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Mayaux J, Decavele M, Dres M, Lecronier M, Demoule A. [Non-invasive ventilation in acute respiratory failure of oncology-hematology patients: What are its current benefits and limitations?]. Rev Mal Respir 2024; 41:382-389. [PMID: 38609766 DOI: 10.1016/j.rmr.2024.03.005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2023] [Accepted: 08/04/2023] [Indexed: 04/14/2024]
Abstract
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.
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Affiliation(s)
- J Mayaux
- Service de médecine intensive et réanimation, département R3S - DMU APPROCHES, hôpital universitaire Pitié-Salpêtrière - Sorbonne université médecine, Paris, France.
| | - M Decavele
- Service de médecine intensive et réanimation, département R3S - DMU APPROCHES, hôpital universitaire Pitié-Salpêtrière - Sorbonne université médecine, Paris, France
| | - M Dres
- Service de médecine intensive et réanimation, département R3S - DMU APPROCHES, hôpital universitaire Pitié-Salpêtrière - Sorbonne université médecine, Paris, France
| | - M Lecronier
- Service de médecine intensive et réanimation, département R3S - DMU APPROCHES, hôpital universitaire Pitié-Salpêtrière - Sorbonne université médecine, Paris, France
| | - A Demoule
- Service de médecine intensive et réanimation, département R3S - DMU APPROCHES, hôpital universitaire Pitié-Salpêtrière - Sorbonne université médecine, Paris, France
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Lemiale V, Mabrouki A. [Invasive mechanical ventilation in patients with solid tumor or hematological malignancy]. Rev Mal Respir 2023; 40:335-344. [PMID: 36959080 DOI: 10.1016/j.rmr.2023.02.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2023] [Accepted: 02/09/2023] [Indexed: 03/25/2023]
Abstract
Invasive mechanical ventilation in onco-hematology patients has become relatively routine, and is now part and parcel of their care pathway. Nevertheless, specific complications and subsequent therapeutic possibilities require discussion. To a greater extent than with regard to other patient populations, cooperation between specialist and ICU physician is mandatory, the objective being to more comprehensively assess a therapeutic project before or during the period of invasive mechanical ventilation. After an overview of recent results concerning ventilated patients in intensive care, this review aims to describe the specific complications and factors associated with mortality in this population.
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Affiliation(s)
- V Lemiale
- Medical intensive care, CHU Saint-Louis, AP-HP, 1, avenue Claude-Vellefaux, 75010 Paris, France.
| | - A Mabrouki
- Medical intensive care, CHU Saint-Louis, AP-HP, 1, avenue Claude-Vellefaux, 75010 Paris, France
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Lemiale V, Yvin E, Kouatchet A, Mokart D, Demoule A, Dumas G. Oxygenation strategy during acute respiratory failure in immunocompromised patients. JOURNAL OF INTENSIVE MEDICINE 2021; 1:81-89. [PMID: 36788802 PMCID: PMC9923978 DOI: 10.1016/j.jointm.2021.09.003] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/02/2021] [Accepted: 09/20/2021] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Virginie Lemiale
- Service de Médecine Intensive et Réanimation, APHP Hopital Saint Louis, 1 Avenue Claude Vellefaux, Paris 75010, France,Corresponding author: Virginie Lemiale, Service de Médecine Intensive et Réanimation, APHP Hopital Saint Louis, 1 Avenue Claude Vellefaux, Paris 75010, France.
| | - Elise Yvin
- Service de Médecine Intensive et Réanimation, APHP Hopital Saint Louis, 1 Avenue Claude Vellefaux, Paris 75010, France
| | - Achille Kouatchet
- Service de Réanimation Médicale et Médecine Hyperbare, Angers 49100, France
| | - Djamel Mokart
- Institut Paoli-Calmettes, Réanimation Medico-Chirurgicale, Marseille 13009, France
| | - Alexandre Demoule
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Médecine Intensive et Réanimation (Département R3S), and Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris 75013, France
| | - Guillaume Dumas
- Service de Médecine Intensive et Réanimation, APHP Hopital Saint Louis, 1 Avenue Claude Vellefaux, Paris 75010, France
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Jiang L, Wan Q, Ma H. Management strategy for hematological malignancy patients with acute respiratory failure. Eur J Med Res 2021; 26:108. [PMID: 34535193 PMCID: PMC8447613 DOI: 10.1186/s40001-021-00579-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/23/2021] [Accepted: 09/06/2021] [Indexed: 02/08/2023] Open
Abstract
Acute respiratory failure (ARF) is still the major cause of intensive care unit (ICU) admission for hematological malignancy (HM) patients although the advance in hematology and supportive care has greatly improved the prognosis. Clinicians have to make decisions whether the HM patients with ARF should be sent to ICU and which ventilation support should be administered. Based on the reported investigations related to management of HM patients with ARF, we propose a selection procedure to manage this population and recommend hematological ICU as the optimal setting to recuse these patients, where hematologists and intensivists can collaborate closely and improve the outcomes. Moreover, noninvasive ventilation (NIV) still has its own place for selected HM patients with ARF who have mild hypoxemia and reversible causes. It is also crucial to monitor the efficacy of NIV closely and switch to invasive mechanical ventilation at appropriate timing when NIV shows no apparent improvement. Otherwise, early IMV should be initiated to HM with ARF who have moderate and severe hypoxemia, adult respiratory distress syndrome, multiple organ dysfunction, and unstable hemodynamic. More studies are needed to elucidate the predictors of ICU mortality and ventilatory mode for HM patients with ARF.
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Affiliation(s)
- Li Jiang
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Qunfang Wan
- Department of Respiratory and Critical Care Medicine, West China Hospital, Sichuan University, Chengdu, China
| | - Hongbing Ma
- Department of Hematology, West China Hospital, Sichuan University, Chengdu, China.
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Pulmonary Complications of Pediatric Hematopoietic Cell Transplantation. A National Institutes of Health Workshop Summary. Ann Am Thorac Soc 2021; 18:381-394. [PMID: 33058742 DOI: 10.1513/annalsats.202001-006ot] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Approximately 2,500 pediatric hematopoietic cell transplants (HCTs), most of which are allogeneic, are performed annually in the United States for life-threatening malignant and nonmalignant conditions. Although HCT is undertaken with curative intent, post-HCT complications limit successful outcomes, with pulmonary dysfunction representing the leading cause of nonrelapse mortality. To better understand, predict, prevent, and/or treat pulmonary complications after HCT, a multidisciplinary group of 33 experts met in a 2-day National Institutes of Health Workshop to identify knowledge gaps and research strategies most likely to improve outcomes. This summary of Workshop deliberations outlines the consensus focus areas for future research.
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Oxygenation Strategy During Acute Respiratory Failure in Critically-Ill Immunocompromised Patients. Crit Care Med 2021; 48:e768-e775. [PMID: 32706556 DOI: 10.1097/ccm.0000000000004456] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/18/2023]
Abstract
OBJECTIVES To assess the response to initial oxygenation strategy according to clinical variables available at admission. DESIGN Multicenter cohort study. SETTING Thirty French and Belgium medical ICU. SUBJECTS Immunocompromised patients with hypoxemic acute respiratory failure. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Data were extracted from the Groupe de Recherche en Reanimation Respiratoire du patient d'Onco-Hématologie database. Need for invasive mechanical ventilation was the primary endpoint. Secondary endpoint was day-28 mortality. Six-hundred forty-nine patients were included. First oxygenation strategies included standard oxygen (n = 245, 38%), noninvasive ventilation (n = 285; 44%), high-flow nasal cannula oxygen (n = 55; 8%), and noninvasive ventilation + high-flow nasal cannula oxygen (n = 64; 10%). Bilateral alveolar pattern (odds ratio = 1.67 [1.03-2.69]; p = 0.04), bacterial (odds ratio = 1.98 [1.07-3.65]; p = 0.03) or opportunistic infection (odds ratio = 4.75 [2.23-10.1]; p < 0.001), noninvasive ventilation use (odds ratio = 2.85 [1.73-4.70]; p < 0.001), Sequential Organ Failure Assessment score (odds ratio = 1.19 [1.10-1.28]; p < 0.001), and ratio of PaO2 and FIO2 less than 100 at ICU admission (odds ratio = 1.96 [1.27-3.02]; p = 0.0002) were independently associated with intubation rate. Day-28 mortality was independently associated with bacterial (odds ratio = 2.34 [1.10-4.97]; p = 0.03) or opportunistic infection (odds ratio = 4.96 [2.11-11.6]; p < 0.001), noninvasive ventilation use (odds ratio = 2.35 [1.35-4.09]; p = 0.003), Sequential Organ Failure Assessment score (odds ratio = 1.19 [1.10-1.28]; p < 0.001), and ratio of PaO2 and FIO2 less than 100 at ICU admission (odds ratio = 1.97 [1.26-3.09]; p = 0.003). High-flow nasal cannula oxygen use was neither associated with intubation nor mortality rates. CONCLUSIONS Some clinical characteristics at ICU admission including etiology and severity of acute respiratory failure enable to identify patients at high risk for intubation.
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Reddy DRS, Botz GH. Triage and Prognostication of Cancer Patients Admitted to the Intensive Care Unit. Crit Care Clin 2020; 37:1-18. [PMID: 33190763 DOI: 10.1016/j.ccc.2020.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
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.
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Affiliation(s)
- Dereddi Raja Shekar Reddy
- Department of Critical Care and Respiratory Care, Division of Anesthesiology, Critical Care and Pain Medicine, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 112, Houston, TX 77030, USA
| | - Gregory H Botz
- Department of Critical Care and Respiratory Care, Division of Anesthesiology, Critical Care and Pain Medicine, University of Texas MD Anderson Cancer Center, 1515 Holcombe Boulevard, Unit 112, Houston, TX 77030, USA.
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Xu J, Yu Y, Liu J. Acute Hypoxemic Respiratory Failure in Immunocompromised Patients: Taking Aggressive Measures to Identify Etiology. Front Med (Lausanne) 2020; 7:433. [PMID: 33015081 PMCID: PMC7511656 DOI: 10.3389/fmed.2020.00433] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2019] [Accepted: 07/06/2020] [Indexed: 02/05/2023] Open
Affiliation(s)
- Jing Xu
- Department of Critical Care Medicine, School of Medicine, Rui Jin Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Yuetian Yu
- Department of Critical Care Medicine, School of Medicine, Ren Ji Hospital, Shanghai Jiao Tong University, Shanghai, China
| | - Jialin Liu
- Department of Critical Care Medicine, School of Medicine, Rui Jin Hospital, Shanghai Jiao Tong University, Shanghai, China
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Barreto LM, Ravetti CG, Athaíde TB, Bragança RD, Pinho NC, Chagas LV, de Lima Bastos F, Nobre V. Factors associated with non-invasive mechanical ventilation failure in patients with hematological neoplasia and their association with outcomes. J Intensive Care 2020; 8:68. [PMID: 32922803 PMCID: PMC7475950 DOI: 10.1186/s40560-020-00484-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/23/2020] [Accepted: 08/20/2020] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND The usefulness of non-invasive mechanical ventilation (NIMV) in oncohematological patients is still a matter of debate. AIM To analyze the rate of noninvasive ventilation failure and the main characteristics associated with this endpoint in oncohematological patients with acute respiratory failure (ARF). METHODS A ventilatory support protocol was developed and implemented before the onset of the study. According to the PaO2/FiO2 (P/F) ratio and clinical judgment, patients received supplementary oxygen therapy, NIMV, or invasive mechanical ventilation (IMV). RESULTS Eighty-two patients were included, average age between 52.1 ± 16 years old; 44 (53.6%) were male. The tested protocol was followed in 95.1% of cases. Six patients (7.3%) received IMV, 59 (89.7%) received NIMV, and 17 (20.7%) received oxygen therapy. ICU mortality rates were significantly higher in the IMV (83.3%) than in the NIMV (49.2%) and oxygen therapy (5.9%) groups (P < 0.001). Among the 59 patients who initially received NIMV, 30 (50.8%) had to eventually be intubated. Higher SOFA score at baseline (1.35 [95% CI = 1.12-2.10], P = 0.007), higher respiratory rate (RR) (1.10 [95% CI = 1.00-1.22], P = 0.048), and sepsis on admission (16.9 [95% CI = 1.93-149.26], P = 0.011) were independently associated with the need of orotracheal intubation among patients initially treated with NIMV. Moreover, NIMV failure was independently associated with ICU (P < 0.001) and hospital mortality (P = 0.049), and mortality between 6 months and 1 year (P < 0.001). CONCLUSION The implementation of a NIMV protocol is feasible in patients with hematological neoplasia admitted to the ICU, even though its benefits still remain to be demonstrated. NIMV failure was associated with higher SOFA and RR and more frequent sepsis, and it was also related to poor prognosis.
