Incidence and prognostic value of respiratory events in acute leukemia

Critically ill adult patients with acute leukemia: a systematic review and meta-analysis

BACKGROUND

To describe the use of life-sustaining therapies and mortality in patients with acute leukemia admitted to the intensive care unit (ICU).

METHODS

The PubMed database was searched from January 1st, 2000 to July 1st, 2023. All studies including adult critically ill patients with acute leukemia were included. Two reviewers independently selected the studies, assessed bias using the Newcastle-Ottawa scale for cohort studies, and performed data extraction from full-text reading. We performed a proportional meta-analysis using a random effects model. The primary outcome was all-cause ICU mortality. Secondary outcomes included reasons for ICU admission, use of organ support therapies (mechanical ventilation, vasopressors and renal replacement therapy), hospital, day-90 and one-year mortality rates.

RESULTS

Of the 1,331 studies screened, 136 (24,861 patients) met the inclusion criteria and were included in the meta-analysis. Acute myeloid leukemia affected 16,269 (66%) patients, acute lymphoblastic leukemia affected 835 (3%) patients, and the type of leukemia was not specified in 7,757 (31%) patients. Acute respiratory failure (70%) and acute circulatory failure (25%) were the main reasons for ICU admission. Invasive mechanical ventilation, vasopressors and renal replacement therapy, were needed in 65%, 53%, and 23% of the patients, respectively. ICU mortality was available in 51 studies (6,668 patients, of whom 2,956 died throughout their ICU stay), resulting in a metanalytical proportion of 52% (95% CI [47%; 57%]; I2 93%). In a meta-regression, variables that influenced ICU mortality included year of publication, and intubation rate.

CONCLUSION

Acute respiratory failure is the main reason for ICU admission in patients with acute leukemia. Mechanical ventilation is the first life-sustaining therapy to be used, and also a strong predictor of mortality.

TRIAL REGISTRATION

This study's protocol was preregistered on PROSPERO (CRD42023439630).

Acute respiratory failure in adult patients with acute myeloid leukemia

INTRODUCTION

Patients with acute myeloid leukemia (AML) are at high risk of developing life-threatening complications. It is estimated that a quarter of adult patients diagnosed with AML will require admission to the intensive care unit (ICU) at least once during their disease. Acute respiratory failure (ARF) is the main reason for ICU admission and is associated with high mortality rates, depending on the etiology of ARF.

AREAS COVERED

In this population, the high prevalence of severe pulmonary infections highlights the importance of immunosuppression caused by the disease and its treatment. In the early stages of the disease, in addition to pneumonia, which should be systematically sought, leukemia-specific lung involvement (leukostasis, leukemic pulmonary infiltration, and acute lysis pneumopathy) is an important cause of ARF in this population, representing up to 60% of cases. This review aims to help understand the pathophysiology and management of leukemia-specific lung involvement, based on the most contemporary literature.

EXPERT OPINION

The number of AML patients requiring ICU care is expected to increase. AML patients admitted to the ICU for ARF have a high mortality rate, but survivors have encouraging long-term outcomes. Future research will focus on improving risk stratification, cytoreduction, oxygenation strategies, and diagnostic techniques for ARF.

Changes in respiratory infection trends during the COVID-19 pandemic in patients with haematologic malignancy

BACKGROUND

The coronavirus disease 2019 (COVID-19) pandemic has changed respiratory infection patterns globally. However, its impact on community-acquired pneumonia (CAP) in high-risk patients with haematological malignancies (HM) is uncertain. We aimed to examine how community-acquired pneumonia aetiology in patients with haematological malignancies changed during the COVID-19 pandemic.

METHODS

This was a retrospective study that included 524 patients with haematological malignancies hospitalised with community-acquired pneumonia between March 2018 and February 2022. Patients who underwent bronchoscopy within 24 h of admission to identify community-acquired pneumonia aetiology were included. Data on patient characteristics, laboratory findings, and results of bronchioalveolar lavage fluid cultures and polymerase chain reaction tests were analysed and compared to identify changes and in-hospital mortality risk factors.

RESULTS

Patients were divided into the 'pre-COVID-19 era' (44.5%) and 'COVID-19 era' (55.5%) groups. The incidence of viral community-acquired pneumonia significantly decreased in the COVID-19 era, particularly for influenza A, parainfluenza, adenovirus, and rhinovirus (pre-COVID-19 era vs. COVID-19 era: 3.0% vs. 0.3%, P = 0.036; 6.5% vs. 0.7%, P = 0.001; 5.6% vs. 1.4%, P = 0.015; and 9.5% vs. 1.7%, P < 0.001, respectively), whereas that of bacterial, fungal, and unknown community-acquired pneumonia aetiologies remain unchanged. Higher Sequential Organ Failure Assessment scores and lower platelet counts correlated with in-hospital mortality after adjusting for potential confounding factors.

CONCLUSIONS

In the COVID-19 era, the incidence of community-acquired pneumonia with viral aetiologies markedly decreased among patients with haematological malignancies, with no changes in the incidence of bacterial and fungal pneumonia. Further studies are required to evaluate the impact of COVID-19 on the prognosis of patients with haematological malignancies and community-acquired pneumonia.

How I manage acute respiratory failure in patients with hematological malignancies

ABSTRACT

Acute respiratory failure (ARF) is common in patients with hematological malignancies notably those with acute leukemia, myelodysplastic syndrome, or allogeneic stem cell transplantation. ARF is the leading reason for intensive care unit (ICU) admission, with a 35% case fatality rate. Failure to identify the ARF cause is associated with mortality. A prompt, well-designed diagnostic workup is crucial. The investigations are chosen according to pretest diagnostic probabilities, estimated by the DIRECT approach: D stands for delay, or time since diagnosis; I for pattern of immune deficiency; R and T for radiological evaluation; E refers to clinical experience, and C to the clinical picture. Thorough familiarity with rapid diagnostic tests helps to decrease the use of bronchoscopy with bronchoalveolar lavage, which can cause respiratory status deterioration in those patients with hypoxemia. A prompt etiological diagnosis shortens the time on unnecessary empirical treatments, decreasing iatrogenic harm and costs. High-quality collaboration between intensivists and hematologists and all crossdisciplinary health care workers is paramount. All oxygen delivery systems should be considered to minimize invasive mechanical ventilation. Treatment of the malignancy is started or continued in the ICU under the guidance of the hematologists. The goal is to use the ICU as a bridge to recovery, with the patient returning to the hematology ward in sufficiently good clinical condition to receive optimal anticancer treatment.

