🫁 Respiratory Management of Critically Ill Pneumocystis Pneumonia Patients
Reizine F, Stiegler V, Lécuyer R, Tessoulin B, Gallais M, Camou F, Morio F, Cady A, Gabriel F, Canet E, Raffi F, Boutoille D, Issa N, Gaborit B, and the PRONOCYSTIS Study Group. Ann Intensive Care. 2025;15:114. doi:10.1186/s13613-025-01503-6
Abstract:
Pneumocystis jirovecii pneumonia (PjP) is an emerging cause of acute respiratory failure (ARF) in immunocompromised patients. Using data from the multicenter PRONOCYSTIS cohort, this study evaluated outcomes associated with different respiratory strategies—standard oxygen (SO), non-invasive ventilation (NIV), and high-flow nasal cannula (HFNC)—in 248 ICU patients. The primary endpoint was intubation rate, with survival analyzed using Cox regression and propensity score methods.
Key Insights:
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A total of 248 patients with PjP were included, with 118 receiving SO, 60 NIV, and 70 HFNC. Nearly 45% of patients overall required mechanical ventilation, and day-90 mortality reached 34.7%.
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Intubation rates were significantly lower with HFNC (28.6%) compared to NIV (45.0%) and SO (55.4%), with p=0.003. Median time to intubation was 2 days from ICU admission.
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Weighted Cox regression showed HFNC as an independent protective factor against intubation (HR 0.41, 95% CI 0.24–0.69, p<0.001). NIV trended toward protection (HR 0.62) but did not reach statistical significance (p=0.056).
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Survival analysis demonstrated no independent association between initial respiratory strategy and day-90 survival after adjustment. While HFNC was linked to survival in unadjusted analysis, this effect disappeared in multivariable modeling.
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Long-term corticosteroid use was a strong independent predictor of mortality (aHR 4.03), alongside solid tumor as an underlying condition (aHR 3.37) and higher SOFA score (aHR 1.24).
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Patients who required intubation had markedly higher day-90 mortality (55% vs 18% in non-intubated), confirming intubation as a critical prognostic turning point.
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HFNC may provide physiological benefits for PjP patients, including reduced inspiratory effort, improved compliance, and avoidance of NIV-associated risks like barotrauma or delayed intubation.
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Prophylaxis against PjP was rare (11.3%) despite being central to prevention, especially important in patients on chronic corticosteroids or with solid tumors.
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ICU and hospital length of stay were significantly longer for patients requiring intubation, emphasizing the morbidity impact of invasive ventilation.
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Despite HFNC’s association with reduced intubation, this did not translate into improved overall survival, highlighting the need for prospective randomized trials to clarify causal benefit.
Conclusion:
In critically ill PjP patients, HFNC reduced the likelihood of intubation compared with standard oxygen or NIV, though without a survival advantage. Intubation itself was strongly associated with mortality, reinforcing the importance of strategies that can avoid mechanical ventilation in this fragile population. Further prospective research is required to refine respiratory support strategies in PjP.
Take-Home for Clinicians: HFNC should be considered a first-line strategy in PjP-associated ARF for its ability to reduce intubation risk, but survival benefit remains unproven. Vigilance for high-risk features such as corticosteroid exposure, solid tumors, and elevated SOFA scores is crucial in guiding prognosis and management.
Discussion Question: Should future ICU protocols position HFNC as the preferred initial respiratory support in immunocompromised patients with PjP, despite the absence of proven survival benefit?
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