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Affiliation(s)
- Lídia Miranda Barreto
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- NIIMI (Interdisciplinary Nucleus of Investigation in Intensive Medicine), Federal University of Minas Gerais, Av. Professor Alfredo Balena, 190/533, Santa Efigênia, Belo Horizonte, Minas Gerais 30130-100 Brazil
| | - Cecilia Gómez Ravetti
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- NIIMI (Interdisciplinary Nucleus of Investigation in Intensive Medicine), Federal University of Minas Gerais, Av. Professor Alfredo Balena, 190/533, Santa Efigênia, Belo Horizonte, Minas Gerais 30130-100 Brazil
| | | | - Renan Detoffol Bragança
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- NIIMI (Interdisciplinary Nucleus of Investigation in Intensive Medicine), Federal University of Minas Gerais, Av. Professor Alfredo Balena, 190/533, Santa Efigênia, Belo Horizonte, Minas Gerais 30130-100 Brazil
| | - Nathália Costa Pinho
- School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | - Lucas Vieira Chagas
- School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
| | | | - Vandack Nobre
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- NIIMI (Interdisciplinary Nucleus of Investigation in Intensive Medicine), Federal University of Minas Gerais, Av. Professor Alfredo Balena, 190/533, Santa Efigênia, Belo Horizonte, Minas Gerais 30130-100 Brazil
| | - on behalf of the Núcleo Interdisciplinar de Investigação em Medicina Intensiva (NIIMI)
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- School of Medicine, Universidade Federal de Minas Gerais, Belo Horizonte, Brazil
- NIIMI (Interdisciplinary Nucleus of Investigation in Intensive Medicine), Federal University of Minas Gerais, Av. Professor Alfredo Balena, 190/533, Santa Efigênia, Belo Horizonte, Minas Gerais 30130-100 Brazil
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Acute and Chronic Respiratory Failure in Cancer Patients. ONCOLOGIC CRITICAL CARE 2020. [PMCID: PMC7123817 DOI: 10.1007/978-3-319-74588-6_43] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
In 2016, there was an estimated 1.8 million new cases of cancer diagnosed in the United States. Remarkable advances have been made in cancer therapy and the 5-year survival has increased for most patients affected by malignancy. There are growing numbers of patients admitted to intensive care units (ICU) and up to 20% of all patients admitted to an ICU carry a diagnosis of malignancy. Respiratory failure remains the most common reason for ICU admission and remains the leading causes of death in oncology patients. There are many causes of respiratory failure in this population. Pneumonia is the most common cause of respiratory failure, yet there are many causes of respiratory insufficiency unique to the cancer patient. These causes are often a result of immunosuppression, chemotherapy, radiation treatment, or hematopoietic stem cell transplant (HCT). Treatment is focused on supportive care and specific therapy for the underlying cause of respiratory failure. Noninvasive modalities of respiratory support are available; however, careful patient selection is paramount as indiscriminate use of noninvasive positive pressure ventilation is associated with a higher mortality if mechanical ventilation is later required. Historically, respiratory failure in the cancer patient had a grim prognosis. Outcomes have improved over the past 20 years. Survivors are often left with significant disability.
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Darmon M, Bourmaud A, Georges Q, Soares M, Jeon K, Oeyen S, Rhee CK, Gruber P, Ostermann M, Hill QA, Depuydt P, Ferra C, Toffart AC, Schellongowski P, Müller A, Lemiale V, Mokart D, Azoulay E. Changes in critically ill cancer patients' short-term outcome over the last decades: results of systematic review with meta-analysis on individual data. Intensive Care Med 2019; 45:977-987. [PMID: 31143998 DOI: 10.1007/s00134-019-05653-7] [Citation(s) in RCA: 94] [Impact Index Per Article: 18.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2019] [Accepted: 05/20/2019] [Indexed: 11/24/2022]
Abstract
PURPOSE The number of averted deaths due to therapeutic advances in oncology and hematology is substantial and increasing. Survival of critically ill cancer patients has also improved during the last 2 decades. However, these data stem predominantly from unadjusted analyses. The aim of this study was to assess the impact of ICU admission year on short-term survival of critically ill cancer patients, with special attention on those with neutropenia. METHODS Systematic review and meta-analysis of individual data according to the guidelines of meta-analysis of observational studies in epidemiology. DATASOURCE Pubmed and Cochrane databases. ELIGIBILITY CRITERIA Adult studies published in English between May 2005 and May 2015. RESULTS Overall, 7354 patients were included among whom 1666 presented with neutropenia at ICU admission. Median ICU admission year was 2007 (IQR 2004-2010; range 1994-2012) and median number of admissions per year was 693 (IQR 450-1007). Overall mortality was 47.7%. ICU admission year was associated with a progressive decrease in hospital mortality (OR per year 0.94; 95% CI 0.93-0.95). After adjustment for confounders, year of ICU admission was independently associated with hospital mortality (OR for hospital mortality per year: 0.96; 95% CI 0.95-0.97). The association was also seen in patients with neutropenia but not in allogeneic stem cell transplant recipients. CONCLUSION After adjustment for patient characteristics, severity of illness and clustering, hospital mortality decreased steadily over time in critically ill oncology and hematology patients except for allogeneic stem cell transplant recipients.
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Affiliation(s)
- Michaël Darmon
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France. .,Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France. .,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris, France.
| | - Aurélie Bourmaud
- Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France.,Public Health Department, Robert Debré University Hospital, AP-HP, Paris, France.,UMRS 1123, Clinical Epidemiology and Economic Evaluation Applied to Vulnerable Populations (Epidémiologie Clinique et Évaluation Économique appliquée aux Populations Vulnérables [ECEVE]), Paris Diderot University, Paris, France
| | - Quentin Georges
- Medical-Surgical ICU, Saint-Etienne University Hospital, Saint-Étienne, France
| | - Marcio Soares
- Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Kyeongman Jeon
- Department of Critical Care Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | - Sandra Oeyen
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Chin Kook Rhee
- Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, The Catholic University of Korea, Seoul, South Korea
| | - Pascale Gruber
- Department of Critical Care, The Royal Marsden Hospital, Fulham Road, London, SW3 6JJ, UK
| | - Marlies Ostermann
- Department of Critical Care and Nephrology, King's College London, Guy's and St Thomas' NHS Foundation Hospital, London, UK
| | - Quentin A Hill
- Department of Haematology, Leeds Teaching Hospitals, Leeds, UK
| | - Pieter Depuydt
- Department of Intensive Care Medicine, Ghent University Hospital, Ghent, Belgium
| | - Christelle Ferra
- Department of Clinical Hematology, ICO-Hospital Germans Trias i Pujol, Josep Carreras Research Institute, Universitat Autònoma de Barcelona, Badalona, Spain
| | - Anne-Claire Toffart
- Thoracic Oncology Unit, Grenoble Alpes University Hospital, Grenoble, France
| | - Peter Schellongowski
- Department of Medicine I, Intensive Care Unit 13i2, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Alice Müller
- Universidade Federal do Rio Grande do Sul, Rio Grande do Sul, Porto Alegre, Brazil
| | - Virginie Lemiale
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France
| | - Djamel Mokart
- Anesthesiology and Intensive Care Unit, Institut Paoli Calmette, Marseille, France
| | - Elie Azoulay
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France.,Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France.,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistic Sorbonne Paris Cité, CRESS), INSERM, Paris, France
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12
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Influence of neutropenia on mortality of critically ill cancer patients: results of a meta-analysis on individual data. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:326. [PMID: 30514339 PMCID: PMC6280476 DOI: 10.1186/s13054-018-2076-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/18/2017] [Accepted: 05/21/2018] [Indexed: 12/13/2022]
Abstract
Background The study objective was to assess the influence of neutropenia on outcome of critically ill cancer patients by meta-analysis of individual data. Secondary objectives were to assess the influence of neutropenia on outcome of critically ill patients in prespecified subgroups (according to underlying tumor, period of admission, need for mechanical ventilation and use of granulocyte colony stimulating factor (G-CSF)). Methods Data sources were PubMed and the Cochrane database. Study selection included articles focusing on critically ill cancer patients published in English and studies in humans from May 2005 to May 2015. For study selection, the study eligibility was assessed by two investigators. Individual data from selected studies were obtained from corresponding authors. Results Overall, 114 studies were identified and authors of 30 studies (26.3% of selected studies) agreed to participate in this study. Of the 7515 included patients, three were excluded due to a missing major variable (neutropenia or mortality) leading to analysis of 7512 patients, including 1702 neutropenic patients (22.6%). After adjustment for confounders, and taking study effect into account, neutropenia was independently associated with mortality (OR 1.41; 95% CI 1.23–1.62; P = 0.03). When analyzed separately, neither admission period, underlying malignancy nor need for mechanical ventilation modified the prognostic influence of neutropenia on outcome. However, among patients for whom data on G-CSF administration were available (n = 1949; 25.9%), neutropenia was no longer associated with outcome in patients receiving G-CSF (OR 1.03; 95% CI 0.70–1.51; P = 0.90). Conclusion Among 7512 critically ill cancer patients included in this systematic review, neutropenia was independently associated with poor outcome despite a meaningful survival. Neutropenia was no longer significantly associated with outcome in patients treated by G-CSF, which may suggest a beneficial effect of G-CSF in neutropenic critically ill cancer patients. Systematic review registration PROSPERO CRD42015026347. Date of registration: Sept 18 2015 Electronic supplementary material The online version of this article (10.1186/s13054-018-2076-z) contains supplementary material, which is available to authorized users.
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Bouteloup M, Perinel S, Bourmaud A, Azoulay E, Mokart D, Darmon M. Outcomes in adult critically ill cancer patients with and without neutropenia: a systematic review and meta-analysis of the Groupe de Recherche en Réanimation Respiratoire du patient d'Onco-Hématologie (GRRR-OH). Oncotarget 2018; 8:1860-1870. [PMID: 27661125 PMCID: PMC5352103 DOI: 10.18632/oncotarget.12165] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2016] [Accepted: 09/14/2016] [Indexed: 01/24/2023] Open
Abstract
PURPOSE Whether neutropenia has an impact on the mortality of critically ill cancer patients remains controversial, yet it is widely used as an admission criterion and prognostic factor. METHODS Systematic review and meta-analysis. Studies on adult cancer patients and intensive care units were searched on PubMed and Cochrane databases (2005-2015). Summary estimates of mortality risk differences were calculated using the random-effects model. RESULTS Among the 1,528 citations identified, 38 studies reporting on 6,054 patients (2,097 neutropenic patients) were included. Median mortality across the studies was 54% [45–64], with unadjusted mortality in neutropenic and non-neutropenic critically ill patients of 60% [53–74] and 47% [41–68], respectively. Overall, neutropenia was associated with a 10% increased mortality risk (6%-14%; I2 = 50%). The admission period was not associated with how neutropenia affected mortality. Mortality significantly dropped throughout the study decade [−11% (−13.5 to −8.4)]. This mortality drop was observed in non-neutropenic patients [−12.1% (−15.2 to −9.0)] but not in neutropenic patients [−3.8% (−8.1 to +5.6)]. Sensitivity analyses disclosed no differences in underlying malignancy, mechanical ventilation use, or Granulocyte-colony stimulating factor use. Seven studies allowed the adjustment of severity results (1,350 patients). Although pooled risk difference estimates were similar to non-adjusted results, there was no significant impact of neutropenia on mortality (risk difference of mortality, 9%; 95% CI, −15 to +33) CONCLUSION Although the unadjusted mortality of neutropenic patients was 11% higher, this effect disappeared when adjusted for severity. Therefore, when cancer patients become critically ill, neutropenia cannot be considered as a decision-making criterion.
