Acute respiratory distress syndrome in patients with malignancies. Intensive Care Med. 2014;40:1106-1114. [PMID: 24898895 DOI: 10.1007/s00134-014-3354-0]

[Non-invasive ventilation in acute respiratory failure of oncology-hematology patients: What are its current benefits and limitations?]

Acute respiratory failure (ARF) is a leading cause, along with sepsis, of admission to the intensive care unit (ICU) of patients with active cancer. Presenting variable clinical severity, ARF in onco-hematological patients has differing etiologies, primarily represented by possibly opportunistic acute infectious pneumonia (de novo hypoxemic ARF), and decompensation in chronic cardiac or respiratory diseases (e.g., acute pulmonary edema or exacerbated chronic obstructive pulmonary disease). In these patients, orotracheal intubation is associated with a doubled risk of in-hospital mortality. Consequently, over the last three decades, numerous researchers have attempted to demonstrate and pinpoint the precise role of non-invasive ventilation (NIV) in the specific context of ARF in onco-hematological patients. While the benefits of NIV in the management of acute pulmonary edema or alveolar hypoventilation (hypercapnic ARF) are well-demonstrated, its positioning in de novo hypoxemic ARF is debatable, and has recently been called into question. In the early 2000s, based on randomized controlled trials, NIV was recommended as first-line treatment, one reason being that it allowed significantly reduced use of orotracheal intubation. In the latest randomized studies, however, the benefits of NIV in terms of survival orotracheal intubation have not been observed; as a result, it is no longer recommended in the management of de novo hypoxemic ARF in onco-haematological patients.

Prediction of Subclinical and Clinical Multiple Organ Failure Dysfunction in Breast Cancer Patients-A Review Using AI Tools

This review explores the interconnection between precursor lesions of breast cancer (typical ductal hyperplasia, atypical ductal/lobular hyperplasia) and the subclinical of multiple organ failure syndrome, both representing early stages marked by alterations preceding clinical symptoms, undetectable through conventional diagnostic methods. Addressing the question "Why patients with breast cancer exhibit a tendency to deteriorate", this study investigates the biological progression from a subclinical multiple organ failure syndrome, characterized by insidious but indisputable lesions, to an acute (clinical) state resembling a cascade akin to a waterfall or domino effect, often culminating in the patient's demise. A comprehensive literature search was conducted using PubMed, Google Scholar, and Scopus databases in October 2023, employing keywords such as "MODS", "SIRS", "sepsis", "pathophysiology of MODS", "MODS in cancer patients", "multiple organ failure", "risk factors", "cancer", "ICU", "quality of life", and "breast cancer". Supplementary references were extracted from the retrieved articles. This study emphasizes the importance of early identification and prevention of the multiple organ failure cascade at the inception of the malignant state, aiming to enhance the quality of life and extend survival. This pursuit contributes to a deeper understanding of risk factors and viable therapeutic options. Despite the existence of the subclinical multiple organ failure syndrome, current diagnostic methodologies remain inadequate, prompting consideration of AI as an increasingly crucial tool for early identification in the diagnostic process.

Evaluation of factors associated with survival in allogeneic stem cell-transplanted patients admitted to the intensive care unit (ICU)

INTRODUCTION

There are conflicting results concerning the outcome of patients after an allogeneic hematopoietic stem cell transplantation (allo-HSCT) who required treatment in the intensive care unit (ICU). The aim of this study was to evaluate the outcome and prognostic parameters in terms of patient survival after allo-HSCT and admission to the ICU within the first 30 days after transplantation.

METHODS

Patients after allo-HSCT, who were ≥18 years and admitted to the ICU after the initiation of conditioning therapy and within the first 30 days after allo-HSCT at the University Hospital of Bonn between January 2017 and April 2021, were analysed retrospectively. Baseline data, laboratory parameters, established scoring systems, vital parameters, and outcome were collected.

RESULTS

44 patients (median age of 63 years) were analysed. The 90-day survival rate was 50% (N = 22) and the 1-year survival rate was 27% (N = 12). The 90-day and 1-year survival rates of patients who required MV were 38% (N = 13) and 18% (N = 6). There was a significant correlation between increased mortality and an APACHE-Score ≥20 (p = 0.03), a SAPS-II-Score ≥60 (p = 0.04) and a SOFA-Score ≥9 (p = 0.03). Invasive mechanical ventilation (p = 0.05) and vasopressor support (p = 0.03) showed a negative correlation with the outcome.

CONCLUSION

This study found several parameters (APACHE-II-Score, SAPS-II-Score, SOFA-Score, MV and vasopressor support) associated with increased mortality after allo-HSCT and admission to the ICU. The outcome of allo-HSCT patients admitted to the ICU is not as poor as previously reported. Even older patients under long-term ventilation may benefit from intensive care therapy.

Histopathologic and Immunohistochemical Assessment of Acute Respiratory Distress Syndrome (ARDS): Challenges and Complexities of Postmortem Diagnosis

Acute respiratory distress syndrome (ARDS) is a life-threatening condition due to acute lung injury (ALI), characterized by rapid-onset respiratory failure, leading to the clinical manifestations of poor lung compliance, severe hypoxemia, and dyspnea. ARDS/ALI has many causes, most commonly related to infections (sepsis, pneumonia), traumas, and multiple transfusions. The objective of this study is to assess the performance of postmortem anatomopathological examination in identifying etiological agents associated with ARDS or ALI in deceased patients from the State of São Paulo from 2017 to 2018. A retrospective cross-sectional study was performed based on the final outcome obtained by histopathology, histochemical, and immunohistochemical examination for ARDS/ALI differential diagnosis at the Pathology Center of the Adolfo Lutz Institute in São Paulo, Brazil. Of the 154 patients clinically diagnosed with ARDS or ALI, 57% tested positive for infectious agents, and the most frequent outcome was influenza A/H1N1 virus infection. In 43% of cases, no etiologic agent was identified. The opportunity to establish a diagnosis, identify particular infections, confirm a microbiological diagnosis, and uncover unanticipated etiologies is provided by postmortem pathologic analysis of ARDS. A molecular assessment could improve the diagnosis accuracy and lead to research into host responses and public health measures.

Extracorporeal Membrane Oxygenation for Adult Patients With Neoplasms: Outcomes and Trend Over the Last 2 Decades

Extracorporeal membrane oxygenation (ECMO) is utilized in the management of severe respiratory and circulatory failure. Advanced malignancy is a relative contraindication, but the indication for ECMO in the oncologic population has not been clearly established because of the wide spectrum of malignant disease and prognoses. The Extracorporeal Life Support Organization database was queried for patients older than 18 years with an International Classification of Diseases code of neoplasm over the past 2 decades (2000-2019). The data were divided into 2 decades to analyze and compare the trends with background and outcomes. One thousand six-hundred ninety-seven patients met inclusion criteria from the latest decade which is over 15 times the previous decade (n = 110). Compared with the previous decade, ECMO was used more in patients with older age (56 vs . 50.5 years old; p < 0.001), cardiac and extracorporeal cardiopulmonary resuscitation (ECPR) support type ( p = 0.011), and lower oxygenation index (23.0 vs . 35.6; p < 0.001) in the latest decade. Although overall survival did not show significant improvement overall (38.9% vs . 33.6%; p = 0.312), survival in pulmonary ECMO has significantly improved in the latest decade (41.6% vs . 29.1%; p = 0.032). Compared with the previously reported data for all adult ECMO, our patients had a significantly lower survival with pulmonary (41.6% vs . 61.1%; p < 0.001) and cardiac (38.4% vs . 44.3%; p = 0.008) support while not with ECPR.

Machine Learning-Based Mortality Prediction Model for Critically Ill Cancer Patients Admitted to the Intensive Care Unit (CanICU)

BACKGROUND

Although cancer patients are increasingly admitted to the intensive care unit (ICU) for cancer- or treatment-related complications, improved mortality prediction remains a big challenge. This study describes a new ML-based mortality prediction model for critically ill cancer patients admitted to ICU.

PATIENTS AND METHODS

We developed CanICU, a machine learning-based 28-day mortality prediction model for adult cancer patients admitted to ICU from Medical Information Mart for Intensive Care (MIMIC) database in the USA (n = 766), Yonsei Cancer Center (YCC, n = 3571), and Samsung Medical Center in Korea (SMC, n = 2563) from 2 January 2008 to 31 December 2017. The accuracy of CanICU was measured using sensitivity, specificity, and area under the receiver operating curve (AUROC).

