Table 2.

The DIRECT approach to acute respiratory failure in immunocompromised patients

D. Delay: time since respiratory symptoms onset, since antibiotic prophylaxis or treatment, since transplantation, since the diagnosis of malignancy or inflammatory disease

I. Immune deficiency: nature of immune defects and ongoing antibiotic prophylaxis will help avoid missing opportunistic infections

R. Radiographic appearance: A chest radiograph will not only report the extent and the patterns of pulmonary infiltrates (consolidation, air bronchogram, nodules, interstitial pattern), but also presence and importance of pleural effusion, mediastinal mass, cardiomegaly, pericarditis, etc

E. Experience: the clinical experience of the ICU team and specialists consultants with this type of patients (treatment-related toxicity, viral reactivation, atypical form of diseases, cardiac involvement, etc.)

C. Clinical picture: the presence of shock is likely to be associated with bacterial infection, but may be seen in hemophagocytic lymphohistiocytosis, toxoplasmosis, adenoviral infections, or HHV6 reactivations. Similarly, absence of fever or presence of tumoral syndrome (liver, spleen, and lymph nodes) will be considered as a possible orientation

CT scan provides a better description of the radiographic patterns and guides the diagnostic strategy towards non-invasive or invasive diagnostic tests