Outcomes for patients with cancer admitted to the ICU requiring ventilatory support: results from a prospective multicenter study. Ventilatory support in critically ill hematology patients with respiratory failure Noninvasive ventilation for treating acute respiratory failure in AIDS patients with Pneumocystis carinii pneumonia Noninvasive ventilation for treatment of acute respiratory failure in patients undergoing solid organ transplantation: a randomized trial. Acute respiratory distress syndrome in patients with hematological malignancies Hematologic malignancies in the medical intensive care unit – Outcomes and prognostic factors Effect of Noninvasive Ventilation vs Oxygen Therapy on Mortality Among Immunocompromised Patients With Acute Respiratory Failure: A Randomized Clinical Trial. A multiple‐center survey on the use in clinical practice of noninvasive ventilation as a first‐line intervention for acute respiratory distress syndrome* Non-invasive pressure support ventilation in patients with acute respiratory failure after bilateral lung transplantation New puzzles for the use of non-invasive ventilation for immunosuppressed patients. Human and financial costs of noninvasive mechanical ventilation in patients affected by COPD and acute respiratory failure. Noninvasive pressure-support ventilation in immunocompromised children with ARDS: a feasibility study Physiological response to pressure support ventilation delivered before and after extubation in patients not capable of totally spontaneous autonomous breathing. Early use of non-invasive ventilation for acute exacerbations of chronic obstructive pulmonary disease on general respiratory wards: a multicentre randomised controlled trial Noninvasive versus invasive ventilation for acute respiratory failure in patients with hematologic malignancies: A 5-year multicenter observational survey* Noninvasive ventilation in immunosuppressed patients with pulmonary infiltrates, fever, and acute respiratory failure. Reversal of acute exacerbations of chronic obstructive lung disease by inspiratory assistance with a face mask. Noninvasive ventilation in severe hypoxemic respiratory failure: a randomized clinical trial. A new Simplified Acute Physiology Score (SAPS II) based on a European/North American multicenter study. Noninvasive continuous positive airway pressure in neutropenic patients with acute respiratory failure requiring intensive care unit admission The Prognosis of Acute Respiratory Failure in Critically Ill Cancer Patients
BACKGROUND This study was undertaken to evaluate the clinical characteristics and outcomes of patients with cancer requiring nonpalliative ventilatory support . METHODS This was a secondary analysis of a prospect i ve cohort study conducted in 28 Brazilian ICUs evaluating adult patients with cancer requiring invasive mechanical ventilation ( MV ) or noninvasive ventilation ( NIV ) during the first 48 h of their ICU stay . We used logistic regression to identify the variables associated with hospital mortality . RESULTS Of 717 patients , 263 ( 37 % ) ( solid tumors = 227 ; hematologic malignancies = 36 ) received  ventilatory support . NIV was initially used in 85 patients ( 32 % ) , and 178 ( 68 % ) received MV . Additionally , NIV followed by MV occurred in 45 patients ( 53 % ) . Hospital mortality rates were 67 % in all patients , 40 % in patients receiving NIV only , 69 % when NIV was followed by MV , and 73 % in patients receiving MV only ( P < .001 ) . Adjusting for the type of admission , newly diagnosed malignancy ( OR , 3.59 ; 95 % CI , 1.28 - 10.10 ) , recurrent or progressive malignancy ( OR , 3.67 ; 95 % CI , 1.25 - 10.81 ) , tumoral airway involvement ( OR , 4.04 ; 95 % CI , 1.30 - 12.56 ) , performance status ( PS ) 2 to 4 ( OR , 2.39 ; 95 % CI , 1.24 - 4.59 ) , NIV followed by MV ( OR , 3.00 ; 95 % CI , 1.09 - 8.18 ) ,  MV  as initial ventilatory strategy ( OR , 3.53 ; 95 % CI , 1.45 - 8.60 ) , and Sequential Organ Failure Assessment score ( each point except the respiratory domain ) ( OR , 1.15 ; 95 % CI , 1.03 - 1.29 ) were associated with hospital mortality . Hospital survival in patients with good PS and nonprogressive malignancy and without tumoral airway involvement was 53 % . Conversely , patients with poor functional capacity and cancer progression had unfavorable outcomes . CONCLUSIONS Patients with cancer with good PS and nonprogressive disease requiring ventilatory support should receive full intensive care , because one-half of these patients survive . On the other h and , provision of palliative care should be considered the main goal for patients with poor PS and progressive underlying malignancy Introduction Hematology patients admitted to the ICU frequently experience respiratory failure and require mechanical ventilation . Noninvasive mechanical ventilation ( NIMV ) may decrease the risk of intubation , but NIMV failure poses its own risks . Methods To establish the impact of ventilatory management and NIMV failure on outcome , data from a prospect i ve , multicenter , observational study were analyzed . All hematology patients admitted