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Affiliation(s)
- Marie Bouteloup
- Medical-Surgical ICU, Hôpital Nord, Université Jean Monnet, Saint-Etienne, France
| | - Sophie Perinel
- Medical-Surgical ICU, Hôpital Nord, Université Jean Monnet, Saint-Etienne, France
| | - Aurélie Bourmaud
- Department of Public Health, Hygée Centre, Lucien Neuwirth Cancer Institut, Saint Priest en Jarez, France
| | - Elie Azoulay
- Medical ICU, Saint-Louis University Hospital, AP-HP, Paris, France.,Faculté de Médecine, Université Paris-Diderot, Sorbonne-Paris-Cité, Paris, France
| | - Djamel Mokart
- Anesthesiology and Intensive Care Unit, Institut Paoli Calmette, Marseille Cedex 9, France
| | - Michael Darmon
- Medical-Surgical ICU, Hôpital Nord, Université Jean Monnet, Saint-Etienne, France.,Thrombosis Research Group, EA 3065, Saint-Etienne University Hospital and Saint-Etienne Medical School, Saint-Etienne, France
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14
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Wang T, Liu G, He K, Lu X, Liang X, Wang M, Zhu R, Li Z, Chen F, Ke J, Lin Q, Qian C, Li B, Wei J, Lv J, Li L, Gao Y, Wu G, Yu X, Wei W, Deng Y, Wang F, Zhang H, Zheng Y, Zhan H, Liao J, Tian Y, Yao D, Zhang J, Chen X, Yang L, Wu J, Chai Y, Shou S, Yu M, Xiang X, Zhang D, Chen F, Xie X, Li Y, Wang B, Zhang W, Miao Y, Eddleston M, He J, Ma Y, Xu S, Li Y, Zhu H, Yu X. The efficacy of initial ventilation strategy for adult immunocompromised patients with severe acute hypoxemic respiratory failure: study protocol for a multicentre randomized controlled trial (VENIM). BMC Pulm Med 2017; 17:127. [PMID: 28931394 PMCID: PMC5607592 DOI: 10.1186/s12890-017-0467-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2017] [Accepted: 08/31/2017] [Indexed: 11/10/2022] Open
Abstract
Background Acute respiratory failure (ARF) is still one of the most severe complications in immunocompromised patients. Our previous systematic review showed noninvasive mechanical ventilation (NIV) reduced mortality, length of hospitalization and ICU stay in AIDS/hematological malignancy patients with relatively less severe ARF, compared to invasive mechanical ventilation (IMV). However, this systematic review was based on 13 observational studies and the quality of evidence was low to moderate. The efficacy of NIV in more severe ARF and in patients with other causes of immunodeficiency is still unclear. We aim to determine the efficacy of the initial ventilation strategy in managing ARF in immunocompromised patients stratified by different disease severity and causes of immunodeficiency, and explore predictors for failure of NIV. Methods and analysis The VENIM is a multicentre randomized controlled trial (RCT) comparing the effects of NIV compared with IMV in adult immunocompromised patients with severe hypoxemic ARF. Patients who meet the indications for both forms of ventilatory support will be included. Primary outcome will be 30-day all-cause mortality. Secondary outcomes will include in-hospital mortality, length of stay in hospital, improvement of oxygenation, nosocomial infections, seven-day organ failure, adverse events of intervention, et al. Subgroups with different disease severity and causes of immunodeficiency will also be analyzed. Discussion VENIM is the first randomized controlled trial aiming at assessing the efficacy of initial ventilation strategy in treating moderate and severe acute respiratory failure in immunocompromised patients. The result of this RCT may help doctors with their ventilation decisions. Trial registration ClinicalTrials.gov NCT02983851. Registered 2 September 2016.
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Affiliation(s)
- Tao Wang
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Gang Liu
- Department of Orthopedics, Peking Union Medical College Hospital, Beijing, China
| | - Kun He
- Department of Gastroenterology, Peking Union Medical College Hospital, Beijing, China
| | - Xin Lu
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Xianquan Liang
- Emergency Department, Guiyang Second People Hospital, Guiyang, China
| | - Meng Wang
- Department of Science and Technology, Beijing Tiantan Hospital, Capital Medical University, Beijing, 100050, China
| | - Rong Zhu
- Department of Ultrasound, Peking Union Medical College Hospital, Beijing, China
| | - Zongru Li
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Feng Chen
- Department of Emergency, Fujian Provincial Hospital, Provincial Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Jun Ke
- Department of Emergency, Fujian Provincial Hospital, Provincial Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Qingming Lin
- Department of Emergency, Fujian Provincial Hospital, Provincial Clinical Medical College of Fujian Medical University, Fuzhou, China
| | - Chuanyun Qian
- Emergency Department, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Bo Li
- Emergency Department, First Affiliated Hospital of Kunming Medical University, Kunming, China
| | - Jie Wei
- Department of Emergency, Renmin Hospital of Wuhan University, Wuhan, China
| | - Jingjun Lv
- Department of Emergency, Renmin Hospital of Wuhan University, Wuhan, China
| | - Li Li
- Emergency Department, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Yanxia Gao
- Emergency Department, First Affiliated Hospital of Zhengzhou University, Zhengzhou, China
| | - Guofeng Wu
- Emergency Department, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Xiaohong Yu
- Emergency Department, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Weiqin Wei
- Emergency Department, Affiliated Hospital of Guizhou Medical University, Guiyang, China
| | - Ying Deng
- Department of Emergency, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Fengping Wang
- Department of Emergency, The Second Affiliated Hospital of Harbin Medical University, Harbin, China
| | - Hong Zhang
- Department of Emergency, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Yun Zheng
- Department of Emergency, The First Affiliated Hospital of Anhui Medical University, Hefei, China
| | - Hong Zhan
- Department of Emergency Medicine, The First Affiliated Hospital of SUN Yat-sen University, Guangzhou, China
| | - Jinli Liao
- Department of Emergency Medicine, The First Affiliated Hospital of SUN Yat-sen University, Guangzhou, China
| | - Yingping Tian
- Emergency Department, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Dongqi Yao
- Emergency Department, Second Hospital of Hebei Medical University, Shijiazhuang, China
| | - Jingsong Zhang
- Department of Emergency, First affiliated hospital of Nanjing Medical University, Nanjing, China
| | - Xufeng Chen
- Department of Emergency, First affiliated hospital of Nanjing Medical University, Nanjing, China
| | - Lishan Yang
- Department of Emergency, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Jiali Wu
- Department of Emergency, General Hospital of Ningxia Medical University, Yinchuan, China
| | - Yanfen Chai
- Emergency Department, Tianjin Medical University General Hospital, Tianjin, China
| | - Songtao Shou
- Emergency Department, Tianjin Medical University General Hospital, Tianjin, China
| | - Muming Yu
- Emergency Department, Tianjin Medical University General Hospital, Tianjin, China
| | - Xudong Xiang
- Department of Emergency Medicine, Second Xiangya Hospital, Institute of Emergency Medicine and Difficult Diseases, Central South University, Changsha, China
| | - Dongshan Zhang
- Department of Emergency Medicine, Second Xiangya Hospital, Institute of Emergency Medicine and Difficult Diseases, Central South University, Changsha, China
| | - Fengying Chen
- Department of Emergency, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Xiufeng Xie
- Department of Emergency, The Affiliated Hospital of Inner Mongolia Medical University, Hohhot, China
| | - Yong Li
- Department of Emergency, Cangzhou City Center Hospital, Cangzhou, China
| | - Bo Wang
- Department of Emergency, Cangzhou City Center Hospital, Cangzhou, China
| | - Wenzhong Zhang
- Department of Emergency, First Hospital of Handan City, Handan, China
| | - Yongli Miao
- Department of Emergency, First Hospital of Handan City, Handan, China
| | - Michael Eddleston
- Pharmacology, Toxicology and Therapeutics, Centre for Cardiovascular Science, University of Edinburgh, Edinburgh, UK
| | - Jianqiang He
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Yong Ma
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Shengyong Xu
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, China
| | - Yi Li
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, China.
| | - Huadong Zhu
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, China.
| | - Xuezhong Yu
- Emergency Department, Peking Union Medical College Hospital, No. 1 Shuaifuyuan, Dongcheng District, Beijing, China.
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15
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Bellani G, Laffey JG, Pham T, Madotto F, Fan E, Brochard L, Esteban A, Gattinoni L, Bumbasirevic V, Piquilloud L, van Haren F, Larsson A, McAuley DF, Bauer PR, Arabi YM, Ranieri M, Antonelli M, Rubenfeld GD, Thompson BT, Wrigge H, Slutsky AS, Pesenti A. Noninvasive Ventilation of Patients with Acute Respiratory Distress Syndrome. Insights from the LUNG SAFE Study. Am J Respir Crit Care Med 2017; 195:67-77. [PMID: 27753501 DOI: 10.1164/rccm.201606-1306oc] [Citation(s) in RCA: 361] [Impact Index Per Article: 51.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
RATIONALE Noninvasive ventilation (NIV) is increasingly used in patients with acute respiratory distress syndrome (ARDS). The evidence supporting NIV use in patients with ARDS remains relatively sparse. OBJECTIVES To determine whether, during NIV, the categorization of ARDS severity based on the PaO2/FiO2 Berlin criteria is useful. METHODS The LUNG SAFE (Large Observational Study to Understand the Global Impact of Severe Acute Respiratory Failure) study described the management of patients with ARDS. This substudy examines the current practice of NIV use in ARDS, the utility of the PaO2/FiO2 ratio in classifying patients receiving NIV, and the impact of NIV on outcome. MEASUREMENTS AND MAIN RESULTS Of 2,813 patients with ARDS, 436 (15.5%) were managed with NIV on Days 1 and 2 following fulfillment of diagnostic criteria. Classification of ARDS severity based on PaO2/FiO2 ratio was associated with an increase in intensity of ventilatory support, NIV failure, and intensive care unit (ICU) mortality. NIV failure occurred in 22.2% of mild, 42.3% of moderate, and 47.1% of patients with severe ARDS. Hospital mortality in patients with NIV success and failure was 16.1% and 45.4%, respectively. NIV use was independently associated with increased ICU (hazard ratio, 1.446 [95% confidence interval, 1.159-1.805]), but not hospital, mortality. In a propensity matched analysis, ICU mortality was higher in NIV than invasively ventilated patients with a PaO2/FiO2 lower than 150 mm Hg. CONCLUSIONS NIV was used in 15% of patients with ARDS, irrespective of severity category. NIV seems to be associated with higher ICU mortality in patients with a PaO2/FiO2 lower than 150 mm Hg. Clinical trial registered with www.clinicaltrials.gov (NCT 02010073).
