Noninvasive Ventilation in Immunocompromised Patients

Abstract

Pulmonary complications are common in immunocompromised (IC) patients. These respiratory complications can lead to acute respiratory failure (ARF), which is the first reason for the patient being admitted in ICU. Noninvasive mechanical ventilation (NIV) can be applied in selected IC patients, with mild-to-moderately severe ARF. NIV with pressure support and positive expiratory pressure improves oxygenation, reduces nosocomial infection rates and prevents tracheal intubation. The survival benefit related to the use of NIV in IC patients with ARF is suggested by retrospective studies, prospective cohort studies and a few randomized controlled studies. These randomized studies were performed more than 10 years ago and they included only a limited number of patients, and therefore, their results are questionable. Furthermore, several studies suggest that intubation after failure of initial NIV is associated with excess mortality. Significant changes in the management of critically ill patients with ARF have been made during the recent years with the improvement in patient’s outcomes. Increased survival is also reported in IC patients managed with invasive mechanical ventilation (MV). In IC patients with ARF, NIV is not an alternative to intubation and invasive MV. An initial trial of NIV in IC patients with mild-to-moderate ARF is reasonable with a close monitoring in an ICU. In patients showing no early (i.e., within 2 hours) clinical and arterial blood gases improvement with NIV, invasive MV should be considered. In such patients who do not respond to NIV, with hypoxemic ARF, tracheal intubation should not be delayed and invasive mechanical ventilation should be applied with lung-protective settings. During the postoperative period, NIV is useful to treat or to prevent an ARF. NIV enables to perform a bronchoscopy with bronchoalveolar lavage in patients with moderate hypoxemia and pulmonary infiltrates without diagnosis. Finally, NIV may be proposed in the context of therapeutic limitations with varying results depending on the context.