RESULTS

A total of 6900 patients were included, with a 28-day mortality of 10.2%/12.7%/36.6% and a 1-year mortality of 30.0%/36.6%/58.5% in the YCC, SMC, and MIMIC-III cohort. Nine clinical and laboratory factors were used to construct the classifier using a random forest machine-learning algorithm. CanICU had 96% sensitivity/73% specificity with the area under the receiver operating characteristic (AUROC) of 0.94 for 28-day, showing better performance than current prognostic models, including the Acute Physiology and Chronic Health Evaluation (APACHE) or Sequential Organ Failure Assessment (SOFA) score. Application of CanICU in two external data sets across the countries yielded 79-89% sensitivity, 58-59% specificity, and 0.75-0.78 AUROC for 28-day mortality. The CanICU score was also correlated with one-year mortality with 88-93% specificity.

CONCLUSION

CanICU offers improved performance for predicting mortality in critically ill cancer patients admitted to ICU. A user-friendly online implementation is available and should be valuable for better mortality risk stratification to allocate ICU care for cancer patients.

Immunocompromised Children With Acute Respiratory Distress Syndrome Possess a Distinct Circulating Inflammatory Profile

Immunocompromised status, with and without stem cell transplant, confers a worse prognosis in pediatric acute respiratory distress syndrome. An improved understanding of the biochemical profile of immunocompromised children with acute respiratory distress syndrome would inform whether specific pathways are targetable, or merely bystanders, in order to improve outcomes in this high-risk subgroup.

OBJECTIVES

We aimed to identify a biomarker profile of immunocompromised children, with and without stem cell transplant, independent of illness severity.

DESIGN SETTINGS AND PARTICIPANTS

This was a secondary analysis of a prospective cohort study of intubated children with Berlin-defined acute respiratory distress syndrome with existing biomarker measurements conducted in a large academic PICU between 2014 and 2019.

MAIN OUTCOMES AND MEASURES

Biomarker levels were compared between immunocompetent and immunocompromised children, with and without stem cell transplant, both prior to and after adjusting for severity of illness.

RESULTS

In 333 children with acute respiratory distress syndrome, 84 were immunocompromised, of whom 39 had a stem cell transplant. Circulating neutrophil levels were strongly correlated with biomarkers, with 14 of 18 measured proteins differentially expressed in patients with versus without neutropenia. In order to identify biomarker levels independent of severity of illness, acute respiratory distress syndrome etiology, and neutrophil levels, we computed predicted (log-transformed) biomarker levels after adjusting for confounders using linear regression and then compared these severity-adjusted levels between immunocompetent and immunocompromised (with and without stem cell transplant) subjects using analyses of variance and post hoc Bonferroni. After multivariable adjustment, 11 biomarkers were higher in immunocompromised subjects without stem cell transplant, relative to immunocompetent, implicating endotheliopathy (angiopoietin-2), tissue damage (procollagen type III N-terminal peptide), and innate immunity. A single biomarker, C-C motif chemokine ligand 22, was lower in immunocompromised subjects with and without stem cell transplant.

CONCLUSIONS AND RELEVANCE

Immunocompromised children with acute respiratory distress syndrome were characterized by elevations in pro-inflammatory and endothelial damage biomarkers. Our study provides insight into mechanisms underlying the molecular heterogeneity of this population and potentially identifies targetable pathways to mitigate their increased mortality risk.

A Case of Acute Respiratory Distress Syndrome Following Pleurodesis With Talc

Management of malignant pleural effusion is a medical challenge, and several methods have been proposed to deal with it including thoracentesis, indwelling pleural catheter placement, and chemical or mechanical pleurodesis. Each method, however, has its advantages and disadvantages. Talc pleurodesis is generally recognized as the most effective and safest method for the induction of chemical pleurodesis. However, in rare cases, it can lead to acute respiratory distress syndrome (ARDS). In this article, we report the case of a patient with metastatic adenocarcinoma to the pleura who presents with shortness of breath and malignant pleural effusion, develops ARDS after pleurodesis with talc, and expires despite the partial improvement of lung involvement. The symptoms and causes of this rare side effect as well as the methods that can be used to deal with it are reviewed in this article.

Analysis of clinical characteristics and prognostic factors of ARDS caused by community-acquired pneumonia in people with different immune status

BACKGROUND

The purpose of this study is to describe the clinical characteristics and prognostic risk factors of acute respiratory distress syndrome (ARDS) caused by community-acquired pneumonia under different immune states.

METHODS

The patients were divided into immunocompetent and immunocompromised groups according to their immune status. The basic clinical data of the two groups were collected and statistically analyzed, and the clinical characteristics and prognostic factors of ARDS caused by community-acquired pneumonia under different immune states were summarized.

RESULTS

128 patients with ARDS caused by community-acquired pneumonia were enrolled. The chest High-Resolution Computed Tomography (HRCT) scores of patients with immunosuppression were higher (236.0 ± 55.0 vs. 207.5 ± 49.6, p < 0.05) and the score of APACHE II was higher (17.3 ± 4.8 vs. 15.1 ± 5.4, p < 0.05). The 28-day intensive care unit (ICU) mortality was higher in the immunocompromised group (54.5% vs. 34.7%, p = 0.045). The 28-day in-hospital mortality in the immunocompetent group was mainly related to NLR and the oxygenation index. The 28-day in-hospital mortality in the immunocompromised group was mainly related to LDH and APACHE II.

CONCLUSION

There are differences in clinical characteristics and mortality of ARDS patients caused by community-acquired pneumonia under different immune states.

What Is Different in Acute Hematologic Malignancy-Associated ARDS? An Overview of the Literature

Background and Objectives: Acute hematologic malignancies are a group of heterogeneous blood diseases with a high mortality rate, mostly due to acute respiratory failure (ARF). Acute respiratory distress syndrome (ARDS) is one form of ARF which represents a challenging clinical condition. The paper aims to review current knowledge regarding the variable pathogenic mechanisms, as well as therapeutic options for ARDS in acute hematologic malignancy patients. Data collection: We provide an overview of ARDS in patients with acute hematologic malignancy, from an etiologic perspective. We searched databases such as PubMed or Google Scholar, including articles published until June 2022, using the following keywords: ARDS in hematologic malignancy, pneumonia in hematologic malignancy, drug-induced ARDS, leukostasis, pulmonary leukemic infiltration, pulmonary lysis syndrome, engraftment syndrome, diffuse alveolar hemorrhage, TRALI in hematologic malignancy, hematopoietic stem cell transplant ARDS, radiation pneumonitis. We included relevant research articles, case reports, and reviews published in the last 18 years. Results: The main causes of ARDS in acute hematologic malignancy are: pneumonia-associated ARDS, leukostasis, leukemic infiltration of the lung, pulmonary lysis syndrome, drug-induced ARDS, radiotherapy-induced ARDS, diffuse alveolar hemorrhage, peri-engraftment respiratory distress syndrome, hematopoietic stem cell transplantation-related ARDS, transfusion-related acute lung injury. Conclusions: The short-term prognosis of ARDS in acute hematologic malignancy relies on prompt diagnosis and treatment. Due to its etiological heterogeneity, precision-based strategies should be used to improve overall survival. Future studies should focus on identifying the relevance of such etiologic-based diagnostic strategies in ARDS secondary to acute hematologic malignancy.

Clinical diagnostic accuracy of respiratory failure in critically ill hematopoietic stem cell transplant patients

RATIONALE

Acute respiratory failure (ARF) is a frequent complication following hematopoietic cell transplantation (HCT). We aimed to characterize the etiologies of ARF in patients who died in the intensive care unit following HCT based on autopsy findings. We then evaluated agreement between the clinical and pathologic diagnosis.

METHODS

We performed a chart review of all HCT patients who died and underwent autopsy in our ICU between 2006-2016. We evaluated the presumed clinical diagnosis and confidence in the diagnosis by chart review, the pathologic diagnosis on autopsy, and whether the clinical-pathologic diagnoses were concordant. When there was discordance, we evaluated whether knowledge of the pathology could have changed management.

RESULTS

Thirteen patients underwent autopsy after dying. Infection was the presumed cause in 11/13 cases. The clinical and pathologic diagnoses were concordant in 6/13(46%). In the seven discordant cases (all clinically diagnosed as infection), autopsy revealed two non-infectious inflammatory causes, one post-transplant lymphoproliferative disorder, and three non-bacterial infectious etiology. Pathologic findings may have changed management in 7/13(54%) cases.

CONCLUSIONS

In a subset of HCT-recipients who died from respiratory failure, discordance was frequent between clinical and pathologic diagnoses. The risks and benefits of obtaining tissue to improve our diagnostic accuracy requires further evaluation.