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Affiliation(s)
- Giacomo Bellani
- 1 Department of Medicine and Surgery, University of Milan-Bicocca, Monza, Italy.,2 Department of Emergency and Intensive Care, San Gerardo Hospital, Monza, Italy
| | - John G Laffey
- 3 Department of Anesthesia.,4 Department of Critical Care Medicine, and.,5 Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.,6 Department of Anesthesia.,7 Department of Physiology.,8 Interdepartmental Division of Critical Care Medicine
| | - Tài Pham
- 9 Assistance Publique-Hôpitaux de Paris, Hôpital Tenon, Unité de Réanimation Médico-Chirurgicale, Pôle Thorax Voies Aériennes, Groupe Hospitalier des Hôpitaux Universitaires de l'Est Parisien, Paris, France.,10 Unité Mixte de Recherche 1153, Inserm, Sorbonne Paris Cité, Epidémiologie Clinique et Statistiques, pour la Recherche en Santé Team, Université Paris Diderot, Paris, France.,11 Sorbonne Universités, Université Pierre et Marie Curie, Paris 06, France
| | - Fabiana Madotto
- 12 Research Centre on Public Health, Department of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - Eddy Fan
- 8 Interdepartmental Division of Critical Care Medicine.,13 Institute of Health Policy, Management and Evaluation, and.,14 Department of Medicine, University of Toronto, Toronto, Canada.,15 Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada
| | - Laurent Brochard
- 4 Department of Critical Care Medicine, and.,8 Interdepartmental Division of Critical Care Medicine.,14 Department of Medicine, University of Toronto, Toronto, Canada.,15 Department of Medicine, University Health Network and Mount Sinai Hospital, Toronto, Canada
| | - Andres Esteban
- 16 Hospital Universitario de Getafe, Centro de Investigación Biomédica en Red de Enfermedades Respiratorias, Madrid, Spain
| | - Luciano Gattinoni
- 17 Department of Anesthesiology, Emergency and Intensive Care Medicine, University Medical Center Göttingen, Göttingen, Germany
| | - Vesna Bumbasirevic
- 18 School of Medicine, University of Belgrade, Belgrade, Serbia.,19 Department of Anesthesia and Intensive Care, Emergency Center, Clinical Center of Serbia, Belgrade, Serbia
| | - Lise Piquilloud
- 20 Adult Intensive Care and Burn Unit, University Hospital of Lausanne, Lausanne, Switzerland.,21 Department of Medical Intensive Care, University Hospital of Angers, Angers, France
| | - Frank van Haren
- 22 Intensive Care Unit, The Canberra Hospital, Canberra, Australia.,23 Australian National University, Canberra, Australia
| | - Anders Larsson
- 24 Section of Anesthesiology and Intensive Care, Department of Surgical Sciences, Uppsala University, Uppsala, Sweden
| | - Daniel F McAuley
- 25 Centre for Experimental Medicine, Queen's University of Belfast, Wellcome-Wolfson Institute for Experimental Medicine, Belfast, United Kingdom.,26 Regional Intensive Care Unit, Royal Victoria Hospital, Belfast, United Kingdom
| | - Philippe R Bauer
- 27 Division of Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, Minnesota
| | - Yaseen M Arabi
- 28 King Saud Bin Abdulaziz University for Health Sciences, Riyadh, Saudi Arabia.,29 King Abdullah International Medical Research Center, Riyadh, Saudi Arabia
| | - Marco Ranieri
- 30 Dipartimento di Anestesia e Rianimazione, Policlinico Umberto I, Sapienza Università di Roma, Roma, Italy
| | - Massimo Antonelli
- 31 Istituto di Anestesiologia e Rianimazione, Università Cattolica del Sacro Cuore-Fondazione Policlinico Universitario A. Gemelli, Roma, Italy
| | - Gordon D Rubenfeld
- 8 Interdepartmental Division of Critical Care Medicine.,14 Department of Medicine, University of Toronto, Toronto, Canada.,32 Sunnybrook Health Sciences Center, Toronto, Canada
| | - B Taylor Thompson
- 33 Division of Pulmonary and Critical Care, Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts
| | - Hermann Wrigge
- 34 Department of Anesthesiology and Intensive Care Medicine, University of Leipzig, Leipzig, Germany
| | - Arthur S Slutsky
- 5 Keenan Research Centre for Biomedical Science, Li Ka Shing Knowledge Institute, St. Michael's Hospital, Toronto, Canada.,8 Interdepartmental Division of Critical Care Medicine.,14 Department of Medicine, University of Toronto, Toronto, Canada
| | - Antonio Pesenti
- 35 Dipartimento di Anestesia, Rianimazione ed Emergenza Urgenza, Fondazione Istituto di ricovero e Cura a Carattere Scientifico Cà Granda-Ospedale Maggiore Policlinico, Milan, Italy; and.,36 Dipartimento di Fisiopatologia Medico-Chirurgica e dei Trapianti, Università degli Studi di Milano, Milan, Italy
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16
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Tu G, He H, Yin K, Ju M, Zheng Y, Zhu D, Luo Z. High-flow Nasal Cannula Versus Noninvasive Ventilation for Treatment of Acute Hypoxemic Respiratory Failure in Renal Transplant Recipients. Transplant Proc 2017; 49:1325-1330. [PMID: 28736002 DOI: 10.1016/j.transproceed.2017.03.088] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Revised: 02/23/2017] [Accepted: 03/15/2017] [Indexed: 02/07/2023]
Abstract
OBJECTIVE This study aimed to evaluate the outcomes of high-flow nasal cannula (HFNC) oxygen therapy compared with noninvasive ventilation (NIV) for the treatment of acute hypoxemic respiratory failure in renal transplant recipients. METHODS Data were retrospectively collected from a tertiary intensive care unit (ICU) from July 1, 2011, to September 31, 2015. All renal recipients who had acute respiratory failure at that period of time were classified into the HFNC or NIV group depending on the initial form of respiratory support. RESULTS A total of 38 patients were enrolled in this study. Twenty patients received HFNC and the other 18 received NIV as the initial respiratory support. The ICU mortality in the HFNC group was 5% (1 patient), compared with 22.2% (4 patients) in the NIV group (P = .083). The median length of the ICU stay was 12 days in the HFNC group, compared with 14 days in the NIV group (P = .297). The number of ventilator-free days at day 28 was significantly higher in the HFNC group than in the NIV group (26 ± 3 vs 21 ± 3; P < .001). The incidences of both pneumothorax (0% vs 22.2%; P = .042) and skin breakdown (0% vs 22.2%; P = .042) were significantly lower in the HFNC group. CONCLUSIONS In renal transplant recipients with acute hypoxemic respiratory failure secondary to severe pneumonia, HFNC achieved outcomes similar to NIV. In addition, HFNC was associated with an increased number of ventilator-free days at day 28 and fewer complications.
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Affiliation(s)
- G Tu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - H He
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - K Yin
- Department of Cardiac Surgery, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - M Ju
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - Y Zheng
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
| | - D Zhu
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China.
| | - Z Luo
- Department of Critical Care Medicine, Zhongshan Hospital, Fudan University, Shanghai, People's Republic of China
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17
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Impact of Initial Ventilatory Strategy in Hematological Patients With Acute Respiratory Failure: A Systematic Review and Meta-Analysis. Crit Care Med 2017; 44:1406-13. [PMID: 26909503 DOI: 10.1097/ccm.0000000000001613] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE Acute respiratory failure in hematological patients is related to a high mortality. Noninvasive mechanical ventilation may benefit a subset of these patients, but the overall effect on mortality and the risks derived from its failure are unclear. Our objective was to review the impact of initial ventilatory strategy on mortality and the risks related to noninvasive mechanical ventilation failure in this group of patients. DATA SOURCES Data sources, including PubMed and conference proceedings, were searched from the year 2000 to January 2015. STUDY SELECTION We selected studies reporting mortality and the need for mechanical ventilation in hematological patients with acute respiratory failure. DATA EXTRACTION Two trained reviewers independently conducted study selection, abstracted data, and assessed the risk of bias. Discrepancies between reviewers were resolved through discussion and consensus. The outcomes explored were all-cause mortality after mechanical ventilation and incidence of noninvasive mechanical ventilation failure. DATA SYNTHESIS A random-effects model was used in all the analysis. Thirteen studies, involving 2,380 patients, were included. Use of noninvasive mechanical ventilation was related to a better outcome than initial intubation (risk ratio, 0.74; 95% CI, 0.65-0.84). Failure of noninvasive mechanical ventilation did not increase the overall risk of death (risk ratio, 1.02; 95% CI, 0.93-1.13). There were signs of publication bias and substantial heterogeneity among the studies. Compensation of this bias by using the trim-and-fill method showed a significant risk of death after noninvasive mechanical ventilation failure (risk ratio, 1.07; 95% CI, 1.00-1.14). Meta-regression analysis showed that the predicted risk of death for the noninvasive mechanical ventilation group acted as a significant moderator, with a higher risk of death after noninvasive mechanical ventilation failure in those studies reporting lower predicted mortality. CONCLUSIONS Noninvasive mechanical ventilation is associated with a lower risk of death in hematological patients with respiratory failure. Noninvasive mechanical ventilation failure may worsen the prognosis, mainly in less severe patients.
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18
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High-Flow Nasal Cannula Oxygenation in Immunocompromised Patients With Acute Hypoxemic Respiratory Failure: A Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique Study. Crit Care Med 2017; 45:e274-e280. [PMID: 27655324 DOI: 10.1097/ccm.0000000000002085] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE In immunocompromised patients with acute respiratory failure, invasive mechanical ventilation remains associated with high mortality. Choosing the adequate oxygenation strategy is of the utmost importance in that setting. High-flow nasal oxygen has recently shown survival benefits in unselected patients with acute respiratory failure. The objective was to assess outcomes of immunocompromised patients with hypoxemic acute respiratory failure treated with high-flow nasal oxygen. DESIGN We performed a post hoc analysis of a randomized controlled trial of noninvasive ventilation in critically ill immunocompromised patients with hypoxemic acute respiratory failure. SETTING Twenty-nine ICUs in France and Belgium. PATIENTS Critically ill immunocompromised patients with hypoxemic acute respiratory failure. INTERVENTION A propensity score-based approach was used to assess the impact of high-flow nasal oxygen compared with standard oxygen on day 28 mortality. MEASUREMENTS AND MAIN RESULTS Among 374 patients included in the study, 353 met inclusion criteria. Underlying disease included mostly malignancies (n = 296; 84%). Acute respiratory failure etiologies were mostly pneumonia (n = 157; 44.4%) or opportunistic infection (n = 76; 21.5%). Noninvasive ventilation was administered to 180 patients (51%). Invasive mechanical ventilation was ultimately needed in 142 patients (40.2%). Day 28 mortality was 22.6% (80 deaths). Throughout the ICU stay, 127 patients (36%) received high-flow nasal oxygen whereas 226 patients received standard oxygen. Ninety patients in each group (high-flow nasal oxygen or standard oxygen) were matched according to the propensity score, including 91 of 180 (51%) who received noninvasive ventilation. High-flow nasal oxygen was neither associated with a lower intubation rate (hazard ratio, 0.42; 95% CI, 0.11-1.61; p = 0.2) nor day 28 mortality (hazard ratio, 0.80; 95% CI, 0.45-1.42; p = 0.45). CONCLUSIONS In immunocompromised patients with hypoxemic acute respiratory failure, high-flow nasal oxygen when compared with standard oxygen did not reduce intubation or survival rates. However, these results could be due to low statistical power or unknown confounders associated with the subgroup analysis. A randomized trial is needed.
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19
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Abstract
Advances in cancer treatment and patient survival are associated with increasing number of these patients requiring intensive care. Over the last 2 decades, there has been a steady improvement in the outcomes of critically ill patients with cancer. This review provides data on the use of the intensive care unit (ICU) and short and long-term outcomes of critically ill patients with cancer, the ICU system practices that influence patients outcomes, and the role of the different clinical variables in predicting the prognosis of these patients.
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Affiliation(s)
- Ayman O Soubani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, 3990 John R- 3 Hudson, Detroit, MI 48201, USA.
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20
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Rathi NK, Haque SA, Nates R, Kosturakis A, Wang H, Dong W, Feng L, Erfe RJ, Guajardo C, Withers L, Finch C, Price KJ, Nates JL. Noninvasivepositive pressure ventilation vsinvasive mechanical ventilation as first-line therapy for acute hypoxemic respiratory failure in cancer patients. J Crit Care 2017; 39:56-61. [PMID: 28213266 DOI: 10.1016/j.jcrc.2017.01.007] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/12/2016] [Revised: 10/20/2016] [Accepted: 01/14/2017] [Indexed: 10/20/2022]
Abstract
PURPOSE The objective was to describe the characteristics and outcomes of critically ill cancer patients who received noninvasive positive pressure ventilation (NIPPV) vs invasive mechanical ventilation as first-line therapy for acute hypoxemic respiratory failure. MATERIAL AND METHODS A retrospective cohort study of consecutive adult intensive care unit (ICU) cancer patients who received either conventional invasive mechanical ventilation or NIPPV as first-line therapy for hypoxemic respiratory failure. RESULTS Of the 1614 patients included, the NIPPV failure group had the greatest hospital length of stay, ICU length of stay, ICU mortality (71.3%), and hospital mortality (79.5%) as compared with the other 2 groups (P < .0001). The variables independently associated with NIPPV failure included younger age (odds ratio [OR], 0.99; 95% confidence interval [CI], 0.98-0.99; P=.031), non-Caucasian race (OR, 1.61; 95% CI, 1.14-2.26; P=.006), presence of a hematologic malignancy (OR, 1.87; 95% CI, 1.33-2.64; P=.0003), and a higher Sequential Organ Failure Assessment score (OR, 1.12; 95% CI, 1.08-1.17; P < .0001). There was no difference in mortality when comparing early vs late intubation (less than or greater than 24 or 48 hours) for the NIPPV failure group. CONCLUSION Noninvasive positive pressure ventilation failure is an independent risk factor for ICU mortality, but NIPPV patients who avoided intubation had the best outcomes compared with the other groups. Early vs late intubation did not have a significant impact on outcomes.