Azacitidine induced lung injury: report and contemporary discussion on diagnosis and management

Azacitidine, a hypomethylating agent, has caused a paradigm shift in the outcomes of patients with myelodysplastic syndrome (MDS) and acute myeloid leukemia (AML) who are not eligible for stem cell transplantation, particularly in combination with BCL2 and IDH inhibitors. Azacitidine and Azacitidine-based combinations have been widely considered a safe low-intensity therapy when compared to traditional conventional treatments. The development of lung toxicity from azacitidine is not a well-characterized adverse event. However, if it happens, it can be fatal, especially if not recognized and treated promptly. In this review, we aim to familiarize the reader with the presentation of azacitidine-induced lung injury, provide our suggested approach to management based on our experience and the current understanding of its mechanism, and review the literature of 20 case reports available on this topic.

Clinical Utility of Stepwise Bronchoalveolar Lavage Fluid Analysis in Diagnosing and Managing Lung Infiltrates in Leukemia/Lymphoma Patients With Febrile Neutropenia

PURPOSE

Febrile neutropenia (FN) is a serious complication in hematologic malignancies, and lung infiltrates (LIs) remain a significant concern. An accurate microbiological diagnosis is crucial but difficult to establish. To address this, we analyzed the utility of a standardized method for performing bronchoalveolar lavage (BAL) along with a two-step strategy for the analysis of BAL fluid.

PATIENTS AND METHODS

This prospective observational study was conducted at a tertiary cancer center from November 2018 to June 2020. Patients age 15 years and older with confirmed leukemia or lymphomas undergoing chemotherapy, with presence of FN, and LIs observed on imaging were enrolled.

RESULTS

Among the 122 enrolled patients, successful BAL was performed in 83.6% of cases. The study used a two-step analysis of BAL fluid, resulting in a diagnostic yield of 74.5%. Furthermore, antimicrobial therapy was modified in 63.9% of patients on the basis of BAL reports, and this population demonstrated a higher response rate (63% v 45%; P = .063).

CONCLUSION

Our study demonstrates that a two-step BAL fluid analysis is safe and clinically beneficial to establish an accurate microbiological diagnosis. Given the crucial impact of diagnostic delays on mortality in hematologic malignancy patients with FN, early BAL studies should be performed to enable prompt and specific diagnosis, allowing for appropriate treatment modifications.

Lower Respiratory Infections in Children With Febrile Neutropenic Leukemia: A Case in a Jordanian Hospital

The study aimed to examine the prevalence of pneumonia in pediatric children diagnosed with leukemia at King Hussein Medical Center, Royal Medical Services, Amman, Jordan. The study was conducted from January 2019 to March 2020. A total of 100 hospitalized leukemia patients with febrile neutropenic episodes were evaluated for the presence of pneumonia. Samples were collected from all patients and tested for microbial growth. Univariate analysis revealed that age (P = .033) and packed cell volume (P = .006) were statistically significant risk factors, associated with the prevalence of pneumonia in leukemia patients with febrile neutropenia episodes. Similarly, as the absolute neutrophil count counts increased with an odds ratio and a 95% confidence interval of 2.386 (0.859-6.625), the odds of pneumonia in febrile neutropenic patients were more prevalent. The study reported the prevalence of pneumonia in immunocompromised febrile neutropenic patients with leukemia, which could lead to the development of evidence-based febrile neutropenic treatment protocol development. It will assure more responsive patient management and treatment.

Prognosis of critically ill immunocompromised patients with virus-detected acute respiratory failure

BACKGROUND

Acute respiratory failure (ARF) is the leading cause of ICU admission. Viruses are increasingly recognized as a cause of pneumonia in immunocompromised patients, but epidemiologic data are scarce. We used the Groupe de Recherche en Réanimation Respiratoire en Onco-Hématologie's database (2003-2017, 72 intensive care units) to describe the spectrum of critically ill immunocompromised patients with virus-detected ARF and to report their outcomes. Then, patients with virus-detected ARF were matched based on clinical characteristics and severity (1:3 ratio) with patients with ARF from other origins.

RESULTS

Of the 4038 immunocompromised patients in the whole cohort, 370 (9.2%) had a diagnosis of virus-detected ARF and were included in the study. Influenza was the most common virus (59%), followed by respiratory syncytial virus (14%), with significant seasonal variation. An associated bacterial infection was identified in 79 patients (21%) and an invasive pulmonary aspergillosis in 23 patients (6%). The crude in-hospital mortality rate was 37.8%. Factors associated with mortality were: neutropenia (OR = 1.74, 95% confidence interval, CI [1.05-2.89]), poor performance status (OR = 1.84, CI [1.12-3.03]), and the need for invasive mechanical ventilation on the day of admission (OR = 1.97, CI [1.14-3.40]). The type of virus was not associated with mortality. After matching, patients with virus-detected ARF had lower mortality (OR = 0.77, CI [0.60-0.98]) than patients with ARF from other causes. This result was mostly driven by influenza-like viruses, namely, respiratory syncytial virus, parainfluenza virus, and human metapneumovirus (OR = 0.54, CI [0.33-0.88]).

CONCLUSIONS

In immunocompromised patients with virus-detected ARF, mortality is high, whatever the species, mainly influenced by clinical severity and poor general status. However, compared to non-viral ARF, in-hospital mortality was lower, especially for patients with detected viruses other than influenza.

[Invasive mechanical ventilation in patients with solid tumor or hematological malignancy]

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.

The association between nutritional risk index and ICU outcomes across hematologic malignancy patients with acute respiratory failure

Patients with hematological malignancies (HM) are at risk of acute respiratory failure (ARF). Malnutrition, a common association with HM, has the potential to influence ICU outcomes. Geriatric nutritional risk index (G-NRI) is a score derived from albumin and weight, which reflects risk of protein-energy malnutrition. We evaluated the association between G-NRI at ICU admission and ICU mortality in HM patients with ARF. We conducted a single center retrospective study of ventilated HM patients between 2014 and 2018. We calculated G-NRI for all patients using their ICU admission albumin and weight. Our primary outcome was ICU mortality. Secondary outcomes included duration of mechanical ventilation and ICU length of stay. Two hundred eighty patients were admitted to the ICU requiring ventilation. Median age was 62 years (IQR 51-68), 42% (n = 118) were females, and median SOFA score was 11 (IQR 9-14). The most common type of HM was acute leukemia (54%) and 40% underwent hematopoietic cell transplant. Median G-NRI was 87 (IQR 79-99). ICU mortality was 51% (n = 143) with a median duration of ventilation of 4 days (IQR 2-7). Mortality across those at severe malnutrition (NRI < 83.5) was 59% (65/111) compared to 46% (76/164) across those with moderate-no risk (p = 0.047). On multivariable analysis, severe NRI (OR 2.34, 95% CI 1.04-5.27, p = 0.04) was significantly associated with ICU mortality. In this single center, exploratory study, severe G-NRI was prognostic of ICU mortality in HM patients admitted with respiratory failure.