to one of the 34 participating ICUs in a 17-month period were followed up . Data on demographics , diagnosis , severity , organ failure , and supportive therapies were recorded . A logistic regression analysis was done to evaluate the risk factors associated with death and NIVM failure . Results Of 450 patients , 300 required ventilatory support  . A diagnosis of congestive heart failure and the initial use of NIMV significantly improved survival , whereas APACHE II score , allogeneic transplantation , and NIMV failure increased the risk of death . The risk factors associated with NIMV success were age , congestive heart failure , and bacteremia . Patients with NIMV failure experienced a more severe respiratory impairment than did those electively intubated . Conclusions NIMV improves the outcome of hematology patients with respiratory insufficiency , but NIMV failure may have the opposite effect . A careful selection of patients with rapidly reversible causes of respiratory failure may increase NIMV success Objective . To compare noninvasive positive pressure ventilation ( NPPV ) vs. invasive mechanical ventilation in AIDS patients with Pneumocystis carinii pneumonia (PCP)-related acute respiratory failure ( ARF ) . Design : A single-center , prospect i ve , case-control trial . Setting : An ICU of a private tertiary hospital specialized in infectious disease . Patients : Forty-eight AIDS patients with severe PCP-related ARF needing mechanical ventilation . Interventions : Twenty-four patients treated with NPPV by a facial mask strictly matched with 24 patients treated with invasive ventilation by endotracheal intubation . Results : Use of NPPV  avoided intubation in 67 % of patients , and avoidance of intubation was associated with improved survival ( 100 % vs. 38 % ; P=0.003 ) . NPPV-treated patients required fewer invasive devices ( P<0.001 ) and had a lower incidence of pneumothoraces ( 8.3 % vs. 37.5 % ; P=0.039 ) . The NPPV-treated group required a nurse workload similar to that of the conventional ventilation group , but this group had a shorter duration of stay in the ICU ( P=0.013 ) . The NPPV-treated group had a lower mortality in the ICU , the hospital and within 2 months of study entry . Differences in mortality between the two groups disappeared after 6 months . Conclusions : The findings of this study seem to provide further support for applying NPPV in AIDS patients with severe PCP-related ARF as a first-line therapeutic choice , but r and omized controlled trials are required to confirm our results CONTEXT Noninvasive ventilation ( NIV ) has been associated with lower rates of endotracheal intubation in population s of patients with acute respiratory failure . OBJECTIVE To compare NIV with st and ard treatment using supplemental oxygen administration to avoid endotracheal intubation in recipients of solid organ transplantation with acute hypoxemic respiratory failure . DESIGN AND SETTING Prospect i ve r and omized study conducted at a 14-bed , general intensive care unit of a university hospital . PATIENTS Of 238 patients who underwent solid organ transplantation from December 1995 to October 1997 , 51 were treated for acute respiratory failure . Of these , 40 were eligible and 20 were r and omized to each group . INTERVENTION Noninvasive ventilation vs st and ard treatment with supplemental oxygen administration . MAIN OUTCOME MEASURES The need for endotracheal intubation and mechanical ventilation at any time during the study , complications not present on admission , duration of ventilatory assistance , length of hospital stay , and intensive care unit mortality . RESULTS The 2 groups were similar at study entry . Within the first hour of treatment , 14 patients ( 70 % ) in the NIV group , and 5 patients ( 25 % ) in the st and ard treatment group improved their ratio of the PaO2 to the fraction of inspired oxygen ( FIO2 ) . Over time , a sustained improvement in PaO2 to FIO2 was noted in 12 patients ( 60 % ) in the NIV group , and in 5 patients ( 25 % ) r and omized to st and ard treatment ( P = .03 ) . The use of NIV was associated with a significant reduction in the rate of endotracheal intubation ( 20 % vs 70 % ; P = .002 ) , rate of fatal complications ( 20 % vs 50 % ; P = .05 ) , length of stay in the intensive care unit by survivors ( mean [ SD ] days , 5.5 [ 3 ] vs 9 [ 4 ] ; P = .03 ) , and intensive care unit mortality ( 20 % vs 50 % ; P = .05 ) . Hospital mortality did not differ . CONCLUSIONS These results indicate that transplantation programs should consider NIV in the treatment of selected recipients of transplantation with acute respiratory failure Abstract Background We investigated the clinical course and mortality of acute respiratory distress syndrome ( ARDS ) in patients with hematological malignancies . Methods Sixty-eight patients with hematological malignancies and ARDS admitted to medical intensive care unit ( ICU ) of a university hospital were analyzed semi- prospect ively in the study . Results The most common etiology of ARDS was pneumonia . The ratio of partial pressure of oxygen in arterial blood to fractional concentration of inspired oxygen ( PO2/FiO2 ) was 104 ( 74–165 ) . Ten patients ( 15 % ) received non-invasive mechanical ventilation ( NIV ) , 21 ( 31 % ) received invasive mechanical ventilation ( MV ) , and 36 ( 53 % ) received both NIV and invasive MV .  