HIGH-FLOW nasal cannula (HFNC) therapy may significantly reduce the need for intubation in critically ill patients with Pneumocystis jirovecii pneumonia (PjP), according to a new multicenter retrospective analysis.
PjP is an increasingly common cause of acute respiratory failure among immunocompromised patients, frequently requiring intensive care admission. Optimal initial ventilatory strategies for this high-risk group have remained uncertain. To address this, researchers conducted an ancillary analysis of the PRONOCYSTIS study, evaluating 248 ICU patients with severe PjP across multiple centers. Patients were managed initially with HFNC, standard oxygen (SO), or non-invasive ventilation (NIV).
Of the cohort, 70 received HFNC, 118 received SO, and 60 received NIV. Intubation rates were notably lower in the HFNC group compared with both NIV (28.6% vs. 45.0%) and SO (28.6% vs. 55.4%). After adjusting for confounders using inverse probability of treatment weighting, HFNC remained independently associated with reduced intubation risk (HR 0.41; 95% CI 0.24–0.69; p < 0.001). NIV did not show a statistically significant association with reduced intubation (HR 0.62; p = 0.056). Survival analysis identified long-term corticosteroid use, presence of a solid tumor, and higher Sequential Organ Failure Assessment (SOFA) scores as independent predictors of mortality. However, the choice of initial respiratory support was not linked to 90-day survival, suggesting that while HFNC may help avoid early intubation, it does not independently improve long-term survival outcomes in this population. The authors conclude that HFNC could be a preferred initial oxygenation strategy in critically ill PjP patients to reduce the likelihood of intubation, though randomized prospective trials are needed to confirm these findings and refine respiratory management protocols. Reference: Reizine F et al. Respiratory management of critically ill pneumocystis pneumonia patients: a multicenter retrospective study. Ann Intensive Care. 2025;15:114.