Noninvasive Mechanical Ventilation in Patients with Viral Pneumonia-Associated Acute Respiratory Distress Syndrome: An Observational Retrospective Study

OBJECTIVES

Appropriate mechanical ventilation may change the prognosis of patients with viral pneumonia-associated acute respiratory distress syndrome (ARDS). This study aimed to identify the factors associated with the success of noninvasive ventilation in the management of patients with ARDS secondary to respiratory viral infection.

METHODS

In this retrospective cohort study, all patients with viral pneumonia-associated ARDS were divided into the noninvasive mechanical ventilation (NIV) success group and the NIV failure group. The demographic and clinical data of all patients were collected. The factors associated with the success of noninvasive ventilation were identified by the logistic regression analysis.

RESULTS

Among this cohort, 24 patients with an average age of 57.9 ± 17.0 years received successful NIVs, and NIV failure occurred in 21 patients with an average age of 54.1 ± 14.0 years. The independent influencing factors for the success of the NIV were the acute physiology and chronic health evaluation (APACHE) II score (odds ratio (OR): 1.83, 95% confidence interval (CI): 1.10-3.03) and lactate dehydrogenase (LDH) (OR: 1.011, 95% CI: 1.00-1.02). When the oxygenation index (OI) is <95 mmHg, APACHE II > 19, and LDH > 498 U/L, the sensitivity and specificity of predicting a failed NIV were (66.6% (95% CI: 43.0%-85.4%) and 87.5% (95% CI: 67.6%-97.3%)); (85.7% (95% CI: 63.7%-97.0%) and 79.1% (95% CI: 57.8%-92.9%)); (90.4% (95% CI: 69.6%-98.8%) and 62.5% (95% CI: 40.6%-81.2%)), respectively. The areas under the receiver operating characteristic curve (AUC) of the OI, APACHE II scores, and LDH were 0.85, which was lower than the AUC of the OI combined with LDH and the APACHE II score (OLA) of 0.97 (P=0.0247).

CONCLUSIONS

Overall, patients with viral pneumonia-associated ARDS receiving successful NIV have lower mortality rates than those for whom NIV failed. In patients with influenza A-associated ARDS, the OI may not be the only indicator of whether NIV can be used; a new indicator of NIV success may be the OLA.

Azacitidine-Induced Pneumonitis in a Patient With Acute Myeloid Leukemia and Hyperleukocytosis

Chemotherapy-related toxicity is a complex aspect of oncologic care. Pulmonary toxicity, in particular, poses a significant challenge, as it can have diverse presentations and can closely mimic other common complications of cancer treatment, such as infections. Azacitidine is an agent widely employed in high-risk myelodysplastic syndrome and acute myeloid leukemia. We present a case of azacitidine-induced pneumonitis, a rare adverse effect, in a 70-year-old patient with acute myeloid leukemia (AML) and hyperleukocytosis. After discontinuation of the drug and introduction of steroids, the patient had complete resolution of symptoms, highlighting the importance of identifying and addressing chemotherapy-induced pneumonitis.

Oxygenation strategy during acute respiratory failure in immunocompromised patients

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

Patient vital signs in relation to ICU admission in treatment of acute leukemia: a retrospective chart review

OBJECTIVES

The objective of the current study was to investigate the relationship between changes in vital signs and intensive care unit (ICU) admission. Windsor Regional Hospital treats 15-20 new patients a year with acute leukemia. These patients are at increased risk of neutropenic fevers and admission to the ICU following induction chemotherapy.

METHODS

Retrospective review examined the correlation between acute leukemia patient vitals and ICU admission. The analysis included 37 patients: 7 ICU versus 30 controls. Changes were compared to baseline over 24 hours prior to ICU admission or 5 days after the initiation of induction chemotherapy in the following vital signs: heart rate (HR), mean arterial pressure (MAP), temperature (T), respiratory rate (RR), and fraction of inspired oxygen (FiO₂) required to maintain a stable oxygen saturation.

RESULTS

RR and FiO₂ demonstrated significant change over baseline leading up to ICU admission within the ICU group. T, HR and MAP did not demonstrate significant changes over time in either group. RR, FiO₂ and HR were significantly higher in the ICU group at time zero compared with the control group. RR was recorded least frequently in the 24 hours leading up to ICU admission.

DISCUSSION

Changes in RR and FiO₂ predicted clinical deterioration requiring ICU admission in acute leukemia patients. This is consistent with the predominant reason for ICU admission which was respiratory failure.

CONCLUSION

We present preliminary evidence to support enhanced monitoring of RR and FiO₂ in acute leukemia patients following induction chemotherapy with early intervention if identified.

Pulmonary infections in patients with and without hematological malignancies: diagnostic yield and safety of flexible bronchoscopy-a retrospective analysis

BACKGROUND

Fiberoptic bronchoscopy (FOB) with broncho-alveolar lavage (BAL) is frequently performed in patients with hematological malignancies and pulmonary opacities. While the safety of the procedure in this patient population has been shown, data about the diagnostic yield widely differ between studies. Furthermore, data comparing diagnostic yield and safety of flexible bronchoscopy to narrow sources of pulmonary infections in patients with and without underlying hematological malignancy are lacking.

METHODS

We carried out a retrospective analysis of bronchoscopies done for the diagnostic work-up of pulmonary infections. Diagnostic yield and the occurrence of complications in patients with and without hematological disease were compared.

RESULTS

In total n=268 bronchoscopies were done in patients suffering from a hematological malignancy (HM) compared to n=408 bronchoscopies in patients without hematological malignancy (NHM). The overall diagnostic yield was similar and did not differ between the groups (HM: 67.2% vs. NHM: 64.7%; P=0.5622). However, when cultures positive for Candida were not considered as clinically relevant diagnostic yield was higher in the HM group (HM: 62.7% vs. NHM: 53.9%; P=0.0261) due to a higher detection rate of fungi and viruses (both P<0.001). Interestingly, the diagnostic yield for bacteria was not decreased by pre-treatment with antibiotics in either group (both P>0.05). There was no difference in the complication rate between the groups and most complications were considered as minor.

CONCLUSIONS

In summary, our data demonstrate similar diagnostic yield and safety of flexible bronchoscopy for diagnosing pulmonary infection in patients with and without underlying hematological malignancy.

