TOPLINE:

Among immunocompromised patients with acute hypoxemic respiratory failure (ARF), frailty, longer hospital-to-ICU transfer time, invasive fungal infection, and unidentified causes of ARF were independently associated with increased 30-day mortality, whereas high-flow nasal oxygen (HFNO) therapy and solid organ transplantation were linked to lower risk.

METHODOLOGY:

• Researchers conducted a retrospective cohort study across 26 countries to identify risk factors associated with mortality and intubation in immunocompromised patients with ARF admitted to the ICU.
• A total of 9854 patients (median age, 64 years; 60.0% men) were included. ARF was defined as partial pressure of oxygen in arterial blood (PaO₂) of < 60 mm Hg, peripheral capillary oxygen saturation of < 90% on room air, respiratory rate of > 30 breaths/min, laboured breathing, respiratory distress, dyspnoea at rest, or cyanosis.
• Data were extracted from electronic medical records and charts and contained details about underlying immunosuppression, cause of ARF, initial oxygenation strategy, and organ support interventions.
• The primary objective was to assess 30-day all-cause mortality and its associated independent factors; the secondary objective was to identify factors associated independently with intubation during ICU stay.

TAKEAWAY:

• The 30-day mortality rate was 47.3%, and overall 62% of patients had infection as the main cause of ARF.
• Independent predictors of increased 30-day mortality were older age (hazard ratio [HR], 1.01), greater frailty (HR, 1.22), longer time from hospital admission to ICU admission (HR, 1.02), coma on ICU admission (HR, 2.04), invasive fungal infection as the cause of ARF (HR, 1.82), disease-specific infiltrates (HR, 1.73), an unidentified cause of ARF (HR, 2.16), use of vasoactive drugs (HR, 2.45), and the need for renal replacement therapy (HR, 2.07).
• Factors associated with lower 30-day mortality included the receipt of a solid organ transplant, systemic vasculitis or connective tissue disease, a higher ratio of PaO₂ to the fraction of inspired oxygen (FiO₂), the receipt of HFNO therapy, and cardiogenic pulmonary edema.
• The need for vasoactive drugs was the strongest independent predictor of intubation; the need for renal replacement therapy, invasive fungal infection, and coma on ICU admission were also linked to a higher risk for intubation. By contrast, acute myeloid leukemia, a higher ratio of PaO₂ to FiO₂, and cardiogenic pulmonary edema were associated with a lower likelihood of intubation.

IN PRACTICE:

“In conclusion, contemporary evidence affirms a shift toward more precise, proactive, and patient-centered care for immunocompromised adults with ARF. Outcomes have improved, and interventions that were once considered high-risk, including invasive mechanical ventilation, should be viewed through a lens of clinical appropriateness rather than therapeutic pessimism ,” experts wrote in a comment accompanying the journal article.

SOURCE:

This study was led by Elie Azoulay, MD, PhD, Université Paris-Cité, INSERM, Institut de Recherche Saint-Louis, Paris, France. It was published online on March 16, 2026, in The Lancet Respiratory Medicine.

LIMITATIONS:

Due to its observational design, this study could not establish causality. Retrospective data collection introduced information bias and led to high rates of missing data for certain variables. Moreover, diagnostic protocols were not standardized and likely varied between participating countries.

DISCLOSURES:

This study was supported by the Groupe de Recherche en Réanimation Onco-Hématologique and the Kirsten and Freddy Johansen Foundation. Several authors reported receiving research grants, consulting fees, speaker honoraria, or travel support from or serving on advisory or data safety monitoring boards of various pharmaceutical and biotechnology companies.

This article was created using several editorial tools, including AI, as part of the process. Human editors reviewed this content before publication.