Over the past decade and boosted by the coronavirus disease 2019(COVID-19)pandemic,high-flow nasal oxygen(HFNO)has been increasingly used in the intensive care unit(ICU)to treat acute hypoxemic respiratory failure(AHR...Over the past decade and boosted by the coronavirus disease 2019(COVID-19)pandemic,high-flow nasal oxygen(HFNO)has been increasingly used in the intensive care unit(ICU)to treat acute hypoxemic respiratory failure(AHRF).In this review,we show that despite this wide and rapid increase in the use of HFNO to treat AHRF,HFNO does not fulfill all the criteria of a"reference treatment".First,there are some inconsistencies between the studies that provided a positive signal toward the possible benefit of HFNO in AHRF.The two high-quality studies were negative in terms of primary outcome although they provided promising signals in favor of HFNO in terms of secondary outcomes or unplanned secondary analysis.The significance of the only positive study suffers from notable limitations and other trials,conducted in COVID-19 and in immunocompromised patients,are definitely negative and do not even provide promising signals in favor of HFNO.Of note,authors of some of the large randomized controlled trials(RCTs)on HFNO have received grants or personal fees from manufacturers of HFNO devices.Second,meta-analyses do not show positive results regarding the efficacy of HFNO on mortality and recent guidelines do not support its use to improve this outcome,although they recommend HFNO use to reduce intubation rate.Third,HFNO is associated with risks that should be accounted for.There are concerns that HFNO may delay intubation,which is in turn associated with higher mortality and prolonged length of stay.In addition,with HFNO,high inspiratory effort may generate high lung strain and overstretch,a phenomenon termed patient self-inflicted lung injury(P-SILI).Fourth,there are concerns regarding access to HFNO in resource-limited settings.Fifth,there are also concerns regarding the deleterious environmental impact of HFNO due to the high volume of consumables and high oxygen flow,which remain to be precisely quantified and balanced with the potential reduction in intubation rate.Considering all these limitations,HFNO is not yet the reference treatment for AHRF.展开更多
Background:Cancer patients who are exposed to sepsis and had previous chemotherapy may have increased severity. Among chemotherapeutic agents, anthracyclines have been associated with cardiac toxicity. Like other chem...Background:Cancer patients who are exposed to sepsis and had previous chemotherapy may have increased severity. Among chemotherapeutic agents, anthracyclines have been associated with cardiac toxicity. Like other chemotherapeutic agents, they may cause endothelial toxicity. The aim of this study was to evaluate the effect of anthracycline treatment on the outcome of cancer patients with sepsis.Methods:Data from cancer patients admitted to intensive care units (ICUs) for sepsis or septic shock were extracted from the Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique database (1994-2015). Comparison between patients who received anthracycline and those who did not was performed using a propensity score, including confounding variables (age and underlying diseases). A competing risk adjusted for severity of illness (Sequential Organ Failure Assessment [SOFA] score) was used to analyze the duration of vasopressor requirement.Results:Among 2046 patients, 1070 (52.3%) patients who received anthracycline were compared with 976 (47.7%) who did not. The underlying disease was mostly acute hematological malignancy (49.2%). Sepsis, mostly pneumonia (47.7%), had developed 2 days (interquartile range [IQR]:1-4 days) prior to ICU admission. Most patients (n=1156/1980,58.4%) required vasopressors for 3 days (IQR: 2-6 days). Factors associated with the need for vasopressors were aplasia (hazard ratio [HR]=1.72, 95% confidence interval [CI]: 1.21 to 2.47, P=0.002) and day 1 respiratory SOFA score (HR=7.07, 95% CI: 2.75 to 22.1, P <0.001). Previous anthracycline treatment was not associated with an increased risk of vasopressor use. The duration of vasopressors was not different between patients who received anthracycline and those who did not (P=0.79). Anthracycline was not associated with ICU mortality.Conclusion:Previous anthracycline treatment did not alter the course of sepsis in a cohort of cancer patients admitted to intensive care with sepsis.展开更多
Acute respiratory failure(ARF)in immunocompromised patients remains challenging to treat.A large number of case require admission to intensive care unit(ICU)where mortality remains high.Oxygenation without intubation ...Acute respiratory failure(ARF)in immunocompromised patients remains challenging to treat.A large number of case require admission to intensive care unit(ICU)where mortality remains high.Oxygenation without intubation is important in this setting.This review summarizes recent studies assessing oxygenation devices for immunocompromised patients.Previous studies showed that non-invasive ventilation(NIV)has been associated with lower intubation and mortality rates.Indeed,in recent years,the outcomes of immunocompromised patients admitted to the ICU have improved.In the most recent randomized controlled trials,including immunocompromised patients admitted to the ICU with ARF,neither NIV nor high-flow nasal oxygen(HFNO)could reduce the mortality rate.In this setting,other strategies need to be tested to decrease the mortality rate.Early admission strategy and avoiding late failure of oxygenation strategy have been assessed in retrospective studies.However,objective criteria are still lacking to clearly discriminate time to admission or time to intubation.Also,diagnosis strategy may have an impact on intubation or mortality rates.On the other hand,lack of diagnosis has been associated with a higher mortality rate.In conclusion,improving outcomes in immunocompromised patients with ARF may include strategies other than the oxygenation strategy alone.This review discusses other unresolved questions to decrease mortality after ICU admission in such patients.展开更多
