but not on mortality rates. Failure to identify ARF etiology is associated with higher rates of both intubation and mortality. This suggests that in addition to selecting the appropriate oxygenation device, clinicians should strive to identify the etiology of ARF.

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