Pulmonary Infectious Complications in Children with Hematologic Malignancies and Chemotherapy-Induced Neutropenia

Infections frequently complicate the treatment course in children with hematologic malignancies undergoing chemotherapy. Febrile neutropenia (FN) remains a major cause of hospital admissions in this population, and respiratory tract is often proven to be the site of infection even without respiratory signs and symptoms. Clinical presentation may be subtle due to impaired inflammatory response. Common respiratory viruses and bacteria are widely identified in these patients, while fungi and, less commonly, bacteria are the causative agents in more severe cases. A detailed history, thorough clinical and basic laboratory examination along with a chest radiograph are the first steps in the evaluation of a child presenting signs of a pulmonary infection. After stratifying patient’s risk, prompt initiation of the appropriate empirical antimicrobial treatment is crucial and efficient for the majority of the patients. High-risk children should be treated with an intravenous antipseudomonal beta lactam agent, unless there is suspicion of multi-drug resistance when an antibiotic combination should be used. In unresponsive cases, more invasive procedures, including bronchoalveolar lavage (BAL), computed tomography (CT)-guided fine-needle aspiration or open lung biopsy (OLB), are recommended. Overall mortality rate can reach 20% with higher rates seen in cases unresponsive to initial therapy and those under mechanical ventilation.

Clinical Significance of Upper Airway Virus Detection in Critically Ill Hematology Patients

RATIONALE

Noninvasive diagnostic multiplex molecular tests may enable the early identification and treatment of viral infections in critically ill immunocompromised patients.

OBJECTIVES

To assess the association between viral detection in nasopharyngeal swabs and ICU mortality in critically ill hematology patients.

METHODS

This was a post hoc analysis of a prospective cohort of critically ill hematology patients admitted to 17 ICUs. Nasal swabs sampled and frozen at ICU admission were tested using a multiplex PCR assay. Predictors of ICU mortality and assay positivity were identified.

MEASUREMENTS AND MAIN RESULTS

Of the 747 patients (447 with acute respiratory failure [ARF]), 21.3% had a virus detected (56.4% rhinovirus/enterovirus and 30.7% influenza/parainfluenza/respiratory syncytial viruses). Overall ICU and hospital mortality rates were 26% and 37%, respectively. Assay positivity was associated with lymphoproliferative disorders, hematopoietic stem cell transplantation, treatment with steroids or other immunosuppressants, ARF (25.5% vs. 16.3%; P = 0.004), and death in the ICU (28.9% vs. 19.3%; P = 0.008). The association with ICU mortality was significant for all viruses and was strongest for influenza/parainfluenza/respiratory syncytial viruses. In patients with ARF, detection of any respiratory virus was independently associated with ICU mortality (odds ratio, 2.07; 95% confidence interval, 1.22-3.50).

CONCLUSIONS

Respiratory virus detection in the upper airway by multiplex PCR assay is common in critically ill hematology patients. In patients with ARF, respiratory virus detection was independently associated with ICU mortality. Multiplex PCR assay may prove helpful for the risk stratification of hematology patients with ARF. Studies to understand whether respiratory tract viruses play a causal role in outcomes are warranted.

Acute and Chronic Respiratory Failure in Cancer Patients

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.

Acute respiratory failure in immunocompromised adults

Acute respiratory failure occurs in up to half of patients with haematological malignancies and 15% of those with solid tumours or solid organ transplantation. Mortality remains high. Factors associated with mortality include a need for invasive mechanical ventilation, organ dysfunction, older age, frailty or poor performance status, delayed intensive care unit admission, and acute respiratory failure due to an invasive fungal infection or unknown cause. In addition to appropriate antibacterial therapy, initial clinical management aims to restore oxygenation and predict the most probable cause based on variables related to the underlying disease, acute respiratory failure characteristics, and radiographic findings. The cause of acute respiratory failure must then be confirmed using the most efficient, least invasive, and safest diagnostic tests. In patients with acute respiratory failure of undetermined cause, a standardised diagnostic investigation should be done immediately at admission before deciding whether to perform more invasive diagnostic procedures or to start empirical treatments. Collaborative and multidisciplinary clinical and research networks are crucial to improve our understanding of disease pathogenesis and causation and to develop less invasive diagnostic strategies and more targeted treatment options.

Salvage extracorporeal membrane oxygenation in induction-associated acute respiratory distress syndrome in acute leukemia patients: A case series

BACKGROUND:

The prognosis of hematologic malignancies has improved over the past three decades. However, the prognosis in hematologic malignancies with severe acute respiratory distress syndrome has remained poor. Initial reports regarding the utility of extracorporeal membrane oxygenation in hematologic malignancies have been controversial, with limited evaluations of acute leukemia patients supported by extracorporeal membrane oxygenation.

METHODS:

We conducted a retrospective review of patients with acute leukemia who developed acute respiratory distress syndrome requiring veno-venous extracorporeal membrane oxygenation support at our facility from July 2015 through August 2017.

RESULTS:

Four cases of acute myelogenous leukemia with respiratory failure and acute respiratory distress syndrome treated with veno-venous extracorporeal membrane oxygenation while undergoing induction chemotherapy were identified. All patients completed induction therapy with addition of extracorporeal membrane oxygenation support, with two patients dying secondary to their acute leukemia and the other two surviving to allogeneic hematopoietic stem cell transplant. Overall, 75% (three of four) survived to decannulation with a 1-year survival rate following extracorporeal membrane oxygenation of 50% (two of four).

CONCLUSION:

Currently, the use of extracorporeal membrane oxygenation in patients with hematologic malignancies who develop severe acute respiratory distress syndrome remains controversial. Although extracorporeal membrane oxygenation in post-allogeneic hematopoietic stem cell transplant is associated with poorer outcomes, our data suggest that salvage extracorporeal membrane oxygenation support is a viable option to manage moderate to severe acute respiratory distress syndrome while completing therapeutic chemotherapy and following in the peri-induction phase of acute leukemia.

Oxygenation/non-invasive ventilation strategy and risk for intubation in immunocompromised patients with hypoxemic acute respiratory failure

We investigated how the initial ventilation/oxygenation management may influence the need for intubation on the coming day in a cohort of immunocompromised patients with acute hypoxemic respiratory failure (ARF).

Data from 847 immunocompromised patients with ARF were used to estimate the probability of intubation at day+1 within the first 3 days of ICU admission, according to oxygenation management. First, noninvasive ventilation (NIV) was compared to oxygen therapy whatever the administration device; then standard oxygen was compared to High Flow Nasal Cannula therapy alone (HFNC), NIV alone or NIV+HFNC. To take into account the oxygenation regimens over time and to handle confounders, propensity score weighting models were used.

In the original sample, the probability of intubation at day+1 was higher in the NIV group vs oxygenation therapy (OR = 1.64, 95CI, 1.09–2.48) or vs the standard oxygen group (OR = 2.05, 95CI: 1.29–3.29); it was also increased in the HFNC group compared to standard oxygen (OR = 2.85, 95CI: 1.37–5.67). However, all these differences disappeared by handling confounding-by-indication in the weighted samples, as well as in the pooled model. Note that adjusted OR for day-28 mortality increased with the day of intubation.

In this large cohort of immunocompromised patients, ventilation/oxygenation management had no impact on the probability of intubation on the coming day.

