Effect of High-Flow Nasal Oxygen vs Standard Oxygen on 28-Day Mortality in Immunocompromised Patients With Acute Respiratory Failure

Elie Azoulay (1) , Virginie Louis (1) , Djamel Mokart (2) , Saad Nseir (3, 4) , Laurent Argaud (5) , Frédéric Pène (6) , Loay Kontar (7) , Fabrice Bruneel (8) , Kada Klouche (9, 10) , François Barbier (11) , Jean Reignier (12, 13) , Lilia Berrahil-Meksen (14) , Guillaume Louis (15) , Jean-Michel Constantin (16) , Julien Mayaux (17, 17) , Florent Wallet (18) , Achille Kouatchet (19) , Vincent Peigne (20) , Igor Théodose , Pierre Perez (21) , Christophe Girault (22) , Samir Jaber (10, 9) , Johanna Oziel (23) , Martine Nyunga , Nicolas Terzi (24) , Lila Bouadma (25) , Christine Lebert , Alexandre Lautrette (26, 27) , Naiké Bigé (28) , Jean-Herlé Raphalen (29, 30) , Laurent Papazian (31) , Michael Darmon (32, 33, 34) , Sylvie Chevret , Alexandre Demoule (17)

1 AP-HP - Hopital Saint-Louis [AP-HP]
2 IPC - Institut Paoli-Calmettes
3 CHRU Lille - Centre Hospitalier Régional Universitaire [CHU Lille]
4 LIRIC - Lille Inflammation Research International Center - U 995
5 Hôpital Edouard Herriot [CHU - HCL]
6 Unité de Soins Intensifs [CHU Cochin]
7 CHU Amiens-Picardie
8 CHV - Centre Hospitalier de Versailles André Mignot
9 PhyMedExp - Physiologie & médecine expérimentale du Cœur et des Muscles [U 1046]
10 CHRU Montpellier - Centre Hospitalier Régional Universitaire [Montpellier]
11 CHRO - Centre Hospitalier Régional d'Orléans
12 Service de Réanimation Polyvalente
13 CHU Nantes - Centre Hospitalier Universitaire de Nantes
14 DSA - Département de soins aigus [Gustave Roussy]
15 CHR Metz-Thionville - Centre hospitalier régional Metz-Thionville
16 CHU Clermont-Ferrand
17 CHU Pitié-Salpêtrière [AP-HP]
18 Service de réanimation médicale - Centre Hospitalier Lyon Sud
19 CHU Angers - Centre Hospitalier Universitaire d'Angers
20 Centre Hospitalier Métropole Savoie [Chambéry]
21 CHRU Nancy - Centre Hospitalier Régional Universitaire de Nancy
22 CHU Rouen
23 Hôpital Avicenne [AP-HP]
24 CHUGA - Centre Hospitalier Universitaire [CHU Grenoble]
25 AP-HP - Hôpital Bichat - Claude Bernard [Paris]
26 Unité de soins intensifs [Clermont Ferrand]
27 CHU Gabriel Montpied [Clermont-Ferrand]
28 CHU Saint-Antoine [AP-HP]
29 Hôpital Necker - Enfants Malades [AP-HP]
30 Service d'Anesthésie Réanimation [CHU Necker]
31 Hôpital Nord [CHU - APHM]
32 AP-HP - Hôpital Cochin Broca Hôtel Dieu [Paris]
33 Hôpital Cochin [AP-HP]
34 Département des maladies respiratoires [CHU Cochin]

Importance High-flow nasal oxygen therapy is increasingly used for acute hypoxemic respiratory failure (AHRF). Objective To determine whether high-flow oxygen therapy decreases mortality among immunocompromised patients with AHRF compared with standard oxygen therapy. Design, Setting, and Participants The HIGH randomized clinical trial enrolled 776 adult immunocompromised patients with AHRF (Pao2 <60 mm Hg or Spo2 <90% on room air, or tachypnea >30/min or labored breathing or respiratory distress, and need for oxygen ≥6 L/min) at 32 intensive care units (ICUs) in France between May 19, 2016, and December 31, 2017. Interventions Patients were randomized 1:1 to continuous high-flow oxygen therapy (n = 388) or to standard oxygen therapy (n = 388). Main Outcomes and Measures The primary outcome was day-28 mortality. Secondary outcomes included intubation and mechanical ventilation by day 28, Pao2:Fio2 ratio over the 3 days after intubation, respiratory rate, ICU and hospital lengths of stay, ICU-acquired infections, and patient comfort and dyspnea. Results Of 778 randomized patients (median age, 64 [IQR, 54-71] years; 259 [33.3%] women), 776 (99.7%) completed the trial. At randomization, median respiratory rate was 33/min (IQR, 28-39) vs 32 (IQR, 27-38) and Pao2:Fio2 was 136 (IQR, 96-187) vs 128 (IQR, 92-164) in the intervention and control groups, respectively. Median SOFA score was 6 (IQR, 4-8) in both groups. Mortality on day 28 was not significantly different between groups (35.6% vs 36.1%; difference, −0.5% [95% CI, −7.3% to +6.3%]; hazard ratio, 0.98 [95% CI, 0.77 to 1.24]; P = .94). Intubation rate was not significantly different between groups (38.7% vs 43.8%; difference, −5.1% [95% CI, −12.3% to +2.0%]). Compared with controls, patients randomized to high-flow oxygen therapy had a higher Pao2:Fio2 (150 vs 119; difference, 19.5 [95% CI, 4.4 to 34.6]) and lower respiratory rate after 6 hours (25/min vs 26/min; difference, −1.8/min [95% CI, −3.2 to −0.2]). No significant difference was observed in ICU length of stay (8 vs 6 days; difference, 0.6 [95% CI, −1.0 to +2.2]), ICU-acquired infections (10.0% vs 10.6%; difference, −0.6% [95% CI, −4.6 to +4.1]), hospital length of stay (24 vs 27 days; difference, −2 days [95% CI, −7.3 to +3.3]), or patient comfort and dyspnea scores. Conclusions and Relevance Among critically ill immunocompromised patients with acute respiratory failure, high-flow oxygen therapy did not significantly decrease day-28 mortality compared with standard oxygen therapy.

Domaines: Pneumologie et système respiratoire; Santé publique et épidémiologie

Elie Azoulay, Virginie Louis, Djamel Mokart, Saad Nseir, Laurent Argaud, et al.. Effect of High-Flow Nasal Oxygen vs Standard Oxygen on 28-Day Mortality in Immunocompromised Patients With Acute Respiratory Failure. Journal of the American Medical Association, 2018, 320 (20), pp.2099-2107. ⟨10.1001/jama.2018.14282⟩. ⟨hal-01906406⟩