A critical care outreach team under strain - Evaluation of the service provided to patients with haematological malignancy during the Covid-19 pandemic

Purpose

Critical Care Outreach Teams (CCOTs) have been associated with improved outcomes in patients with haematological malignancy (HM). This study aims to describe CCOT activation by patients with HM before and during the Covid-19 pandemic, assess amny association with worse outcomes, and examine the psychological impact on the CCOT.

Materials and methods

A retrospective, mixed-methods analysis was performed in HM patients reviewed by the CCOT over a two-year period, 01 July 2019 to 31 May 2021.

Results

The CCOT increased in size during the surge period and reviewed 238 HM patients, less than in the pre- and post-surge periods. ICU admission in the baseline, surge and the non-surge periods were 41.7%, 10.4% and 47.9% respectively. ICU mortality was 22.5%, 0% and 21.7% for the same times. Time to review was significantly decreased (p = 0.012). Semi-structured interviews revealed four themes of psychological distress: 1) time-critical work; 2) non-evidence based therapies; 3) feelings of guilt; 4) increased decision-making responsibility.

Conclusions

Despite the increase in total hospital referrals, the number of patients with HM that were reviewed during the surge periods decreased, as did their ICU admission rate and mortality. The quality of care provided was not impaired, as reflected by the number of patients receiving bedside reviews and the shorter-than-pre-pandemic response time.

High-flow nasal cannula oxygen in patients with haematological malignancy: a retrospective observational study

Patients with haematological malignancies (HM) face high rates of intensive care unit (ICU) admission and mortality. High-flow nasal cannula oxygen (HFNCO) is increasingly used to support HM patients in ward settings, but there is limited evidence on the safety and efficacy of HFNCO in this group. We retrospectively reviewed all HM patients receiving ward-based HFNCO, supervised by a critical care outreach service (CCOS), from January 2014 to January 2019. We included 130 consecutive patients. Forty-three (33.1%) were weaned off HFNCO without ICU admission. Eighty-seven (66.9%) were admitted to ICU, 20 (23.3%) required non-invasive and 34 (39.5%) invasive mechanical ventilation. ICU and hospital mortality were 42% and 55% respectively. Initial FiO₂ < 0.4 (OR 0.27, 95% CI 0.09-0.81, p = 0.019) and HFNCO use on the ward > 1 day (OR 0.16, 95% CI 0.04, 0.59, p = 0.006) were associated with reduced likelihood for ICU admission. Invasive ventilation was associated with reduced survival (OR 0.27, 95%CI 0.1-0.7, p = 0.007). No significant adverse events were reported. HM patients receiving ward-based HFNCO have higher rates of ICU admission, but comparable hospital mortality to those requiring CCOS review without respiratory support. Results should be interpreted cautiously, as the model proposed depends on the existence of CCOS.

Extracorporeal membrane oxygenation in patients with hematologic malignancies: a systematic review and meta-analysis

Hematological malignancies (HM) have been, until recently, viewed as contraindications to extracorporeal membrane oxygenation (ECMO) due to bleeding and infectious complications. However, conflicting literature regarding whether ECMO should be used for patients with HM still exists. We conducted a random effects meta-analysis to investigate the outcomes of patients with HM on ECMO. We searched Medline, Embase, Scopus, and Cochrane through 10 October 2021. Risk of bias and certainty of evidence were assessed using the JBI checklists and GRADE approach respectively. Thirteen observational studies (422 patients with HM, 9778 controls without HM) were included. The pooled in-hospital mortality for patients with HM and those with hematopoietic stem cell transplants for HM indications needing ECMO were 79.1% (95%CI: 70.2-86.9%) and 87.7% (95%CI: 80.4-93.8%), respectively. Subgroup analyses found that mortality was higher in adults than children (85.1% vs 67.9%, p_interaction = 0.003), and in Asia compared to North America and Europe (93.8% vs 69.6%, p_interaction < 0.001). Pooled ECMO duration was 10.0 days (95%CI: 7.5-12.5); pooled ICU and hospital lengths of stay were 19.8 days (95%CI: 12.4-27.3) and 43.9 days (95%CI: 29.4-58.4) respectively. Age (regression coefficient [B]: 0.008, 95%CI: 0.003-0.014), proportion of males (B: 1.799, 95%CI: 0.079-3.519), and ECMO duration (B: - 0.022, 95%CI: - 0.043 to - 0.001) were significantly associated with higher mortality. In-hospital mortality of patients with HM who needed ECMO was 79.1%, with better outcomes in children, and in North America and Europe. ECMO should not be regarded as routine support therapy in these patients but can be carefully considered on a case-by-case basis.

Association between timing of intubation and clinical outcomes of critically ill patients: A meta-analysis

PURPOSE

Optimal timing of intubation is controversial. We attempted to investigate the association between timing of intubation and clinical outcomes of critically ill patients.

METHODS

PubMed was systematically searched for studies reporting on mortality of critically ill patients undergoing early versus late intubation. Studies involving patients with new coronavirus disease (COVID-19) were excluded because a relevant meta-analysis has been published. "Early" intubation was defined according to the authors of the included studies. All-cause mortality was the primary outcome. Pooled risk ratio (RR) and 95% confidence intervals (CI) were calculated using a random effects model. The meta-analysis was registered with PROSPERO (CRD42021284850).

RESULTS

In total, 27 studies involving 15,441 intubated patients (11,943 early, 3498 late) were included. All-cause mortality was lower in patients undergoing early versus late intubation (7338 deaths; 45.8% versus 53.5%; RR 0.92, 95% CI 0.87-0.97; p = 0.001). This was also the case in the sensitivity analysis of studies defining "early" as intubation within 24 h from admission in the intensive care unit (6279 deaths; 45.8% versus 53.6%; RR 0.93, 95% CI 0.89-0.98; p = 0.005).

CONCLUSION

Avoiding late intubation may be associated with lower mortality in critically ill patients without COVID-19.

Extracorporeal Membrane Oxygenation for Patients with Thoracic Neoplasms: An Extracorporeal Life Support Organization (ELSO) Registry Analysis

BACKGROUND

Extracorporeal Membrane Oxygenation (ECMO) is utilized in the management of severe cardiopulmonary failure but the indication in the oncologic population has not been clearly established. Among malignancies, thoracic neoplasms are unique in their potential direct impact on cardiopulmonary function. This study aims to better define the role of ECMO for thoracic neoplasms.

METHODS

The Extracorporeal Life Support Organization registry was queried for patients older than 18 years with an International Classification of Diseases code of thoracic neoplasm over the past two decades (2000-2019). Outcomes and clinical data including associated procedures were analyzed.

RESULTS

Four hundred ninety-eight patients met inclusion criteria: 34 upper airway, 247 lung, 45 unspecified respiratory tract, 4 pleura, 19 heart, 40 mediastinum, 108 esophagus, and 1 unspecified neoplasm. One hundred ninety-eight patients survived to discharge (39.8%; "survival"). Upper airway neoplasms were associated with better survival (73.5%; p=0.005) while lung neoplasms were associated with worse survival (30.0%; p<0.001) when compared with all adult ECMO runs. Of the 498 cases, 94 (18.9%) were started after thoracic or airway procedures. Favorable survival was associated with tracheal procedures (66.7%, n=9), while poor survival was seen with pneumonectomy (13.3%, n=30), any type of lung resection (23.7%, n=76), and esophageal procedures (21.4%, n=14).

CONCLUSIONS

The outcome for ECMO among patients with a thoracic neoplasm is variable, depending on clinical factors including tumor subtype and type of associated procedure. Clinicians should continue to focus on individualized patient selection to achieve optimal results.

High-flow nasal cannula for respiratory failure in adult patients

The high-flow nasal cannula (HFNC) has been recently used in several clinical settings for oxygenation in adults. In particular, the advantages of HFNC compared with low-flow oxygen systems or non-invasive ventilation include enhanced comfort, increased humidification of secretions to facilitate expectoration, washout of nasopharyngeal dead space to improve the efficiency of ventilation, provision of a small positive end-inspiratory pressure effect, and fixed and rapid delivery of an accurate fraction of inspired oxygen (FiO₂) by minimizing the entrainment of room air. HFNC has been successfully used in critically ill patients with several conditions, such as hypoxemic respiratory failure, hypercapneic respiratory failure (exacerbation of chronic obstructive lung disease), post-extubation respiratory failure, pre-intubation oxygenation, and others. However, the indications are not absolute, and much of the proven benefit remains subjective and physiologic. This review discusses the practical application and clinical uses of HFNC in adults, including its unique respiratory physiologic effects, device settings, and clinical indications.