ICU mortality was 77 % in the cohort . None of the variables with relevance to the underlying hematological disease was associated with mortality . The presence of two or more organ failures was the only independent risk factor for mortality ( P = 0.045 ) , whereas NIV was associated with low mortality ( P = 0.001 ) . The Kaplan – Meier curve of mortality , with respect to the type of MV support , demonstrated that NIV was associated with the lowest mortality ( P < 0.001 ) . Conclusion The mortality of ARDS in critically ill patients with hematological malignancies is quite high . The presence of multi-organ failure is independently associated with high mortality whereas the use of NIV is independently associated with low mortality Abstract Objectives To analyze clinical characteristics , treatment , outcomes of critically ill patients with hematologic malignancies ( HM ) admitted to the medical intensive care unit ( ICU ) and to identify predictors of adverse outcome . Methods We analyzed prospect ively 170 patients . Data included : demographic characteristics , hematologic diagnosis , reasons for ICU admission , transplant status , the presence of neutropenia , acute physiology and chronic health evaluation-II and sequential organ failure assessment scores , and level of organ support . Predictors of ICU mortality were evaluated using univariate and multivariate analysis . Results In total , 73 % of patients had high- grade malignancy , 47.6 % received intensive chemotherapy before admission , and 30 % underwent hematologic stem cell transplantation procedure . In total , 116 ( 68.2 % ) of patients were mechanically ventilated ; 88 ( 51.8 % ) required invasive mechanical ventilation ( MV ) . Non-invasive ventilation started in 28 ( 16.5 % ) patients and was successful in 11 ( 6.5 % ) . The ICU mortality rate was 53.5 % , and the mortality of MV patients was 75.9 % . Need for vasopressors at admission and MV were identified as independent predictors of fatal outcome . Conclusion The ICU mortality of critically ill patients with HM is high , particularly in the group of MV . Need for vasopressors at admission and MV were independent predictors of ICU mortality . Majority of patients required invasive MV due to severe respiratory failure and non-invasive MV was sufficient only in small number of cases with favorable outcome IMPORTANCE Noninvasive ventilation has been recommended to decrease mortality among immunocompromised patients with hypoxemic acute respiratory failure . However , its effectiveness for this indication remains unclear . OBJECTIVE To determine whether early noninvasive ventilation improved survival in immunocompromised patients with nonhypercapnic acute hypoxemic respiratory failure . DESIGN , SETTING , AND PARTICIPANTS Multicenter r and omized trial conducted among 374 critically ill immunocompromised patients , of whom 317 ( 84.7 % ) were receiving treatment for hematologic malignancies or solid tumors , at 28 intensive care units ( ICUs ) in France and Belgium between August 12 , 2013 , and January 2 , 2015 . INTERVENTIONS Patients were r and omly assigned to early noninvasive ventilation ( n = 191 ) or oxygen therapy alone ( n = 183 ) . MAIN OUTCOMES AND MEASURES The primary outcome was day-28 mortality . Secondary outcomes were intubation , Sequential Organ Failure Assessment score on day 3 , ICU-acquired infections , duration of mechanical ventilation , and ICU length of stay . RESULTS At r and omization , median oxygen flow was 9 L/min ( interquartile range , 5 - 15 ) in the noninvasive ventilation group and 9 L/min ( interquartile range , 6 - 15 ) in the oxygen group . All patients in the noninvasive ventilation group received the first noninvasive ventilation session immediately after r and omization . On day 28 after r and omization , 46 deaths ( 24.1 % ) had occurred in the noninvasive ventilation group vs 50 ( 27.3 % ) in the oxygen group ( absolute difference , -3.2 [ 95 % CI , -12.1 to 5.6 ] ; P = .47 ) . Oxygenation failure occurred in 155 patients overall ( 41.4 % ) , 73 ( 38.2 % ) in the noninvasive ventilation group and 82 ( 44.8 % ) in the oxygen group ( absolute difference , -6.6 [ 95 % CI , -16.6 to 3.4 ] ; P = .20 ) . There were no significant differences in ICU-acquired infections , duration of mechanical ventilation , or lengths of ICU or hospital stays . CONCLUSIONS AND RELEVANCE Among immunocompromised patients admitted to the ICU with hypoxemic acute respiratory failure , early noninvasive ventilation compared with oxygen therapy alone did not reduce 28-day mortality . However , study power was limited . TRIAL REGISTRATION clinical trials.gov Identifier : NCT01915719 Objective : In r and omized studies of heterogeneous patients with hypoxemic acute respiratory failure , noninvasive positive pressure ventilation ( NPPV ) was associated with