High-flow nasal cannula failure in critically ill cancer patients with acute respiratory failure: Moving from avoiding intubation to avoiding delayed intubation

BACKGROUND: High-flow nasal cannula (HFNC) is increasingly used in critically ill cancer patients with acute respiratory failure (ARF) to avoid mechanical ventilation (MV). The objective was to assess prognostic factors associated with mortality in ICU cancer patients requiring MV after HFNC failure, and to identify predictive factors of intubation. METHODS: We conducted a retrospective study from 2012–2016 in a cancer referral center. All consecutive onco-hematology adult patients admitted to the ICU treated with HFNC were included. HFNC failure was defined by intubation requirement. RESULTS: 202 patients were included, 104 successfully treated with HFNC and 98 requiring intubation. ICU and hospital mortality rates were 26.2% (n = 53) and 42.1% (n = 85) respectively, and 53.1% (n = 52) and 68.4% (n = 67) in patients requiring MV. Multivariate analysis identified 4 prognostic factors of hospital mortality after HFNC failure: complete/partial remission (OR = 0.2, 95%CI = 0.04–0.98, p<0.001) compared to patients with refractory/relapse disease (OR = 3.73, 95%CI = 1.08–12.86), intubation after day 3 (OR = 7.78, 95%CI = 1.44–41.96), number of pulmonary quadrants involved on chest X-ray (OR = 1.93, 95%CI = 1.14–3.26, p = 0.01) and SAPSII at ICU admission (OR = 1.06, 95%CI = 1–1.12, p = 0.019). Predictive factors of intubation were the absence of sepsis (sHR = 0.32, 95%CI = 0.12–0.74, p = 0.0087), Sp02<95% 15 minutes after HFNC initiation (sHR = 2.05, 95%CI = 1.32–3.18, p = 0.0014), number of quadrants on X-ray (sHR = 1.73, 95%CI = 1.46–2.06, p<0.001), Fi02>60% at HFNC initiation (sHR = 3.12, 95%CI = 2.06–4.74, p<0.001) and SAPSII at ICU admission (sHR = 1.03, 95%CI = 1.02–1.05, p<0.01). CONCLUSION: Duration of HFNC may be predictive of an excess mortality in ARF cancer patients. Early warning scores to predict HFNC failure are needed to identify patients who would benefit from early intubation.