文摘Over the past decade and boosted by the coronavirus disease 2019(COVID-19)pandemic,high-flow nasal oxygen(HFNO)has been increasingly used in the intensive care unit(ICU)to treat acute hypoxemic respiratory failure(AHRF).In this review,we show that despite this wide and rapid increase in the use of HFNO to treat AHRF,HFNO does not fulfill all the criteria of a"reference treatment".First,there are some inconsistencies between the studies that provided a positive signal toward the possible benefit of HFNO in AHRF.The two high-quality studies were negative in terms of primary outcome although they provided promising signals in favor of HFNO in terms of secondary outcomes or unplanned secondary analysis.The significance of the only positive study suffers from notable limitations and other trials,conducted in COVID-19 and in immunocompromised patients,are definitely negative and do not even provide promising signals in favor of HFNO.Of note,authors of some of the large randomized controlled trials(RCTs)on HFNO have received grants or personal fees from manufacturers of HFNO devices.Second,meta-analyses do not show positive results regarding the efficacy of HFNO on mortality and recent guidelines do not support its use to improve this outcome,although they recommend HFNO use to reduce intubation rate.Third,HFNO is associated with risks that should be accounted for.There are concerns that HFNO may delay intubation,which is in turn associated with higher mortality and prolonged length of stay.In addition,with HFNO,high inspiratory effort may generate high lung strain and overstretch,a phenomenon termed patient self-inflicted lung injury(P-SILI).Fourth,there are concerns regarding access to HFNO in resource-limited settings.Fifth,there are also concerns regarding the deleterious environmental impact of HFNO due to the high volume of consumables and high oxygen flow,which remain to be precisely quantified and balanced with the potential reduction in intubation rate.Considering all these limitations,HFNO is not yet the reference treatment for AHRF.
文摘Background:Cancer patients who are exposed to sepsis and had previous chemotherapy may have increased severity. Among chemotherapeutic agents, anthracyclines have been associated with cardiac toxicity. Like other chemotherapeutic agents, they may cause endothelial toxicity. The aim of this study was to evaluate the effect of anthracycline treatment on the outcome of cancer patients with sepsis.Methods:Data from cancer patients admitted to intensive care units (ICUs) for sepsis or septic shock were extracted from the Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique database (1994-2015). Comparison between patients who received anthracycline and those who did not was performed using a propensity score, including confounding variables (age and underlying diseases). A competing risk adjusted for severity of illness (Sequential Organ Failure Assessment [SOFA] score) was used to analyze the duration of vasopressor requirement.Results:Among 2046 patients, 1070 (52.3%) patients who received anthracycline were compared with 976 (47.7%) who did not. The underlying disease was mostly acute hematological malignancy (49.2%). Sepsis, mostly pneumonia (47.7%), had developed 2 days (interquartile range [IQR]:1-4 days) prior to ICU admission. Most patients (n=1156/1980,58.4%) required vasopressors for 3 days (IQR: 2-6 days). Factors associated with the need for vasopressors were aplasia (hazard ratio [HR]=1.72, 95% confidence interval [CI]: 1.21 to 2.47, P=0.002) and day 1 respiratory SOFA score (HR=7.07, 95% CI: 2.75 to 22.1, P <0.001). Previous anthracycline treatment was not associated with an increased risk of vasopressor use. The duration of vasopressors was not different between patients who received anthracycline and those who did not (P=0.79). Anthracycline was not associated with ICU mortality.Conclusion:Previous anthracycline treatment did not alter the course of sepsis in a cohort of cancer patients admitted to intensive care with sepsis.
文摘Acute respiratory failure(ARF)in immunocompromised patients remains challenging to treat.A large number of case require admission to intensive care unit(ICU)where mortality remains high.Oxygenation without intubation is important in this setting.This review summarizes recent studies assessing oxygenation devices for immunocompromised patients.Previous studies showed that non-invasive ventilation(NIV)has been associated with lower intubation and mortality rates.Indeed,in recent years,the outcomes of immunocompromised patients admitted to the ICU have improved.In the most recent randomized controlled trials,including immunocompromised patients admitted to the ICU with ARF,neither NIV nor high-flow nasal oxygen(HFNO)could reduce the mortality rate.In this setting,other strategies need to be tested to decrease the mortality rate.Early admission strategy and avoiding late failure of oxygenation strategy have been assessed in retrospective studies.However,objective criteria are still lacking to clearly discriminate time to admission or time to intubation.Also,diagnosis strategy may have an impact on intubation or mortality rates.On the other hand,lack of diagnosis has been associated with a higher mortality rate.In conclusion,improving outcomes in immunocompromised patients with ARF may include strategies other than the oxygenation strategy alone.This review discusses other unresolved questions to decrease mortality after ICU admission in such patients.