a significant reduction in endotracheal intubation . The role of NPPV in patients with acute respiratory distress syndrome ( ARDS ) is still unclear . The objective was to investigate the application of NPPV as a first‐line intervention in patients with early ARDS , describing what happens in everyday clinical practice in centers having expertise with NPPV . Design : Prospect i ve , multiple‐center cohort study . Setting : Three European intensive care units having expertise with NPPV . Patients : Between March 2002 and April 2004 , 479 patients with ARDS were admitted to the intensive care units . Three hundred and thirty‐two ARDS patients were already intubated , so 147 were eligible for the study . Interventions : Application of NPPV . Measurements and Main Results : NPPV  improved gas exchange and avoided intubation in 79 patients ( 54 % ) . Avoidance of intubation was associated with less ventilator‐associated pneumonia ( 2 % vs. 20 % ; p < .001 ) and a lower intensive care unit mortality rate ( 6 % vs. 53 % ; p < .001 ) . Intubation was more likely in patients who were older ( p = .02 ) , had a higher Simplified Acute Physiology Score ( SAPS ) II ( p < .001 ) , or needed a higher level of positive end‐expiratory pressure ( p = .03 ) and pressure support ventilation ( p = .02 ) . Only SAPS II > 34 and a Pao2/Fio2 ≤175 after 1 hr of NPPV were independently associated with NPPV failure and need for endotracheal intubation . Conclusions : In expert centers , NPPV applied as first‐line intervention in ARDS avoided intubation in 54 % of treated patients . A SAPS II > 34 and the inability to improve Pao2/Fio2 after 1 hr of NPPV were predictors of failure Abstract . Objective : To evaluate non-invasive ventilation ( NIV ) prospect ively in a group of patients developing acute respiratory failure ( ARF ) after bilateral lung transplantation ( BLT ) . Setting : General intensive care unit ( ICU ) of Rome " La Sapienza " University . Patients : Twenty-one patients ( 18 with cystic fibrosis ) undergoing BLT . Results : All consecutive patients developing ARF ( according to predefined criteria ) and requiring ventilatory support , received non-invasive pressure support ventilation through a face-mask ( PEEP 5 cmH2O , PSV 14±2 cmH2O ) for a mean period of 5±4 days . Eighteen out of 21 patients avoided intubation and were discharged from the ICU ; 3 patients required intubation : 1 of them survived while 2 developed septic shock and died . Conclusions : NIV administration was well tolerated and avoided intubation in the large majority of patients ( 86 % ) ; in NIV responders the rate of complications was low and ICU mortality nil . NIV should be considered as an interesting alternative to conventional ventilation in patients who require ventilatory support after BLT On October 27 , 2015 , Lemile and colleagues published an article in JAMA entitled " Effect of Noninvasive Ventilation vs. Oxygen Therapy on Mortality among Immunocompromised Patients with Acute Respiratory Failure : A R and omized Clinical Trial " , which investigated the effects of non-invasive ventilation ( NIV ) in 28-day mortality of 374 critically ill immunosuppressed patients . The authors found that among immunosuppressed patients admitted to the intensive care unit ( ICU ) with hypoxemic acute respiratory failure , early NIV compared with oxygen therapy alone did not reduce 28-day mortality . Furthermore , different from the previous publications , there were no significant differences in ICU-acquired infections , duration of mechanical ventilation , or lengths of ICU or hospital stays . The study power was limited , median oxygen flow used was higher than used before or 9 L/min , NIV setting s provided tidal volumes higher than what is considered protective nowadays or from 7 to 10 mL/kg of ideal body weight and the hypoxemic respiratory failure was moderate to severe ( median PaO2/FIO2 was around 140 ) , a group prone to failure in noninvasive ventilatory support . Doubts arose regarding the early use of NIV in immunosuppressed critically ill patients with non-hypercapnic hypoxemic respiratory failure that need to be solved in the near future STUDY OBJECTIVES It has been suggested that noninvasive mechanical ventilation ( NIMV ) may be a time-consuming procedure for medical and paramedical personnel . We carried out a prospect i ve trial in 10 consecutive COPD patients aim ed at assessing the human and economic re sources needed to ventilate patients by NIMV and we compared these with those needed by a group of six patients receiving invasive mechanical ventilation ( InMV ) .  