Outcome for cancer patients requiring mechanical ventilation

Admission of advanced lung cancer patients to intensive care unit: a retrospective study of 76 patients

BACKGROUND

Criteria for admitting patients with incurable diseases to the medical intensive care unit (MICU) remain unclear and have ethical implications.

METHODS

We retrospectively evaluated MICU outcomes and identified risk factors for MICU mortality in consecutive patients with advanced lung cancer admitted to two university-hospital MICUs in France between 1996 and 2006.

RESULTS

Of 76 included patients, 49 had non-small cell lung cancer (stage IIIB n = 20; stage IV n = 29). In 60 patients, MICU admission was directly related to the lung cancer (complication of cancer management, n = 30; cancer progression, n = 14; and lung-cancer-induced diseases, n = 17). Mechanical ventilation was required during the MICU stay in 57 patients. Thirty-six (47.4%) patients died in the MICU. Three factors were independently associated with MICU mortality: use of vasoactive agents (odds ratio [OR] 6.81 95% confidence interval [95%CI] [1.77-26.26], p = 0.005), mechanical ventilation (OR 6.61 95%CI [1.44-30.5], p = 0.015) and thrombocytopenia (OR 5.13; 95%CI [1.17-22.5], p = 0.030). In contrast, mortality was lower in patients admitted for a complication of cancer management (OR 0.206; 95%CI [0.058-0.738], p = 0.015). Of the 27 patients who returned home, four received specific lung cancer treatment after the MICU stay.

CONCLUSIONS

Patients with acute complications of treatment for advanced lung cancer may benefit from MCIU admission. Further studies are necessary to assess outcomes such as quality of life after MICU discharge.

The Outcomes of Adult Patients with Haematological Malignancy Requiring Admission to the Intensive Care Unit

A literature review was conducted to ascertain the prognosis of patients with haematological malignancies admitted to the intensive care unit (ICU) and to identify any factors that could be shown to influence outcome. Studies that examined outcomes among patients with haematological malignancy admitted to ICU were evaluated. Pooled outcome data relating to ICU, hospital and six-month mortality were compiled. A qualitative assessment of the evidence relating to putative determinants of prognosis was made. Observational studies examining outcomes among over 10,000 haematological malignancy patients admitted to the ICU were identified. Approximately 40% of such patients survived until hospital discharge. The principle determinants of short-term survival would appear to be related to the severity of the acute illness and the consequent physiological derangement or organ system dysfunction. In the longer term, factors relating to the prognosis of the underlying malignancy appear to be important.

Intensive care of the cancer patient: recent achievements and remaining challenges

A few decades have passed since intensive care unit (ICU) beds have been available for critically ill patients with cancer. Although the initial reports showed dismal prognosis, recent data suggest that an increased number of patients with solid and hematological malignancies benefit from intensive care support, with dramatically decreased mortality rates. Advances in the management of the underlying malignancies and support of organ dysfunctions have led to survival gains in patients with life-threatening complications from the malignancy itself, as well as infectious and toxic adverse effects related to the oncological treatments. In this review, we will appraise the prognostic factors and discuss the overall perspective related to the management of critically ill patients with cancer. The prognostic significance of certain factors has changed over time. For example, neutropenia or autologous bone marrow transplantation (BMT) have less adverse prognostic implications than two decades ago. Similarly, because hematologists and oncologists select patients for ICU admission based on the characteristics of the malignancy, the underlying malignancy rarely influences short-term survival after ICU admission. Since the recent data do not clearly support the benefit of ICU support to unselected critically ill allogeneic BMT recipients, more outcome research is needed in this subgroup. Because of the overall increased survival that has been reported in critically ill patients with cancer, we outline an easy-to-use and evidence-based ICU admission triage criteria that may help avoid depriving life support to patients with cancer who can benefit. Lastly, we propose a research agenda to address unanswered questions.

Aggressive end-of-life care significantly influenced propensity for hospice enrollment within the last three days of life for Taiwanese cancer decedents

CONTEXT

Late hospice enrollment exacts a substantial toll from patients, families, hospices, and society. The relationship between the propensity for late hospice enrollment and aggressive health services received at the end of life (EOL) has been underinvestigated.

OBJECTIVES

To identify determinants of hospice enrollment within the last three days of life.

METHODS

Retrospective population-based cohort study using administrative data for 31,529 Taiwanese cancer decedents who used hospice care in their last year of life.

RESULTS

Rates of hospice enrollment within the last three days of life (16.80%-18.73%) remained constant over 2001-2006. After adjustment for patient demographics and disease characteristics, physician specialty, availability of health care resources at the hospital and regional levels, and historical trends, late hospice enrollment was more likely if Taiwanese cancer patients received chemotherapy, had multiple emergency room visits or hospital admissions, and used the intensive care unit in their last month of life (adjusted odds ratio [95% confidence interval] (AOR [95% CI]): 1.61 [1.44-1.80], 1.40 [1.29-1.52], 1.78 [1.51-2.09], and 1.45 [1.19-1.76], respectively). Late hospice enrollment was less likely for patients with hospital stays>14 days or who received cardiopulmonary resuscitation in their last month of life (AOR [95% CI]: 0.51 [0.45-0.58] and 0.41 [0.25-0.65], respectively).

CONCLUSION

Aggressive EOL care played a more significant role than patient, physician, or hospital characteristics in determining the propensity of Taiwanese cancer patients to be enrolled in hospice care within their last three days of life. Clinical and health policies should aim to avoid aggressive care when it will not benefit patients but may preclude timely hospice enrollment.

Epidemiology of Acute Respiratory Failure in Patients with HM (ICU Only)

Pulmonary complications are common in hematological patients, particularly those receiving a hematological stem cell transplant (HSCT), and a significant percentage of them will require intensive care unit (ICU) admission. Acute respiratory failure in these patients is a threatening event, with a very poor outcome, particularly when mechanical ventilation (MV) is required. For many years, oncologists and intensivists had a pessimistic vision of the dismal outcome of those hematological patients requiring admission to the ICU. The bleak experience in this population led some authors to suggest early withdrawal of support, or even withholding the option of mechanical ventilation altogether. However, over the last years this vision seems to be changing. Great progress has been made in stem cell transplantation that can be ascribed to a better understanding of the human leukocyte antigen (HLA) system for donor selection, more effective and less toxic immunosupression for prevention and treatment of graft-versus host disease (GVHD), and significant advances in infectious disease therapy. Also improvements in ventilatory and supportive care, such as the early implantation of noninvasive ventilation (NIV), may avoid intubation in a significant percentage of patients suffering from acute respiratory failure. As a result of all this, the proportion of both hematological patients requiring management in the ICU and those requiring MV is decreasing. Also the survival rate of HSCT recipients admitted to the ICU has been steadily improving. In this chapter we will report on the epidemiology of acute respiratory failure in patients with hematological malignancies.