Treatment of acute respiratory failure: high-flow nasal cannula

Background: High-flow nasal cannulas (HFNCs) have recently been used for several conditions, such as hypoxemic respiratory failure, hypercapnic respiratory failure, post-extubation respiratory failure, and preintubation oxygenation, in critically ill patients.Current Concepts: The advantages of HFNC compared with those of low-flow oxygen systems or noninvasive ventilation include enhanced comfort, increased humidification of secretions to facilitate expectoration, washout of the nasopharyngeal dead space to improve ventilation efficiency, provisioning for low positive end-inspiratory pressure effect, and fixed and rapid delivery of accurate fraction of inspired oxygen by minimizing the entrainment of room air. However, the indications are not absolute, with much of the proven benefit being subjective and physiologic.Discussion and Conclusion: The goal of this review is to discuss the practical application and clinical uses of HFNCs in patients with acute respiratory failure, highlighting its unique respiratory and physiologic effects, device settings, and clinical indications.

A comprehensive analysis of 5-year outcomes in patients with cancer admitted to intensive care units

Background

The aim of this study was to evaluate the long-term (5-year) clinical outcomes of patients who received intensive care unit (ICU) treatment using Korean nationwide data.

Methods

All patients aged >18 years with ICU admission according to Korean claims data from January 2008 to December 2010 were enrolled. These enrolled patients were followed up until December 2015. The primary outcome was ICU mortality.

Results

Among all critically ill patients admitted to the ICU (n=323,765), patients with cancer showed higher ICU mortality (18.6%) than those without cancer (13.2%, p<0.001). However, there was no significant difference in ICU mortality at day 28 among patients without cancer (14.5%) and those with cancer (lung cancer or hematologic malignancies) (14.3%). Compared to patients without cancer, hazard ratios of those with cancer for ICU mortality at 5 years were: 1.90 (1.87–1.94) for lung cancer; 1.44 (1.43–1.46) for other solid cancers; and 3.05 (2.95–3.16) for hematologic malignancies.

Conclusion

This study showed that the long-term survival rate of patients with cancer was significantly worse than that of general critically ill patients. However, short term outcomes of critically ill patients with cancer were not significantly different from those of general patients, except for those with lung cancer or hematologic malignancies.

Incidence and Outcomes of Respiratory Failure After Non-Myeloablative Related Haploidentical Blood or Marrow Transplant

BACKGROUND

Respiratory failure is a devastating complication of allogenic blood or marrow transplant (BMT). Prior data suggest 20% and 15% of BMT patients develop respiratory failure and ARDS, respectively. Non-myeloablative (NMA) haploidentical BMT allows donor pool expansion and may decrease complications. Incidence, outcomes, and risk factors for respiratory failure after NMA haploidentical BMT are unknown.

RESEARCH QUESTION

Determine the incidence of respiratory failure after NMA haploidentical BMT and explore outcomes and risk factors for respiratory failure.

STUDY DESIGN AND METHODS

Single-center, retrospective study of all patients > 18 years old undergoing NMA haploidentical BMT from 2004-2016. The primary outcome was respiratory failure (high-flow nasal cannula oxygen, non-invasive ventilation [NIV], or invasive mechanical ventilation [IMV]) within 2 years after BMT. Respiratory failure incidence is reported as incidence rate ratios (IRR) with 95% confidence intervals. Unadjusted and multivariable Cox proportional hazards models with adjustment for a priori identified patient-level characteristics were used. Results are presented as hazard ratios (HR) with 95% CIs.

RESULTS

520 patients underwent NMA haploidentical BMT; 82 (15.8%) developed respiratory failure (IRR 0.114/person-year) at a median of 0.34 years (25^th, 75^th percentiles 0.06, 0.75 years) after BMT. Older age (HR 1.04, 1.02, 1.07), transplant for MDS (HR 1.99, 1.07, 3.72), and parent donor (HR 3.49, 1.32, 9.26) were associated with increased risk of respiratory failure; higher pre-transplant DLCO (% pred) was associated with lower risk (HR 0.98, 0.77, 0.99). Sixty-one (11.7%) patients required IMV; 30 were successfully extubated. Only 37 (7%) patients had ARDS. Of the 82 with respiratory failure, 43 (52.4%) and 61 (77.2%) died during index hospitalization and by 2 years, respectively. Only 40 (49%) had non-relapse mortality.

INTERPRETATION

Incidence of respiratory failure and ARDS after NMA haploidentical BMT is modest at 15% by 2 years after transplant. Despite successful extubation in more than 50% of patients, respiratory failure, regardless of cause, is associated with a high rate of death by 2 years, from both relapse and non-relapse causes. Age, BMT for MDS, parental donor, and pre-transplant DLCO were risk factors for respiratory failure.

Oxygenation strategy during acute respiratory failure in immunocompromised patients

Acute respiratory failure (ARF) in immunocompromised patients remains challenging to treat. A large number of case require admission to intensive care unit (ICU) where mortality remains high. Oxygenation without intubation is important in this setting. This review summarizes recent studies assessing oxygenation devices for immunocompromised patients. Previous studies showed that non-invasive ventilation (NIV) has been associated with lower intubation and mortality rates. Indeed, in recent years, the outcomes of immunocompromised patients admitted to the ICU have improved. In the most recent randomized controlled trials, including immunocompromised patients admitted to the ICU with ARF, neither NIV nor high-flow nasal oxygen (HFNO) could reduce the mortality rate. In this setting, other strategies need to be tested to decrease the mortality rate. Early admission strategy and avoiding late failure of oxygenation strategy have been assessed in retrospective studies. However, objective criteria are still lacking to clearly discriminate time to admission or time to intubation. Also, diagnosis strategy may have an impact on intubation or mortality rates. On the other hand, lack of diagnosis has been associated with a higher mortality rate. In conclusion, improving outcomes in immunocompromised patients with ARF may include strategies other than the oxygenation strategy alone. This review discusses other unresolved questions to decrease mortality after ICU admission in such patients.

Implications of intensive care unit admissions among medicare beneficiaries following resection of pancreatic cancer

BACKGROUND

Intensive care unit (ICU) use has increased among patients with cancer. We sought to define factors associated with ICU admissions among patients with pancreatic cancer and characterize trends in mortality among hospital survivors.

METHODS

The Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database was used to identify patients with pancreatic cancer who underwent resection. Multivariable analyses were conducted to identify factors associated with ICU admission and mortality among hospital survivors.

RESULTS

Among 6422 Medicare beneficiaries who underwent resection of pancreatic cancer, 2386 (37.1%) had an ICU admission. Patients with ICU admissions were more likely to be younger (10-year increase odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.77-0.89), male (OR: 1.17, 95% CI 1.05-1.30) and undergo resection at a teaching hospital (OR: 1.19, 95% CI: 1.05-1.36). While the majority of patients survived to hospital discharge (n = 2106; 88.3%), a majority of patients (n = 1296; 54.3%) died within 6 months. Among patients who had subsequent ICU admissions, 1- and 5-year survival was only 31.8% and 11.0%, respectively.

CONCLUSIONS

Over one-third of patients with pancreatic cancer had an ICU admission. While most patients survived hospitalization, more than one-half of patients died within 6 months of discharge and two-thirds died within 1 year. These data should serve to guide patient-provider discussions around prognosis relative to ICU utilization.

Critically ill cancer patient's resuscitation: a Belgian/French societies' consensus conference

To respond to the legitimate questions raised by the application of invasive methods of monitoring and life-support techniques in cancer patients admitted in the ICU, the European Lung Cancer Working Party and the Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique, set up a consensus conference. The methodology involved a systematic literature review, experts' opinion and a final consensus conference about nine predefined questions1. Which triage criteria, in terms of complications and considering the underlying neoplastic disease and possible therapeutic limitations, should be used to guide admission of cancer patient to intensive care units?2. Which ventilatory support [High Flow Oxygenation, Non-invasive Ventilation (NIV), Invasive Mechanical Ventilation (IMV), Extra-Corporeal Membrane Oxygenation (ECMO)] should be used, for which complications and in which environment?3. Which support should be used for extra-renal purification, in which conditions and environment?4. Which haemodynamic support should be used, for which complications, and in which environment?5. Which benefit of cardiopulmonary resuscitation in cancer patients and for which complications?6. Which intensive monitoring in the context of oncologic treatment (surgery, anti-cancer treatment …)?7. What specific considerations should be taken into account in the intensive care unit?8. Based on which criteria, in terms of benefit and complications and taking into account the neoplastic disease, patients hospitalized in an intensive care unit (or equivalent) should receive cellular elements derived from the blood (red blood cells, white blood cells and platelets)?9. Which training is required for critical care doctors in charge of cancer patients?

