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Westhoff M, Neumann P, Geiseler J, Bickenbach J, Arzt M, Bachmann M, Braune S, Delis S, Dellweg D, Dreher M, Dubb R, Fuchs H, Hämäläinen N, Heppner H, Kluge S, Kochanek M, Lepper PM, Meyer FJ, Neumann B, Putensen C, Schimandl D, Schönhofer B, Schreiter D, Walterspacher S, Windisch W. [Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]. Pneumologie 2024; 78:453-514. [PMID: 37832578 DOI: 10.1055/a-2148-3323] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/15/2023]
Abstract
The guideline update outlines the advantages as well as the limitations of NIV in the treatment of acute respiratory failure in daily clinical practice and in different indications.Non-invasive ventilation (NIV) has a high value in therapy of hypercapnic acute respiratory failure, as it significantly reduces the length of ICU stay and hospitalization as well as mortality.Patients with cardiopulmonary edema and acute respiratory failure should be treated with continuous positive airway pressure (CPAP) and oxygen in addition to necessary cardiological interventions. This should be done already prehospital and in the emergency department.In case of other forms of acute hypoxaemic respiratory failure with only mild or moderately disturbed gas exchange (PaO2/FiO2 > 150 mmHg) there is no significant advantage or disadvantage compared to high flow nasal oxygen (HFNO). In severe forms of ARDS NIV is associated with high rates of treatment failure and mortality, especially in cases with NIV-failure and delayed intubation.NIV should be used for preoxygenation before intubation. In patients at risk, NIV is recommended to reduce extubation failure. In the weaning process from invasive ventilation NIV essentially reduces the risk of reintubation in hypercapnic patients. NIV is regarded useful within palliative care for reduction of dyspnea and improving quality of life, but here in concurrence to HFNO, which is regarded as more comfortable. Meanwhile NIV is also recommended in prehospital setting, especially in hypercapnic respiratory failure and pulmonary edema.With appropriate monitoring in an intensive care unit NIV can also be successfully applied in pediatric patients with acute respiratory insufficiency.
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Affiliation(s)
- Michael Westhoff
- Klinik für Pneumologie, Lungenklinik Hemer - Zentrum für Pneumologie und Thoraxchirurgie, Hemer
| | - Peter Neumann
- Abteilung für Klinische Anästhesiologie und Operative Intensivmedizin, Evangelisches Krankenhaus Göttingen-Weende gGmbH
| | - Jens Geiseler
- Medizinische Klinik IV - Pneumologie, Beatmungs- und Schlafmedizin, Paracelsus-Klinik Marl, Marl
| | - Johannes Bickenbach
- Klinik für Operative Intensivmedizin und Intermediate Care, Uniklinik RWTH Aachen, Aachen
| | - Michael Arzt
- Schlafmedizinisches Zentrum der Klinik und Poliklinik für Innere Medizin II, Universitätsklinikum Regensburg, Regensburg
| | - Martin Bachmann
- Klinik für Atemwegs-, Lungen- und Thoraxmedizin, Beatmungszentrum Hamburg-Harburg, Asklepios Klinikum Harburg, Hamburg
| | - Stephan Braune
- IV. Medizinische Klinik: Akut-, Notfall- und Intensivmedizin, St. Franziskus-Hospital, Münster
| | - Sandra Delis
- Klinik für Pneumologie, Palliativmedizin und Geriatrie, Helios Klinikum Emil von Behring GmbH, Berlin
| | - Dominic Dellweg
- Klinik für Innere Medizin, Pneumologie und Gastroenterologie, Pius-Hospital Oldenburg, Universitätsmedizin Oldenburg
| | - Michael Dreher
- Klinik für Pneumologie und Internistische Intensivmedizin, Uniklinik RWTH Aachen
| | - Rolf Dubb