ICU and 6-month outcome of oncology patients in the intensive care unit

BACKGROUND

Advances in oncological care have led to improved short- and long-term prognosis of cancer patients but admission to the intensive care unit (ICU) remains controversial.

AIM

The objective was to assess the outcome of patients with haematological malignancies and solid tumours admitted to the ICU as emergencies, and to identify risk factors for mortality.

DESIGN AND METHODS

Retrospective and prospective analysis of 185 cancer patients admitted to the ICU at Guy's Hospital (259 admissions), a large tertiary referral oncology centre between February 2004 and July 2008.

RESULTS

One hundred and fifteen patients had haematological malignancies of whom 30.4% died in ICU. Seventy patients had solid tumours. ICU mortality was 27.1%. Fifty-four patients had >1 admission to ICU. ICU survivors had significantly lower acute physiology and chronic health evaluation II scores and less failed organ systems on admission to ICU and less organ failure during stay in the ICU. Neutropenia, sepsis and re-admission were not associated with an increased mortality. Six-month mortality rates for patients with haematological malignancies and solid tumours were 73 and 78.6%, respectively.

CONCLUSION

Short-term outcome of critically ill cancer patients in ICU is better than previously reported. The decision to admit cancer patients to ICU should depend on the severity of the acute illness rather than factors related to the malignancy. In appropriate patients, invasive organ support and re-admission should not be withheld.

Mechanical ventilation in cancer patients: clinical characteristics and outcomes

Acute respiratory failure with the need for mechanical ventilation is a severe and frequent complication, and a leading reason for admission to the intensive care unit (ICU) in patients with malignancies. Nevertheless, improvements in patient survival have been observed over the last decade. This article reviews the epidemiology of adult patients with malignancies requiring ventilatory support. Criteria used to assist decisions to admit a patient to the ICU and to select the initial ventilatory strategy are discussed.

Acute respiratory failure in the patient with cancer: diagnostic and management strategies

Acute respiratory failure (ARF) remains the major reason for admission to the intensive care unit (ICU) in patients with cancer and is often associated with high mortality, especially in those who require mechanical ventilation. The diagnosis and management of ARF in patients who have cancer pose unique challenges to the intensivist. This article reviews the most common causes of ARF in patients with cancer and discusses recent advances in the diagnostic and management approaches of these disorders. Timely diagnosis and treatment of reversible causes of respiratory failure, including earlier use of noninvasive ventilation and judicious ventilator and fluid management in patients with acute lung injury, are essential to achieve an optimal outcome. Close collaboration between oncologists and intensivists helps ensure that clear goals, including direction of treatment and quality of life, are established for every patient with cancer who requires mechanical ventilation for ARF.

Admission criteria and prognostication in patients with cancer admitted to the intensive care unit

Critical care for patients with cancer was once considered inappropriate because of a perceived poor prognosis for their long-term survival. Three decades of research has yielded evidence to support the use of critical care resources for many patients with cancer. A methodical approach to triage and evaluation of critically ill patients regardless of baseline medical diagnosis, coupled with an appreciation for the likely prognosis of their current cancer, is most likely to yield the fairest and most accurate appropriation of care. No clinical scoring system has emerged that accurately defines the severity of illness and likelihood for survival in patients with cancer. This article reviews the studies that have attempted to apply mortality prediction scales or scoring systems to these patients. Clinical judgment with incorporation of consensus opinions from the literature should be used to develop admission or restriction criteria for intensive care of patients with cancer.

Prognostic Factors in Critically Ill Patients with Solid Tumours Admitted to an Oncological Intensive Care Unit

The mortality and prognostic factors for patients admitted to the intensive care unit (ICU) with solid tumours are unclear. The aim of this study was to describe demographic, clinical and survival data and to identify factors associated with mortality in critically ill patients with solid tumours. A prospective observational cohort study of 177 critically ill patients with solid tumours admitted to a medical-surgical oncological ICU was undertaken. There were no interventions. Among the admissions, 66% were surgical, 79.7% required mechanical ventilation during their stay in the ICU and 31.6% presented with severe sepsis or septic shock. In a multivariate analysis, independent prognostic factors for in-ICU death were the need for vasopressors (OR: 22.66, 95% confidence interval: 6.09 to 82.22, P <0.001) and the acute physiology and chronic health evaluation (APACHE) II score (OR: 1.92, 95% confidence interval: 1.43 to 2.58, P <0.001). Cox multivariate analysis identified the length of stay in the ICU, Charlson comorbidity index score greater than 2, and the need for vasopressors as independent predictors of death after ICU discharge. The mortality rate in the ICU was 21.4%. Improved outcomes in critically ill cancer patients extended to the subgroup of patients with solid tumours. Independent prognostic factors for in-ICU death were the need for vasopressors and the APACHE II score, while the length of stay in the ICU, Charlson comorbidity index score >2, and the need for vasopressors were independent predictors of death after ICU discharge.

Six-month prognosis of patients with lung cancer admitted to the intensive care unit

BACKGROUND

Intensive care unit (ICU) admission of patients with lung cancer remains debated because of the poor short-term prognosis. However, ICU admission of such patients should also be assessed on the possibility to administer specific anticancer treatment and the long-term outcome thereafter.

OBJECTIVES

To identify predictive factors of hospital and 6-month mortality in critically ill lung-cancer patients.

DESIGN AND SETTING

Retrospective study conducted in the ICU of a university hospital.

PATIENTS

One hundred five consecutive lung-cancer patients included between 1 January 1997 and 31 December 2006.

INTERVENTIONS

None.

RESULTS

Of the 105 patients (mean age 64.8 years), 87 (83%) had a non-small cell lung cancer (NSCLC). Extensive disease was diagnosed in 85 patients (83%) (NSCLC stages IIIB and IV or disseminated small cell lung cancer). The main reasons for ICU admission were acute respiratory failure (59%) and/or hemoptysis (45%). Forty-three patients (41%) needed mechanical ventilation (MV). The ICU, hospital and 6-month mortality rates were 43, 54 and 73%, respectively. A performance status (PS) >or=2 [odds ratio OR = 3.6 (95% confidence interval CI (1.5-8.7)] and acute respiratory failure [OR = 3.5 (95% CI (1.5-8.4)] predicted hospital mortality. In a multivariate Cox model, the cancer progression [hazard ratio HR = 6.1 (95% CI 2.2-17)] and the need for MV [HR = 3.6 (95% CI 1.35-9.4)] were independently associated with 6-month mortality. Two-thirds of the ICU survivors were able to receive anticancer treatment.

CONCLUSIONS

ICU admission should be considered in selected patients with lung cancer (PS <2, no cancer disease progression).

Admission factors associated with hospital mortality in patients with haematological malignancy admitted to UK adult, general critical care units: a secondary analysis of the ICNARC Case Mix Programme Database

Introduction

Patients with haematological malignancy admitted to intensive care have a high mortality. Adverse prognostic factors include the number of organ failures, invasive mechanical ventilation and previous bone marrow transplantation. Severity-of-illness scores may underestimate the mortality of critically ill patients with haematological malignancy. This study investigates the relationship between admission characteristics and outcome in patients with haematological malignancies admitted to intensive care units (ICUs) in England, Wales and Northern Ireland, and assesses the performance of three severity-of-illness scores in this population.