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Affiliation(s)
- Nisha K Rathi
- Department of Critical Care, University of Texas MD Anderson Cancer Center, Houston, TX.
| | - Sajid A Haque
- Department of Critical Care, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Ron Nates
- Department of Critical Care, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Alyssa Kosturakis
- Department of Critical Care, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Hao Wang
- Department of Critical Care, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Wenli Dong
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Lei Feng
- Department of Biostatistics, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Rose J Erfe
- Department of Critical Care, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Christina Guajardo
- Department of Critical Care, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Laura Withers
- Department of Critical Care, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Clarence Finch
- Department of Critical Care, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Kristen J Price
- Department of Critical Care, University of Texas MD Anderson Cancer Center, Houston, TX
| | - Joseph L Nates
- Department of Critical Care, University of Texas MD Anderson Cancer Center, Houston, TX
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21
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Huang HB, Xu B, Liu GY, Lin JD, Du B. Use of noninvasive ventilation in immunocompromised patients with acute respiratory failure: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:4. [PMID: 28061910 PMCID: PMC5219799 DOI: 10.1186/s13054-016-1586-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 12/08/2016] [Indexed: 12/15/2022]
Abstract
Background Acute respiratory failure (ARF) remains a common hazardous complication in immunocompromised patients and is associated with increased mortality rates when endotracheal intubation is needed. We aimed to evaluate the effect of early noninvasive ventilation (NIV) compared with oxygen therapy alone in this patient population. Methods We searched for relevant studies in MEDLINE, EMBASE, and the Cochrane database up to 25 July 2016. Randomized controlled trials (RCTs) were included if they reported data on any of the predefined outcomes in immunocompromised patients managed with NIV or oxygen therapy alone. Results were expressed as risk ratio (RR) and mean difference (MD) with accompanying 95% confidence interval (CI). Results Five RCTs with 592 patients were included. Early NIV significantly reduced short-term mortality (RR 0.62, 95% CI 0.40 to 0.97, p = 0.04) and intubation rate (RR 0.52, 95% CI 0.32 to 0.85, p = 0.01) when compared with oxygen therapy alone, with significant heterogeneity in these two outcomes between the pooled studies. In addition, early NIV was associated with a shorter length of ICU stay (MD −1.71 days, 95% CI −2.98 to 1.44, p = 0.008) but not long-term mortality (RR 0.92, 95% CI 0.74 to 1.15, p = 0.46). Conclusions The limited evidence indicates that early use of NIV could reduce short-term mortality in selected immunocompromised patients with ARF. Further studies are needed to identify in which selected patients NIV could be more beneficial, before wider application of this ventilator strategy. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1586-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hui-Bin Huang
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China.,Department of Critical Care Medicine, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350000, People's Republic of China
| | - Biao Xu
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China.,Critical Care Medicine Center, the PLA 302 Hospital, No. 100 Xisihuanzhong Road, Fengtai District, Beijing, 100039, People's Republic of China
| | - Guang-Yun Liu
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Jian-Dong Lin
- Department of Critical Care Medicine, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350000, People's Republic of China
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China.
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22
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Liu J, Bell C, Campbell V, DeBacker J, Tamberg E, Lee C, Mehta S. Noninvasive Ventilation in Patients With Hematologic Malignancy. J Intensive Care Med 2017; 34:885066617690725. [PMID: 28142306 DOI: 10.1177/0885066617690725] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
INTRODUCTION Noninvasive ventilation (NIV) is commonly used as first-line therapy for immunocompromised patients with acute respiratory failure. However, it may not be appropriate for all patients, as failure of NIV and delayed endotracheal intubation (ETI) may increase mortality. We report our center's experience and outcomes for patients with active hematologic malignancy (HM) treated with NIV. METHODS We conducted a retrospective study of consecutive patients with HM who were admitted to the intensive care unit (ICU) of Mount Sinai Hospital for acute respiratory failure between January 1, 2010, and May 31, 2015, and were initially treated with NIV. We compared the characteristics of patients who were successfully treated with NIV and avoided intubation and those who failed NIV. RESULTS Seventy-nine patients (mean age 56 ± 14 years, mean Acute Physiology and Chronic Health Evaluation II score 27 ± 5) with HM were treated with NIV for acute respiratory failure. The etiology of respiratory failure was multifactorial in 31 (39%) patients, with features of pneumonia in 61 (77%) patients, severe sepsis or septic shock in 33 (42%) patients, and pulmonary edema in 24 (30%) patients. The majority of patients were admitted with acute leukemia (n = 60, 76%), 8 (10%) with lymphoma, and 11 (14%) with chronic leukemia, multiple myeloma, or myelodysplastic syndrome. Of the 79 patients treated with NIV, 44 (56%) failed NIV and required ETI, 7 (9%) had a do-not-intubate (DNI) order and died, and 28 (35%) avoided ETI. Compared with patients who avoided ETI, those who failed NIV or had a DNI order and died were more likely to have acute leukemia (84% vs 61%; P = .02) and at baseline had higher Paco2 (39 vs 30; P = .038), higher fraction of inspired oxygen (Fio2) requirements (0.6 vs 0.4; P = .002), and more vasopressor use (31% vs 11%; P = .059). The ICU mortality was 42%; 3-month mortality was 57% overall and was significantly lower in the NIV success patients compared with the NIV failure group (21% vs 74%; P < .001). CONCLUSION Two-thirds of patients with HM and respiratory failure failed NIV and required ETI, and had high subsequent mortality. Patients who failed NIV had higher Paco2, higher Fio2, and a trend toward more vasopressor use.
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Affiliation(s)
- Jiajia Liu
- 1 Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Conor Bell
- 2 National University of Ireland, Galway, Ireland
| | - Vagia Campbell
- 3 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Julian DeBacker
- 3 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Erik Tamberg
- 3 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Christie Lee
- 3 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Sangeeta Mehta
- 3 Interdepartmental Division of Critical Care Medicine, Department of Medicine, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
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23
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Cheng Q, Tang Y, Yang Q, Wang E, Liu J, Li X. The prognostic factors for patients with hematological malignancies admitted to the intensive care unit. SPRINGERPLUS 2016; 5:2038. [PMID: 27995015 PMCID: PMC5127914 DOI: 10.1186/s40064-016-3714-z] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 06/05/2016] [Accepted: 11/21/2016] [Indexed: 12/15/2022]
Abstract
Owing to the nature of acute illness and adverse effects derived from intensive chemotherapy, patients with hematological malignancies (HM) who are admitted to the Intensive Care Unit (ICU) often present with poor prognosis. However, with advances in life-sustaining therapies and close collaborations between hematologists and intensive care specialists, the prognosis for these patients has improved substantially. Many studies from different countries have examined the prognostic factors of these critically ill HM patients. However, there has not been an up-to-date review on this subject, and very few studies have focused on the prognosis of patients with HM admitted to the ICU in Asian countries. Herein, we aim to explore the current situation and prognostic factors in patients with HM admitted to ICU, mainly focusing on studies published in the last 10 years.
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Affiliation(s)
- Qian Cheng
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, 410013 Hunan China
| | - Yishu Tang
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, 410013 Hunan China
| | - Qing Yang
- Department of Medicine, Yale New Haven Hospital, New Haven, CT USA
| | - Erhua Wang
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, 410013 Hunan China
| | - Jing Liu
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, 410013 Hunan China
| | - Xin Li
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, 410013 Hunan China
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24
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Wang T, Zhang L, Luo K, He J, Ma Y, Li Z, Zhao N, Xu Q, Li Y, Yu X. Noninvasive versus invasive mechanical ventilation for immunocompromised patients with acute respiratory failure: a systematic review and meta-analysis. BMC Pulm Med 2016; 16:129. [PMID: 27567894 PMCID: PMC5002326 DOI: 10.1186/s12890-016-0289-y] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2016] [Accepted: 08/19/2016] [Indexed: 01/12/2023] Open
Abstract
Background To determine the effects of noninvasive mechanical ventilation (NIV) compared with invasive mechanical ventilation (IMV) as the initial mechanical ventilation on clinical outcomes when used for treatment of acute respiratory failure (ARF) in immunocompromised patients. Methods We searched PubMed, EMBASE, the Cochrane Central Register of Controlled Trials (CENTRAL), the Chinese Biomedical Literature Database (CBM) and other databases. Subgroup analyses by disease severity and causes of immunodeficiency were also conducted. Results Thirteen observational studies with a total of 2552 patients were included. Compared to IMV, NIV was shown to significantly reduce in-hospital mortality (OR 0.43, 95 % CI 0.23 to 0.80, P value = 0.007) and 30-day mortality (OR 0.34, 95 % CI 0.20 to 0.61, P value < 0.0001) in overall analysis. Subgroup analysis showed NIV had great advantage over IMV for less severe, AIDS, BMT and hematological malignancies patients in reducing mortality and duration of ICU stay. Conclusions The overall evidence we obtained shows NIV does more benefits or at least no harm to ARF patients with certain causes of immunodeficiency or who are less severe. Electronic supplementary material The online version of this article (doi:10.1186/s12890-016-0289-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Tao Wang
- Emergency Department, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Lixi Zhang
- Department of Cardiology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Kai Luo
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China
| | - Jianqiang He
- Emergency Department, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Yong Ma
- Emergency Department, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Zongru Li
- Department of Pneumology, Peking Union Medical College Hospital, Beijing, 100730, China
| | - Na Zhao
- Department of Anesthesiology, Beijing Obstetrics and Gynecology Hospital, Capital Medical University, Beijing, 100026, China
| | - Qun Xu
- Department of Epidemiology and Biostatistics, Institute of Basic Medical Sciences Chinese Academy of Medical Sciences, School of Basic Medicine Peking Union Medical College, Beijing, 100005, China
| | - Yi Li
- Emergency Department, Peking Union Medical College Hospital, Beijing, 100730, China.
| | - Xuezhong Yu
- Emergency Department, Peking Union Medical College Hospital, Beijing, 100730, China.
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25
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Vadde R, Pastores SM. Management of Acute Respiratory Failure in Patients With Hematological Malignancy. J Intensive Care Med 2016; 31:627-641. [PMID: 26283185 DOI: 10.1177/0885066615601046] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
Acute respiratory failure (ARF) is the leading cause of intensive care unit admission in patients with hematologic malignancies and is associated with a high mortality. The main causes of ARF are bacterial and opportunistic pulmonary infections and noninfectious lung disorders. Management consists of a systematic clinical evaluation aimed at identifying the most likely cause, which in turn determines the best first-line empirical treatments. The need for mechanical ventilation is a major determinant of prognosis. Beneficial outcomes have been demonstrated with early use of noninvasive ventilation (NIV) in selected patients with hematologic malignancies. However, most of these studies did not control the time between onset of ARF to NIV implementation nor accounted for the etiology of ARF or the presence of associated organ dysfunction at the time of NIV initiation. Moreover, the benefits demonstrated with NIV in these patients were derived from studies with high mortality rates of intubated patients. Additional studies are therefore warranted to determine the appropriate patients with hematologic malignancy and ARF who may benefit from prophylactic or curative NIV.
