Effect of non-invasive oxygenation strategies in immunocompromised patients with severe acute respiratory failure: a post-hoc analysis of a randomised trial
Effect of non-invasive oxygenation strategies in immunocompromised patients with severe acute respiratory failure: a post-hoc analysis of a randomised trial
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DOI：
10.1016/s2213-2600(16)30093-5
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发表时间：
2016-08-01
影响因子：
76.2
通讯作者：
Thille, Arnaud W.
中科院分区：
文献类型：
--
作者：
Frat, Jean-Pierre;Ragot, Stephanie;Thille, Arnaud W.
背景：在急性呼吸衰竭的免疫功能低下患者中，无创通气的使用是有争议的，而高流量鼻插管氧治疗作为标准氧治疗的替代方案正在增长。我们的目的是比较免疫功能低下的急性呼吸衰竭患者接受标准氧治疗与单独使用高流量鼻插管氧治疗或高流量鼻插管氧联合无创通气治疗的结果。方法：我们对一组免疫功能低下的非高碳酸血症性急性呼吸衰竭患者进行了一项多中心、随机对照试验的事后亚组分析。在试验中，来自法国和比利时的23个重症监护病房的患者被随机分配（1:1:1）接受标准氧气，单独接受高流量鼻插管，或在无创通气期间间隔接受高流量鼻插管的无创通气（无创通气组）。重度中性粒细胞减少、急性慢性呼吸衰竭、心源性肺水肿、休克或意识改变的患者被排除在外。主要结局是随机分组后28天内需要气管插管的患者比例。结果82例免疫功能低下患者中，标准氧疗30例，单纯高流量鼻插管26例，无创通气加间隔高流量鼻插管26例。单独使用高流量鼻插管治疗的26例患者中有8例（31%），使用标准氧治疗的30例患者中有13例（43%），使用无创通气治疗的26例患者中有17例（65%）需要在28天插管（p=0.04）。采用无创通气治疗的患者插管的优势比（OR）高于采用高流量鼻插管治疗的患者：OR为4.25 （95% CI 1.33-13.56）。单纯高流量鼻插管与标准氧组的OR差异无统计学意义：OR为1.72（0.57-5.18）。经多变量logistic回归，与气管插管和死亡率独立相关的两个因素是年龄和使用无创通气作为一线治疗。无创通气可能与插管和死亡风险增加有关，在急性低氧性呼吸衰竭的免疫功能低下患者中应谨慎使用。
Background 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.Methods 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.Findings 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.Interpretation 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.