Methods

A secondary analysis of the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme Database was conducted on admissions to 178 adult, general ICUs in England, Wales and Northern Ireland between 1995 and 2007. Multivariate logistic regression analysis was used to identify factors associated with hospital mortality. The Acute Physiology and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiology Score (SAPS) II and ICNARC score were evaluated for discrimination (the ability to distinguish survivors from nonsurvivors); and the APACHE II, SAPS II and ICNARC mortality probabilities were evaluated for calibration (the accuracy of the estimated probability of survival).

Results

There were 7,689 eligible admissions. ICU mortality was 43.1% (3,312 deaths) and acute hospital mortality was 59.2% (4,239 deaths). ICU and hospital mortality increased with the number of organ failures on admission. Admission factors associated with an increased risk of death were bone marrow transplant, Hodgkin's lymphoma, severe sepsis, age, length of hospital stay prior to intensive care admission, tachycardia, low systolic blood pressure, tachypnoea, low Glasgow Coma Score, sedation, PaO₂:FiO₂, acidaemia, alkalaemia, oliguria, hyponatraemia, hypernatraemia, low haematocrit, and uraemia. The ICNARC model had the best discrimination of the three scores analysed, as assessed by the area under the receiver operating characteristic curve of 0.78, but all scores were poorly calibrated. APACHE II had the highest accuracy at predicting hospital mortality, with a standardised mortality ratio of 1.01. SAPS II and the ICNARC score both underestimated hospital mortality.

Conclusions

Increased hospital mortality is associated with the length of hospital stay prior to ICU admission and with severe sepsis, suggesting that, if appropriate, such patients should be treated aggressively with early ICU admission. A low haematocrit was associated with higher mortality and this relationship requires further investigation. The severity-of-illness scores assessed in this study had reasonable discriminative power, but none showed good calibration.

Critical care management of cancer patients: cause for optimism and need for objectivity

PURPOSE OF REVIEW

In the 1990s, cancer patients were described as poor candidates for ICU admission on the basis of high mortality rates and management costs. Over the last decade, however, advances in the management of malignancies and organ failures have led to substantial increases in survival. This review discusses current outcomes of critically ill cancer patients and recent insights into prognostic factors. Persistent areas of uncertainty are emphasized.

RECENT FINDINGS

New drugs, diagnostic tools, and management strategies are available for malignancies and organ failures. Survival after ICU admission has increased in patients with solid tumors, hematological malignancies, or autologous hematopoietic cell transplantation. A few patient subgroups remain poor candidates for ICU management (i.e., allogeneic hematopoietic cell transplantation recipients and patients with advanced lung cancer). Careful evaluation of potential benefits from ICU admission is crucial to limit inappropriate ICU admission, nonbeneficial care, and suboptimal resource utilization.

SUMMARY

ICU admission of selected cancer patients leads to meaningful survival. The optimal time of ICU admission needs to be determined, and patient selection criteria by both hemato-oncologists and intensivists should be improved. Long-term studies of overall survival, disease-free survival, and quality of life are needed.

The effect of implementing high-intensity intensive care unit staffing model on outcome of critically ill oncology patients

OBJECTIVE

Implementing high-intensity staffing model improves outcome in general intensive care units (ICUs). We studied the effect of implementing such a model on the outcome of critically ill medical patients in an oncology ICU.

DESIGN

We compared admission rates, ICU mortality rates (MRs), 28-day MRs, length of stay (LOS) for patients discharged alive, and bed turnover rates of medical patients admitted to the ICU in the year 2004 (before an intensivist model was established) with those in the years 2006 and 2007 (after the model was established). We allowed for 1 year of transition to implement the changes required including the transformation of the ICU to a closed ICU with daily multidisciplinary rounds led by an intensivist as described in the Leapfrog model.

RESULTS

ICU admissions increased from 236 patients (2004) to 388 (2006) and 446 (2007). There was no significant difference in the disease severity of illness when compared by Acute Physiology and Chronic Health Evaluation II scores, 20.6 (before) vs. 20.9 (after) (p = 0.386). ICU MR for the consecutive years decreased from 35.17% (95% confidence interval [CI]: 29.08-41.26) to 23.97% (95% CI: 19.72-28.22) and 22.87% (95% CI: 18.97-26.77), and 28-day MRs decreased from 47.69% (95% CI: 40.68-54.7) to 38.24% (95% CI: 32.91-43.58) and 29.84% (95% CI: 24.79-34.89). LOS (for patients who survived) decreased from a mean of 4.26 days (95% CI: 3.19-5.33) to 2.63 (95% CI: 2.4-2.86) and 2.63 (95% CI: 2.4-2.86). Bed turnover rates increased from 5.0 patient/bed (95% CI: 4.22-5.78) to 6.9 patient/bed (95% CI: 6.04-7.77) and 7.56 patient/bed (95% CI: 6.67-8.44).

CONCLUSION

Implementing a high-intensity staffing model is associated with significant improvements in MRs, LOS, and bed utilization of critically ill oncology patients.

Characteristics and outcomes of cancer patients in European ICUs

Introduction

Increasing numbers of cancer patients are being admitted to the intensive care unit (ICU), either for cancer-related complications or treatment-associated side effects, yet there are relatively few data concerning the epidemiology and prognosis of cancer patients admitted to general ICUs. The aim of this study was to assess the characteristics of critically ill cancer patients, and to evaluate their prognosis.

Methods

This was a substudy of the Sepsis Occurrence in Acutely Ill Patients (SOAP) study, a cohort, multicentre, observational study that included data from all adult patients admitted to one of 198 participating ICUs from 24 European countries during the study period. Patients were followed up until death, hospital discharge or for 60 days.

Results

Of the 3147 patients enrolled in the SOAP study, 473 (15%) had a malignancy, 404 (85%) had solid tumours and 69 (15%) had haematological cancer. Patients with solid cancers had the same severity of illness as the non-cancer population, but were older, more likely to be a surgical admission and had a higher frequency of sepsis. Patients with haematological cancer were more severely ill and more commonly had sepsis, acute lung injury/acute respiratory distress syndrome, and renal failure than patients with other malignancies; these patients also had the highest hospital mortality rate (58%). The outcome of all cancer patients was comparable with that in the non-cancer population, with a 27% hospital mortality rate. However, in the subset of patients with more than three failing organs, more than 75% of patients with cancer died compared with about 50% of patients without cancer (p = 0.01).

Conclusions

In this large European study, patients with cancer were more often admitted to the ICU for sepsis and respiratory complications than other ICU patients. Overall, the outcome of patients with solid cancer was similar to that of ICU patients without cancer, whereas patients with haematological cancer had a worse outcome.

