Early non-invasive ventilation for acute respiratory failure in immunocompromised patients (IVNIctus): study protocol for a multicenter randomized controlled trial

Virginie Lemiale, Matthieu Resche-Rigon, Elie Azoulay, Study Group for Respiratory Intensive Care in Malignancies Groupe de Recherche en Réanimation Respiratoire du patient d’Onco-Hématologie, Virginie Lemiale, Matthieu Resche-Rigon, Elie Azoulay, Study Group for Respiratory Intensive Care in Malignancies Groupe de Recherche en Réanimation Respiratoire du patient d’Onco-Hématologie

Abstract

Background: Acute respiratory failure (ARF) remains the leading reason for intensive care unit (ICU) admission of immunocompromised patients. In the most severe cases, high-flow oxygen therapy may fail to ensure adequate gas exchange, and mechanical ventilation (MV) must be used. This scenario is associated with high mortality rates of 40 to 60%, depending on the cause of ARF and type of immune deficiency. The use of non-invasive ventilation (NIV) in this situation has been criticized as potentially delaying the initiation of optimal treatment. In contrast, early NIV used prophylactically in patients with ARF who do not meet the criteria for invasive MV (IMV) may obviate the need for IMV, thereby decreasing the morbidity and mortality rates. We aim to demonstrate that a management strategy including early NIV decreases 28-day mortality rates compared to oxygen therapy alone in immunocompromised patients with ARF.

Methods/design: This is a multicenter parallel-group randomized controlled trial comparing early NIV to oxygen therapy alone in immunocompromised patients with ARF. All immunocompromised adult patients admitted to admission for ARF are eligible for randomization. Patient with ARF onset more than 72 hours earlier or ARF related to cardiogenic pulmonary edema or hypercapnia, or with a need for immediate endotracheal intubation or other organ failure are not eligible.After inclusion patient are allocated to receive early NIV (intervention arm) or oxygen therapy only (control arm).We plan to enroll 374 patients in 29 ICUs. An interim analysis is planned after the inclusion of 187 patients. The main objective is to demonstrate early NIV increases survival as compared to oxygen therapy alone. Other outcomes include the need of IMV, organ failure evolution, nosocomial infections rate, 6 months survival.

Discussion: This study is expected to demonstrate an improved 28-day survival in immunocompromised patients managed with early NIV.

Registration number: Clinicaltrials.gov NCT01915719. Registered on 26 July 2013.

Figures

Figure 1
Figure 1
Outcomes associated with the in-ICU use of non-invasive ventilation in immunocompromised patients. Adapted from Azoulay E, 13.
Figure 2
Figure 2
Study diagram. ARF, acute respiratory failure; NIV non-invasive ventilation.

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