DESIGN The daily cost and the minutes spent by medical doctors ( MDs ) , respiratory therapists ( RTs ) , and nurses ( Ns ) were recorded during the first 48 h of ventilation in 10 patients during NIMV ( group A ) and in six who received InMV ( group B ) after an initial unsuccessful attempt with NIMV . In two subgroups of patients ( five for group A and four for group B ) , the analysis was also performed , except for RTs , for the total length of mechanical ventilation . SETTING A respiratory ICU . PATIENTS At hospital admission , the two groups of COPD patients did not differ for blood gas values ( PaCO2 = 88.2+/-9.8 mm Hg for group A vs 90.5+/-12.8 mm Hg for group B , and pH = 7.21 + 0.08 vs 7.20 + 0.08 , respectively ) or for clinical and neurologic status , but patients of group B had not tolerated NIMV . MEASUREMENTS AND RESULTS The total time spent at the bedside in the first 6 h did not differ between group A and B ( group A = 72.3 min [ MD ] , 87.2 min [ RT ] , and 178.8 min [ N ] vs 98.8 min [ MD ] , 12.5 min [ RT ] , and 197.6 min [ N ] for group B ) . In the following 42 h , a plateau was reached so that there was a significant reduction for both groups in the time of assistance given by Ns ( p<0.001 ) but not by MDs or RTs . The total costs were also not different between the two groups ( $ 806+/-73 [ US dollars per day ] vs $ 864+/-44 for group A and B , respectively ) . In the subgroups monitored for the entire period of ventilation , a significant reduction in the time of assistance , for both MDs and Ns , was observed after approximately the first half . CONCLUSIONS We conclude that in the first 48 h of ventilation , daily NIMV is neither more expensive nor time-consuming and staff dem and ing than InMV . After the first few days of ventilation , NIMV was significantly less time-consuming than InMV , for MDs and Ns , so that medical and paramedical time expenditure seems not to be a major problem during NIMV Objective To verify the feasibility of non-invasive ventilation ( NIV ) in immunocompromised children affected by ARDS . Setting University Hospital PICU . Patients Twenty-three consecutive immunocompromised children treated with NIV for ARDS . Interventions All consecutive patients received NIV through a face-mask or a helmet . Results No differences were found regarding admission data and severity scores between NIV responders and non-responders . Early and sustained improvement in PaO2/FiO2 ratio were observed in 82 and 74 % of cases , respectively . 13 out of 23 patients ( 54.5 % ) avoided intubation and were discharged from the PICU ; ten patients required intubation : two of them survived and eight patients died ( two refractory hypoxemia , three septic shock , three multi-organ failure ) . PICU and intra-hospital mortality was significantly higher for NIV-nonresponders ( P < 0.001 ) . PICU stay was significantly shorter for NIV responders ( P = 0.03 ) . NIV responders had significantly lower heart and respiratory rate at the end of treatment ( P < 0.001 and P = 0.048 , respectively ) . Conclusions NIV administration is feasible and well tolerated in immunocompromised children with ARDS . A short NIV trial can be used to verify the usefulness of the technique . A r and omized controlled trial is needed to confirm the efficacy of NIV in immunocompromised children requiring ventilatory support for ARDS We design ed a prospect i ve , physiological study in 12 patients affected by chronic respiratory disorders . The study was aim ed at assessing the diaphragm energy expenditure ( PTPdi ) , lung resistance ( RL ) and elastance ( EL ) , arterial blood gases ( ABG ) , breathing pattern , and dyspnea measured by a visual analog scale during invasive pressure support ventilation ( i-PSV ) and noninvasive PSV ( n-PSV ) . The ventilator setting s were kept the same . Both i-PSV and n-PSV significantly reduced the PTPdi per minute , compared with that during a T-piece trial ( 204.4 + /- 93.8 cm H(2)O x s/min [ i-PSV ] ; 197.5 + /- 119.8 [ n-PSV ] ; 393.8 + /- 129.0 [ T-piece ] ) . Expired tidal volume ( VTe ) was significantly higher ( p < 0.05 ) during n-PSV ( 615 + /- 166 ml ) than during i-PSV ( 519 + /- 140 ml ) . The respiratory pump ( PTPdi/VTe ) was more effective ( p < 0.05 ) with noninvasive ventilation ( 22.3 + /- 2.3 cm H(2)O x s/L for i-PSV versus 17.2 + /- 3.3 for n-PSV ) . RL and EL were similar with the two modes of ventilation . Overall dyspnea was significantly ( p < 0.05 ) better during n-PSV than i-PSV , whereas ABG were similar . We have shown , in patients affected by stable chronic respiratory disorders not ready to sustain totally spontaneous breathing , that i-PSV and n-PSV are equally effective in reducing the PTPdi and in improving ABG , but that n-PSV seems to be better tolerated BACKGROUND Within the intensive-care unit , non-invasive ventilation ( NIV ) can prevent the need for intubation and the mortality associated with severe episodes of chronic obstructive pulmonary disease ( COPD ) . The aim of this study was to find whether the introduction of NIV , early after the admission on a general respiratory ward , was effective at reducing the need for intubation and the mortality associated with acute exacerbations of COPD . METHODS We did a prospect i ve multicentre r and omised controlled study comparing NIV with st and ard therapy in patients with mild to moderate acidosis .  NIV was administered on the ward with a simple non-invasive ventilator and a st and ardised predefined protocol . Patients were recruited from 14 UK hospitals over 22 months . FINDINGS 236 patients were recruited , 118 received st and ard therapy alone and 118 additional NIV . The two groups had similar characteristics at enrolment . The use of NIV significantly reduced the need for intubation as defined by the failure criteria . 