Respiratory support in oncology ward setting: a prospective descriptive study

BACKGROUND

Mechanical ventilation in cancer patients is a critical issue The present prospective descriptive study was designed (1) to assess the patient population needing respirator support in ward setting at a premier state-run oncology institute in India, (2) to observe and analyze the course of their disease while on respirator, and (3) to coordinate better quality of life measures in cancer patients at the institute based on the present study's outcomes.

METHODS

Beginning from March 2005 to March 2006, all cancer patients who were connected to respirator in the wards were enrolled in the current study. Our anesthesiology department at the cancer institute also has primary responsibility for airway management and mechanical ventilation in high dependency units of oncology wards. Preventilation variables in cancer patients were assessed to judge the futility of mechanical ventilation in ward setting. Subsequently, patients were observed for disease course while on respirator. Final outcome with its etio-pathogenesis was correlated with predicted futility of mechanical ventilation.

RESULTS

Over a period of 1 year, 132 (46 men and 86 women) cancer patients with median age 40 years (range 1-75 years) were connected to respirator in oncology wards. Based on the preventilation variables and indications for respirator support, right prediction of medical futility and hospital discharge was made in 77% of patients. Underestimation and overestimation of survival to hospital discharge was made in 10% cases and 13% cases, respectively.

CONCLUSION

Based on preventilation variables, prediction of outcome in cancer patients needing respirator support can be made in 77% cases. This high probability of prediction can be used to educate patients, and their families and primary physicians, for well-informed and documented advance directives, formulated and regularly revised DNAR policies, and judicious use of respirator support for better quality-of-life outcomes.

Predictors of noninvasive ventilation failure in patients with hematologic malignancy and acute respiratory failure

OBJECTIVES

The current trend to manage critically ill hematologic patients admitted with acute respiratory failure is to perform noninvasive ventilation to avoid endotracheal intubation. However, failure of noninvasive ventilation may lead to an increased mortality.

DESIGN

Retrospective study to determine the frequency of noninvasive ventilation failure and identify its determinants.

SETTING

Medical intensive care unit in a University hospital.

PATIENTS

All consecutive patients with hematologic malignancies admitted to the intensive care unit over a 10-yr period who received noninvasive ventilation.

RESULTS

A total of 99 patients were studied. Simplified Acute Physiology Score II at admission was 49 (median, interquartile range, 39-57). Fifty-three patients (54%) failed noninvasive ventilation and required endotracheal intubation. Their PaO2/FiO2 ratio was significantly lower (175 [101-236] vs. 248 [134-337]) and their respiratory rate under noninvasive ventilation was significantly higher (32 breaths/min [30-36] vs. 28 [27-30]). Forty-seven patients (89%) who failed noninvasive ventilation required vasopressors. Hospital mortality was 79% in those who failed noninvasive ventilation, and 41% in those who succeeded. Patients who failed noninvasive ventilation had a significantly longer intensive care unit stay (13 days [8-23] vs. 5 [2-8]) and a significantly higher rate of intensive care unit-acquired infections (32% compared with 7%). Factors independently associated with noninvasive ventilation failure by multivariate analysis were respiratory rate under noninvasive ventilation, longer delay between admission and noninvasive ventilation first use, need for vasopressors or renal replacement therapy, and acute respiratory distress syndrome.

CONCLUSIONS

Failure of noninvasive ventilation occurs in half the critically ill hematologic patients and is associated with an increased mortality. Predictors of noninvasive ventilation failure might be used to guide decisions regarding intubation.

Trends in quality of end-of-life care for Taiwanese cancer patients who died in 2000-2006

BACKGROUND

Quality of end-of-life care received by cancer patients has never been explored in an entire Asian country for all ages and cancer groups.

PATIENTS AND METHODS

Retrospective cohort study to examine trends in quality of end-of-life care among a cohort of 242 530 Taiwanese cancer patients who died in 2000-2006.

RESULTS

In the last month of life, cancer care tended to become increasingly aggressive as shown by (i) intensive use of chemotherapy (15.45%-17.28%), (ii) frequent emergency room visits (15.69%-20.99%) and >14-day hospital stays (41.48%-46.20%), (iii) admissions to intensive care units (10.04%-12.41%), and (iv) hospital deaths (59.11%-65.40%). Use of cardiopulmonary resuscitation (13.09%-8.41%), intubation (26.01%-21.07%), and mechanical ventilation (27.46%-27.05%) decreased, whereas use of hospice services increased considerably (7.34%-16.83%). Among those receiving hospice services, rates of referrals to hospice services in the last 3 days of life decreased from 17.88% to 17.13% but remained steady after adjusting for selected covariates.

CONCLUSIONS

The quality of end-of-life care for Taiwanese cancer decedents was substantially inferior to that previously reported and to that recommended as benchmarks for not providing overly aggressive care near the end of life.

[Diagnostic strategy for acute respiratory failure in patients with haematological malignancy]

INTRODUCTION

About 15% of patients with haematological malignancy develop acute respiratory failure (ARF), necessitating admission to intensive care where their mortality is of the order of 50%.

STATE OF THE ART

The prognosis of these patients is not determined by the pathological characteristics of the malignancy but by the cause of the acute respiratory failure. In effect, the need to resort to mechanical ventilation in the presence of dysfunction of other organs dominates the prognosis. Even if the use of non-invasive ventilation in these patients has reduced the need for intubation and reduced the mortality, its prolonged use in the most severely affected patients prevents the optimal diagnostic and therapeutic management.

PERSPECTIVES

Fibreoptic bronchoscopy with broncho-alveolar lavage (BAL) is considered the cornerstone of aetiological diagnosis but its diagnostic effectiveness is poor, at best 50%, and this has led to increasing interest in high resolution CT scanning and regularly reawakens a transitory enthusiasm for surgical lung biopsy. Furthermore, in hypoxaemic patients, fibreoptic bronchoscopy with BAL may be the origin of the resort to mechanical ventilation, and thus increased mortality. The place of recently developed non-invasive tools is under evaluation. In effect, though the individual performance of diagnostic molecular techniques on sputum, blood, urine or naso- pharyngeal secretions has been established, the combination of these tools as an alternative to BAL has not yet been reported.

CONCLUSION

This review deals with acute respiratory failure in patients with haematological malignancy. It includes a review of the recent literature and considers the current controversies, in particular the risk-benefit balance of fibreoptic bronchoscopy with BAL in severely hypoxaemic patients.

Resource use and outcome in critically ill patients with hematological malignancy: a retrospective cohort study

Introduction

The paucity of data on resource use in critically ill patients with hematological malignancy and on these patients' perceived poor outcome can lead to uncertainty over the extent to which intensive care treatment is appropriate. The aim of the present study was to assess the amount of intensive care resources needed for, and the effect of treatment of, hemato-oncological patients in the intensive care unit (ICU) in comparison with a nononcological patient population with a similar degree of organ dysfunction.

Methods

A retrospective cohort study of 101 ICU admissions of 84 consecutive hemato-oncological patients and 3,808 ICU admissions of 3,478 nononcological patients over a period of 4 years was performed.