Characteristics of early acute respiratory distress syndrome in newly diagnosed acute myeloid leukemia

Acute respiratory complications occur frequently during the early phase of acute myeloid leukemia (AML) but information on the most severe form, acute respiratory distress syndrome (ARDS), is lacking. We retrospectively analyzed 280 patients with newly diagnosed AML in order to describe the incidence, risk factors and early mortality associated with ARDS within 15 d. Univariate and then multivariate analysis were performed. ARDS developed in 9% of patients and was associated with 64% day-30 mortality. White blood cell count on admission was an independent risk factor for ARDS (OR = 1.007, 95% CI = 1.001-1.012, p = .012) with a moderate prediction ability (AUC 0.704, p = .001). Other variables were associated with ARDS in univariate but not in multivariate analysis: body mass index (p = .06), transfusions (p = .001) and sepsis (p < .0001). Leukemia-specific complications and documented infections were the most frequent ARDS etiologies and were sometimes associated, with no clear distinctive temporal pattern.

The utility and safety of flexible bronchoscopy in critically ill acute leukemia patients: a retrospective cohort study

PURPOSE

Flexible bronchoscopy with bronchoalveolar lavage (BAL) is commonly performed in immunocompromised patients. Nevertheless, it remains unclear whether bronchoscopy with BAL leads to changes in medical management or is associated with procedural complications among critically ill acute leukemia (AL) patients.

METHODS

We evaluated 71 AL patients who underwent diagnostic bronchoscopy with BAL in the intensive care unit (ICU) between 1 January 2007 and 31 December 2012. We recorded baseline characteristics, vital signs (before, during, and after the procedure), changes in medical management following the procedure, and procedural complications. Using a multivariable logistic regression model, we explored the relationship between patient characteristics and whether bronchoscopy changed management or caused complications. Patient characteristics included as predictors in the regression model were age, sex, immunosuppression status (those undergoing active chemotherapy), and the Acute Physiology And Chronic Health Evaluation II score.

RESULTS

The most common indication for ICU admission was respiratory failure (51 patients, 72%), followed by sepsis (14 patients, 20%). Overall, the results obtained from bronchoscopy with BAL were associated with a change in management in 32 patients (45%), most commonly a change in antimicrobial therapy as a result of an infectious pathogen being identified (17 patients, 24%). Complications were documented in nine patients (13%) and included post-procedural hypoxia (six patients, 8%), the need for intubation (one patient, 9% of non-intubated patients), and tracheal perforation (one patient, 1%). No clinically significant changes in patient vital signs were observed during or immediately following the procedure. Patient characteristics did not predict whether bronchoscopy was associated with changes in medical management or procedural complications in multivariable analyses.

CONCLUSIONS

Flexible bronchoscopy with BAL is relatively safe and helps to guide medical management among patients with AL admitted to the ICU.

Managing the oncologic patient with suspected pneumonia in the intensive care unit

INTRODUCTION

Solid cancer patients are frequently admitted in intensive care units for critical events. Improving survival rates in this setting is considered an achievable goal today. Respiratory failure is the main reason for admission, representing a primary target for research.

AREAS COVERED

This review presents a diagnostic and therapeutic algorithm for pneumonia and other severe respiratory events in the solid cancer population. It aims to increase awareness of the risk factors and the different etiologies in this changing scenario in which neutropenia no longer seems to be a decisive factor in poor outcome. Bacterial pneumonia is the leading cause, but opportunistic diseases and non-infectious etiologies, especially unexpected adverse effects of radiation, biological drugs and monoclonal antibodies, are becoming increasingly frequent. Options for respiratory support and diagnostics are discussed and indications for antibiotics in the management of pneumonia are detailed. Expert commentary: Prompt initiation of critical care to facilitate optimal decision-making in the management of respiratory failure, early etiological assessment and appropriate antibiotic therapy are cornerstones in management of severe pneumonia in oncologic patients.

Respiratory events in ward are associated with later intensive care unit (ICU) admission and hospital mortality in onco-hematology patients not admitted to ICU after a first request

INTRODUCTION

Prognostic impact of delayed intensive care unit(ICU) admission in critically ill cancer patients remains debatable. We determined predictive factors for later ICU admission and mortality in cancer patients initially not admitted after their first ICU request.

METHODS

All cancer patients referred for an emergency ICU admission between 1 January 2012 and 31 August 2013 were included.

RESULTS

Totally, 246(54.8%) patients were immediately admitted. Among 203(45.2%) patients denied at the first request, 54(26.6%) were admitted later. A former ICU stay [OR: 2.75(1.12-6.75)], a request based on a clinical respiratory event[OR: 2.6(1.35-5.02)] and neutropenia[OR: 2.25(1.06-4.8)] were independently associated with later ICU admission. Survival of patients admitted immediately and later did not differ at ICU(78.5% and 70.4%, respectively; p = 0.2) or hospital(74% and 66%, respectively; p = 0.24) discharge. Hospital mortality of patients initially not admitted was 29.7% and independently associated with malignancy progression[OR: 3.15(1.6-6.19)], allogeneic hematopoietic stem cell transplantation[OR: 2.5(1.06-5.89)], a request based on a clinical respiratory event[OR: 2.36(1.22-4.56)] and severe sepsis[OR: 0.27(0.08-0.99)].

CONCLUSION

Compared with immediate ICU admission, later ICU admission was not associated with hospital mortality. Clinical respiratory events were independently associated with both later ICU admission and hospital mortality.

Bacterial Pneumonia in Patients with Cancer: Novel Risk Factors and Management

Bacterial pneumonias exact unacceptable morbidity on patients with cancer. Although the risk is often most pronounced among patients with treatment-induced cytopenias, the numerous contributors to life-threatening pneumonias in cancer populations range from derangements of lung architecture and swallow function to complex immune defects associated with cytotoxic therapies and graft-versus-host disease. These structural and immunologic abnormalities often make the diagnosis of pneumonia challenging in patients with cancer and impact the composition and duration of therapy. This article addresses host factors that contribute to pneumonia susceptibility, summarizes diagnostic recommendations, and reviews current guidelines for management of bacterial pneumonia in patients with cancer.

Characteristics and predictors of mortality of patients with hematologic malignancies requiring invasive mechanical ventilation

RATIONALE:

Acute respiratory failure (ARF) may complicate the course of hematologic malignancies (HMs). Our objective was to study the characteristics, outcomes and predictors of mortality of patients with HMs who required intubation for ARF.

METHODS:

This retrospective cohort study evaluated all patients with HMs who were admitted to the Intensive Care Unit (ICU) of King Abdul-Aziz Medical City-Riyadh between 2008 and 2013 and required invasive mechanical ventilation. We noted their baseline characteristics, treatments and different outcomes. Multivariable logistic regression analysis was performed to evaluate predictors of hospital mortality.