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Affiliation(s)
- Rakesh Vadde
- 1 Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Stephen M Pastores
- 2 Department of Anesthesiology and Critical Care Medicine, Memorial Sloan Kettering Cancer Center, New York, NY, USA
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26
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Torres VBL, Soares M. Patients with hematological malignancies admitted to intensive care units: new challenges for the intensivist. Rev Bras Ter Intensiva 2016; 27:193-5. [PMID: 26465241 PMCID: PMC4592109 DOI: 10.5935/0103-507x.20150040] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Affiliation(s)
| | - Marcio Soares
- Programa de Pós-Graduação em Clínica Médica, Universidade Federal do Rio de Janeiro, Rio de Janeiro, RJ, BR
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27
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Fujiwara Y, Yamaguchi H, Kobayashi K, Marumo A, Omori I, Yamanaka S, Yui S, Fukunaga K, Ryotokuji T, Hirakawa T, Okabe M, Wakita S, Tamai H, Okamoto M, Nakayama K, Takeda S, Inokuchi K. The Therapeutic Outcomes of Mechanical Ventilation in Hematological Malignancy Patients with Respiratory Failure. Intern Med 2016; 55:1537-45. [PMID: 27301502 DOI: 10.2169/internalmedicine.55.5822] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/06/2022] Open
Abstract
Objective In hematological malignancy patients, the complication of acute respiratory failure often reaches a degree of severity that necessitates mechanical ventilation. The objective of the present study was to investigate the therapeutic outcomes of mechanical ventilation in hematological malignancy patients with respiratory failure and to analyze the factors that are associated with successful treatment in order to identify the issues that should be addressed in the future. Methods The present study was a retrospective analysis of 71 hematological malignancy patients with non-cardiogenic acute respiratory failure who were treated with mechanical ventilation at Nippon Medical School Hospital between 2003 and 2014. Results Twenty-six patients (36.6%) were treated with mechanical ventilation in an intensive care unit (ICU). Non-invasive positive pressure ventilation (NPPV) was applied in 29 cases (40.8%). The rate of successful mechanical ventilation treatment with NPPV alone was 13.8%. The rate of endotracheal extubation was 17.7%. A univariate analysis revealed that the following factors were associated with the successful extubation of patients who received invasive mechanical ventilation: respiratory management in an ICU (p=0.012); remission of the hematological disease (p=0.011); female gender (p=0.048); low levels of accompanying non-respiratory organ failure (p=0.041); and the non-use of extracorporeal circulation (p=0.005). A subsequent multivariate analysis revealed that respiratory management in an ICU was the only variable associated with successful extubation (p=0.030). Conclusion The outcomes of hematological malignancy patients who receive mechanical ventilation treatment for respiratory failure are very poor. Respiratory management in an ICU environment may be useful in improving the therapeutic outcomes of such patients.
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28
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Lemiale V, Resche-Rigon M, Mokart D, Pène F, Rabbat A, Kouatchet A, Vincent F, Bruneel F, Nyunga M, Lebert C, Perez P, Meert AP, Benoit D, Chevret S, Azoulay E. Acute respiratory failure in patients with hematological malignancies: outcomes according to initial ventilation strategy. A groupe de recherche respiratoire en réanimation onco-hématologique (Grrr-OH) study. Ann Intensive Care 2015; 5:28. [PMID: 26429355 PMCID: PMC4883632 DOI: 10.1186/s13613-015-0070-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 09/14/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND In patients with hematological malignancies and acute respiratory failure (ARF), noninvasive ventilation was associated with a decreased mortality in older studies. However, mortality of intubated patients decreased in the last years. In this study, we assess outcomes in those patients according to the initial ventilation strategy. METHODS We performed a post hoc analysis of a prospective multicentre study of critically ill hematology patients, in 17 intensive care units in France and Belgium. Patients with hematological malignancies admitted for ARF in 2010 and 2011 and who were not intubated at admission were included in the study. A propensity score-based approach was used to assess the impact of NIV compared to oxygen only on hospital mortality. RESULTS Among 1011 patients admitted to ICU during the study period, 380 met inclusion criteria. Underlying diseases included lymphoid (n = 162, 42.6 %) or myeloid (n = 141, 37.1 %) diseases. ARF etiologies were pulmonary infections (n = 161, 43 %), malignant infiltration (n = 65, 17 %) or cardiac pulmonary edema (n = 40, 10 %). Mechanical ventilation was ultimately needed in 94 (24.7 %) patients, within 3 [2-5] days of ICU admission. Hospital mortality was 32 % (123 deaths). At ICU admission, 142 patients received first-line noninvasive ventilation (NIV), whereas 238 received oxygen only. Fifty-five patients in each group (NIV or oxygen only) were matched according the propensity score. NIV was not associated with decreased hospital mortality [OR 1.5 (0.62-3.65)]. CONCLUSIONS In hematology patients with acute respiratory failure, initial treatment with NIV did not improve survival compared to oxygen only. CLINICAL TRIAL gov number NCT 01172132.
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Affiliation(s)
- Virginie Lemiale
- AP-HP, Hôpital Saint-Louis, Medical ICU, 1 avenue Claude Vellefaux, 75010, Paris, France.
| | | | | | | | - Antoine Rabbat
- Respiratory Unit, Cochin Teaching Hospital, Paris, France.
| | | | | | | | | | | | | | | | | | - Sylvie Chevret
- Biostatistics Department, Saint Louis Teaching Hospital, Paris, France.
| | - Elie Azoulay
- AP-HP, Hôpital Saint-Louis, Medical ICU, 1 avenue Claude Vellefaux, 75010, Paris, France.
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Barreto LM, Torga JP, Coelho SV, Nobre V. Main characteristics observed in patients with hematologic diseases admitted to an intensive care unit of a Brazilian university hospital. Rev Bras Ter Intensiva 2015; 27:212-9. [PMID: 26331970 PMCID: PMC4592114 DOI: 10.5935/0103-507x.20150034] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2015] [Accepted: 06/06/2015] [Indexed: 11/20/2022] Open
Abstract
Objective To evaluate the clinical characteristics of patients with hematological disease
admitted to the intensive care unit and the use of noninvasive mechanical
ventilation in a subgroup with respiratory dysfunction. Methods A retrospective observational study from September 2011 to January 2014. Results Overall, 157 patients were included. The mean age was 45.13 (± 17.2) years
and 46.5% of the patients were female. Sixty-seven (48.4%) patients had sepsis,
and 90 (57.3%) patients required vasoactive vasopressors. The main cause for
admission to the intensive care unit was acute respiratory failure (94.3%). Among
the 157 studied patients, 47 (29.9%) were intubated within the first 24 hours, and
38 (24.2%) underwent noninvasive mechanical ventilation. Among the 38 patients who
initially received noninvasive mechanical ventilation, 26 (68.4%) were
subsequently intubated, and 12 (31.6%) responded to this mode of ventilation.
Patients who failed to respond to noninvasive mechanical ventilation had higher
intensive care unit mortality (66.7% versus 16.7%; p = 0.004) and a longer stay in
the intensive care unit (9.6 days versus 4.6 days, p = 0.02) compared with the
successful cases. Baseline severity scores (SOFA and SAPS 3) and the total
leukocyte count were not significantly different between these two subgroups. In a
multivariate logistic regression model including the 157 patients, intubation at
any time during the stay in the intensive care unit and SAPS 3 were independently
associated with intensive care unit mortality, while using noninvasive mechanical
ventilation was not. Conclusion In this retrospective study with severely ill hematologic patients, those who
underwent noninvasive mechanical ventilation at admission and failed to respond to
it presented elevated intensive care unit mortality. However, only intubation
during the intensive care unit stay was independently associated with a poor
outcome. Further studies are needed to define predictors of noninvasive mechanical
ventilation failure.
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Affiliation(s)
| | - Júlia Pereira Torga
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, BR
| | - Samuel Viana Coelho
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, BR
| | - Vandack Nobre
- Hospital das Clínicas, Universidade Federal de Minas Gerais, Belo Horizonte, MG, BR
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Scaravilli V, Grasselli G, Castagna L, Zanella A, Isgrò S, Lucchini A, Patroniti N, Bellani G, Pesenti A. Prone positioning improves oxygenation in spontaneously breathing nonintubated patients with hypoxemic acute respiratory failure: A retrospective study. J Crit Care 2015; 30:1390-4. [PMID: 26271685 DOI: 10.1016/j.jcrc.2015.07.008] [Citation(s) in RCA: 168] [Impact Index Per Article: 18.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2015] [Revised: 06/17/2015] [Accepted: 07/13/2015] [Indexed: 12/16/2022]
Abstract
PURPOSE Prone positioning (PP) improves oxygenation and outcome of patients with acute respiratory distress syndrome undergoing invasive ventilation. We evaluated feasibility and efficacy of PP in awake, non-intubated, spontaneously breathing patients with hypoxemic acute respiratory failure (ARF). MATERIAL AND METHODS We retrospectively studied non-intubated subjects with hypoxemic ARF treated with PP from January 2009 to December 2014. Data were extracted from medical records. Arterial blood gas analyses, respiratory rate, and hemodynamics were retrieved 1 to 2 hours before pronation (step PRE), during PP (step PRONE), and 6 to 8 hours after resupination (step POST). RESULTS Fifteen non-intubated ARF patients underwent 43 PP procedures. Nine subjects were immunocompromised. Twelve subjects were discharged from hospital, while 3 died. Only 2 maneuvers were interrupted, owing to patient intolerance. No complications were documented. PP did not alter respiratory rate or hemodynamics. In the subset of procedures during which the same positive end expiratory pressure and Fio2 were utilized throughout the pronation cycle (n=18), PP improved oxygenation (Pao2/Fio2 124±50 mmHg, 187±72 mmHg, and 140±61 mmHg, during PRE, PRONE, and POST steps, respectively, P<.001), while pH and Paco2 were unchanged. CONCLUSIONS PP was feasible and improved oxygenation in non-intubated, spontaneously breathing patients with ARF.
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Affiliation(s)
- Vittorio Scaravilli
- Dipartimento di Scienze della Salute, Università degli Studi di Milano Bicocca, Via Cadore 48, 20900, Monza, MB, Italy.
| | - Giacomo Grasselli
- Dipartimento di Emergenza e Urgenza, Ospedale San Gerardo, Via Pergolesi 33, 20900, Monza, MB, Italy
| | - Luigi Castagna
- Dipartimento di Scienze della Salute, Università degli Studi di Milano Bicocca, Via Cadore 48, 20900, Monza, MB, Italy
| | - Alberto Zanella
- Dipartimento di Scienze della Salute, Università degli Studi di Milano Bicocca, Via Cadore 48, 20900, Monza, MB, Italy
| | - Stefano Isgrò
- Dipartimento di Emergenza e Urgenza, Ospedale San Gerardo, Via Pergolesi 33, 20900, Monza, MB, Italy
| | - Alberto Lucchini
- Dipartimento di Emergenza e Urgenza, Ospedale San Gerardo, Via Pergolesi 33, 20900, Monza, MB, Italy
| | - Nicolò Patroniti
- Dipartimento di Scienze della Salute, Università degli Studi di Milano Bicocca, Via Cadore 48, 20900, Monza, MB, Italy; Dipartimento di Emergenza e Urgenza, Ospedale San Gerardo, Via Pergolesi 33, 20900, Monza, MB, Italy
| | - Giacomo Bellani
- Dipartimento di Scienze della Salute, Università degli Studi di Milano Bicocca, Via Cadore 48, 20900, Monza, MB, Italy; Dipartimento di Emergenza e Urgenza, Ospedale San Gerardo, Via Pergolesi 33, 20900, Monza, MB, Italy
| | - Antonio Pesenti
- Dipartimento di Scienze della Salute, Università degli Studi di Milano Bicocca, Via Cadore 48, 20900, Monza, MB, Italy; Dipartimento di Emergenza e Urgenza, Ospedale San Gerardo, Via Pergolesi 33, 20900, Monza, MB, Italy
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Lee HY, Rhee CK, Lee JW. Feasibility of high-flow nasal cannula oxygen therapy for acute respiratory failure in patients with hematologic malignancies: A retrospective single-center study. J Crit Care 2015; 30:773-7. [PMID: 25840520 DOI: 10.1016/j.jcrc.2015.03.014] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2014] [Revised: 03/11/2015] [Accepted: 03/11/2015] [Indexed: 11/28/2022]
Abstract
PURPOSE This study investigated the feasibility of high-flow nasal cannula (HFNC) oxygen therapy for acute respiratory failure in adult patients with hematologic malignancies. MATERIALS AND METHODS We identified 45 acute respiratory failure patients with hematologic malignancies who received HFNC therapy between March 2012 and June 2014 at Seoul St Mary's Hospital. Their medical records were reviewed retrospectively to identify useful prognostic factors for successful treatment. RESULTS Of the 45 patients, 15 (33.3%) successfully recovered, and 30 were changed to invasive ventilation due to failed HFNC treatment. The etiologies of acute respiratory failure were bacterial pneumonia (57.8%), Pneumocystis jirovecii pneumonia (17.8%), pulmonary edema (8.9%), and bronchiolitis obliterans organizing pneumonia (8.9%). The overall mortality rate was 62.2%. The HFNC treatment success rate was significantly different between the survivors and nonsurvivors. To evaluate risk factors for HFNC treatment failure, differences between the HFNC treatment success and failure groups were compared. There were no significant differences in the severity of underlying medical conditions. The percentage of bacterial pneumonia was significantly higher in the HFNC treatment failure group compared with the success group (73.3% vs 26.7%; P = .004). CONCLUSIONS High-flow nasal cannula offers an interesting alternative to invasive ventilation in acute respiratory failure patients with hematologic malignancies. However, attention must be paid to the appropriate choice of HFNC settings such as oxygen flow.