32/118 ( 27 % ) of the st and ard group failed compared with 18/118 ( 15 % ) of the NIV group ( p=0.02 ) . In-hospital mortality was also reduced by NIV , 24/118 ( 20 % ) died in the st and ard group compared with 12/118 ( 10 % ) in the NIV group ( p=0.05 ) . In both groups pH , PaCO2 , and respiratory rate improved at 4 h ( p<0.01 ) . However , NIV led to a more rapid improvement in pH in the first hour ( p=0.02 ) and a greater fall in respiratory rate at 4 h ( p=0.035 ) . The duration of breathlessness was also reduced by NIV ( p=0.025 ) . INTERPRETATION The early use of NIV for mildly and moderately acidotic patients with COPD in the general ward setting leads to more rapid improvement of physiological variables , a reduction in the need for invasive mechanical ventilation ( with objective criteria ) , and a reduction in in-hospital mortality Background : Mortality is high among patients with hematologic malignancies admitted to intensive care units for acute respiratory failure . Early noninvasive mechanical ventilation seems to improve outcomes . Objective : To characterize noninvasive mechanical ventilation use in Italian intensive care units for acute respiratory failure patients with hematologic malignancies and its impact on outcomes vs. invasive mechanical ventilation . Design , Setting , Participants : Retrospective analysis of observational data prospect ively collected in 2002–2006 on 1,302 patients with hematologic malignancies admitted with acute respiratory failure to 158 Italian intensive care units . Measurements : Mortality ( intensive care unit and hospital ) was assessed in patients treated initially with noninvasive mechanical ventilation vs. invasive mechanical ventilation and in those treated with invasive mechanical ventilation ab initio vs. after noninvasive mechanical ventilation failure . Findings were adjusted for propensity scores reflecting the probability of initial treatment with noninvasive mechanical ventilation . Results : Few patients ( 21 % ) initially received noninvasive mechanical ventilation ; 46 % of these later required invasive mechanical ventilation . Better outcomes were associated with successful noninvasive mechanical ventilation ( vs. invasive mechanical ventilation ab initio and vs. invasive mechanical ventilation after noninvasive mechanical ventilation failure ) , particularly in patients with acute lung injury/adult respiratory distress syndrome ( mortality : 42 % vs. 69 % and 77 % , respectively ) . Delayed vs. immediate invasive mechanical ventilation was associated with slightly but not significantly higher hospital mortality ( 65 % vs. 58 % , p = .12 ) . After propensity-score adjustment , noninvasive mechanical ventilation was associated with significantly lower mortality than invasive mechanical ventilation . Limitations : The population could not be stratified according to specific hematologic diagnoses . Furthermore , the study was observational , and treatment groups may have included unaccounted for differences in covariates although the risk of this bias was minimized with propensity score regression adjustment . Conclusions : In patients with hematologic malignancies , acute respiratory failure should probably be managed initially with noninvasive mechanical ventilation . Further study is needed to determine whether immediate invasive mechanical ventilation might offer some benefits for those with acute lung injury/adult respiratory distress syndrome BACKGROUND Avoiding intubation is a major goal in the management of respiratory failure , particularly in immunosuppressed patients . Nevertheless , there are only limited data on the efficacy of noninvasive ventilation in these high-risk patients . METHODS We conducted a prospect i ve , r and omized trial of intermittent noninvasive ventilation , as compared with st and ard treatment with supplemental oxygen and no ventilatory support , in 52 immunosuppressed patients with pulmonary infiltrates , fever , and an early stage of hypoxemic acute respiratory failure .  Periods of noninvasive ventilation delivered through a face mask were alternated every three hours with periods of spontaneous breathing with supplemental oxygen . The ventilation periods lasted at least 45 minutes . Decisions to intubate were made according to st and ard , predetermined criteria . RESULTS The base-line characteristics of the two groups were similar ; each group of 26 patients included 15 patients with hematologic cancer and neutropenia . Fewer patients in the noninvasive-ventilation group than in the st and ard-treatment group required endotracheal intubation ( 12 vs. 20 , P=0.03 ) , had serious complications ( 13 vs. 21 , P=0.02 ) , died in the intensive care unit ( 10 vs. 18 , P=0.03 ) , or died in the hospital ( 13 vs. 21 , P=0.02 ) . CONCLUSIONS In selected immunosuppressed patients with pneumonitis and acute respiratory failure , early initiation of noninvasive