RESULTS:

During the 6-year period, 190 patients with HMs were admitted to the ICU and 122 (64.2%) required intubation for ARF. These patients had mean age of 57.2 ± 19.3 years and Acute Physiology and Chronic Health Evaluation II score of 28.0 ± 7.8 and were predominantly males (63.4%). Lymphoma (44.3%) and acute leukemia (38.5%) were the most common hematologic malignancy. Noninvasive ventilation (NIV) was tried in 22 patients (18.0%) but failed. The code status was changed to “Do-Not-Resuscitate” for 39 patients (32.0%) during ICU stay. Hospital mortality was 70.5% and most deaths (81.4%) occurred in the ICU. The mortality of patients with “Do-Not-Resuscitate” status was 97.4%. On multivariable logistic regression analysis, male gender (odds ratio (OR), 6.74; 95% confidence interval (CI), 2.24–20.30), septic shock (OR, 6.61; 95% CI, 1.93–22.66) were independent mortality predictors. Remission status, non-NIV failure and chemotherapy during ICU stay were not associated with mortality.

CONCLUSIONS:

Patients with HMs requiring intubation had high mortality (70.5%). Male gender and presence of septic shock were independent predictors of mortality.

Critical care of patients with cancer

Answer questions and earn CME/CNE The increasing prevalence of patients living with cancer in conjunction with the rapid progress in cancer therapy will lead to a growing number of patients with cancer who will require intensive care treatment. Fortunately, the development of more effective oncologic therapies, advances in critical care, and improvements in patient selection have led to an increased survival of critically ill patients with cancer. As a consequence, critical care has become an important cornerstone in the continuum of modern cancer care. Although, in many aspects, critical care for patients with cancer does not differ from intensive care for other seriously ill patients, there are several challenging issues that are unique to this patient population and require special knowledge and skills. The optimal management of critically ill patients with cancer necessitates expertise in oncology, critical care, and palliative medicine. Cancer specialists therefore have to be familiar with key principles of intensive care for critically ill patients with cancer. This review provides an overview of the state-of-the-art in the individualized management of critically ill patients with cancer. CA Cancer J Clin 2016;66:496-517. © 2016 American Cancer Society.

Chest radiographic and CT findings in hyperleukocytic acute myeloid leukemia: A retrospective cohort study of 73 patients

Hyperleukocytic acute myeloid leukemia (AML) is associated with pulmonary complications and high early mortality rate, but given its rarity, data on chest radiographic presentation are scarce.We retrospectively reviewed the charts of 73 AML patients admitted with white blood cell count >100 × 10/L between 2003 and 2014 in order to describe the chest radiographic and computed tomography (CT) findings and to correlate them with AML subtype and respiratory symptoms.Forty-two of the 73 patients (58%) overall and 36 of the 54 patients (67%) with clinical signs of pulmonary leukostasis had abnormal radiographs on admission. The presence of radiographic abnormalities was significantly associated with dyspnea and oxygen/ventilatory support requirements (P < 0.01) and with day 28 mortality (45% vs 13%, P = 0.005) but not with monocytic subtype of AML. Sixteen patients had isolated focal basilar airspace opacities, unilateral (n = 13) or bilateral (n = 3), while 16 patients had bilateral diffuse opacities, interstitial (n = 12) or airspace and interstitial (n = 4). Two patients had isolated pleural effusion, 2 patients had unilateral midlung airspace opacities, and 6 patients had a combination of focal airspace and diffuse interstitial opacities. Overall, 2 patterns accounted for 75% of abnormal findings: bilateral diffuse opacities tended to be associated with monocytic AML, whereas basilar focal airspace opacities were more frequent in nonmonocytic AML (P < 0.05). Eighteen patients had CT scans, revealing interlobular septal thickening (n = 12), airspace (n = 11) and ground-glass (n = 9) opacities, pleural effusions (n = 12), and acute pulmonary embolism (n = 2).Hyperleukocytic AML is frequently associated with abnormal chest radiographs, involving mostly focal basilar airspace opacities (more frequent in nonmonocytic AML) or diffuse bilateral opacities. CT scan should be considered broadly due to the suboptimal resolution of radiographs for detecting signs of leukostasis.

Increased mortality in hematological malignancy patients with acute respiratory failure from undetermined etiology: a Groupe de Recherche en Réanimation Respiratoire en Onco-Hématologique (Grrr-OH) study

BACKGROUND

Acute respiratory failure (ARF) is the most frequent complication in patients with hematological malignancies and is associated with high morbidity and mortality. ARF etiologies are numerous, and despite extensive diagnostic workflow, some patients remain with undetermined ARF etiology.

METHODS

This is a post-hoc study of a prospective multicenter cohort performed on 1011 critically ill hematological patients. Relationship between ARF etiology and hospital mortality was assessed using a multivariable regression model adjusting for confounders.

RESULTS

This study included 604 patients with ARF. All patients underwent noninvasive diagnostic tests, and a bronchoscopy and bronchoalveolar lavage (BAL) was performed in 155 (25.6%). Definite diagnoses were classified into four exclusive etiological categories: pneumonia (44.4%), non-infectious diagnoses (32.6%), opportunistic infection (10.1%) and undetermined (12.9%), with corresponding hospital mortality rates of 40, 35, 55 and 59%, respectively. Overall hospital mortality was 42%. By multivariable analysis, factors associated with hospital mortality were invasive pulmonary aspergillosis (OR 7.57 (95% CI 3.06-21.62); p < 0.005), use of invasive mechanical ventilation (OR 1.65 (95% CI 1.07-2.55); p = 0.02), a SOFA score >7 (OR 3.32 (95% CI 2.15-5.15); p < 0.005) and an undetermined ARF etiology (OR 2.92 (95% CI 1.71-5.07); p < 0.005).

CONCLUSIONS

In patients with hematological malignancies and ARF, up to 13% remain with undetermined ARF etiology despite comprehensive diagnostic workup. Undetermined ARF etiology is independently associated with hospital mortality. Studies to guide second-line diagnostic strategies are warranted. ClinicalTrials.Gov NCT01172132.

