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Semin Respir Crit Care Med
DOI: 10.1055/a-2707-2920
Review Article

Noninfectious Severe Pulmonary Complications in Immunocompromised Critically Ill Patients

Authors

  • Silvia De Rosa

    1   Centre for Medical Sciences, University of Trento, Trento, Italy
    2   Anesthesia and Intensive Care, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari di Trento, Trento, Italy

  • Sergio Lassola

    2   Anesthesia and Intensive Care, Santa Chiara Hospital, Azienda Provinciale per i Servizi Sanitari di Trento, Trento, Italy

  • Francesca Gualdi

    3   Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
    4   Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy

  • Denise Battaglini

    3   Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genoa, Italy
    4   Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
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Abstract

Noninfectious pulmonary complications are a significant cause of morbidity and mortality in immunocompromised patients, particularly in those undergoing hematopoietic stem cell transplantation, solid organ transplantation, chemotherapy, or immunotherapy. These syndromes often mimic infections, leading to delayed diagnosis and inappropriate treatment. Acute complications include peri-engraftment respiratory distress syndrome, diffuse alveolar hemorrhage, drug-induced lung injury, immune checkpoint inhibitor-related pneumonitis, and radiation pneumonitis, while late or chronic complications, such as organizing pneumonia, interstitial lung disease, bronchiolitis obliterans syndrome, and chronic graft-versus-host disease-related lung involvement, typically develop months to years after therapy. Accurate and timely diagnosis is essential, relying on high-resolution CT, bronchoalveolar lavage, and, in selected cases, lung biopsy to differentiate these conditions from infections. Current treatments remain largely empirical, focusing on corticosteroids, supportive intensive care, and immunosuppressive adjustment, although novel strategies, including inhaled hemostatic agents and JAK inhibitors, are emerging. Despite advances in supportive management, late-onset complications remain associated with poor long-term functional outcomes. Future directions include the development of biomarkers, artificial intelligence-assisted radiological tools, and multicenter registries to improve classification, risk stratification, and treatment. In this narrative review, we highlight current evidence around noninfectious pulmonary complications in the critical care setting, diagnosis, and treatment.

Keywords

noninfectious pulmonary complications - acute respiratory distress syndrome - respiratory failure - organizing pneumonia - pneumonia

Contributors' Statement

S.D.R. and D.B.: conceptualization, writing first draft, and review—editing. S.L. and F.G.: review—editing. All authors read and approved the submitted version.




Publication History

Received: 31 August 2025

Accepted: 22 September 2025

Article published online:
17 October 2025

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