Association of Thoracic Computed Tomographic Measurements and Outcomes in Patients with Hematologic Malignancies Requiring Mechanical Ventilation

Rationale: Patients with hematologic malignancies requiring mechanical ventilation have historically experienced poor outcomes.Objectives: We aimed to determine whether body composition characteristics derived from thoracic computed tomographic (CT) imaging were associated with time to liberation from mechanical ventilation.Methods: We evaluated mechanically ventilated patients with hematological malignancies admitted between 2014 and 2018. We included patients with thoracic CT imaging completed between 1 month before and 48 hours after intensive care unit (ICU) admission. We assessed the association of carinal skeletal muscle cross-sectional area (CSA), subcutaneous fat CSA, and fat index (fat/skeletal muscle ratio) with time to liberation from mechanical ventilation within 28 days. We accounted for the competing event of death within 28 days of mechanical ventilation.Results: One hundred fifty-six patients were included; the mean age was 57 years (standard deviation 14) and 39% were female. Thirty-seven percent had received a hematopoietic stem cell transplant, and the median ratio of arterial oxygen tension/pressure to fraction of inspired oxygen was 134 mm Hg (interquartile range [IQR], 92-205). Median skeletal muscle CSA was 68 cm² (IQR, 54-88) and subcutaneous fat CSA was 38 cm² (IQR, 27-52). Forty-two percent of patients were liberated from mechanical ventilation within 28 days and 56% died in the ICU. Subcutaneous fat CSA (subdistribution hazard ratio [sHR], 0.81; 95% confidence interval [95% CI], -0.68 to 0.97) and fat index (sHR, 0.81; 95% CI, -0.68 to 0.97) were significantly associated with longer time to liberation from mechanical ventilation. Skeletal muscle CSA was not associated with time to liberation from ventilation (sHR, 1.08; 95% CI, -0.94 to 1.23).Conclusions: Body composition measurements based on thoracic CT scans were associated with time to liberation from ventilation. These could represent novel surrogate markers of physical frailty in patients with hematologic malignancies receiving mechanical ventilation.

Identifying the Risk Factors for Mortality in Patients with Cancer and COVID-19 in Hamadan, the West of Iran

Purpose

Since cancer patients are at higher risk of COVID-19, the present study was conducted to investigate the epidemiology of these patients and identify the affecting risk factors on their mortality.

Methods

The present retrospective cohort study was conducted on 66 hospitalized patients with cancer and COVID-19 in Hamadan in 2020. In the present study, demographic, clinical, and laboratory information and patients’ outcome were collected through a checklist and its impact on death was assessed. Data were analyzed in SPSS-24 software and the significance level of the tests was considered at 5%.

Results

The mean (standard deviation (SD)) age of patients was 61.6 (13.5) years. Forty patients (60.6%) were male. Twenty and five patients (37.9%) died at the end of study. The results of logistic regression model revealed that the nausea, mechanical ventilation, admission to ICU, and length of hospital stay in the ward had a significant impact on the odds of death among cancer patients with COVID-19 (p < 0.05).

Conclusion

Owing to high mortality rate in cancer patients with COVID-19 and due to underlying diseases and more severe clinical symptoms than other patients with coronavirus, these patients need intensive care and specific treatments. However, screening these patients and early identifying and vaccinating of them can reduce the mortality rate in these patients.

Contraindications to the Initiation of Veno-Venous ECMO for Severe Acute Respiratory Failure in Adults: A Systematic Review and Practical Approach Based on the Current Literature

(1) Background: Extracorporeal membrane oxygenation (ECMO) is increasingly used for acute respiratory failure with few absolute but many relative contraindications. The provider in charge often has a difficult time weighing indications and contraindications to anticipate if the patient will benefit from this treatment, a decision that often decides life and death for the patient. To assist in this process in coming to a good evidence-based decision, we reviewed the available literature. (2) Methods: We performed a systematic review through a literature search of the MEDLINE database of former and current absolute and relative contraindications to the initiation of ECMO treatment. (3) Results: The following relative and absolute contraindications were identified in the literature: absolute-refusal of the use of extracorporeal techniques by the patient, advanced stage of cancer, fatal intracerebral hemorrhage/cerebral herniation/intractable intracranial hypertension, irreversible destruction of the lung parenchyma without the possibility of transplantation, and contraindications to lung transplantation; relative-advanced age, immunosuppressed patients/pharmacological immunosuppression, injurious ventilator settings > 7 days, right-heart failure, hematologic malignancies, especially bone marrow transplantation and graft-versus-host disease, SAPS II score ≥ 60 points, SOFA score > 12 points, PRESERVE score ≥ 5 points, RESP score ≤ -2 points, PRESET score ≥ 6 points, and "do not attempt resuscitation" order (DN(A)R status). (4) Conclusions: We provide a simple-to-follow algorithm that incorporates absolute and relative contraindications to the initiation of ECMO treatment. This algorithm attempts to weigh pros and cons regarding the benefit for an individual patient and hopefully assists caregivers to make better, informed decisions.

High flow nasal cannula for adult acute hypoxemic respiratory failure in the ED setting: A narrative review

Introduction

High flow nasal cannula (HFNC) is a noninvasive ventilation (NIV) system that has demonstrated promise in the emergency department (ED) setting.

Objective

This narrative review evaluates the utility of HFNC in adult patients with acute hypoxemic respiratory failure in the ED setting.

Discussion

HFNC provides warm (37 °C), humidified (100% relative humidity) oxygen at high flows with a reliable fraction of inspired oxygen (FiO₂). HFNC can improve oxygenation, reduce airway resistance, provide humidified flow that can flush anatomical dead space, and provide a low amount of positive end expiratory pressure. Recent literature has demonstrated efficacy in acute hypoxemic respiratory failure, including pneumonia, acute respiratory distress syndrome (ARDS), coronavirus disease 2019 (COVID-19), interstitial lung disease, immunocompromised states, the peri-intubation state, and palliative care, with reduced need for intubation, length of stay, and mortality in some of these conditions. Individual patient factors play an important role in infection control risks with respect to the use of HFNC in patients with COVID-19. Appropriate personal protective equipment, adherence to hand hygiene, surgical mask placement over the HFNC device, and environmental controls promoting adequate room ventilation are the foundation for protecting healthcare personnel. Frequent reassessment of the patient placed on HFNC is necessary; those with severe end organ dysfunction, thoracoabdominal asynchrony, significantly increased respiratory rate, poor oxygenation despite HFNC, and tachycardia are at increased risk of HFNC failure and need for further intervention.

Conclusions

HFNC demonstrates promise in several conditions requiring respiratory support. Further randomized trials are needed in the ED setting.

Therapeutics for paediatric oncological emergencies

Background

With advancements in the field of oncology, cancer survival rates have improved dramatically but modern cancer treatments also come with an increasing number of disease and treatment-associated complications. This article provides an updated narrative review on the pathophysiology, clinical presentations and latest management strategies for common paediatric oncological emergencies.

Methods

An extensive PubMed^® search of all human studies in the English literature was performed in Clinical Queries for different oncology syndromes and conditions using the following Medical Subject Headings: “tumour lysis syndrome”, “hyperleukocytosis”, “disseminated intravascular coagulation”, “superior mediastinal syndrome”, “superior vena cava syndrome”, “sepsis”, “severe inflammatory response syndrome”, “acute respiratory distress syndrome”, “posterior reversible encephalopathy syndrome” and “reversible posterior leukoencephalopathy syndrome”. Categories were limited to clinical trials and reviews for ages from birth to 18 years.

Results

The general description, presentation and management of these oncologic emergencies are systematically described. Early recognition along with prompt and proactive treatment can reduce the chances of potential complications and improve the clinical outcomes, thereby improving not only survival rates in oncology patients but also their clinical outcomes and quality of life.

Conclusions

Oncologic emergencies are associated with significant mortality and morbidity. Healthcare professionals involved with the care of oncology patients must be vigilant of these emergencies.

Clinical outcomes of immunocompromised patients on extracorporeal membrane oxygenation support for severe acute respiratory failure

OBJECTIVES

There are limited data regarding extracorporeal membrane oxygenation (ECMO) support in immunocompromised patients, despite an increase in ECMO use in patients with respiratory failure. The aim of this study was to investigate the clinical characteristics and outcomes of immunocompromised patients requiring ECMO support for severe acute respiratory failure.

