Non-invasive Ventilation in Adult Cancer Patients With Acute Respiratory Failure - A Systematic Review of Clinical Outcomes and Predictors of Failure

Sep 30, 2026

Acute respiratory failure (ARF) drives unplanned ICU admissions in adults with active solid or hematologic cancer, with particularly high short-term mortality when ARDS is present. A PRISMA-guided, scenario-based systematic review evaluated benefits and harms of non-invasive ventilation (NIV) versus oxygen or high-flow nasal cannula (HFNC), and identified predictors of NIV failure. Searches covered PubMed (inception to 31 Aug 2025), Scopus, and the Cochrane Library (2010 to 31 Aug 2025). Primary outcomes were NIV failure (intubation during the index episode) and in-hospital mortality; secondary outcomes included length of stay, complications, and failure predictors across 26 included studies (~12,000 patients). Evidence suggests no decline in intubation or mortality for early NIV in de novo hypoxemia. In cancer-related ARDS, NIV failure was common (about 60% to 80%) and strongly linked to death, with independent predictors including shock, worse PaO2/FiO2, invasive fungal infection, higher severity scores, and undetermined etiology. Observational data suggested lower ICU mortality with early NIV when cancer ARF coexisted with cardiac dysfunction. Limitations include heterogeneity, residual confounding, and variable protocols. Overall, NIV advantages appear context dependent, with no clear benefit over HFNC/oxygen in de novo hypoxemia and a need for vigilant escalation in ARDS.

LanguageEnglish

CategoryHealthcare

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Pages14

Reading Time35 min

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Abstract

Introduction And Background

How to cite this article

Review began 11/20/2025 Review ended 12/04/2025 Published 12/09/2025 © Copyright 2025 Abu Zaher et al. This is an open access article distributed under the terms of the Creative Commons Attribution License CCBY 4.0. , which permits unrestricted use , distribution , and reproduction in any medium , provided the original author and source are credited. DOI: 10.7759/cureus.98833 Open Access Review Article Non-invasive Ventilation in Adult Cancer Patients With Acute Respiratory Failure: A Systematic Review of Clinical Outcomes and Predictors of Failure Mohamad Abu Zaher 1 , Osman El Jundi 2 , Hanan Arain 3 1. Renal, Broomfield Hospital, Chelmsford, GBR 2. Respiratory Medicine, Istanbul Atlas University, Istanbul, TUR 3. Respiratory Medicine, Anglia Ruskin University, Chelmsford, GBR Corresponding author: Mohamad Abu Zaher, [mohammadabuzaher@gmail.com](mohammadabuzaher@gmail.com) Abstract Acute respiratory failure (ARF) is a leading cause of unexpected admissions to the ICU in adults with active solid or haematologic cancer. Early trials highlighted some benefits of non-invasive ventilation (NIV) delivered with supplemental oxygen versus conventional oxygen. Whether this is still maintained in the high-flow nasal cannula (HFNC) era is doubtful. Therefore, a Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA)-guided, scenario-based systematic review was conducted to evaluate the effectiveness and harms of NIV versus oxygen/HFNC and to identify predictors and outcomes of NIV failure in adult cancer patients with ARF. Searches on PubMed from inception to 31 August 2025, Scopus, and the Cochrane Library from 2010 to 31 August 2025 were completed. In this review of trials and studies, primary outcomes were NIV failure, defined as intubation during the index episode, and in-hospital mortality. Secondary outcomes were length of stay, complications, and predictors of NIV failure. Two reviewers screened, extracted, and assessed risk of bias using Cochrane Risk of Bias 2 (RoB 2) and the Newcastle-Ottawa Scale. We did not perform a formal meta-analysis, and studies were compared qualitatively. Twenty-six studies met the inclusion criteria, including four randomised trials and 22 cohorts, with a pooled sample of approximately 12,000 patients. In de novo hypoxemic respiratory failure, the largest recent trial and adjusted cohorts showed no decline in intubation or mortality rates with early NIV versus oxygen or high-flow nasal cannula. In cancer-related acute respiratory distress syndrome (ARDS), a form of ARF, NIV failure was common at about 60% to 80% and greatly linked to death. In the case of NIV failure, independent predictors of failure included shock, lower arterial oxygen partial pressure to inspired oxygen fraction ratio (PaO₂/FiO₂), invasive fungal infection, higher severity scores, and undetermined aetiology. However, in cases of cancer and acute respiratory failure with cardiac dysfunction, observational data suggested lower ICU mortality with early NIV. Limitations of this review include heterogeneity, residual confounding, and variable protocols. To conclude, benefits of NIV in cancer-related ARF are context dependent. There is no clear advantage of NIV over HFNC/oxygen in de novo hypoxemia. In addition, high failure risk in ARDS with NIV mandates vigilant escalation. A context-specific NIV approach rather than a blanket one is highly recommended in the HFNC era. Categories: Internal Medicine, Oncology, Pulmonology Keywords: acute respiratory failure (arf), bilevel positive airway pressure-bipap, continuous positive airway pressure (cpap), haemato-oncology, high-flow nasal cannula (hfnc), intensive respiratory care, niv (non-invasive ventilation) Introduction And Background Acute respiratory failure is a prime reason for unplanned ICU admission in adults with active solid tumours or haematologic malignancies. In these cases, short-term mortality is high, and it is even

FAQs

What was the main purpose of this systematic review?

To evaluate the effectiveness and harms of non-invasive ventilation (NIV) versus oxygen/HFNC in adult cancer patients with acute respiratory failure, and to identify predictors and outcomes of NIV failure.

What were the primary outcomes in the included trials and studies?

Primary outcomes were NIV failure—defined as intubation during the index episode—and in-hospital mortality.

What does the review indicate about NIV use in de novo hypoxemic respiratory failure?

The review found no clear decline in intubation or mortality rates with early NIV versus oxygen or high-flow nasal cannula in de novo hypoxemia.

Which factors were identified as independent predictors of NIV failure?

Independent predictors included shock, lower PaO2/FiO2, invasive fungal infection, higher severity scores, and undetermined etiology.

Sep 30, 2026

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