- Akademie der Kreiskliniken Reutlingen GmbH, Reutlingen
| | - Hans Fuchs
- Zentrum für Kinder- und Jugendmedizin, Neonatologie und pädiatrische Intensivmedizin, Universitätsklinikum Freiburg
| | | | - Hans Heppner
- Klinik für Geriatrie und Geriatrische Tagesklinik Klinikum Bayreuth, Medizincampus Oberfranken Friedrich-Alexander-Universität Erlangen-Nürnberg, Bayreuth
| | - Stefan Kluge
- Klinik für Intensivmedizin, Universitätsklinikum Hamburg-Eppendorf, Hamburg
| | - Matthias Kochanek
- Klinik I für Innere Medizin, Hämatologie und Onkologie, Universitätsklinikum Köln, Köln
| | - Philipp M Lepper
- Klinik für Innere Medizin V - Pneumologie, Allergologie und Intensivmedizin, Universitätsklinikum des Saarlandes und Medizinische Fakultät der Universität des Saarlandes, Homburg
| | - F Joachim Meyer
- Lungenzentrum München - Bogenhausen-Harlaching) München Klinik gGmbH, München
| | - Bernhard Neumann
- Klinik für Neurologie, Donauisar Klinikum Deggendorf, und Klinik für Neurologie der Universitätsklinik Regensburg am BKH Regensburg, Regensburg
| | - Christian Putensen
- Klinik und Poliklinik für Anästhesiologie und Operative Intensivmedizin, Universitätsklinikum Bonn, Bonn
| | - Dorit Schimandl
- Klinik für Pneumologie, Beatmungszentrum, Zentralklinik Bad Berka GmbH, Bad Berka
| | - Bernd Schönhofer
- Klinik für Innere Medizin, Pneumologie und Intensivmedizin, Evangelisches Klinikum Bethel, Universitätsklinikum Ost Westphalen-Lippe, Bielefeld
| | | | - Stephan Walterspacher
- Medizinische Klinik - Sektion Pneumologie, Klinikum Konstanz und Lehrstuhl für Pneumologie, Universität Witten-Herdecke, Witten
| | - Wolfram Windisch
- Lungenklinik, Kliniken der Stadt Köln gGmbH, Lehrstuhl für Pneumologie Universität Witten/Herdecke, Köln
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Oliveira DSD, Firmo RC, Silva Júnior JRD. Comparação da Mortalidade entre Pacientes com Neoplasias submetidos à Ventilação Invasiva e não Invasiva: Estudo de Coorte Retrospectiva. REVISTA BRASILEIRA DE CANCEROLOGIA 2022. [DOI: 10.32635/2176-9745.rbc.2022v68n3.2466] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/14/2022] Open
Abstract
Introdução: O paciente com câncer apresenta alta prevalência de insuficiência respiratória aguda (IRpA) relacionada a complicações do tratamento oncológico. O suporte ventilatório mecânico e a principal terapêutica para resolução dessas complicações. No entanto, tal recurso pode aumentar a mortalidade. Objetivo: Verificar a taxa de mortalidade e os fatores intervenientes de pacientes oncológicos com IRpA expostos a ventilação mecânica invasiva (VMI) e não invasiva (VNI). Método: Estudo de coorte retrospectiva. Foram incluídos 121 pacientes oncológicos em ventilação mecânica separados em grupos: neoplasias hematológicas em VMI (HVMI, n=17), neoplasias hematológicas em VNI (HVNI, n=36), neoplasias solidas em VMI (SVMI, n=39) e neoplasias solidas em VNI (SVNI, n=29). Os desfechos avaliados foram: taxa de mortalidade, tempo de internamento, tempo de exposição a ventilação mecânica, taxa de falha da VNI e fatores relacionados a falha da VNI. Resultados: A taxa de mortalidade geral foi de 47,9%, distribuídos em HVMI (82,4%), HVNI (27,8%), SVMI (69,2%) e SVNI (24,1%). O escore APACHE III elevado foi associado a uma maior taxa de mortalidade. A taxa de mortalidade associada a falha da VNI foi de 71,4% HVNI e 77,8% SVNI. As variáveis associadas a maior taxa de falha da VNI foram o APACHE III>7 e o tempo de exposição a VNI>72 horas. Conclusão: A taxa de mortalidade de pacientes com neoplasia hematológica e solida em IRpA mostrou-se menor em pacientes expostos a VNI.