METHODS

Between January 2012 and December 2015, all consecutive adult patients with severe acute respiratory failure who underwent ECMO for respiratory support at 16 tertiary or university-affiliated hospitals in South Korea were enrolled retrospectively. The patients were divided into 2 groups based on the immunocompromised status at the time of ECMO initiation. In-hospital and 6-month mortalities were compared between the 2 groups. In addition, association of immunocompromised status with 6-month mortality was evaluated with logistic regression analysis.

RESULTS

Among 461 patients, 118 (25.6%) were immunocompromised. Immunocompromised patients were younger and had lower haemoglobin and platelet counts than immunocompetent patients. Ventilatory parameters and the use of adjunctive/rescue therapies were similar between the 2 groups, but prone positioning was more commonly used in immunocompetent patients. Successful weaning rates from ECMO (46.6% vs 58.9%; P = 0.021) was lower and hospital mortality (66.1% vs 59.8%; P = 0.22) was higher in immunocompromised patients. In addition, immunocompromised status was associated with higher 6-month mortality (74.6% vs 64.7%, adjusted odds ratio 2.10, 95% confidence interval 1.02-4.35; P = 0.045).

CONCLUSIONS

Immunocompromised patients treated with ECMO support for severe acute respiratory failure had poorer short- and long-term prognoses than did immunocompetent patients.

Etiology-associated heterogeneity in acute respiratory distress syndrome: a retrospective cohort study

Background

Heterogeneity in acute respiratory distress syndrome (ARDS) has led to many statistically negative clinical trials. Etiology is considered an important source of pathogenesis heterogeneity in ARDS but previous studies have usually adopted a dichotomous classification, such as pulmonary versus extrapulmonary ARDS, to evaluate it. Etiology-associated heterogeneity in ARDS remains poorly described.

Methods

In this retrospective cohort study, we described etiology-associated heterogeneity in gas exchange abnormality (PaO₂/FiO₂ [P/F] and ventilatory ratios), hemodynamic instability, non-pulmonary organ dysfunction as measured by the Sequential Organ Failure Assessment (SOFA) score, biomarkers of inflammation and coagulation, and 30-day mortality. Linear regression was used to model the trajectory of P/F ratios over time. Wilcoxon rank-sum tests, Kruskal–Wallis rank tests and Chi-squared tests were used to compare between-etiology differences.

Results

From 1725 mechanically ventilated patients in the ICU, we identified 258 (15%) with ARDS. Pneumonia (48.4%) and non-pulmonary sepsis (11.6%) were the two leading causes of ARDS. Compared with pneumonia associated ARDS, extra-pulmonary sepsis associated ARDS had a greater P/F ratio recovery rate (difference = 13 mmHg/day, p = 0.01), more shock (48% versus 73%, p = 0.01), higher non-pulmonary SOFA scores (6 versus 9 points, p < 0.001), higher d-dimer levels (4.2 versus 9.7 mg/L, p = 0.02) and higher mortality (43% versus 67%, p = 0.02). In pneumonia associated ARDS, there was significant difference in proportion of shock (p = 0.005) between bacterial and non-bacterial pneumonia.

Conclusion

This study showed that there was remarkable etiology-associated heterogeneity in ARDS. Heterogeneity was also observed within pneumonia associated ARDS when bacterial pneumonia was compared with other non-bacterial pneumonia. Future studies on ARDS should consider reporting etiology-specific data and exploring possible effect modification associated with etiology.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12890-021-01557-9.

Influence of immunosuppression in patients with severe acute respiratory distress syndrome on veno-venous extracorporeal membrane oxygenation therapy

Prognosis of patients suffering from acute respiratory distress syndrome (ARDS) is poor. This is especially true for immunosuppressed patients. It is controverisal whether these patients should receive veno‐venous extracorporeal membrane oxygenation (VV ECMO) while evidence on this topic is sparse. We report retrospective data of a single‐center registry of patients with severe ARDS requiring ECMO support between October 2010 and June 2019. Patients were analyzed by their status of immunosuppression. ECMO weaning success and hospital survival were analyzed before and after propensity score matching (PSM). Moreover, ventilator free days (VFD) were compared. A total of 288 patients were analyzed (age 55 years, 67% male), 88 (31%) presented with immunosuppression. Survival rates were lower in immunosuppressed patients (27% vs. 53%, P < .001 and 27% vs. 48% after PSM, P = .006). VFD (60 days) were lower for patients with immunosuppression (11.9 vs. 22.4, P < .001), and immunosuppression was an independent predictor for mortality in multivariate analysis. Hospital survival was 20%, 14%, 35%, and 46% for patients with oncological malignancies, solid organ transplantation, autoimmune diseases, and HIV, respectively. In this analysis immunosuppression was an independent predictor for mortality. However, there were major differences in the weaning and survival rates between the etiologies of immunosuppression which should be considered in decision making.

The Impact of Preintubation Noninvasive Ventilation on Outcomes in Pediatric Acute Respiratory Distress Syndrome

OBJECTIVES

There is evidence that noninvasive ventilation decreases the need for invasive mechanical ventilation. However, children with pediatric acute respiratory distress syndrome who fail noninvasive ventilation may have worse outcomes than those who are intubated without exposure to noninvasive ventilation. Our objective was to evaluate the impact of preintubation noninvasive ventilation on children with pediatric acute respiratory distress syndrome.

DESIGN

Secondary analysis of data from the Randomized Evaluation of Sedation Titration for Respiratory Failure trial.

SETTING

Thirty-one PICUs in the United States.

PATIENTS

Children 2 weeks to 17 years old with pediatric acute respiratory distress syndrome receiving invasive mechanical ventilation, excluding those admitted with tracheostomies.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Of 2,427 subjects receiving invasive mechanical ventilation, preintubation noninvasive ventilation was used in 995 (41%). Compared with subjects without preintubation noninvasive ventilation use, subjects with preintubation noninvasive ventilation use were more likely to have a history of seizures (10% vs 8%; p = 0.04) or cancer (11% vs 6%; p < 0.001) and have moderate or severe pediatric acute respiratory distress syndrome by the end of their first full day of invasive mechanical ventilation (68% vs 60%; p < 0.001). Adjusting for age, severity of illness on PICU admission, and baseline functional status, preintubation noninvasive ventilation use resulted in longer invasive mechanical ventilation duration (median 7.0 vs 6.0 d), longer PICU (10.8 vs 8.9 d), and hospital (17 vs 14 d) lengths of stay, and higher 28-day (5% vs 4%) and 90-day (8% vs 5%) inhospital mortalities (all comparisons p < 0.001). Longer duration of noninvasive ventilation before intubation was associated with worse outcomes.

CONCLUSIONS

In children with pediatric acute respiratory distress syndrome, preintubation noninvasive ventilation use is associated with worse outcomes when compared with no preintubation noninvasive ventilation use. These data can be used to inform the design of clinical studies to evaluate best noninvasive ventilation practices in children with pediatric acute respiratory distress syndrome.

Cancer Is an Independent Risk Factor for Acute Respiratory Distress Syndrome in Critically Ill Patients: A Single Center Retrospective Cohort Study

BACKGROUND

Acute Respiratory Distress Syndrome (ARDS) is a frequent cause of respiratory failure in intensive care unit (ICU) patients and results in significant morbidity and mortality. ARDS often develops as a result of a local or systemic inflammatory insult. Cancer can lead to systemic inflammation but whether cancer is an independent risk factor for developing ARDS is unknown. We hypothesized that critically ill cancer patients admitted to the ICU were at increased risk for the diagnosis of ARDS.

METHODS

Retrospective cohort study of critically ill patients admitted between July 2017 and December 2018 at an academic medical center in Columbus, Ohio. The primary outcome was the association of patients with malignancy and the diagnosis of ARDS in a multivariable logistic regression model with covariables selected a priori informed through the construction of a directed acyclic graph.

RESULTS

412 ARDS cases were identified with 166 of those patients having active cancer. There was an association between cancer and ARDS, with an odds ratio (OR) of 1.55 (95% CI 1.26-1.92, P < 0.001). When adjusted for our pre-specified confounding variables, the association remained statistically significant (OR 1.57, 95% CI 1.15-2.13, P = 0.004). In an unadjusted pre-specified subgroup analysis, hematologic malignancy (OR 1.81, 95% CI 1.30-2.53, P < 0.001) was associated with increased odds of developing ARDS while non-metastatic solid tumors (OR 0.51, 95% CI 0.31-0.85, P = 0.01) had statistically significant negative association. Cancer patients with ARDS had a significantly higher ICU (70.5% vs 39.8%, P < 0.001) and hospital (72.9% vs 40.7%, P < 0.001) mortality compared to ARDS patients without active malignancy.