Results

As assessed by Therapeutic Intervention Scoring System points, resource use was higher in hemato-oncological patients than in nononcological patients (median (interquartile range), 214 (102 to 642) versus 95 (54 to 224), P < 0.0001). Severity of disease at ICU admission was a less important predictor of ICU resource use than necessity for specific treatment modalities. Hemato-oncological patients and nononcological patients with similar admission Simplified Acute Physiology Score scores had the same ICU mortality. In hemato-oncological patients, improvement of organ function within the first 48 hours of the ICU stay was the best predictor of 28-day survival.

Conclusion

The presence of a hemato-oncological disease per se is associated with higher ICU resource use, but not with increased mortality. If withdrawal of treatment is considered, this decision should not be based on admission parameters but rather on the evolutional changes in organ dysfunctions.

Diagnostic bronchoscopy in hematology and oncology patients with acute respiratory failure: prospective multicenter data

OBJECTIVE

To describe the diagnostic yields of test strategies with and without fiberoptic bronchoscopy and bronchoalveolar lavage (FO-BAL), as well as outcomes, in cancer patients with acute respiratory failure (ARF).

DESIGN

Prospective observational study.

SETTING

Fifteen intensive care units in France.

PATIENTS

In all, 148 cancer patients, including 45 bone marrow transplant recipients (27 allogeneic, 18 autologous) with hypoxemic ARF.

INTERVENTION

None.

RESULTS

Overall, 146 causes of ARF were identified in 128 patients (97 [66.4%] pulmonary infections). The cause of ARF was identified in 50.5% of the 101 patients who underwent FO-BAL and in 66.7% of the other patients. FO-BAL was the only conclusive test in 34 (33.7%) of the 101 investigated patients. Respiratory status deterioration after FO-BAL occurred in 22 of 45 (48.9%) nonintubated patients, including 16 (35.5%) patients who required ventilatory support. Hospital mortality was 55.4% (82 deaths) overall and was not significantly different in the groups with and without FO-BAL. By multivariate analysis, mortality was affected by characteristics of the malignancy (remission, allogeneic bone marrow transplantation), cause of ARF (ARF during neutropenia recovery, cause not identified), and need for life-sustaining treatments (mechanical ventilation and vasopressors).

CONCLUSION

In critically ill cancer patients with ARF, a diagnostic strategy that does not include FO-BAL may be as effective as FO-BAL without exposing the patients to respiratory status deterioration.

Trends in end-of-life ICU use among older adults with advanced lung cancer

BACKGROUND

There is increasing concern about the appropriateness of intensive medical care near the end of life in ICUs throughout the United States. As a result of hospice expansion in the 1990s, we hypothesized that ICU use decreased over time in older adults with advanced lung cancer.

METHODS

Retrospective analysis using the linked Surveillance, Epidemiology and End Results Medicare database. There were 45,627 Medicare beneficiaries > or = 66 years of age with confirmed stage IIIB or IV lung cancer between January 1, 1992, and December 31, 2002, who died within a year of their cancer diagnosis from 1993 through 2002.

RESULTS

ICU use in the last 6 months of life increased from 17.5% in 1993 to 24.7% in 2002 (p < 0.001). After adjusting for patient characteristics, there was a 6.6% annual increase in ICU use from 1993 to 2002. During the same period, hospice use had risen from 28.8 to 49.9% (p < 0.001). A total of 6.2% of patients received both end-of-life ICU care and hospice care, a percentage that increased over time. The total health-care cost for Medicare fee-for-service patients during last 6 months was $40,929 for ICU users and $27,160 for non-ICU users (p < 0.001).

CONCLUSION

Despite increasing hospice use, ICU utilization among older adults dying with advanced lung cancer continued to rise in the United States during the 1990s.

The ICU trial: a new admission policy for cancer patients requiring mechanical ventilation

OBJECTIVE

Cancer patients requiring mechanical ventilation are widely viewed as poor candidates for intensive care unit (ICU) admission. We designed a prospective study evaluating a new admission policy titled The ICU Trial.

DESIGN

Prospective study.

SETTING

Intensive care unit.

PATIENTS

One hundred eighty-eight patients requiring mechanical ventilation and having at least one other organ failure.

INTERVENTIONS

Over a 3-yr period, all patients with hematologic malignancies or solid tumors proposed for ICU admission underwent a triage procedure. Bedridden patients and patients in whom palliative care was the only cancer treatment option were not admitted to the ICU. Patients at earliest phase of the malignancy (diagnosis < 30 days) were admitted without any restriction. All other patients were prospectively included in The ICU Trial, consisting of a full-code ICU admission followed by reappraisal of the level of care on day 5.

MEASUREMENTS AND MAIN RESULTS

Among the 188 patients, 103 survived the first 4 ICU days and 85 died from the acute illness. Hospital survival was 21.8% overall. Among the 103 survivors on day 5, none of the characteristics of the malignancy were significantly different between the 62 patients who died and the 41 who survived. Time course of organ dysfunction over the first 6 ICU days differed significantly between survivors and nonsurvivors. Organ failure scores were more accurate on day 6 than at admission or on day 3 for predicting survival. All patients who required initiation of mechanical ventilation, vasopressors, or dialysis after 3 days in the ICU died.

CONCLUSIONS

Survival was 40% in mechanically ventilated cancer patients who survived to day 5 and 21.8% overall. If these results are confirmed in future interventional studies, we recommend ICU admission with full-code management followed by reappraisal on day 6 in all nonbedridden cancer patients for whom lifespan-extending cancer treatment is available.

Nurse-physician perspectives on the care of dying patients in intensive care units: collaboration, moral distress, and ethical climate

OBJECTIVE

To explore registered nurses' and attending physicians' perspectives on caring for dying patients in intensive care units (ICUs), with particular attention to the relationships among moral distress, ethical climate, physician/nurse collaboration, and satisfaction with quality of care.

DESIGN

Descriptive pilot study using a survey design.

SETTING

Fourteen ICUs in two institutions in different regions of Virginia.

SUBJECTS

Twenty-nine attending physicians who admitted patients to the ICUs and 196 registered nurses engaged in direct patient care.

INTERVENTIONS

Survey questionnaire.

MEASUREMENTS AND MAIN RESULTS

At the first site, registered nurses reported lower collaboration (p<.001), higher moral distress (p<.001), a more negative ethical environment (p<.001), and less satisfaction with quality of care (p=.005) than did attending physicians. The highest moral distress situations for both registered nurses and physicians involved those situations in which caregivers felt pressured to continue unwarranted aggressive treatment. Nurses perceived distressing situations occurring more frequently than did physicians. At the second site, 45% of the registered nurses surveyed reported having left or considered leaving a position because of moral distress. For physicians, collaboration related to satisfaction with quality of care (p<.001) and ethical environment (p=.004); for nurses, collaboration was related to satisfaction (p<.001) and ethical climate (p<.001) at both sites and negatively related to moral distress at site 2 (p=.05). Overall, registered nurses with higher moral distress scores had lower satisfaction with quality of care (p<.001), lower perception of ethical environment (p<.001), and lower perception of collaboration (p<.001).

