Is immunosuppression status a risk factor for noninvasive ventilation failure in patients with acute hypoxemic respiratory failure? A post hoc matched analysis

Recent European/American guidelines recommend noninvasive ventilation (NIV) as a first-line therapy to manage acute hypoxemic respiratory failure in immunocompromised patients. By contrast, NIV may have deleterious effects in nonimmunocompromised patients and experts have been unable to offer a recommendation. Immunocompromised patients have particularly high mortality rates when they require intubation. However, it is not clear whether immunosuppression status is a risk factor for NIV failure. We assessed the impact of immunosuppression status on NIV failure in a post hoc analysis pooling two studies including patients with de novo acute hypoxemic respiratory failure treated with NIV. Patients with hypercapnia, acute exacerbation of chronic lung disease, cardiogenic pulmonary edema, or with do-not-intubate order were excluded.

Among the 208 patients included in the analysis, 71 (34%) were immunocompromised. They had higher severity scores upon ICU admission, higher pressure-support levels, and minute ventilation under NIV, and were more likely to have bilateral lung infiltrates than nonimmunocompromised patients. Intubation and in-ICU mortality rates were higher in immunocompromised than in nonimmunocompromised patients: 61% vs. 43% (p = 0.02) and 38% vs. 15% (p < 0.001), respectively. After adjustment or using a propensity score-matched analysis, immunosuppression was not associated with intubation, whereas it remained independently associated with ICU mortality with an adjusted odds ratio of 2.64 (95% CI 1.24–5.67, p = 0.01).

Immunosuppression status may directly influence mortality but does not seem to be associated with an increased risk of intubation in patients with de novo acute hypoxemic respiratory failure treated with NIV. Studies in this specific population are needed.