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

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

Expert Rev Respir Med. 2018 Aug 12;:

Authors: de Jong A, Calvet L, Lemiale V, Demoule A, Mokart D, Darmon M, Jaber S, Azoulay E

INTRODUCTION: A growing number of immunocompromised (IC) patients with acute hypoxemic respiratory failure (ARF) is admitted to the intensive care unit (ICU) worldwide. Initial management of these patients aims primarily to avoid invasive mechanical ventilation (IMV), while adequately managing hypoxemia. Areas covered: This review provides an overview of the current knowledge of the ways to prevent intubation in IC patients with ARF, including discussion about optimal timing of ICU admission, available respiratory support therapies and the best ways to identify ARF etiology. Expert commentary: Striking differences oppose ARF incidence, characteristics, aetiologies 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 as the results for the most recent trials are either neutral or harmful. NIV use in the most hypoxemic patients may be associated with increased mortality. High flow nasal cannula oxygen (HFNC) offers interesting physiological benefits and the results of its use in hypoxemic ARF are promising in non-IC patients. A proper evaluation of its use is required in IC patients as to demonstrate its superiority compared to standard oxygen therapy. Whatever the technique of oxygenation used, day-to-day decisions must strive to avoid delayed intubation, and at the same time make every effort to identify ARF aetiology.

PMID: 30101630 [PubMed - as supplied by publisher]

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