Epidemiology, ventilation, and outcomes of acute respiratory failure in immunocompromised patients from 103 intensive care units in 26 countries: a retrospective observational study
Abstract
Background: Acute hypoxaemic respiratory failure (ARF) is the leading cause of intensive care unit (ICU) admission among immunocompromised patients. However, contemporary data regarding the epidemiology, management, and outcomes of ARF in this population remain scarce. We aimed to identify predictors of mortality and intubation in immunocompromised patients admitted to the ICU with ARF. Methods: This retrospective observational study was conducted in 103 ICUs in 26 countries. Adults (≥18 years) with ARF and immunodeficiency were eligible for inclusion. Patient data, including information on the nature of underlying immunosuppression, the cause of ARF, and the oxygenation strategy, were obtained from electronic medical records or medical charts. The primary outcome was to report 30-day mortality and identify associated factors in patients with complete data for all variables. Cox proportional hazards models were used to identify variables associated with mortality, and differences between groups were compared with χ2 tests or two-sided Wilcoxon rank-sum tests, with p values of less than 0·05 considered significant. Findings: 9854 immunocompromised patients with ARF admitted to participating ICUs between Jan 1, 2017, and Dec 31, 2023, were included in the study. The median age was 64 years (IQR 54-71); 3941 (40·0%) patients were female and 5913 (60·0%) were male. The main causes of immunodeficiency were a haematological malignancy (4759 [48·3%] of 9854 patients) or solid malignancy (3818 [38·7%] patients). Infection was the leading cause of ARF (6610 [62·0%] of 9854 patients); 5288 (53·7%) patients had more than one contributing cause of ARF, and no cause was identified in 1490 (15·1%) patients. The median partial pressure of oxygen in arterial blood (PaO2)/fractional concentration of oxygen in inspired air (FiO2) ratio was 198 [IQR 141-208]. The 30-day mortality rate was 47·3% (4662 patients). Predictors of higher mortality were older age (hazard ratio 1·01 [IQR 1·00-1·02]), higher Charlson Comorbidity Index score (1·04 [1·01-1·07]), higher Frailty Index score (1·22 [1·16-1·28]), longer time from hospital to ICU admission (1·02 [1·01-1·03]), higher respiratory rate (1·02 [1·02-1·03]), coma at ICU admission (2·04 [1·72-2·43]), invasive fungal infection as cause of ARF (1·82 [1·45-2·28]), disease-specific infiltrates (1·73 [1·32-2·26]), unidentified cause of ARF (2·16 [1·74-2·68]), and use of vasoactive drugs (2·45 [2·10-2·86]) or renal replacement therapy (2·07 [1·74-2·48]). Protective factors included receipt of a solid organ transplant (0·62 [0·49-0·79]), systemic vasculitis or connective tissue disease (0·61 (0·47-0·78]), higher PaO2/FiO2 ratio (0·78 [0·72-0·84]), receipt of high-flow nasal oxygen therapy (0·78 [0·64-0·95]), and cardiogenic pulmonary oedema (0·67 [0·51-0·89]). Interpretation: In this large international cohort of immunocompromised patients with ARF, we identified key risk and protective factors for mortality and intubation. These findings could improve outcomes by informing timely clinical decisions, goals-of-care discussions, and management in this vulnerable population. Funding: Kirsten and Freddy Johansen Foundation and Groupe de Recherche en Réanimation Onco-Hématologique.
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BibTeX
@article{azoulay2026epidemiology,
title = {{Epidemiology, ventilation, and outcomes of acute respiratory failure in immunocompromised patients from 103 intensive care units in 26 countries: a retrospective observational study}},
author = {Elie Azoulay and Colleen Mcevoy and Pedro Castro and Ali Ait Hssain and Fabio Silvio Taccone and Sheila Myatra and Guillaume Dumas and Jan-Hendrik Naendrup and Gaston Burghi and Cristina Gutiérrez and Joseph Nates and Ricard Ferrer and Laurent Argaud and Raphaël Clere-Jehl and Damien Vimpere and Huiqing Ge and Anne-Sophie Moreau and Yaseen Arabi and Maria Theodorakopoulou and Christina-Chrysanthi Theocharidou and Luca Montini and Djamel Mokart and Igor Théodose and Julien Leroy and Muriel Picard and Nathalie Layios and Antoine Hérault and Achille Kouatchet and Thomas Karvunidis and Naïke Bigé and Maxens Decavele and Bertrand Pavlovsky and Philippe Bauer and Martin Balik and Laveena Munshi and Sami Hraiech and Melda Turkoglu and Jing Tao and Peter Schellongowski and Florent Wallet and Victoria Metaxa and Philipp Eller and Sascha David and Peter Pickkers and Piotr Szychowiak and Emmanuel Canet and Pedro Povoa and Kathryn Puxty and Sara Fernandez and Anders Perner and Samir Jaber and Michael Darmon and Virginie Lemiale},
journal = {The Lancet Respiratory Medicine},
year = {2026},