ventilation is associated with significant reductions in the rates of endotracheal intubation and serious complications and an improved likelihood of survival to hospital discharge BACKGROUND Patients with acute exacerbations of chronic obstructive pulmonary disease may require endotracheal intubation with mechanical ventilation . We design ed , and here report on the efficacy of , a noninvasive ventilatory-assistance apparatus to provide inspiratory-pressure support by means of a face mask . METHODS We assessed the short-term ( 45-minute ) physiologic effects of the apparatus in 11 patients with acute exacerbations of chronic obstructive pulmonary disease and evaluated its therapeutic efficacy in 13 such patients ( including 3 of the 11 in the physiologic study ) who were treated for several days and compared with 13 matched historical-control patients . RESULTS In the physiologic study , after 45 minutes of inspiratory positive airway pressure by face mask , the mean ( + /- SD ) arterial pH rose from 7.31 + /- 0.08 to 7.38 + /- 0.07 ( P less than 0.01 ) , the partial pressure of carbon dioxide fell from 68 + /- 17 mm Hg to 55 + /- 15 mm Hg ( P less than 0.01 ) , and the partial pressure of oxygen rose from 52 + /- 12 mm Hg to 69 + /- 16 mm Hg ( P less than 0.05 ) . These changes were accompanied by marked reductions in respiratory rate ( from 31 + /- 7 to 21 + /- 9 breaths per minute , P less than 0.01 ) . Only 1 of the 13 patients treated with inspiratory positive airway pressure needed tracheal intubation and mechanical ventilation , as compared with 11 of the 13 historical controls ( P less than 0.001 ) . Two patients in each group died . As compared with the controls , the treated patients had a more transient need for ventilatory assistance ( 3 + /- 1 vs. 12 + /- 11 days , P less than 0.01 ) and a shorter stay in the intensive care unit ( 7 + /- 3 vs. 19 + /- 13 days , P less than 0.01 ) . CONCLUSIONS Inspiratory positive airway pressure delivered by a face mask can obviate the need for conventional mechanical ventilation in patients with acute exacerbations of chronic obstructive pulmonary disease The efficacy of noninvasive ventilation ( NIV ) to avoid intubation and improve survival was assessed in 105 patients with severe acute hypoxemic respiratory failure ( arterial O2 tension or saturation persistently 60 mm Hg or less or 90 % or less , respectively ; breathing conventional Venturi oxygen at a maximal concentration [ 50 % ] ) , excluding hypercapnia , admitted into intensive care units of three hospitals . Patients were r and omly allocated within 24 hours of fulfilling inclusion criteria to receive NIV ( n=51 ) or high-concentration oxygen therapy ( n=54 ) . The primary end-point variable was the decrease in the intubation rate . Both groups had similar characteristics . Compared with oxygen therapy , NIV decreased the need for intubation ( 13 , 25 % vs. 28 , 52 % , p=0.010 ) , the incidence of septic shock ( 6 , 12 % vs. 17 , 31 % , p=0.028 ) , and the intensive care unit mortality ( 9 , 18 % vs. 21 , 39 % , p=0.028 ) and increased the cumulative 90-day survival ( p=0.025 ) . The improvement of arterial hypoxemia and tachypnea was higher in the noninvasive ventilation group with time ( p=0.029 each ) . Multivariate analyses showed NIV to be independently associated with decreased risks of intubation ( odds ratio , 0.20 ; p=0.003 ) and 90-day mortality ( odds ratio , 0.39 ; p=0.017 ) . The use of noninvasive ventilation prevented intubation , reduced the incidence of septic shock , and improved survival in these patients compared with high-concentration oxygen therapy OBJECTIVE To develop and vali date a new Simplified Acute Physiology Score , the SAPS II , from a large sample of surgical and medical patients , and to provide a method to convert the score to a probability of hospital mortality . DESIGN AND SETTING The SAPS II and the probability of hospital mortality were developed and vali date d using data from consecutive admissions to 137 adult medical and /or surgical intensive care units in 12 countries . PATIENTS The 13,152 patients were r and omly divided into developmental ( 65 % ) and validation ( 35 % ) sample s. Patients younger than 18 years , burn patients , coronary care patients , and cardiac surgery patients were excluded . OUTCOME MEASURE Vital status at hospital discharge . RESULTS The SAPS II includes only 17 variables : 12 physiology variables , age , type of admission ( scheduled surgical , unscheduled surgical , or medical ) , and three underlying disease variables ( acquired immunodeficiency syndrome , metastatic cancer , and hematologic malignancy ) . Goodness-of-fit tests indicated that the model performed well in the developmental sample and vali date d well in an independent sample of patients ( P = .883 and P = .104 in the developmental and validation sample s , respectively ) . The area under the receiver operating characteristic curve was 0.88 in the developmental sample and 0.86 in the validation sample . CONCLUSION The SAPS II , based on a large international sample of patients , provides an estimate