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Affiliation(s)
- Hwa Young Lee
- Division of Respiratory, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, Seoul St Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Chin Kook Rhee
- Division of Respiratory, Allergy and Critical Care Medicine, Department of Internal Medicine, College of Medicine, Seoul St Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea.
| | - Jong Wook Lee
- Division of Hematology, Catholic Blood and Marrow Transplantation Center, Seoul St Mary's Hospital, The Catholic University of Korea, Seoul, Republic of Korea.
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Azevedo LCP, Caruso P, Silva UVA, Torelly AP, Silva E, Rezende E, Netto JJ, Piras C, Lobo SMA, Knibel MF, Teles JM, Lima RA, Ferreira BS, Friedman G, Rea-Neto A, Dal-Pizzol F, Bozza FA, Salluh JIF, Soares M. Outcomes for patients with cancer admitted to the ICU requiring ventilatory support: results from a prospective multicenter study. Chest 2014; 146:257-266. [PMID: 24480886 DOI: 10.1378/chest.13-1870] [Citation(s) in RCA: 110] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
BACKGROUND This study was undertaken to evaluate the clinical characteristics and outcomes of patients with cancer requiring nonpalliative ventilatory support. METHODS This was a secondary analysis of a prospective cohort study conducted in 28 Brazilian ICUs evaluating adult patients with cancer requiring invasive mechanical ventilation (MV) or noninvasive ventilation (NIV) during the first 48 h of their ICU stay. We used logistic regression to identify the variables associated with hospital mortality. RESULTS Of 717 patients, 263 (37%) (solid tumors = 227; hematologic malignancies = 36) received ventilatory support. NIV was initially used in 85 patients (32%), and 178 (68%) received MV. Additionally, NIV followed by MV occurred in 45 patients (53%). Hospital mortality rates were 67% in all patients, 40% in patients receiving NIV only, 69% when NIV was followed by MV, and 73% in patients receiving MV only (P < .001). Adjusting for the type of admission, newly diagnosed malignancy (OR, 3.59; 95% CI, 1.28-10.10), recurrent or progressive malignancy (OR, 3.67; 95% CI, 1.25-10.81), tumoral airway involvement (OR, 4.04; 95% CI, 1.30-12.56), performance status (PS) 2 to 4 (OR, 2.39; 95% CI, 1.24-4.59), NIV followed by MV (OR, 3.00; 95% CI, 1.09-8.18), MV as initial ventilatory strategy (OR, 3.53; 95% CI, 1.45-8.60), and Sequential Organ Failure Assessment score (each point except the respiratory domain) (OR, 1.15; 95% CI, 1.03-1.29) were associated with hospital mortality. Hospital survival in patients with good PS and nonprogressive malignancy and without tumoral airway involvement was 53%. Conversely, patients with poor functional capacity and cancer progression had unfavorable outcomes. CONCLUSIONS Patients with cancer with good PS and nonprogressive disease requiring ventilatory support should receive full intensive care, because one-half of these patients survive. On the other hand, provision of palliative care should be considered the main goal for patients with poor PS and progressive underlying malignancy.
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Affiliation(s)
- Luciano C P Azevedo
- ICU, Hospital Sirio-Libanes, Criciúma, Brazil; Programa de Pós-Graduação em Oncologia, Criciúma, Brazil
| | | | - Ulysses V A Silva
- ICU, Universidade Federal do Rio Grande do Sul, Porto Alegre, Criciúma, Brazil
| | - André P Torelly
- ICU, Santa Casa de Misericórdia de Porto Alegre, Criciúma, Brazil
| | - Eliézer Silva
- ICU, Hospital Israelita Albert Einstein, Criciúma, Brazil; ICU, Fundação Pio XII, Hospital do Câncer de Barretos, Barretos, Criciúma, Brazil
| | - Ederlon Rezende
- ICU, Hospital do Servidor Público Estadual, São Paulo, Criciúma, Brazil
| | - José J Netto
- ICU, Instituto Nacional de Câncer, Hospital do Câncer II, Criciúma, Brazil
| | - Claudio Piras
- ICU, Vitória Apart Hospital, Vitória, Criciúma, Brazil
| | - Suzana M A Lobo
- Division of Critical Care Medicine, Department of Internal Medicine, Medical School and Hospital de Base, São José do Rio Preto, Criciúma, Brazil
| | | | - José M Teles
- ICU, Hospital Português, Salvador, Criciúma, Brazil
| | | | | | - Gilberto Friedman
- ICU, Universidade Federal do Rio Grande do Sul, Porto Alegre, Criciúma, Brazil
| | - Alvaro Rea-Neto
- ICU, Hospital de Clínicas da Universidade Federal do Paraná, Curitiba, Criciúma, Brazil
| | - Felipe Dal-Pizzol
- Laboratório de Fisiopatologia Experimental, Programa de Pós-Graduação Ciências da Saúde, Unidade Acadêmica de Ciências da Saúde, Universidade do Extremo Sul Catarinense, Criciúma, Brazil
| | - Fernando A Bozza
- D'Or Institute for Research and Education, Rio de Janeiro, Criciúma, Brazil
| | | | - Márcio Soares
- Programa de Pós-Graduação em Oncologia, Criciúma, Brazil; D'Or Institute for Research and Education, Rio de Janeiro, Criciúma, Brazil
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Kostakou E, Rovina N, Kyriakopoulou M, Koulouris NG, Koutsoukou A. Critically ill cancer patient in intensive care unit: Issues that arise. J Crit Care 2014; 29:817-22. [DOI: 10.1016/j.jcrc.2014.04.007] [Citation(s) in RCA: 46] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2013] [Revised: 03/01/2014] [Accepted: 04/16/2014] [Indexed: 12/15/2022]
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Lemiale V, Resche-Rigon M, Azoulay E. Early non-invasive ventilation for acute respiratory failure in immunocompromised patients (IVNIctus): study protocol for a multicenter randomized controlled trial. Trials 2014; 15:372. [PMID: 25257210 PMCID: PMC4190291 DOI: 10.1186/1745-6215-15-372] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2014] [Accepted: 09/04/2014] [Indexed: 01/08/2023] Open
Abstract
Background Acute respiratory failure (ARF) remains the leading reason for intensive care unit (ICU) admission of immunocompromised patients. In the most severe cases, high-flow oxygen therapy may fail to ensure adequate gas exchange, and mechanical ventilation (MV) must be used. This scenario is associated with high mortality rates of 40 to 60%, depending on the cause of ARF and type of immune deficiency. The use of non-invasive ventilation (NIV) in this situation has been criticized as potentially delaying the initiation of optimal treatment. In contrast, early NIV used prophylactically in patients with ARF who do not meet the criteria for invasive MV (IMV) may obviate the need for IMV, thereby decreasing the morbidity and mortality rates. We aim to demonstrate that a management strategy including early NIV decreases 28-day mortality rates compared to oxygen therapy alone in immunocompromised patients with ARF. Methods/Design This is a multicenter parallel-group randomized controlled trial comparing early NIV to oxygen therapy alone in immunocompromised patients with ARF. All immunocompromised adult patients admitted to admission for ARF are eligible for randomization. Patient with ARF onset more than 72 hours earlier or ARF related to cardiogenic pulmonary edema or hypercapnia, or with a need for immediate endotracheal intubation or other organ failure are not eligible. After inclusion patient are allocated to receive early NIV (intervention arm) or oxygen therapy only (control arm). We plan to enroll 374 patients in 29 ICUs. An interim analysis is planned after the inclusion of 187 patients. The main objective is to demonstrate early NIV increases survival as compared to oxygen therapy alone. Other outcomes include the need of IMV, organ failure evolution, nosocomial infections rate, 6 months survival. Discussion This study is expected to demonstrate an improved 28-day survival in immunocompromised patients managed with early NIV. Trial registration Registration number: Clinicaltrials.gov NCT01915719. Registered on 26 July 2013. Electronic supplementary material The online version of this article (doi:10.1186/1745-6215-15-372) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Virginie Lemiale
- Medical ICU, Assistance Publique Hopitaux de Paris, St Louis Hospital, 1 avenue Claude Vellefaux, 75010 Paris, France.
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Abstract
After the institution of positive-pressure ventilation, the use of noninvasive ventilation (NIV) through an interface substantially increased. The first technique was continuous positive airway pressure; but, after the introduction of pressure support ventilation at the end of the 20th century, this became the main modality. Both techniques, and some others that have been recently introduced and which integrate some technological innovations, have extensively demonstrated a faster improvement of acute respiratory failure in different patient populations, avoiding endotracheal intubation and facilitating the release of conventional invasive mechanical ventilation. In acute settings, NIV is currently the first-line treatment for moderate-to-severe chronic obstructive pulmonary disease exacerbation as well as for acute cardiogenic pulmonary edema and should be considered in immunocompromised patients with acute respiratory insufficiency, in difficult weaning, and in the prevention of postextubation failure. Alternatively, it can also be used in the postoperative period and in cases of pneumonia and asthma or as a palliative treatment. NIV is currently used in a wide range of acute settings, such as critical care and emergency departments, hospital wards, palliative or pediatric units, and in pre-hospital care. It is also used as a home care therapy in patients with chronic pulmonary or sleep disorders. The appropriate selection of patients and the adaptation to the technique are the keys to success. This review essentially analyzes the evidence of benefits of NIV in different populations with acute respiratory failure and describes the main modalities, new devices, and some practical aspects of the use of this technique.
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Affiliation(s)
- Arantxa Mas
- Critical Care Department, Consorci Sanitari Integral (CSI), Hospital Sant Joan Despí Moisès Broggi and Hospital General de l’Hospitalet, University of Barcelona, Barcelona, Spain
| | - Josep Masip
- Critical Care Department, Consorci Sanitari Integral (CSI), Hospital Sant Joan Despí Moisès Broggi and Hospital General de l’Hospitalet, University of Barcelona, Barcelona, Spain
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Cancer patients with ARDS: survival gains and unanswered questions. Intensive Care Med 2014; 40:1168-70. [PMID: 25023529 DOI: 10.1007/s00134-014-3394-5] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2014] [Accepted: 07/01/2014] [Indexed: 12/12/2022]
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[Intensive care management of hematological and oncological patients]. Internist (Berl) 2014; 54:1080-6. [PMID: 23963277 DOI: 10.1007/s00108-013-3259-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Management of critically ill cancer patients warrants stringent admission criteria and clear concepts concerning duration and limits of intensive care. Recent developments in mechanical ventilation and sepsis therapy can easily be used to improve the outcome of critically ill cancer patients. The incidence and overall prognosis of cancer is constantly growing and, thus, the number of critically ill cancer patients is increasing. Furthermore, novel oncology drugs-in particular immune modulators-produce unexpected and substantial side effects. Therefore, the development of an interdisciplinary algorithm by oncologists and intensivists remains an important and dynamic challenge.