month = may,
doi = {10.1016/s2213-2600(26)00046-9},
url = {https://hal.science/hal-05560327v2},
note = {CC BY 4.0},
}
RIS
TY - JOUR
TI - Epidemiology, ventilation, and outcomes of acute respiratory failure in immunocompromised patients from 103 intensive care units in 26 countries: a retrospective observational study
AU - Elie Azoulay
AU - Colleen Mcevoy
AU - Pedro Castro
AU - Ali Ait Hssain
AU - Fabio Silvio Taccone
AU - Sheila Myatra
AU - Guillaume Dumas
AU - Jan-Hendrik Naendrup
AU - Gaston Burghi
AU - Cristina Gutiérrez
AU - Joseph Nates
AU - Ricard Ferrer
AU - Laurent Argaud
AU - Raphaël Clere-Jehl
AU - Damien Vimpere
AU - Huiqing Ge
AU - Anne-Sophie Moreau
AU - Yaseen Arabi
AU - Maria Theodorakopoulou
AU - Christina-Chrysanthi Theocharidou
AU - Luca Montini
AU - Djamel Mokart
AU - Igor Théodose
AU - Julien Leroy
AU - Muriel Picard
AU - Nathalie Layios
AU - Antoine Hérault
AU - Achille Kouatchet
AU - Thomas Karvunidis
AU - Naïke Bigé
AU - Maxens Decavele
AU - Bertrand Pavlovsky
AU - Philippe Bauer
AU - Martin Balik
AU - Laveena Munshi
AU - Sami Hraiech
AU - Melda Turkoglu
AU - Jing Tao
AU - Peter Schellongowski
AU - Florent Wallet
AU - Victoria Metaxa
AU - Philipp Eller
AU - Sascha David
AU - Peter Pickkers
AU - Piotr Szychowiak
AU - Emmanuel Canet
AU - Pedro Povoa
AU - Kathryn Puxty
AU - Sara Fernandez
AU - Anders Perner
AU - Samir Jaber
AU - Michael Darmon
AU - Virginie Lemiale
PY - 2026
DA - 2026/05/16
JO - The Lancet Respiratory Medicine
DO - 10.1016/s2213-2600(26)00046-9
UR - https://hal.science/hal-05560327v2
AB - Background: Acute hypoxaemic respiratory failure (ARF) is the leading cause of intensive care unit (ICU) admission among immunocompromised patients. However, contemporary data regarding the epidemiology, management, and outcomes of ARF in this population remain scarce. We aimed to identify predictors of mortality and intubation in immunocompromised patients admitted to the ICU with ARF. Methods: This retrospective observational study was conducted in 103 ICUs in 26 countries. Adults (≥18 years) with ARF and immunodeficiency were eligible for inclusion. Patient data, including information on the nature of underlying immunosuppression, the cause of ARF, and the oxygenation strategy, were obtained from electronic medical records or medical charts. The primary outcome was to report 30-day mortality and identify associated factors in patients with complete data for all variables. Cox proportional hazards models were used to identify variables associated with mortality, and differences between groups were compared with χ2 tests or two-sided Wilcoxon rank-sum tests, with p values of less than 0·05 considered significant. Findings: 9854 immunocompromised patients with ARF admitted to participating ICUs between Jan 1, 2017, and Dec 31, 2023, were included in the study. The median age was 64 years (IQR 54-71); 3941 (40·0%) patients were female and 5913 (60·0%) were male. The main causes of immunodeficiency were a haematological malignancy (4759 [48·3%] of 9854 patients) or solid malignancy (3818 [38·7%] patients). Infection was the leading cause of ARF (6610 [62·0%] of 9854 patients); 5288 (53·7%) patients had more than one contributing cause of ARF, and no cause was identified in 1490 (15·1%) patients. The median partial pressure of oxygen in arterial blood (PaO2)/fractional concentration of oxygen in inspired air (FiO2) ratio was 198 [IQR 141-208]. The 30-day mortality rate was 47·3% (4662 patients). Predictors of higher mortality were older age (hazard ratio 1·01 [IQR 1·00-1·02]), higher Charlson Comorbidity Index score (1·04 [1·01-1·07]), higher Frailty Index score (1·22 [1·16-1·28]), longer time from hospital to ICU admission (1·02 [1·01-1·03]), higher respiratory rate (1·02 [1·02-1·03]), coma at ICU admission (2·04 [1·72-2·43]), invasive fungal infection as cause of ARF (1·82 [1·45-2·28]), disease-specific infiltrates (1·73 [1·32-2·26]), unidentified cause of ARF (2·16 [1·74-2·68]), and use of vasoactive drugs (2·45 [2·10-2·86]) or renal replacement therapy (2·07 [1·74-2·48]). Protective factors included receipt of a solid organ transplant (0·62 [0·49-0·79]), systemic vasculitis or connective tissue disease (0·61 (0·47-0·78]), higher PaO2/FiO2 ratio (0·78 [0·72-0·84]), receipt of high-flow nasal oxygen therapy (0·78 [0·64-0·95]), and cardiogenic pulmonary oedema (0·67 [0·51-0·89]). Interpretation: In this large international cohort of immunocompromised patients with ARF, we identified key risk and protective factors for mortality and intubation. These findings could improve outcomes by informing timely clinical decisions, goals-of-care discussions, and management in this vulnerable population. Funding: Kirsten and Freddy Johansen Foundation and Groupe de Recherche en Réanimation Onco-Hématologique.
SN - 2213-2600
SN - 2213-2619
ER -