CONCLUSION

In this single center retrospective cohort study, cancer was found to be an independent risk factor for the diagnosis of ARDS in critically ill patients. To our knowledge, we are the first report an independent association between cancer and ARDS in critically ill patients.

Survival in Immunocompromised Patients Ultimately Requiring Invasive Mechanical Ventilation: A Pooled Individual Patient Data Analysis

Rationale: Acute respiratory failure (ARF) is associated with high mortality in immunocompromised patients, particularly when invasive mechanical ventilation is needed. Therefore, noninvasive oxygenation/ventilation strategies have been developed to avoid intubation, with uncertain impact on mortality, especially when intubation is delayed. Objectives: We sought to report trends of survival over time in immunocompromised patients receiving invasive mechanical ventilation. The impact of delayed intubation after failure of noninvasive strategies was also assessed. Methods: Systematic review and meta-analysis using individual patient data of studies that focused on immunocompromised adult patients with ARF requiring invasive mechanical ventilation. Studies published in English were identified through PubMed, Web of Science, and Cochrane Central (2008-2018). Individual patient data were requested from corresponding authors for all identified studies. We used mixed-effect models to estimate the effect of delayed intubation on hospital mortality and described mortality rates over time. Measurements and Main Results: A total of 11,087 patients were included (24 studies, three controlled trials, and 21 cohorts), of whom 7,736 (74%) were intubated within 24 hours of ICU admission (early intubation). The crude mortality rate was 53.2%. Adjusted survivals improved over time (from 1995 to 2017, odds ratio [OR] for hospital mortality per year, 0.96 [0.95-0.97]). For each elapsed day between ICU admission and intubation, mortality was higher (OR, 1.38 [1.26-1.52]; P < 0.001). Early intubation was significantly associated with lower mortality (OR, 0.83 [0.72-0.96]), regardless of initial oxygenation strategy. These results persisted after propensity score analysis (matched OR associated with delayed intubation, 1.56 [1.44-1.70]). Conclusions: In immunocompromised intubated patients, survival has improved over time. Time between ICU admission and intubation is a strong predictor of mortality, suggesting a detrimental effect of late initial oxygenation failure.

Temporal changes in the epidemiology, management, and outcome from acute respiratory distress syndrome in European intensive care units: a comparison of two large cohorts

Background

Mortality rates for patients with ARDS remain high. We assessed temporal changes in the epidemiology and management of ARDS patients requiring invasive mechanical ventilation in European ICUs. We also investigated the association between ventilatory settings and outcome in these patients.

Methods

This was a post hoc analysis of two cohorts of adult ICU patients admitted between May 1–15, 2002 (SOAP study, n = 3147), and May 8–18, 2012 (ICON audit, n = 4601 admitted to ICUs in the same 24 countries as the SOAP study). ARDS was defined retrospectively using the Berlin definitions. Values of tidal volume, PEEP, plateau pressure, and FiO₂ corresponding to the most abnormal value of arterial PO₂ were recorded prospectively every 24 h. In both studies, patients were followed for outcome until death, hospital discharge or for 60 days.

Results

The frequency of ARDS requiring mechanical ventilation during the ICU stay was similar in SOAP and ICON (327[10.4%] vs. 494[10.7%], p = 0.793). The diagnosis of ARDS was established at a median of 3 (IQ: 1–7) days after admission in SOAP and 2 (1–6) days in ICON. Within 24 h of diagnosis, ARDS was mild in 244 (29.7%), moderate in 388 (47.3%), and severe in 189 (23.0%) patients. In patients with ARDS, tidal volumes were lower in the later (ICON) than in the earlier (SOAP) cohort. Plateau and driving pressures were also lower in ICON than in SOAP. ICU (134[41.1%] vs 179[36.9%]) and hospital (151[46.2%] vs 212[44.4%]) mortality rates in patients with ARDS were similar in SOAP and ICON. High plateau pressure (> 29 cmH₂O) and driving pressure (> 14 cmH₂O) on the first day of mechanical ventilation but not tidal volume (> 8 ml/kg predicted body weight [PBW]) were independently associated with a higher risk of in-hospital death.

Conclusion

The frequency of and outcome from ARDS remained relatively stable between 2002 and 2012. Plateau pressure > 29 cmH₂O and driving pressure > 14 cmH₂O on the first day of mechanical ventilation but not tidal volume > 8 ml/kg PBW were independently associated with a higher risk of death. These data highlight the continued burden of ARDS and provide hypothesis-generating data for the design of future studies.

Failure of Noninvasive Ventilation in Acute Respiratory Failure is Associated with Higher Mortality in Patients with Solid Tumors: A Retrospective Cohort Study

BACKGROUND

Noninvasive Ventilation (NIV) is a well-established treatment for Acute Respiratory Failure (ARF) in hematological cancer. However, the NIV impact on mortality in patients with solid tumors is unclear.

OBJECTIVE

To define the factors associated with NIV failure and mortality and to describe the mortality risk of patients with solid tumors requiring NIV for ARF treatment in the intensive care unit (ICU).

METHODS

A retrospective cohort study of patients with solid tumors admitted into an ICU between Jan 2016 and Dec 2017, for cancer treatment, with ARF diagnosis that had used the NIV as first-line treatment. Our primary outcome was ICU and in-hospital mortality. The secondary outcome was NIV failure. A Cox proportional hazards regression was used to identify variables associated with mortality and NIV failure. Kaplan-Meier analyses were performed to demonstrate cumulative survival.

RESULTS

A total of 226 patients with solid tumors were included. The ICU and hospital mortality rates were 57.5% and 69.5%, respectively. NIV failed in 52.2% of the patients. The use of vasopressors (HR 2.48 [95% CI: 1.43-4.30] p = 0.001), baseline lactate (HR 1.20 [95% CI: 1.07-1.35] p = 0.003), baseline PaO₂/FiO₂ ratio (HR1.33 [1.11-1.55] p = 0.002), and NIV success (HR0.17 [95% CI: 0.10-0.27] p = 0.005) was independently associated with hospital mortality. The use of vasopressors (HR 2.58 [95% CI: 1.41-4.73] p = 0.02), NIV duration (HR 0.93 [95% CI: 0.89-0.97] p = 0.003), and baseline lactate (HR 1.13 [95% CI: 1.06-1.20] p = 0.001) was associated with NIV failure.

CONCLUSIONS

NIV failure was independently associated with an increase in both ICU and hospital mortality rates. In patients with NIV therapy indication, the duration of this intervention was associated with NIV failure.

[Cancer patients in the intensive care unit]

Over the past 20 years, demographic changes and a longer life expectancy of cancer patients has significantly increased the prevalence of this patient group in the intensive care unit (ICU). A fundamental finding is that acute organ dysfunction, rather than the underlying malignancy, determines the prognosis of ICU patients. While hematologic patients often suffer from a more severe disease course, patients with solid tumors do not present an increased hospital mortality compared to the normal population. As with other indications, the decision to transfer a cancer patient to an ICU should be made as soon as possible. While early transfer is associated with reduced hospital mortality, the presence of multiorgan failure on ICU admission is associated with increased mortality. Overall, the intensive care and hospital survival of critically ill hematologic or oncologic patients has improved over the last two decades and is now as high as 50 to 60%. After surviving an intensive care stay, one fifth of all patients have a good long-term prognosis. Thus, the former paradigm of general rejection of cancer patients for ICU care is no longer justified. For optimal care of cancer patients requiring intensive care, close cooperation between hematologists/oncologists and intensive care physicians is essential.

Acute respiratory failure in immunosuppressed patients admitted to ICU

INTRODUCTION

The number of hospitalized immunosuppressed adults is a growing and often develop severe complications that require admission to an Intensive Care Unit (ICU). The main cause of admission is acute respiratory failure (ARF). The goal of the study was to determine if ARF represents an independent risk factor for hospital mortality and in particular, we sought to ascertain if any risk factors were independently and identifiably associated with a bad outcome.

METHODS

We perform a retrospective study of a prospectively collected data from patients admitted to an ICU. Adult patients with known immunosuppressive condition admitted to ICU were included.

RESULTS

A total of 248 patients were included. Of 248 patients, 117 (47.2%) had a diagnosis of ARF at the time of ICU admission. Patients with ARF had a significantly higher in-hospital mortality (53.4% vs. 28.2% p = 0.001). Factors independently associated with hospital mortality were diagnosis of ARF at ICU admission, the presence of septic shock, use of continuous renal replacement therapy and failure of high-flow nasal canula(HFNC)/non-invasive (NIV) respiratory therapies.

CONCLUSION

We identified ARF on admission and failure of HFNC/NIV to be independently associated with increased hospital mortality in immunosuppressed patients.