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Johnson CS, Frei CR, Metersky ML, Anzueto AR, Mortensen EM. Non-invasive mechanical ventilation and mortality in elderly immunocompromised patients hospitalized with pneumonia: a retrospective cohort study. BMC Pulm Med 2014; 14:7. [PMID: 24468062 PMCID: PMC3914374 DOI: 10.1186/1471-2466-14-7] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2013] [Accepted: 01/22/2014] [Indexed: 11/30/2022] Open
Abstract
Background Mortality after pneumonia in immunocompromised patients is higher than for immunocompetent patients. The use of non-invasive mechanical ventilation for patients with severe pneumonia may provide beneficial outcomes while circumventing potential complications associated with invasive mechanical ventilation. The aim of our study was to determine if the use of non-invasive mechanical ventilation in elderly immunocompromised patients with pneumonia is associated with higher all-cause mortality. Methods In this retrospective cohort study, data were obtained from the Department of Veterans Affairs administrative databases. We included veterans age ≥65 years who were immunocompromised and hospitalized due to pneumonia. Multilevel logistic regression analysis was used to determine the relationship between the use of invasive versus non-invasive mechanical ventilation and 30-day and 90-day mortality. Results Of 1,946 patients in our cohort, 717 received non-invasive mechanical ventilation and 1,229 received invasive mechanical ventilation. There was no significant association between all-cause 30-day mortality and non-invasive versus invasive mechanical ventilation in our adjusted model (odds ratio (OR) 0.85, 95% confidence interval (CI) 0.66-1.10). However, those patients who received non-invasive mechanical ventilation had decreased 90-day mortality (OR 0.66, 95% CI 0.52-0.84). Additionally, receipt of guideline-concordant antibiotics in our immunocompromised cohort was significantly associated with decreased odds of 30-day mortality (OR 0.31, 95% CI 0.24-0.39) and 90-day mortality (OR 0.41, 95% CI 0.31-0.53). Conclusions Our findings suggest that physicians should consider the use of non-invasive mechanical ventilation, when appropriate, for elderly immunocompromised patients hospitalized with pneumonia.
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Affiliation(s)
| | | | | | | | - Eric M Mortensen
- University of Texas Southwestern Medical Center, 5323 Harry Hines Blvd, Dallas, TX 75390, USA.
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Wigmore TJ, Farquhar-Smith P, Lawson A. Intensive care for the cancer patient - unique clinical and ethical challenges and outcome prediction in the critically ill cancer patient. Best Pract Res Clin Anaesthesiol 2013; 27:527-43. [PMID: 24267556 DOI: 10.1016/j.bpa.2013.10.002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2013] [Accepted: 10/04/2013] [Indexed: 10/26/2022]
Abstract
With the rising number of cancer cases and increasing survival times, cancer patients with critical illness are increasingly presenting to the intensive care unit. This article considers the unique challenges they pose in terms of oncological-specific disease processes and treatment and reviews current trends in outcome prediction. We also consider the ethical standpoints surrounding the treatment of patients for whom there may be no cure and their subsequent transition to palliative care, should it become necessary.
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Türkog˘lu M, Erdem GU, Suyanı E, Sancar ME, Yalçın MM, Aygencel G, Akı Z, Sucak G. Acute respiratory distress syndrome in patients with hematological malignancies. Hematology 2013; 18:123-130. [DOI: 10.1179/1607845412y.0000000038] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Affiliation(s)
- Melda Türkog˘lu
- Department of Medical Intensive Care UnitSchool of Medicine, Gazi University Besevler, Ankara, Turkey
| | - Gökmen Umut Erdem
- Department of Medical Intensive Care UnitSchool of Medicine, Gazi University Besevler, Ankara, Turkey
| | - Elif Suyanı
- Department of HematologySchool of Medicine, Gaza University Besevler, Ankara, Turkey
| | - Muhammed Erkam Sancar
- Department of Medical Intensive Care UnitSchool of Medicine, Gazi University Besevler, Ankara, Turkey
| | | | - Gülbin Aygencel
- Department of Medical Intensive Care UnitSchool of Medicine, Gazi University Besevler, Ankara, Turkey
| | - Zeynep Akı
- Department of HematologySchool of Medicine, Gaza University Besevler, Ankara, Turkey
| | - Gülsan Sucak
- Department of HematologySchool of Medicine, Gaza University Besevler, Ankara, Turkey
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Bernal T, Albaiceta GM. [Noninvasive ventilation in the critical hematological patient: friend, enemy or both?]. Med Intensiva 2013; 37:441-2. [PMID: 23582145 DOI: 10.1016/j.medin.2013.02.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2013] [Accepted: 02/18/2013] [Indexed: 11/25/2022]
Affiliation(s)
- T Bernal
- Servicio de Hematología y Hemoterapia, Hospital Universitario Central de Asturias, Oviedo, España
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Namendys-Silva SA, González-Herrera MO, García-Guillén FJ, Texcocano-Becerra J, Herrera-Gómez A. Outcome of critically ill patients with hematological malignancies. Ann Hematol 2013; 92:699-705. [PMID: 23328791 DOI: 10.1007/s00277-013-1675-7] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2012] [Accepted: 01/04/2013] [Indexed: 01/23/2023]
Abstract
The prognosis for patients with hematological malignancies (HMs) admitted to the intensive care unit (ICU) is poor. The objective of this study was to evaluate the clinical characteristics and hospital outcomes of critically ill patients with HMs admitted to an oncological ICU. This is a prospective, observational cohort study. A total of 102 patients with HMs admitted to ICU from January 2008 to April 2011 were included. Univariate and multivariate logistic regressions were used to identify factors associated with hospital mortality. During the study period, 3,776 patients with HM were admitted to the Department of Hematology of the Instituto Nacional de Cancerología located in Mexico City, Mexico. After being evaluated by the intensivist, 102 (2.68 %) patients were admitted to the ICU. The ICU mortality rates for patients who had two or less organ system failures and for those with three or more organ system dysfunctions were 20 % (5/25) and 70.1 % (54/77), respectively (P < 0.0001). A multivariate analysis identified independent prognostic factors of in-hospital death as neutropenia at the time of ICU admission (odds ratio (OR), 4.24; 95 % confidence interval (CI), 1.36-13.19, P = 0.012), the need for vasopressors (OR, 4.49; 95 % CI, 1.07-18.79, P = 0.040), need for invasive mechanical ventilation (OR, 4.49; 95 % CI, 1.07-18.79, P = 0.040), and serum creatinine >106 μmol/L (OR, 3.21; 95 % CI, 1.05-9.85, P = 0.041). The ICU and hospital mortality rates were 46.1 and 57.8 %, respectively. The independent prognostic factors of in-hospital death were the need for invasive mechanical ventilation, the need for vasopressors, serum creatinine >106 μmol/L, and neutropenia at the time of ICU admission.
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Affiliation(s)
- Silvio A Namendys-Silva
- Department of Critical Care Medicine, Instituto Nacional de Cancerología, México. Av. San Fernando No. 22, Col. Sección XVI, Delegación Tlalpan, Mexico City, Mexico.
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Non-invasive mechanical ventilation in hematology patients with hypoxemic acute respiratory failure: a false belief? Bone Marrow Transplant 2012; 47:469-72. [PMID: 22472967 DOI: 10.1038/bmt.2011.232] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
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Molina R, Bernal T, Borges M, Zaragoza R, Bonastre J, Granada RM, Rodriguez-Borregán JC, Núñez K, Seijas I, Ayestaran I, Albaiceta GM. Ventilatory support in critically ill hematology patients with respiratory failure. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2012; 16:R133. [PMID: 22827955 PMCID: PMC3580718 DOI: 10.1186/cc11438] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/13/2012] [Accepted: 07/24/2012] [Indexed: 11/12/2022]
Abstract
Introduction Hematology patients admitted to the ICU frequently experience respiratory failure and require mechanical ventilation. Noninvasive mechanical ventilation (NIMV) may decrease the risk of intubation, but NIMV failure poses its own risks. Methods To establish the impact of ventilatory management and NIMV failure on outcome, data from a prospective, multicenter, observational study were analyzed. All hematology patients admitted to one of the 34 participating ICUs in a 17-month period were followed up. Data on demographics, diagnosis, severity, organ failure, and supportive therapies were recorded. A logistic regression analysis was done to evaluate the risk factors associated with death and NIVM failure. Results Of 450 patients, 300 required ventilatory support. A diagnosis of congestive heart failure and the initial use of NIMV significantly improved survival, whereas APACHE II score, allogeneic transplantation, and NIMV failure increased the risk of death. The risk factors associated with NIMV success were age, congestive heart failure, and bacteremia. Patients with NIMV failure experienced a more severe respiratory impairment than did those electively intubated. Conclusions NIMV improves the outcome of hematology patients with respiratory insufficiency, but NIMV failure may have the opposite effect. A careful selection of patients with rapidly reversible causes of respiratory failure may increase NIMV success.
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Noninvasive ventilation for acute respiratory failure in patients with hematologic malignancies: what an Italian 5-year multicenter survey tells us. Crit Care Med 2011; 39:2358-9. [PMID: 21926491 DOI: 10.1097/ccm.0b013e3182266069] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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Non-invasive ventilation in patients with hematological malignancies: the saga continues, but where is the finale? Intensive Care Med 2010; 36:1633-1635. [PMID: 20607515 DOI: 10.1007/s00134-010-1949-7] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2010] [Accepted: 06/18/2010] [Indexed: 10/19/2022]
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Soares M, Silva UVA, Teles JMM, Silva E, Caruso P, Lobo SMA, Dal Pizzol F, Azevedo LP, de Carvalho FB, Salluh JIF. Validation of four prognostic scores in patients with cancer admitted to Brazilian intensive care units: results from a prospective multicenter study. Intensive Care Med 2010; 36:1188-95. [PMID: 20221751 DOI: 10.1007/s00134-010-1807-7] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/25/2009] [Accepted: 02/17/2010] [Indexed: 12/15/2022]
Abstract
OBJECTIVE The aim of the present study was to validate the Simplified Acute Physiology Score II (SAPS II) and 3 (SAPS 3), the Mortality Probability Models III (MPM(0)-III), and the Cancer Mortality Model (CMM) in patients with cancer admitted to several intensive care units (ICU). DESIGN Prospective multicenter cohort study. SETTING Twenty-eight ICUs in Brazil. PATIENTS Seven hundred and seventeen consecutive patients (solid tumors 93%; hematological malignancies 7%) included over a 2-month period. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Discrimination was assessed by area under receiver operating characteristic (AROC) curves and calibration by Hosmer-Lemeshow goodness-of-fit test. The main reasons for ICU admission were postoperative care (57%), sepsis (15%) and respiratory failure (10%). The ICU and hospital mortality rates were 21 and 30%, respectively. When all 717 patients were evaluated, discrimination was superior for both SAPS II (AROC = 0.84) and SAPS 3 (AROC = 0.84) scores compared to CMM (AROC = 0.79) and MPM(0)-III (AROC = 0.71) scores (P < 0.05 in all comparisons). Calibration was better using CMM and the customized equation of SAPS 3 score for South American countries (CSA). MPM(0)-III, SAPS II and standard SAPS 3 scores underestimated mortality (standardized mortality ratio, SMR > 1), while CMM tended to overestimation (SMR = 0.48). However, using the SAPS 3 for CSA resulted in more precise estimations of the probability of death [SMR = 1.02 (95% confidence interval = 0.87-1.19)]. Similar results were observed when scheduled surgical patients were excluded. CONCLUSIONS In this multicenter study, the customized equation of SAPS 3 score for CSA was found to be accurate in predicting outcomes in cancer patients requiring ICU admission.
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Affiliation(s)
- Márcio Soares
- ICU, Hospital de Câncer-I, Instituto Nacional de Câncer, Centro de Tratamento Intensivo, 10 degrees Andar; Pça. Cruz Vermelha, 23, Rio de Janeiro, RJ, CEP 20230-130, Brazil.
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Soares M, Salluh JI, Azoulay É. Noninvasive ventilation in patients with malignancies and hypoxemic acute respiratory failure: A still pending question. J Crit Care 2010; 25:37-8. [DOI: 10.1016/j.jcrc.2009.04.001] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/18/2009] [Accepted: 04/12/2009] [Indexed: 10/20/2022]
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