User login
Early noninvasive ventilation, compared with oxygen therapy alone, did not reduce 28-day all-cause mortality in critically ill immunocompromised patients with acute respiratory failure, based on a randomized, parallel-group study of 374 patients conducted in 28 ICUs in France and Belgium.
Overall, 46 of 191 patients (24%) in the noninvasive ventilation group died, compared with 50 of 183 (27%) in the oxygen-alone group. A similar number of patients from each group required intubation – 38% in the noninvasive ventilation group and 45% in the oxygen group – with similar time to intubation. Nearly 85% of the patients were receiving treatment for hematologic malignancies or solid tumors, researchers reported in a study published online Oct. 7 in JAMA.
No significant differences between groups were observed in requirement for intubation, ICU or hospital length of stay, or duration of invasive mechanical ventilation. The study found no evidence that noninvasive ventilation influenced mortality estimates or was beneficial to any subgroup based on hypoxemia severity or underlying condition.
The study was limited, however, by a lower than expected mortality rate with oxygen alone, and as a result was not powered to detect significant between-group differences. Based on earlier studies, the researchers assumed a 35% mortality rate in the oxygen-alone group, but the actual rate was 27% (JAMA. 2015 Oct 7. doi: 10.1001/jama.2015.12402).
“Therefore, there remains uncertainty regarding our null finding, which may nonetheless fail to exclude a clinically important effect,” wrote Dr. Virginie Lemiale of Saint-Louis University Hospital, Paris, and colleagues.
Furthermore, high-flow nasal oxygen was used in about 40% of all patients, which may have decreased requirements for intubation as well as mortality rates. High-flow nasal oxygen was used more often in the oxygen group (44%) than in the noninvasive ventilation group (31%) (P = .01).
Dr. Lemiale and coauthors reported having no disclosures.
In contrast to reports from 10 years ago, the current study by Lemiale et al. failed to demonstrate a mortality benefit for noninvasive ventilation, compared with oxygen alone. However, the results should be interpreted in the context of recent advances in ICU care. Targeted chemotherapy, prophylactic use of antibiotics, and improved supportive care have contributed to overall mortality declines in the immunocompromised critically ill population. Dr. Lemiale and colleagues anticipated a higher baseline mortality rate (35% vs. 27% observed). The lower mortality rate limited the study’s power to detect a mortality difference between groups.
Second, patients in this trial may have had a lower acuity of illness, evidenced by less tachypnea, compared with that seen in earlier studies.
Third, the oxygen-alone group received more high-flow oxygen via nasal cannula than the noninvasive ventilation group, which may have diluted the benefits of noninvasive ventilation.
As efforts continue to reduce requirements for invasive mechanical ventilation, further examination of strategies for noninvasive ventilation, such as high-flow oxygen, compared with noninvasive ventilation, are warranted.
Dr. Bhakti Patel is a clinical instructor of medicine in the section of pulmonary and critical care, department of medicine, University of Chicago. Dr. John Kress is professor of medicine and director of the Medical Intensive Care Unit at University of Chicago Medicine. These remarks were part of an editorial accompanying the report (JAMA. 2015 Oct 7. doi: 10.1001/jama.2015.12401). Dr. Patel and Dr. Kress reported having no disclosures.
In contrast to reports from 10 years ago, the current study by Lemiale et al. failed to demonstrate a mortality benefit for noninvasive ventilation, compared with oxygen alone. However, the results should be interpreted in the context of recent advances in ICU care. Targeted chemotherapy, prophylactic use of antibiotics, and improved supportive care have contributed to overall mortality declines in the immunocompromised critically ill population. Dr. Lemiale and colleagues anticipated a higher baseline mortality rate (35% vs. 27% observed). The lower mortality rate limited the study’s power to detect a mortality difference between groups.
Second, patients in this trial may have had a lower acuity of illness, evidenced by less tachypnea, compared with that seen in earlier studies.
Third, the oxygen-alone group received more high-flow oxygen via nasal cannula than the noninvasive ventilation group, which may have diluted the benefits of noninvasive ventilation.
As efforts continue to reduce requirements for invasive mechanical ventilation, further examination of strategies for noninvasive ventilation, such as high-flow oxygen, compared with noninvasive ventilation, are warranted.
Dr. Bhakti Patel is a clinical instructor of medicine in the section of pulmonary and critical care, department of medicine, University of Chicago. Dr. John Kress is professor of medicine and director of the Medical Intensive Care Unit at University of Chicago Medicine. These remarks were part of an editorial accompanying the report (JAMA. 2015 Oct 7. doi: 10.1001/jama.2015.12401). Dr. Patel and Dr. Kress reported having no disclosures.
In contrast to reports from 10 years ago, the current study by Lemiale et al. failed to demonstrate a mortality benefit for noninvasive ventilation, compared with oxygen alone. However, the results should be interpreted in the context of recent advances in ICU care. Targeted chemotherapy, prophylactic use of antibiotics, and improved supportive care have contributed to overall mortality declines in the immunocompromised critically ill population. Dr. Lemiale and colleagues anticipated a higher baseline mortality rate (35% vs. 27% observed). The lower mortality rate limited the study’s power to detect a mortality difference between groups.