Management of neutropenic patients in the intensive care unit (NEWBORNS EXCLUDED) recommendations from an expert panel from the French Intensive Care Society (SRLF) with the French Group for Pediatric Intensive Care Emergencies (GFRUP), the French Society of Anesthesia and Intensive Care (SFAR), the French Society of Hematology (SFH), the French Society for Hospital Hygiene (SF2H), and the French Infectious Diseases Society (SPILF)

Neutropenia is defined by either an absolute or functional defect (acute myeloid leukemia or myelodysplastic syndrome) of polymorphonuclear neutrophils and is associated with high risk of specific complications that may require intensive care unit (ICU) admission. Specificities in the management of critically ill neutropenic patients prompted the establishment of guidelines dedicated to intensivists. These recommendations were drawn up by a panel of experts brought together by the French Intensive Care Society in collaboration with the French Group for Pediatric Intensive Care Emergencies, the French Society of Anesthesia and Intensive Care, the French Society of Hematology, the French Society for Hospital Hygiene, and the French Infectious Diseases Society. Literature review and formulation of recommendations were performed using the Grading of Recommendations Assessment, Development and Evaluation system. Each recommendation was then evaluated and rated by each expert using a methodology derived from the RAND/UCLA Appropriateness Method. Six fields are covered by the provided recommendations: (1) ICU admission and prognosis, (2) protective isolation and prophylaxis, (3) management of acute respiratory failure, (4) organ failure and organ support, (5) antibiotic management and source control, and (6) hematological management. Most of the provided recommendations are obtained from low levels of evidence, however, suggesting a need for additional studies. Seven recommendations were, however, associated with high level of evidences and are related to protective isolation, diagnostic workup of acute respiratory failure, medical management, and timing surgery in patients with typhlitis.

Management of Acute Respiratory Failure in Patients With Hematological Malignancy

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.

ECIL guidelines for treatment of Pneumocystis jirovecii pneumonia in non-HIV-infected haematology patients

The initiation of systemic antimicrobial treatment of Pneumocystis jirovecii pneumonia (PCP) is triggered by clinical signs and symptoms, typical radiological and occasionally laboratory findings in patients at risk of this infection. Diagnostic proof by bronchoalveolar lavage should not delay the start of treatment. Most patients with haematological malignancies present with a severe PCP; therefore, antimicrobial therapy should be started intravenously. High-dose trimethoprim/sulfamethoxazole is the treatment of choice. In patients with documented intolerance to this regimen, the preferred alternative is the combination of primaquine plus clindamycin. Treatment success should be first evaluated after 1 week, and in case of clinical non-response, pulmonary CT scan and bronchoalveolar lavage should be repeated to look for secondary or co-infections. Treatment duration typically is 3 weeks and secondary anti-PCP prophylaxis is indicated in all patients thereafter. In patients with critical respiratory failure, non-invasive ventilation is not significantly superior to intubation and mechanical ventilation. The administration of glucocorticoids must be decided on a case-by-case basis.

Intensive care for cancer patients: An interdisciplinary challenge for cancer specialists and intensive care physicians

Every sixth to eighth European intensive care unit patient suffers from an underlying malignant disease. A large proportion of these patients present with cancer-related complications. This review explains why the prognosis of critically ill cancer patients has improved substantially over the last decades and which risk factors are of prognostic importance. Furthermore, the main reasons for intensive care unit admission – acute respiratory failure and septic complications – are discussed with regard to diagnostic and therapeutic specifics. In addition, we discuss potential intensive care unit admission criteria with respect to cancer prognosis. The successful management of critically ill cancer patients requires a close collaboration of intensivists with hematologists, oncologists and colleagues from other disciplines, such as infectious disease specialists, microbiologists, radiologists, surgeons, pharmacists, and others.

How to manage lung infiltrates in adults suffering from haematological malignancies outside allogeneic haematopoietic stem cell transplantation

Pulmonary complications affect up to 40% of patients with severe neutropenia lasting for more than 10 d. As they are frequently associated with fever and elevation of C‐reactive protein or other signs of inflammation, they are mostly handled as pneumonia. However, the differential diagnosis is broad, and a causative microbial agent remains undetected in the majority of cases. Pulmonary side effects from cytotoxic treatment or pulmonary involvement by the underlying malignancy must always be taken into account and may provide grounds for invasive diagnostic procedures in selected patients. Pneumocystis jirovecii (in patients not receiving co‐trimoxazole as prophylaxis), multi‐resistant gram‐negative bacilli, mycobacteria or respiratory viruses may be involved. High‐risk patients may be infected by filamentous fungi, such as Aspergillus spp., but these infections are seldom proven when treatment is initiated. Microorganisms isolated from cultures of blood, bronchoalveolar lavage or respiratory secretions need careful interpretation as they may be irrelevant for determining the aetiology of pulmonary infiltrates, particularly when cultures yield coagulase‐negative staphylococci, enterococci or Candida species. Non‐culture based diagnostics for detecting Aspergillus galactomannan, beta‐D‐glucan or DNA from blood, bronchoalveolar lavage or tissue samples can facilitate the diagnosis, but must always be interpreted in the context of clinical and imaging findings. Systemic antifungal treatment with mould‐active agents, given in combination with broad‐spectrum antibiotics, improves clinical outcome when given pre‐emptively. Co‐trimoxazole remains the first‐line treatment for Pneumocystis pneumonia, while cytomegalovirus pneumonia will respond to ganciclovir or foscarnet in most cases. The clinical outcome of acute respiratory failure can also be successful with proper intensive care, when indicated.

Initial respiratory status in hyperleukocytic acute myeloid leukemia: prognostic significance and effect of leukapheresis

This study investigated whether initial respiratory status in hyperleukocytic acute myeloid leukemia (AML), as defined by oxygen/ventilatory support, is (1) associated with early mortality and overall survival and (2) improved after leukapheresis. A retrospective chart review of 89 patients requiring leukapheresis was performed. White blood cell count (WBC) decreased from 153 (56-475) × 10(9)/L to 60 (17-259) × 10(9)/L after first leukapheresis (p < 0.01). Initial respiratory status was room air (n = 40), low (n = 31) or high flow oxygen therapy (n = 8) or mechanical ventilation (n = 10). As compared to admission, respiratory status significantly deteriorated after both first and second leukapheresis (p < 0.01) and was not different at day 5 for patients still alive (p = 0.131). Both day 28 mortality and overall survival were significantly affected by initial respiratory status (p < 0.01). Despite being effective in reducing WBC, leukapheresis did not improve respiratory status of hyperleukocytic AML patients, a factor strongly associated with survival.

Pneumonia in the neutropenic cancer patient

PURPOSE OF REVIEW

Pneumonia is the leading cause of death among neutropenic cancer patients, particularly those with acute leukaemia. Even with empiric therapy, case fatality rates of neutropenic pneumonias remain unacceptably high. However, recent advances in the management of neutropenic pneumonia offer hope for improved outcomes in the cancer setting. This review summarizes recent literature regarding the clinical presentation, microbiologic trends, diagnostic advances and therapeutic recommendations for cancer-related neutropenic pneumonia.

RECENT FINDINGS

Although neutropenic patients acquire pathogens both in community and nosocomial settings, patients' obligate healthcare exposures result in the frequent identification of multidrug-resistant bacterial organisms on conventional culture-based assessment of respiratory secretions. Modern molecular techniques, including expanded use of galactomannan testing, have further facilitated identification of fungal pathogens, allowing for aggressive interventions that appear to improve patient outcomes. Multiple interested societies have issued updated guidelines for antibiotic therapy of suspected neutropenic pneumonia. The benefit of antibiotic medications may be further enhanced by agents that promote host responses to infection.

