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Expert Rev Respir Med. 2018 Oct;12(10):867-880. doi: 10.1080/17476348.2018.1511430. Epub 2018 Aug 28.

The challenge of avoiding intubation in immunocompromised patients with acute respiratory failure.

Author information

1
a Medical Intensive Care Unit , University of Paris-Diderot, Saint Louis Hospital , Paris , France.
2
b Anesthesiology and Intensive Care; Anesthesia and Critical Care Department B , Saint Eloi Teaching Hospital, PhyMedExp, University of Montpellier , Montpellier , France.
3
c Service de Pneumologie et Réanimation Médicale , Groupe Hospitalier Pitié-Salpêtrière, Assistance Publique-Hôpitaux de Paris, INSERM et Université Pierre et Marie Curie , Paris , France.
4
d Réanimation Polyvalente et Département d'Anesthésie et de Réanimation , Institut Paoli-Calmettes , Marseille , France.
5
e ECSTRA Team, and Clinical Epidemiology , UMR 1153 (Center of Epidemiology and Biostatistics, Sorbonne Paris Cité, CRESS), INSERM, Paris Diderot Sorbonne University , Paris , France.

Abstract

A growing number of immunocompromised (IC) patients with acute hypoxemic respiratory failure (ARF) is admitted to the intensive care unit (ICU) worldwide. Areas covered: This review provides an overview of the current knowledge of the ways to prevent intubation in IC patients with ARF. Expert commentary: Striking differences oppose ARF incidence, characteristics, etiologies and management between IC and non-IC patients. Survival benefits have been reported with early admission to ICU in IC patients. Then, while managing hypoxemia and associated organ dysfunction, the identification of the cause of ARF will be guided by a rigorous clinical assessment at the bedside, further assisted by an invasive or noninvasive diagnostic strategy based on clinical probability for each etiology. Finally, the initial respiratory support aims to avoid mechanical ventilation for the many yet recognizing those patients for whom delaying intubation expose them to suboptimal management. We advocate for not using noninvasive ventilation (NIV) in this setting. A proper evaluation of High-flow nasal cannula oxygen (HFNC)  is required in IC patients as to demonstrate its superiority compared to standard oxygen therapy. Day-to-day decisions must strive to avoid delayed intubation, and make every effort to identify ARF etiology.

KEYWORDS:

Immunosuppression; leukemia; lymphoma; mechanical ventilation; neutropenia; noninvasive ventilation; oxygen

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