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Shen CI, Yang SY, Chiu HY, Chen WC, Yu WK, Yang KY. Prognostic factors for advanced lung cancer patients with do-not-intubate order in intensive care unit: a retrospective study. BMC Pulm Med 2022; 22:245. [PMID: 35751074 PMCID: PMC9229461 DOI: 10.1186/s12890-022-02042-7] [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: 02/11/2022] [Accepted: 06/16/2022] [Indexed: 11/23/2022] Open
Abstract
Background The survival of patients with lung cancer undergoing critical care has improved. An increasing number of patients with lung cancer have signed a predefined do-not-intubate (DNI) order before admission to the intensive care unit (ICU). These patients may still be transferred to the ICU and even receive non-invasive ventilation (NIV) support. However, there is still a lack of prognostic predictions in this cohort. Whether patients will benefit from ICU care remains unclear. Methods We retrospectively collected data from patients with advanced lung cancer who had signed a DNI order before ICU admission in a tertiary medical center between 2014 and 2016. The clinical characteristics and survival outcomes were discussed. Results A total of 140 patients (median age, 73 years; 62.1% were male) were included, had been diagnosed with stage III or IV non-small cell lung cancer (NSCLC) (AJCC 7th edition), and signed a DNI. Most patients received NIV during ICU stay. The median APACHE II score was 14 (standard error [SE], ± 0.66) and the mean PaO2/FiO2 ratio (P/F ratio) was 174.2 (SD, ± 104 mmHg). The APACHE II score was significantly lower in 28-day survivors (survivor: 12 (± 0.98) vs. non-survivor: 15 (± 0.83); p = 0.019). The P/F ratio of the survivors was higher than that of non-survivors (survivors: 209.6 ± 111.4 vs. non-survivors: 157.9 ± 96.7; p = 0.006). Patients with a P/F ratio ≥ 150 had better 28-day survival (p = 0.005). By combining P/F ratio ≥ 150 and APACHE II score < 16, those with high P/F ratios and low APACHE II scores during ICU admission had a notable 28-day survival compared with the rest (p < 0.001). These prognostic factors could also be applied to 90-day survival (p = 0.003). The prediction model was significant for those with driver mutations in 90-day survival (p = 0.021). Conclusions P/F ratio ≥ 150 and APACHE II score < 16 were significant prognostic factors for critically ill patients with lung cancer and DNI. This prediction could be applied to 90-day survival in patients with driver mutations. These findings are informative for clinical practice and decision-making. Supplementary Information The online version contains supplementary material available at 10.1186/s12890-022-02042-7.
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Affiliation(s)
- Chia-I Shen
- Department of Chest Medicine, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei, 112, Taiwan.,School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, 155, Section 2, Linong Street, Taipei, 112, Taiwan.,Institute of Clinical Medicine, College of Medicine, National Yang Ming Chiao Tung University, 155, Section 2, Linong Street, Taipei, 112, Taiwan
| | - Shan-Yao Yang
- Department of Chest Medicine, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei, 112, Taiwan
| | - Hwa-Yen Chiu
- School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, 155, Section 2, Linong Street, Taipei, 112, Taiwan.,Department of Internal Medicine, Taipei Veterans General Hospital Hsinchu Branch, Hsinchu County, Taiwan.,Institute of Biophotonics, National Yang Ming Chiao Tung University, 155, Section 2, Linong Street, Taipei, 112, Taiwan
| | - Wei-Chih Chen
- Department of Chest Medicine, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei, 112, Taiwan.,School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, 155, Section 2, Linong Street, Taipei, 112, Taiwan.,Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang Ming Chiao Tung University, 155, Section 2, Linong Street, Taipei, 112, Taiwan
| | - Wen-Kuang Yu
- Department of Chest Medicine, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei, 112, Taiwan.,School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, 155, Section 2, Linong Street, Taipei, 112, Taiwan
| | - Kuang-Yao Yang
- Department of Chest Medicine, Taipei Veterans General Hospital, 201, Section 2, Shih-Pai Road, Taipei, 112, Taiwan. .,School of Medicine, College of Medicine, National Yang Ming Chiao Tung University, 155, Section 2, Linong Street, Taipei, 112, Taiwan. .,Institute of Emergency and Critical Care Medicine, College of Medicine, National Yang Ming Chiao Tung University, 155, Section 2, Linong Street, Taipei, 112, Taiwan. .,Cancer Progression Research Center, National Yang Ming Chiao Tung University, 155, Section 2, Linong Street, Taipei, 112, Taiwan.