CONCLUSIONS

Registered nurses experienced more moral distress and lower collaboration than physicians, they perceived their ethical environment as more negative, and they were less satisfied with the quality of care provided on their units than were physicians. Provider assessments of quality of care were strongly related to perception of collaboration. Improving the ethical climate in ICUs through explicit discussions of moral distress, recognition of differences in nurse/physician values, and improving collaboration may mitigate frustration arising from differences in perspective.

Outcome and Code Status of Lung Cancer Patients Admitted to the Medical ICU

OBJECTIVES

To determine the outcome of lung cancer patients admitted to the medical ICU (MICU), to examine their code status at MICU admission and prior to death, and to determine which subspecialty physician was responsible for the change in code status.

DESIGN

Retrospective chart review study.

SETTING

A 19-bed MICU in a tertiary-care university hospital.

PATIENTS

Consecutive patients with a diagnosis of lung cancer admitted to the MICU from July 2002 to June 2004.

MEASUREMENTS AND MAIN RESULTS

Forty-seven patients with a diagnosis of lung cancer accounted for 53 MICU admissions. Mean (+/- SD) age at MICU admission was 65 +/- 10 years. Sixty-six percent were male. Eighty-three percent had non-small cell lung cancer (NSCLC); 64% of these were stage IV NSCLC. The most common organ system implicated on MICU admission was pulmonary, with 38% of patients presenting with pneumonia. Overall MICU mortality was 43%, and in-hospital mortality was 60%. Patients who required mechanical ventilation or had more advanced lung cancer stage had the worst prognosis, with mortality rates of 74% and 68%, respectively. Seventy-four percent of patients were "full code" at MICU admission. Subsequently, the code status was changed to "do not resuscitate" in 49% of these cases. The pulmonary/critical care physician was involved in this change 96% of the time and was the sole physician in 65% of cases.

CONCLUSIONS

This study confirms that patients with lung cancer admitted to the MICU have a high mortality. Despite this, the majority of patients are full code on MICU admission. Pulmonary/critical care physicians play an important role in the end-of-life decision making of lung cancer patients admitted to the MICU, perhaps because of their availability in the MICU and also because of their sense of responsibility in maintaining and withdrawing life support.

Diagnostic strategy in cancer patients with acute respiratory failure

OBJECTIVE

Nearly 15% of cancer patients experience acute respiratory failure (ARF) requiring admission to the intensive care unit, where their mortality is about 50%. This review focuses on ARF in cancer patients. The most recent literature is reviewed, and emphasis is placed on current controversies, most notably the risk/benefit ratio of fiberoptic bronchoscopy and BAL in patients with severe hypoxemia.

BACKGROUND

Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) is the cornerstone of the causal diagnosis. However, the low diagnostic yield of about 50%, related to the widespread use of broad-spectrum antimicrobial therapy in cancer patients, has generated interest in high-resolution computed tomography (HRCT) and primary surgical lung biopsy. In patients with hypoxemia, bronchoscopy and BAL may trigger a need for invasive mechanical ventilation, thus considerably decreasing the chances of survival.

DISCUSSION

The place for recently developed, effective, noninvasive diagnostic tools (tests on sputum, blood, urine, and nasopharyngeal aspirates) needs to be determined. The prognosis is not markedly influenced by cancer characteristics; it is determined chiefly by the cause of ARF, need for mechanical ventilation, and presence of other organ failures. Although noninvasive ventilation reduces the need for endotracheal intubation and diminishes mortality rate, its prolonged use in patients with severe disease may preclude optimal diagnostic and therapeutic management. The appropriateness of switching to endotracheal mechanical ventilation in patients who fail noninvasive ventilation warrants evaluation.

CONCLUSION

This review discusses risks and benefits from invasive and non invasive diagnostic and therapeutic strategies in critically ill cancer patients with acute respiratory failure. Avenues for research are also suggested in order to improve survival in these very high risk patients.

Outcome of critically ill allogeneic hematopoietic stem-cell transplantation recipients: a reappraisal of indications for organ failure supports

PURPOSE

Because the overall outcome of critically ill hematologic patients has improved, we evaluated the short-term and long-term outcomes of the poor risk subgroup of allogeneic hematopoietic stem-cell transplantation (HSCT) recipients requiring admission to the intensive care unit (ICU).

PATIENTS AND METHODS

This was a retrospective multicenter study of allogeneic HSCT recipients admitted to the ICU between 1997 and 2003.

RESULTS

Two hundred nine critically ill allogeneic HSCT recipients were included in the study. Admission in the ICU occurred during the engraftment period (< or = 30 days after transplantation) for 70 of the patients and after the engraftment period for 139 patients. The overall in-ICU, in-hospital, 6-month, and 1-year survival rates were 48.3%, 32.5%, 27.2%, and 21%, respectively. Mechanical ventilation was required in 122 patients and led to a dramatic decrease in survival rates, resulting in in-ICU, in-hospital, 6-month, and 1-year survival rates of 18%, 15.6%, 14%, and 10.6%, respectively. Mechanical ventilation, elevated bilirubin level, and corticosteroid treatment for the indication of active graft-versus-host disease (GVHD) were independent predictors of death in the whole cohort. In the subgroup of patients requiring mechanical ventilation, associated organ failures, such as shock and liver dysfunction, were independent predictors of death. ICU admission during engraftment period was associated with acceptable outcome in mechanically ventilated patients, whereas patients with late complications of HSCT in the setting of active GVHD had a poor outcome.

CONCLUSION

Extensive unlimited intensive care support is justified for allogeneic HSCT recipients with complications occurring during the engraftment period. Conversely, initiation or maintenance of mechanical ventilation is questionable in the setting of active GVHD.

Caspofungin treatment in severely ill, immunocompromised patients: a case-documentation study of 118 patients

BACKGROUND

Caspofungin has shown efficacy in empirical antifungal therapy in neutropenic patients, refractory invasive Aspergillus infections and invasive candidiasis. Here we report the currently largest series of patients treated with caspofungin outside clinical trials.

METHODS

Centres in Germany that were known to treat patients with invasive fungal infections were asked to fill out detailed questionnaires for all patients treated with caspofungin. No effort was made to influence the decision to use caspofungin.

RESULTS

A total of 118 patients were evaluable (median age 48 years, interquartile range 38-58), out of which 41 (35%) suffered from acute leukaemia, 31 (26%) had allogeneic stem cell transplants, 16 (14%) lymphoma or myeloma, 8 (7%) autologous stem cell transplants and 22 (19%) other causes for immunosuppression. One hundred and six patients were evaluable for efficacy out of which 68 (64%) patients achieved a complete or partial remission. A total of 81 out of 115 (70%) patients were alive 30 days after the end of caspofungin therapy. Response rates were similar in proven (20/32, 63%) and probable (27/46, 59%) infections, in neutropenic patients (41/55, 75%) and in patients who were (44/70, 63%) or were not (24/36, 67%) refractory to antifungal pre-treatment. The response rate in mechanically ventilated patients was 29% (7/24). Caspofungin was well tolerated, even in 14 patients, who were concomitantly treated with ciclosporin A, no drug-related elevations of bilirubin, alanine aminotransferase or creatinine were found.