Second, patients in this trial may have had a lower acuity of illness, evidenced by less tachypnea, compared with that seen in earlier studies.
Third, the oxygen-alone group received more high-flow oxygen via nasal cannula than the noninvasive ventilation group, which may have diluted the benefits of noninvasive ventilation.
As efforts continue to reduce requirements for invasive mechanical ventilation, further examination of strategies for noninvasive ventilation, such as high-flow oxygen, compared with noninvasive ventilation, are warranted.
Dr. Bhakti Patel is a clinical instructor of medicine in the section of pulmonary and critical care, department of medicine, University of Chicago. Dr. John Kress is professor of medicine and director of the Medical Intensive Care Unit at University of Chicago Medicine. These remarks were part of an editorial accompanying the report (JAMA. 2015 Oct 7. doi: 10.1001/jama.2015.12401). Dr. Patel and Dr. Kress reported having no disclosures.
Early noninvasive ventilation, compared with oxygen therapy alone, did not reduce 28-day all-cause mortality in critically ill immunocompromised patients with acute respiratory failure, based on a randomized, parallel-group study of 374 patients conducted in 28 ICUs in France and Belgium.
Overall, 46 of 191 patients (24%) in the noninvasive ventilation group died, compared with 50 of 183 (27%) in the oxygen-alone group. A similar number of patients from each group required intubation – 38% in the noninvasive ventilation group and 45% in the oxygen group – with similar time to intubation. Nearly 85% of the patients were receiving treatment for hematologic malignancies or solid tumors, researchers reported in a study published online Oct. 7 in JAMA.
No significant differences between groups were observed in requirement for intubation, ICU or hospital length of stay, or duration of invasive mechanical ventilation. The study found no evidence that noninvasive ventilation influenced mortality estimates or was beneficial to any subgroup based on hypoxemia severity or underlying condition.
The study was limited, however, by a lower than expected mortality rate with oxygen alone, and as a result was not powered to detect significant between-group differences. Based on earlier studies, the researchers assumed a 35% mortality rate in the oxygen-alone group, but the actual rate was 27% (JAMA. 2015 Oct 7. doi: 10.1001/jama.2015.12402).
“Therefore, there remains uncertainty regarding our null finding, which may nonetheless fail to exclude a clinically important effect,” wrote Dr. Virginie Lemiale of Saint-Louis University Hospital, Paris, and colleagues.
Furthermore, high-flow nasal oxygen was used in about 40% of all patients, which may have decreased requirements for intubation as well as mortality rates. High-flow nasal oxygen was used more often in the oxygen group (44%) than in the noninvasive ventilation group (31%) (P = .01).
Dr. Lemiale and coauthors reported having no disclosures.
Early noninvasive ventilation, compared with oxygen therapy alone, did not reduce 28-day all-cause mortality in critically ill immunocompromised patients with acute respiratory failure, based on a randomized, parallel-group study of 374 patients conducted in 28 ICUs in France and Belgium.
Overall, 46 of 191 patients (24%) in the noninvasive ventilation group died, compared with 50 of 183 (27%) in the oxygen-alone group. A similar number of patients from each group required intubation – 38% in the noninvasive ventilation group and 45% in the oxygen group – with similar time to intubation. Nearly 85% of the patients were receiving treatment for hematologic malignancies or solid tumors, researchers reported in a study published online Oct. 7 in JAMA.
No significant differences between groups were observed in requirement for intubation, ICU or hospital length of stay, or duration of invasive mechanical ventilation. The study found no evidence that noninvasive ventilation influenced mortality estimates or was beneficial to any subgroup based on hypoxemia severity or underlying condition.
The study was limited, however, by a lower than expected mortality rate with oxygen alone, and as a result was not powered to detect significant between-group differences. Based on earlier studies, the researchers assumed a 35% mortality rate in the oxygen-alone group, but the actual rate was 27% (JAMA. 2015 Oct 7. doi: 10.1001/jama.2015.12402).
“Therefore, there remains uncertainty regarding our null finding, which may nonetheless fail to exclude a clinically important effect,” wrote Dr. Virginie Lemiale of Saint-Louis University Hospital, Paris, and colleagues.
Furthermore, high-flow nasal oxygen was used in about 40% of all patients, which may have decreased requirements for intubation as well as mortality rates. High-flow nasal oxygen was used more often in the oxygen group (44%) than in the noninvasive ventilation group (31%) (P = .01).
Dr. Lemiale and coauthors reported having no disclosures.
Key clinical point: Noninvasive ventilation, compared with oxygen therapy alone, did not reduce 28-day mortality among immunocompromised patients with acute respiratory failure.
Major finding: After 28 days, 46 of 191 patients (24%) in the noninvasive ventilation group had died, compared with 50 of 183 (27%) in the oxygen-alone group.
Data source: The randomized, parallel-group study was conducted in 28 ICUs in France and Belgium and included 374 immunocompromised patients with acute respiratory failure.
Disclosures: Dr. Lemiale and coauthors reported having no disclosures.