SUMMARY

Neutropenic cancer patients have numerous potential causes for pulmonary infiltrates and clinical deterioration, with lower respiratory tract infections among the most deadly. Early clinical suspicion, diagnosis and intervention for neutropenic pneumonia provide cancer patients' best hope for survival.

Do immunocompromised children benefit from having surgical lung biopsy performed?

BACKGROUND

Surgical lung biopsy is considered a gold standard for the evaluation of pulmonary disease in immunocompromised children. However, in the literature, its accuracy and the rate of complications vary.

OBJECTIVE

We aimed to evaluate the yield of surgical lung biopsies in the management of persistent pulmonary findings in immunocompromised children.

METHODS

We performed a retrospective review of clinical records of immunocompromised children who underwent surgical lung biopsies, and evaluated the impact that preoperative factors had on outcomes.

RESULTS

Twenty-five patients underwent 27 surgical lung biopsies. The underlying immunodeficiency included allogeneic stem cell transplantation (n = 12), chemotherapy for solid tumors (n = 6), hematologic malignancy (n = 4), primary immunodeficiency (n = 4) and chronic steroid use (n = 1). Biopsies provided a specific histopathologic or microbiologic diagnosis in 10 cases (37%). No preoperative factor predicted a diagnostic biopsy. Five of the 27 biopsies were beneficial for the patients (18%). A major complication related to the procedure was reported for 1 biopsy (4%).

CONCLUSIONS

We conclude that surgical lung biopsy in pediatric immunocompromised patients appears to be safe, but has a relatively low diagnostic yield and an even lower yield with regards to the benefit it provides.

Pneumonia during remission induction chemotherapy in patients with acute leukemia

BACKGROUND

Pneumonia is a major cause of death during induction chemotherapy for acute leukemia. The purpose of this study was to quantify the incidence, risk factors, and outcomes of pneumonia in patients with acute leukemia.

METHODS

We conducted a retrospective cohort study of 801 patients with acute myeloid leukemia (AML), myelodysplastic syndrome (MDS), or acute lymphocytic leukemia (ALL) who underwent induction chemotherapy.

MEASUREMENTS AND MAIN RESULTS

Pneumonia was present at induction start in 85 patients (11%). Of the 716 remaining patients, 148 (21%) developed pneumonia. The incidence rate of pneumonia was higher in MDS and AML than in ALL (0.013 vs. 0.008 vs. 0.003 pneumonias per day, respectively; P < 0.001). In multivariate analysis, age greater than or equal to 60 years, AML, low platelet count, low albumin level, neutropenia, and neutrophil count greater than 7,300 were risk factors. The case fatality rate of pneumonia was 17% (40 of 233). Competing risk analysis demonstrated that in the absence of pneumonia, death was rare: 28-day mortality was 6.2% for all patients but only 1.26% in those without pneumonia. Compared with patients without pneumonia, patients with pneumonia had more intensive care unit days, longer hospital stays, and 49% higher costs (P < 0.001).

CONCLUSIONS

Pneumonia after induction chemotherapy for acute leukemia continues to be common, and it is the most important determinant of early mortality after induction chemotherapy. Given the high incidence, morbidity, mortality, and cost of pneumonia, interventions aimed at prevention are warranted in patients with acute leukemia.

Management of Acute Myeloid Leukemia in the Intensive Care Setting

Patients with acute myeloid leukemia (AML) who are newly diagnosed or relapsed and those who are receiving cytotoxic chemotherapy are predisposed to conditions such as sepsis due to bacterial and fungal infections, coagulopathies, hemorrhage, metabolic abnormalities, and respiratory and renal failure. These conditions are common reasons for patients with AML to be managed in the intensive care unit (ICU). For patients with AML in the ICU, providers need to be aware of common problems and how to manage them. Understanding the pathophysiology of complications and the recent advances in risk stratification as well as newer therapy for AML are relevant to the critical care provider.

Do quality of life or physical function at diagnosis predict short-term outcomes during intensive chemotherapy in AML?

BACKGROUND

Intensive chemotherapy (IC) used to treat acute myeloid leukemia (AML) is associated with toxicity, particularly in older adults. Emerging data suggest that baseline quality of life (QOL) and physical function may predict outcomes in oncology, although data in AML are limited. We investigated the association between baseline QOL and physical function with short-term treatment outcomes in adults and elderly AML patients.

MATERIALS AND METHODS

We conducted a prospective, longitudinal study of adults (age 18+) AML patients undergoing IC. Before starting IC, patients completed the European Organisation for the Research and Treatment of Cancer (EORTC) 30-item questionnaire (QLQ-C30) and Functional Assessment of Cancer Therapy Fatigue subscale (FACT-Fatigue) in addition to physical function tests (grip strength, timed chair stands, 2-min walk test). Outcomes included 60-day mortality, intensive care unit (ICU) admission and achievement of complete remission (CR). Logistic regression was carried out to evaluate each outcome.

RESULTS

Of the 239 patients (median age 57.5 years), 56.7% were male and median Charlson comorbidity score was 0. Sixty-day mortality, ICU admission and CR occurred in 9 (3.7%), 15 (6.3%) and 167 (69.9%) patients, respectively. Using univariate regression, neither QOL nor physical function at presentation was predictive of 60-day mortality (all P > 0.05), whereas ICU admission (P < 0.001) and remission status at 30 days (P = 0.007) were. Fatigue (P = 0.004) and role functioning (P = 0.003) were predictors of ICU admission; QOL and physical function were not. A higher Charlson score predicted ICU admission (P = 0.01) and remission status (P = 0.002). The cytogenetic risk group was associated with achievement of CR (P = 0.02); QOL and physical function were not (all P > 0.05). Findings were similar when patients age 60+ were examined. Relationships between fatigue and role functioning with ICU admission deserve further exploration.

CONCLUSIONS

Baseline QOL and physical function tests in this prospective study were not associated with short-term mortality, ICU admission or achievement of CR after the first cycle of chemotherapy.

Disseminated Fusarium infection in a patient with acute lymphoblastic leukemia: A case report and review of the literature

Fusarium is a common soil mold. In severely immunocompromised patients, this fungus may cause disseminated disease and is often confused with Aspergillus, as the two pathogens have similar histopathological appearances. Disseminated Fusarium infection may cause significant morbidity and mortality in immunocompromised patients. The current case report presents a 20-year-old male with acute lymphoblastic leukemia who developed disseminated Fusarium infection during induction chemotherapy. Early diagnosis and treatment is extremely important since the mortality rate is extremely high in such patients. The clinician must consider that the clinical presentation of Fusarium infection resembles that of Aspergillus. There is no optimal treatment for patients with Fusarium infection; however, combination antifungal therapy may have benefit without significant toxicity.