CONCLUSIONS

This open case study of severely ill patients with invasive fungal infections demonstrates both excellent efficacy and very low toxicity of caspofungin.

Characteristics and outcomes of cancer patients requiring mechanical ventilatory support for >24 hrs

OBJECTIVES

To describe the characteristics of a large cohort of cancer patients receiving mechanical ventilation for >24 hrs and to identify clinical features predictive of in-hospital death.

DESIGN

Prospective cohort study.

SETTING

Ten-bed oncologic medical-surgical intensive care unit.

PATIENTS

A total of 463 consecutive patients were included over a 45-month period.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data were collected on the day of admission to the intensive care unit. The intensive care unit and hospital mortality rates were 50% and 64%, respectively. There were 359 (78%) patients with solid tumors and 104 (22%) with hematologic malignancies; 35 (8%) patients had leukopenia. Sepsis (63%), coma (15%), invasion or compression by tumor (11%), pulmonary embolism (7%), and cardiopulmonary arrest (6%) were the main reasons for mechanical ventilation. The independent unfavorable risk factors for mortality were older age (odds ratio, 3.09; 95% confidence interval, 1.61-5.93, for patients 40-70 yrs old, and odds ratio, 9.26; 95% confidence interval, 4.16-20.58, for patients >70 yrs old); performance status 3-4 (odds ratio, 2.51; 95% confidence interval, 1.40-4.51); cancer recurrence/progression (odds ratio, 3.43; 95% confidence interval, 1.81-6.53); Pao2/Fio2 ratio <150 (odds ratio, 2.64; 95% confidence interval, 1.40-4.99); Sequential Organ Failure Assessment score (excluding respiratory domain, each 4 points; odds ratio, 2.34; 95% confidence interval, 1.70-3.24); and airway/pulmonary invasion or compression by tumor as a reason for mechanical ventilation (odds ratio, 5.73; 95% confidence interval, 1.92-17.08).

CONCLUSIONS

Severity of acute organ failures, poor performance status, cancer status, and older age were the main determinants of mortality. The appropriate use of such easily available clinical characteristics may avoid forgoing intensive care for patients with a chance of survival.

Documented and clinically suspected bacterial infection precipitating intensive care unit admission in patients with hematological malignancies: impact on outcome

OBJECTIVE

To assess the impact of documented and clinically suspected bacterial infection precipitating ICU admission on in-hospital mortality in patients with hematological malignancies.

DESIGN AND SETTING

Prospective observational study in a 14-bed medical ICU at a tertiary university hospital.

PATIENTS

A total of 172 consecutive patients with hematological malignancies admitted to the ICU for a life-threatening complication over a 4-year period were categorized into three main groups according to their admission diagnosis (documented bacterial infection, clinically suspected bacterial infection, nonbacterial complications) by an independent panel of three physicians blinded to the patient's outcome and C-reactive protein levels.

RESULTS

In-hospital and 6-months mortality rates in documented bacterial infection (n=42), clinically suspected bacterial infection (n=40) vs. nonbacterial complications (n=90) were 50.0% and 42.5% vs. 65.6% (p=0.09 and 0.02) and 56.1% and 48.7% vs. 72.1% (p=0.11 and 0.02), respectively. Median baseline C-reactive protein levels in the first two groups were 23 mg/dl and 21.5 mg/dl vs. 10.7 mg/dl (p<0.001 and p=0.001) respectively. After adjustment for the severity of critical and underlying hematological illness and the duration of hospitalization before admission documented (OR 0.20; 95% CI 0.06-0.62, p=0.006) and clinically suspected bacterial infection (OR 0.18; 95% CI 0.06-0.53, p=0.002) were associated with a more favorable outcome than nonbacterial complications.

CONCLUSIONS

Severely ill patients with hematological malignancies admitted to the ICU because of documented or clinically suspected bacterial infection have a better outcome than those admitted with nonbacterial complications. These patients should receive advanced life-supporting therapy for an appropriate period of time.

Acute respiratory failure in the cancer patient: the role of non-invasive mechanical ventilation

The most common cause of ICU admission in patients affected by a hematologic or solid cancer is acute respiratory failure, often associated with a respiratory infection. The prognosis of these critically ill patients is disappointingly low especially if they require endotracheal intubation. In the last 10 years, non-invasive mechanical ventilation (NIV), delivered through a face or nose mask, has been increasingly used as an alternative to invasive ventilation. There is good evidence that, compared to the standard medical therapy alone or with invasive mechanical ventilation, NIV may improve survival and reduce the rate of infectious complications in patients affected by hematologic cancers. Patients with a solid tumor and "reversible" acute respiratory failure are also likely to benefit from NIV, while the use of NIV in palliative care of terminally ill patients still needs to be elucidated. The success of NIV is strictly dependent on its "early" use and on the experience of the staff involved.

Management of infections in critically ill neutropenic cancer patients

Because of improving antineoplastic treatment options with increasing cure rates, prolonging survival, and improving quality of life, the reluctance to admit patients with malignant disease to an intensive care unit is not justified; thus, the number of patients with malignancies treated in intensive care units rises. The use of more aggressive anticancer regimens leads to an increase of attendant infections, which are the most frequent and often life-threatening complications in cancer patients. A multidisciplinary practical approach to evaluation and treatment is needed to optimize treatment results and to meet the various diagnostic and therapeutic challenges in this subset of patients on an intensive care unit.

Impact of two different comorbidity measures on the 6-month mortality of critically ill cancer patients

OBJECTIVE

To evaluate the impact of two different comorbidity measures on the 6-month mortality of severely ill cancer patients.

DESIGN AND SETTING

Prospective cohort study in a ten-bed oncological medical-surgical intensive care unit (ICU).

PATIENTS

A total of 772 consecutive patients were included over a 45-month period. The mean age was 57.6+/-16.4 years, and 642 (83%) patients had solid tumors.

MEASUREMENTS AND RESULTS

Data were collected on admission and during ICU stay. Comorbidities were evaluated using the Charlson Comorbidity Index (CCI) and the Adult Comorbidity Evaluation (ACE-27). The ICU, hospital, and 6-month mortality rates were 34%, 47%, and 58%, respectively. The most frequent comorbidities were hypertension (33%), diabetes mellitus (8%), and chronic pulmonary disease (7%). There were important differences between the two indices regarding the comorbidity evaluation. Using the ACE-27, 389 patients (50%) had comorbid ailments that were classified as mild (31%), moderate (14%), and severe (5%) according to the comorbidity severity. According to the CCI, 212 patients (27%) had a comorbidity, and their median score was 1 (1-2). In the multivariable Cox proportional hazard models only the presence of a severe comorbidity by the ACE-27 was associated with increased mortality. The CCI was not independently associated with the outcome. Other outcome predictors were older age, poor performance status, active cancer, need of mechanical ventilation, and severity of acute organ failures.

