Effect of High-Flow Nasal Oxygen vs Standard Oxygen on 28-Day Mortality in Immunocompromised Patients With Acute Respiratory Failure: The HIGH Randomized Clinical Trial
JAMA, 2018 · Multicenter, parallel-group randomized clinical trial
Clinical question
Does high-flow nasal cannula (HFNC) oxygen reduce 28-day mortality compared with standard oxygen therapy in immunocompromised patients with acute respiratory failure?
What the trial found
In critically ill immunocompromised patients with acute hypoxemic respiratory failure, high-flow nasal oxygen did not significantly reduce 28-day mortality or intubation rate compared with standard oxygen.
Current guideline position
ESICM and ATS guidelines suggest trial of HFNC in hypoxemic respiratory failure with low threshold for invasive mechanical ventilation.
Clinical interpretation
Demonstrated that while HFNC improves comfort and oxygenation, it does not confer a mortality advantage over standard oxygen in immunocompromised hosts, and close bedside monitoring is essential to avoid delayed emergency intubation.
Host immune defects, neutropenic sepsis, acute respiratory failure (PJP/Aspergillus), tumor lysis syndrome, leukostasis, CAR-T CRS/ICANS, and ICU triage.
Pathophysiologic mechanisms (shunt vs V/Q mismatch), dynamic ROX index trajectories, P-SILI prevention, and evidence-based oxygen escalation ladders.
Acute, diffuse inflammatory lung injury causing hypoxemia and bilateral infiltrates not fully explained by cardiac failure or fluid overload.