Acute respiratory distress syndrome emerging after surgical debridement in a patient with extranodal natural killer/T cell lymphoma

Background

Extranodal natural killer/T cell lymphoma (ENKL) is a rare subtype of non-Hodgkin lymphoma, and lung involvement is extremely rare. The patients with pulmonary ENKL always presented unspecific symptoms of the respiratory system, such as cough with sputum and varying degrees of fever, while developing into acute respiratory distress (ARDS) was seldomly reported, especially promoted by the surgical procedure.

Case presentation

Here we describe a patient with nasal ENKL and most likely lung dissemination that was regarded as an infection at first. After nonresponse to a period of anti-infective therapy, this patient received surgical debridement. While the histopathology did not show the evidence of infection, but consistent with ENKL. The patient got refractory hypoxemia rapidly after surgery, with the LDH surging to a much higher level than before surgery. The ARDS was diagnosed, and he died on the 5th day after surgery. We postulate that ARDS was due to aggressive lymphoma proliferation promoted by the surgical procedure.

Conclusions

Pulmonary ENKL developing into ARDS was scarce, and was likely attributed to the aggressive tumor cell proliferation after surgery in this case.

Triage and Prognostication of Cancer Patients Admitted to the Intensive Care Unit

Cancer remains a leading cause of morbidity and mortality. Advances in cancer screening, early detection, targeted therapies, and supportive care have led to improvements in outcomes and quality of life. The rapid increase in novel cancer therapies can cause life-threatening adverse events. The need for intensive care unit (ICU) care is projected to increase. Until 2 decades ago, cancer diagnosis often precluded ICU admission. Recently, substantial cancer survival has been achieved; therefore, ICU denial is not recommended. ICU resources are limited and expensive; hence, appropriate utilization is needed. This review focuses on triage and prognosis in critically ill cancer patients requiring ICU admission.

Critical Care of Hematopoietic Stem Cell Transplant Patients

Life-threatening complications are frequent after hematopoietic stem cell transplant (HSCT), and optimum critical care is essential to ensuring good outcomes. The immunologic consequences of HSCT result in a markedly different host response to critical illness. Infection is the most common cause of critical illness but noninfectious complications are frequent. Respiratory failure or sepsis are the typical presentations but the sequelae of HSCT can affect nearly any organ system. Pattern recognition can facilitate anticipation and early intervention in post-HSCT critical illness. HSCT critical care is a multidisciplinary endeavor. Continued investigation and focus on process improvement will continue to improve outcomes.

Palliative, Ethics, and End-of-Life Care Issues in the Cancer Patient

End-of-life care of critically ill adult patients with advanced or incurable cancers is imbued with major ethical challenges. Oncologists, hospitalists, and intensivists can inadvertently subjugate themselves to the perceived powers of autonomous patients. Therapeutic illusion and poor insight by surrogates in physicians' ability to offer accurate prognosis, missed opportunities and miscommunication by clinicians, and lack of systematic or protocolized approach represent important barriers to high-quality palliative care. Enhanced collaboration, models that allow clinicians and surrogates to share the burdens of decision, and institutional support for early integration of palliative care can foster an ethical climate.

Acute respiratory failure in immunocompromised patients: outcome and clinical features according to neutropenia status

Background

The impact of neutropenia in critically ill immunocompromised patients admitted in a context of acute respiratory failure (ARF) remains uncertain. The primary objective was to assess the prognostic impact of neutropenia on outcomes of these patients. Secondary objective was to assess etiology of ARF according to neutropenia.

Methods

We performed a post hoc analysis of a prospective multicenter multinational study from 23 ICUs belonging to the Nine-I network. Between November 2015 and July 2016, all adult immunocompromised patients with ARF admitted to the ICU were included in the study. Adjusted analyses included: (1) a hierarchical model with center as random effect; (2) propensity score (PS) matched cohort; and (3) adjusted analysis in the matched cohort.

Results

Overall, 1481 patients were included in this study of which 165 had neutropenia at ICU admission (11%). ARF etiologies distribution was significantly different between neutropenic and non-neutropenic patients, main etiologies being bacterial pneumonia (48% vs 27% in neutropenic and non-neutropenic patients, respectively). Initial oxygenation strategy was standard supplemental oxygen in 755 patients (51%), high-flow nasal oxygen in 165 (11%), non-invasive ventilation in 202 (14%) and invasive mechanical ventilation in 359 (24%). Before adjustment, hospital mortality was significantly higher in neutropenic patients (54% vs 42%; p = 0.006). After adjustment for confounder and center effect, neutropenia was no longer associated with outcome (OR 1.40, 95% CI 0.93–2.11). Similar results were observed after matching (52% vs 46%, respectively; p = 0.35) and after adjustment in the matched cohort (OR 1.04; 95% CI 0.63–1.72).

Conclusion

Neutropenia at ICU admission is not associated with hospital mortality in this cohort of critically ill immunocompromised patients admitted for ARF. In neutropenic patients, main ARF etiologies are bacterial and fungal infections.

Impact of early ICU admission on outcome of critically ill and critically ill cancer patients: A systematic review and meta-analysis

OBJECTIVE

Prognostic impact of early ICU admission remains controversial. The aim of this review was to investigate the impact of early ICU admission in the general ICU population and in critically ill cancer patients and to report level of evidences of this later.

METHODS

Systematic review and meta-analysis performed on articles published between 1970 and 2017. Two authors extracted data. Influence of early ICU admission on mortality is reported as Risk Ratio (95%CI) using both fixed and random-effects model.

DATA SYNTHESIS

For general ICU population, 31 studies reporting on 73,213 patients were included (including 66,797 patients with early ICU admission) and for critically ill cancer patients 14 studies reporting on 2414 patients (including 1272 with early ICU admission) were included. Early ICU admission was associated with decreased mortality using a random effect model (RR 0.65; 95% confidence interval 0.58-0.73; I² = 66%) in overall ICU population as in critically ill cancer patients (RR 0.69; 95% confidence interval 0.52-0.90; I² = 85%). To explore heterogeneity, a meta-regression was performed. Characteristics of the trials (prospective vs. retrospective, monocenter vs. multicenter) had no impact on findings. Publication after 2010 (median publication period) was associated with a lower effect of early ICU admission (estimate 0.37; 95%CI 0.14-0.60; P = 0.002) in the general ICU population. A significant publication bias was observed.

CONCLUSION

Theses results suggest that early ICU admission is associated with decreased mortality in the general ICU population and in CICP. These results were however obtained from high risk of bias studies and a high heterogeneity was noted. Systematic review registration: PROSPERO 2018 CRD42018094828.

[Hemato-oncology and intensive care medicine : From taboo to indispensable]

Intensivmediziner werden im Kontext der Versorgung von kritisch kranken Krebspatienten vor eine zunehmende Bandbreite spezifischer Herausforderungen gestellt. Neben einer adäquaten Therapiezielfindung umfasst diese die Versorgung des akuten respiratorischen Versagens (ARV) mit speziellen differenzialdiagnostischen Überlegungen, das Management immunologischer Nebenwirkungen innovativer Krebstherapien sowie eine Vielzahl an Krankheitsbildern, die ausschließlich bei Krebspatienten auftreten. Um diesen Herausforderungen gerecht werden zu können, widmet sich die Initiative „Intensive Care in Hematologic and Oncologic Patients (iCHOP)“ seit einigen Jahren diesen Themen. Unterstützt durch mehrere österreichische und deutsche Fachgesellschaften für Intensivmedizin, Hämatologie und Onkologie wurde kürzlich der „1. Konsens zur Versorgung kritisch kranker Krebspatienten“ mit Empfehlungen zum klinischen Management sowie infrastrukturellen und ausbildungsassoziierten Themen verfasst. Das Auftreten eines ARV steht bei kritisch kranken Krebspatienten seit jeher im Fokus der Forschung. Während die nichtinvasive Beatmung lange als Goldstandard der Therapie galt, zeigen hochqualitative Studien jedoch keine relevanten klinischen Vorteile dieser Techniken inklusive der High-flow-nasal-oxygen-Therapie im Vergleich zur konventionellen Sauerstofftherapie. Hingegen rückt eine nichtgeklärte Ätiologie des ARV als einziger potenziell modifizierbarer Risikofaktor in den Fokus. Dementsprechend sind evidenzbasierte und rigoros angewendete Diagnosealgorithmen bei diesen Patienten von eminenter Bedeutung. Des Weiteren stellen das Erkennen und das Management der immer häufiger vorkommenden vielgestaltigen immuntherapieassoziierten Toxizität Intensivmediziner vor zunehmende Herausforderungen.