CONCLUSIONS

Severe comorbidities must be considered in the outcome evaluation of ICU cancer patients. The ACE-27 seems to be a useful instrument for prognostic assessment in this population.

The prognosis of acute respiratory failure in critically ill cancer patients

Acute respiratory failure (ARF) in patients with cancer is frequently a fatal event. To identify factors associated with survival of cancer patients admitted to an intensive care unit (ICU) for ARF, we conducted a prospective 5-year observational study in a medical ICU in a teaching hospital in Paris, France. The patients were 203 cancer patients with ARF mainly due to infectious pneumonia (58%), but also noninfectious pneumonia (9%), congestive heart failure (12%), and no identifiable cause (21%). We measured clinical characteristics and ICU and hospital mortality rates.ICU mortality was 44.8% and hospital mortality was 47.8%. Noninvasive mechanical ventilation was used in 79 (39%) patients and conventional mechanical ventilation in 114 (56%), the mortality rates being 48.1% and 75.4%, respectively. Among the 14 patients with late noninvasive mechanical ventilation failure (>48 hours), only 1 survived. The mortality rate was 100% in the 19 noncardiac patients in whom conventional mechanical ventilation was started after 72 hours. By multivariable analysis, factors associated with increased mortality were documented invasive aspergillosis (odds ratio [OR], 2.13; 95% confidence intervals [CI], 1.05-14.74), no definite diagnosis (OR, 3.85; 95% CI, 1.26-11.70), vasopressors (OR, 3.19; 95% CI, 1.28-7.95), first-line conventional mechanical ventilation (OR, 8.75; 95% CI, 2.35-35.24), conventional mechanical ventilation after noninvasive mechanical ventilation failure (OR, 17.46; 95% CI, 5.04-60.52), and late noninvasive mechanical ventilation failure (OR, 10.64; 95% CI, 1.05-107.83). Hospital mortality was lower in patients with cardiac pulmonary edema (OR, 0.16; 95% CI, 0.03-0.72). Survival gains achieved in critically ill cancer patients in recent years extend to patients requiring ventilatory assistance. The impact of conventional mechanical ventilation on survival depends on the time from ICU admission to conventional mechanical ventilation and on the patient's response to noninvasive mechanical ventilation.

Diagnosis and management of drug-associated interstitial lung disease

Symptoms of drug-associated interstitial lung disease (ILD) are nonspecific and can be difficult to distinguish from a number of illnesses that commonly occur in patients with non-small-cell lung cancer (NSCLC) on therapy. Identification of drug involvement and differentiation from other illnesses is problematic, although radiological manifestations and clinical tests enable many of the alternative causes of symptoms in advanced NSCLC to be excluded. In lung cancer patients, high-resolution computed tomography (HRCT) is more sensitive than a chest radiograph in evaluating the severity and progression of parenchymal lung disease. Indeed, the use of HRCT imaging has led to the recognition of many distinct patterns of lung involvement and, along with clinical signs and symptoms, helps to predict both outcome and response to treatment. This manuscript outlines the radiology of drug-associated ILD and its differential diagnosis in NSCLC. An algorithm that uses clinical tests to exclude alternative diagnoses is also described.

Noninvasive mechanical ventilation as a palliative treatment of acute respiratory failure in patients with end-stage solid cancer

Noninvasive ventilation (NIV) is widely used in the treatment of acute respiratory failure (ARF), but not in patients with end-stage solid cancer in whom any form of mechanical ventilation tends to be avoided. In a prospective study, we investigated the use of NIV in 23 patients with solid malignancies receiving palliative care and who were affected by severe hypoxic or hypercapnic ARF. The most frequent causes of ARF were exacerbations of pre-existing pulmonary diseases and pneumonia. After one hour, NIV significantly improved PaO2/FiO2 (from 154+/-48 to 187+/-55) and the Borg dyspnoea score (from 5.5+/-1.2 to 2.3+/-0.3). NIV also improved pH, but only in the subset of hypercapnic patients. Thirteen of 23 (57%) patients were successfully ventilated and discharged alive, while 10/23 patients (43%) met the criteria for intubation or died after an initial trial of NIV. Only two of these patients accepted invasive ventilation. The mortality rate in this subgroup was 9/10 (90%). A higher Simplified Acute Physiology Score (SAPS II) and a lower PaO2/FiO2 on admission were associated with a lower probability of survival. Patients with ARF and end-stage solid malignancies have an overall ICU and 1-year mortality rate of 39% and 87%, respectively, but despite this, a consistent subset of patients may still be successfully treated with NIV, if the cause of ARF is reversible.

Outcome in Noninvasively and Invasively Ventilated Hematologic Patients With Acute Respiratory Failure

STUDY OBJECTIVES

The survival rate of patients with a hematologic malignancy requiring mechanical ventilation (MV) in the ICU has improved over the last few decades. The objective of this study was to identify the factors affecting the in-hospital mortality of these particular patients, and to assess whether the use of noninvasive positive pressure ventilation (NPPV) was protective in our study population.

DESIGN

We retrospectively collected variables in 166 consecutive patients with hematologic malignancies who had acute respiratory failure (ARF) requiring MV, and identified factors obtained within 24 h of ICU admission affecting in-hospital mortality in univariate and multivariate stepwise logistic regression analyses. The effect of NPPV on mortality was assessed using a pair-wise matched exposed-unexposed analysis.

RESULTS

The mean simplified acute physiology score (SAPS) II was 58.9. The in-hospital mortality rate was 71%. In a multivariate logistic regression analysis, the in-hospital mortality rate was predicted by increasing severity of illness, as measured by SAPS II (odds ratio [OR] per point of increase, 1.07; 95% confidence interval [CI], 1.04 to 1.11) and a diagnosis of acute myelogenous leukemia (OR, 2.73; 95% CI, 1.05 to 7.11). Female sex (OR, 0.36; 95% CI, 0.16 to 0.82), endotracheal intubation (ETI) within 24 h of ICU admission (OR, 0.29; 95% CI, 0.11 to 0.78), and recent bacteremia (defined as blood cultures positive for bacteria < 48h before or < 24h after ICU admission) [OR, 0.22; 95% CI, 0.08 to 0.61] were associated with a lower mortality rate. Twenty-seven patients who received NPPV were matched for SAPS II (+/- 3) with 52 patients who required immediate ETI on a 1:2 basis. The crude in-hospital mortality rate was 65.4% in both groups.

CONCLUSION

Although the in-hospital mortality rate in hematologic patients who develop ARF remains high, the reluctance to intubate and start treatment with invasive MV in this population is unjustified, especially when bacteremia has precipitated ICU admission.