Dyspnea as a marker of prognosis in immunocompromised patients with acute respiratory failure

Alexandre Demoule; Maxens Decavèle; Sangeeta Mehta; Philippe R Bauer; Victoria Metaxa; Frédéric Pène; Christophe Girault; Laveena Munshi; Fabio Silvio Taccone; Massimo Antonelli; Francois Barbier; Andreas Barratt-Due; Gaston Burghi; Emmanuel Canet; Achille Kouatchet; Virginie Lemiale; Ignacio Martin-Loeches; Djamel Mokart; Anne-Sophie Moreau; Luca Montini; Peter Pickkers; Jordi Rello; Peter Schellongowski; Nicolas Terzi; Miia Valkonen; Andry van de Louw; Elie Azoulay; Michael Darmon; Efraim investigators and the Nine-I study group

doi:10.1016/j.aicoj.2026.100091

Dyspnea as a marker of prognosis in immunocompromised patients with acute respiratory failure

Ann Intensive Care. 2026 May 19:16:100091. doi: 10.1016/j.aicoj.2026.100091. eCollection 2026.

Authors

Alexandre Demoule^{1

2}, Maxens Decavèle^{1

2}, Sangeeta Mehta³, Philippe R Bauer⁴, Victoria Metaxa⁵, Frédéric Pène⁶, Christophe Girault⁷, Laveena Munshi³, Fabio Silvio Taccone⁸, Massimo Antonelli⁹, Francois Barbier¹⁰, Andreas Barratt-Due¹¹, Gaston Burghi¹², Emmanuel Canet¹³, Achille Kouatchet¹⁴, Virginie Lemiale¹⁵, Ignacio Martin-Loeches¹⁶, Djamel Mokart¹⁷, Anne-Sophie Moreau¹⁸, Luca Montini^{9

19}, Peter Pickkers²⁰, Jordi Rello^{21

22

23}, Peter Schellongowski²⁴, Nicolas Terzi²⁵, Miia Valkonen²⁶, Andry van de Louw²⁷, Elie Azoulay^{15

28}, Michael Darmon^{15

28

29}; Efraim investigators and the Nine-I study group

Affiliations

¹ AP-HP. Sorbonne Université, Hôpital Pitié-Salpêtrière, Service de Médecine Intensive - Réanimation (Département "R3S"), Paris, France.
² Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.
³ Department of Medicine, Sinai Health System, Interdepartmental Division of Critical Care Medicine, University of Toronto, Toronto, Ontario, Canada.
⁴ Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN 55905, United States of America.
⁵ Department of Critical Care, King's College Hospital NHS Foundation Trust, London SE5 9RS, United Kingdom.
⁶ Université Paris Cité, Assistance Publique - Hôpitaux de Paris, Hôpital Cochin, DMU Réanimation-Urgences, Service de Médecine Intensive Réanimation, Institut Cochin, INSERM U1016, CNRS UMR8104, Paris, France.
⁷ Medical Intensive Care Unit, CHU Rouen, and Univ Rouen Normandie, Normandie Univ, GRHVN-UR 3830, F-76000 Rouen, France.
⁸ Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium.
⁹ Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario A.Gemelli IRCCS, Rome, Italy.
¹⁰ Medical Intensive Care Unit, La Source Hospital, CHR Orléans, Orléans, France.
¹¹ Department of Anesthesia and Intensive Care, Division of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway.
¹² Intensive Care Unit, Hospital Maciel, Montevideo, Uruguay.
¹³ Medecine Intensive Reanimation, Nantes University Hospital and Nantes Université, Nantes, France.
¹⁴ Department of Medical Intensive Care Medicine, University Hospital of Angers, Angers, France.
¹⁵ Medecine Intensive et Réanimation, AP-HP, Hôpital Saint-Louis, Paris, France.
¹⁶ Trinity College Dublin, School of Medicine, Dublin, Ireland.
¹⁷ Département d'Anesthésie-Réanimation, Institut Paoli-Calmettes, Marseilles, France.
¹⁸ Médecine Intensive et Réanimation, Centre Hospitalier Universitaire de Lille, Lille, France.
¹⁹ Catholic University of Sacred Heart, Rome, Italy.
²⁰ The Department of Intensive Care Medicine (710), Radboud University Medical Center, Nijmegen, the Netherlands.
²¹ Medicine Department, Universitat Internacional de Catalunya, Spain.
²² Clinical Research Pneumonia and Sepsis (CRIPS) Research Group-Vall d'Hebron Institute Research (VHIR), Barcelona, Spain.
²³ Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto Salud Carlos III, Madrid, Spain.
²⁴ Department of Medicine I, Medical University of Vienna, Vienna, Austria.
²⁵ Medical Intensive Care Unit, University Hospital of Rennes, Rennes, France.
²⁶ Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki 00014, Finland.
²⁷ Division of Pulmonary and Critical Care Medicine, Penn State Health Milton Hershey Medical Center, Hershey, PA 17036, United States of America.
²⁸ ICU-People Research Team, INSERM 1342, Institut de Recherche Saint-Louis, Paris, France.
²⁹ INSERM 1342, Institut de Recherche Saint-Louis, Paris, France.

Abstract

Background: Acute hypoxemic respiratory failure (AHRF) is the leading cause of intensive care unit (ICU) admission in immunocompromised patients, in whom both intubation and mortality rates are higher than in the general ICU population. This study explores dyspnea on admission as it relates to clinical outcomes.

Methods: Secondary analysis of the Efraim study, a prospective multinational cohort study of immunocompromised patients with AHRF admitted to the ICU. Dyspnea was quantified by a numeric rating scale (dyspnea-NRS) from zero to 10. Factors associated with dyspnea-NRS were assessed with linear regression. Hierarchical model was used to assess factors independently associated with invasive mechanical ventilation (intubation) and hospital mortality.

Results: 547 patients were included. On ICU admission, median dyspnea-NRS was 5 (interquartile range 4-7). Variables independently associated with dyspnea-NRS were underlying immune defect unrelated to hematological malignancy, chronic heart failure, high SOFA score and respiratory rate. Intubation rate was 41 %. Variables independently associated with intubation were dyspnea-NRS ≥5 (odds ratio [OR] 2.61, p < 0.001), high SOFA (OR per point 1.10, p = 0.006) and fungal infection (OR 2.02, p = 0.020)., while respiratory rate and PaO₂/FiO₂ were not. Hospital mortality was 37 %. Variables independently associated with hospital mortality were age (OR per year 1.02, P = 0.009), SOFA score (OR per point, 1.13, P < 0.001) and dyspnea-NRS (OR per point 1.19, P < 0.001).

Conclusions: In immunocompromised patients admitted to the ICU for AHRF, dyspnea at admission is moderate to severe and is associated with clinical outcomes. Dyspnea-NRS ≥5 is associated with an increase in intubation rate and hospital mortality.

Keywords: Acute respiratory failure; Comfort; Diagnosis; Dyspnea; High flow oxygen; Immunocompromised; Intubation; Mechanical ventilation; Non-invasive ventilation; Outcome..