of the risk of death without having to specify a primary diagnosis . This is a starting point for future evaluation of the efficiency of intensive care units Objective To evaluate the tolerance and the efficacy of noninvasive continuous positive airway pressure ( CPAP ) in severe acute respiratory failure occurring in intensive care unit ( ICU ) neutropenic patients with hematologic malignancies , and to establish predictive variables of efficacy of this method . Design Prospect i ve study over a 5-yr period . Setting Hematologic and medical intensive care unit of a teaching hospital . Methods Among 129 neutropenic patients admitted to the ICU , 64 patients presented with febrile acute hypoxemic normocapnic respiratory failure ( Pao2/Fio2 ratio < 200 ) and were enrolled . In addition to st and ard therapy , patients received CPAP with a facial mask . The initial setting s of the CPAP were 6 cm H2O positive end-expiratory pressure and Fio2 0.8 ( 80 % ) . Physiologic measurements were performed at the end of 45 mins of ventilation with first adjustments . CPAP was used with a sequential mode ( 45 mins/3 hrs ) . CPAP was efficient if intubation was avoided . Results The setting of CPAP , after adjustments , was as follows : positive end-expiratory pressure 7 ± 1 cm H2O and Fio2 0.7 ± 0.1 ( 70 % ± 10 % ) . For the 64 patients , CPAP was administered for a total of 6 ± 2 hrs during the first 24 hrs . The mean duration of CPAP was 7 ± 3 days . A reduction in respiratory rate to less than 25 breaths/min was achieved in 53 % of patients . Pao2/Fio2 ratio increased from 128 ± 32 to 218 ± 28 . CPAP was successful in avoiding endotracheal intubation in 16/64 patients . A total of 16 responders and four nonresponders survived . Hepatic failure was a criterion indicating the failure of CPAP1/16 vs. 26/48 ( p = .001 ) . In multivariate analysis , two variables were predictive of failure of CPAPSimplified Acute Physiology Score II ( 58 ± 14 vs. 41 ± 11 ) and a hepatic failure at the entry into the study . Conclusion CPAP was efficient in 25 % of cases . All the responders survived . This noninvasive method was used as a way to avoid mechanical ventilation , which is well correlated with a poor prognosis in neutropenic ICU patients . Further controlled studies are needed to confirm the efficacy of noninvasive CPAP and to evaluate the most appropriate selection of immunocompromised patients Abstract : Acute respiratory failure ( ARF ) in patients with cancer is frequently a fatal event . To identify factors associated with survival of cancer patients admitted to an intensive care unit ( ICU ) for ARF , we conducted a prospect i ve 5-year observational study in a medical ICU in a teaching hospital in Paris , France . The patients were 203 cancer patients with ARF mainly due to infectious pneumonia ( 58 % ) , but also noninfectious pneumonia ( 9 % ) , congestive heart failure ( 12 % ) , and no identifiable cause ( 21 % ) . We measured clinical characteristics and ICU and hospital mortality rates . ICU mortality was 44.8 % and hospital mortality was 47.8 % . Noninvasive mechanical ventilation was used in 79 ( 39 % ) patients and conventional mechanical ventilation in 114 ( 56 % ) , the mortality rates being 48.1 % and 75.4 % , respectively . Among the 14 patients with late noninvasive mechanical ventilation failure ( > 48 hours ) , only 1 survived . The mortality rate was 100 % in the 19 noncardiac patients in whom  conventional mechanical ventilation was started after 72 hours . By multivariable analysis , factors associated with increased mortality were documented invasive aspergillosis ( odds ratio [ OR ] , 2.13 ; 95 % confidence intervals [ CI ] , 1.05 - 14.74 ) , no definite diagnosis ( OR , 3.85 ; 95 % CI , 1.26 - 11.70 ) , vasopressors ( OR , 3.19 ; 95 % CI , 1.28 - 7.95 ) , first-line conventional mechanical ventilation ( OR , 8.75 ; 95 % CI , 2.35 - 35.24 ) , conventional mechanical ventilation after noninvasive mechanical ventilation failure ( OR , 17.46 ; 95 % CI , 5.04 - 60.52 ) , and late noninvasive mechanical ventilation failure ( OR , 10.64 ; 95 % CI , 1.05 - 107.83 ) . Hospital mortality was lower in patients with cardiac pulmonary edema ( OR , 0.16 ; 95 % CI , 0.03 - 0.72 ) . Survival gains achieved in critically ill cancer patients in recent years extend to patients requiring ventilatory assistance . The impact of conventional mechanical ventilation on survival depends on the time from ICU admission to conventional mechanical ventilation and on the patient 's response to noninvasive mechanical ventilation . Abbreviations : ARDS = acute respiratory distress syndrome , ARF = acute respiratory failure , BAL = bronchoalveolar lavage , HSCT = human stem-cell transplant , ICU = intensive care unit , MV = mechanical ventilation , NIMV = noninvasive mechanical ventilation
Background To determine the effects of noninvasive mechanical ventilation ( NIV ) compared with invasive mechanical ventilation ( IMV ) as the initial mechanical ventilation on clinical outcomes when used for treatment of acute respiratory failure ( ARF ) in immunocompromised patients .