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Johnny JD. Risk Stratification in Noninvasive Respiratory Support Failure: A Narrative Review. Crit Care Nurse 2022; 42:62-67. [PMID: 35640897 DOI: 10.4037/ccn2022156] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
Abstract
TOPIC/CLINICAL RELEVANCE The use of noninvasive respiratory support, including noninvasive ventilation and high-flow nasal cannula therapy, has increased over the years. Failure of noninvasive respiratory support, defined as the need for invasive mechanical ventilation, increases the mortality rate. PURPOSE To familiarize critical care nurses with available risk stratification assessments and identify common concepts and limitations. CONTENT COVERED Few risk stratification assessments are available to identify patients at risk of failure of noninvasive respiratory support. Although many studies have analyzed risk, substantial variation in study design, definitions, terminology, and outcomes have led to a wide range of findings, making clinical application difficult. Further study is needed to broaden known assessments to general patient populations, determine diagnostic accuracy during critical periods, and analyze noninvasive ventilation and high-flow nasal cannula therapy. Risk stratification could allow for better implementation of preventive strategies and patient education. CONCLUSION Future research opportunities include improving study design for risk stratification and implementing preventive strategies for patients requiring noninvasive respiratory support. Clinically, risk stratification can provide an opportunity to share knowledge and facilitate conversations with patients and families.
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Affiliation(s)
- Jace D Johnny
- Jace D. Johnny is a nurse practitioner in the Pulmonary and Critical Care Division at University of Utah Health, Salt Lake City, Utah
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Man MY, Shum HP, Lam SM, Li J, Yan WW, Yeung MW. Effect of the underlying malignancy on critically ill septic patient's outcome. Asia Pac J Clin Oncol 2021; 18:473-480. [PMID: 34818459 DOI: 10.1111/ajco.13638] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2021] [Accepted: 06/26/2021] [Indexed: 11/27/2022]
Abstract
BACKGROUND Sepsis is an important cause of mortality and morbidity among critically ill patients with underlying malignancy. METHODS Patients with sepsis admitted to the intensive care unit (ICU) of the Pamela Youde Nethersole Eastern Hospital from January 1, 2010 to April 30, 2019 were recruited. Demographics, laboratory parameter, and outcome were analyzed. Those with underlying malignancy were matched with those without malignancy based on their severity of organ failure (defined by the sequential organ failure assessment [SOFA] score) and septic source. RESULTS Two hundred sixty-three patients with underlying active malignancy were matched with 259 patients without malignancy. Those with malignancy had higher APACHE IV score (89 vs. 83), lower albumin (22.1 vs. 24.4), neutrophil count (6.0 vs. 9.3), hemoglobin (8.0 vs. 9.8), platelet count (113 vs. 133), less use of mechanical ventilation (35.7% vs. 45.9%), renal replacement therapy (22.1% vs. 28.2%) and vasopressor (66.2% vs. 74.9%), higher 30-day (34.2% vs. 24.3%) ICU (22.4% vs. 18.9%), and 1-year (62.4% vs. 36.7%) mortality compared with those without malignancy. A higher APACHE IV score and pulmonary sepsis were predictors of 30-day mortality by Cox regression analysis. CONCLUSION Disease severity and pulmonary sepsis, but not underlying malignancy, predicted short-term mortality among critically ill septic patients.
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Affiliation(s)
- Man-Yee Man
- Department of Intensive care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Hoi-Ping Shum
- Department of Intensive care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Sin-Man Lam
- Department of Intensive care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Jacky Li
- Department of Intensive care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Wing-Wa Yan
- Department of Intensive care, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
| | - Mei-Wan Yeung
- Department of Clinical Oncology, Pamela Youde Nethersole Eastern Hospital, Chai Wan, Hong Kong
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Rice DR, Hyer JM, Tsilimigras D, Pawlik TM. Implications of intensive care unit admissions among medicare beneficiaries following resection of pancreatic cancer. J Surg Oncol 2021; 125:405-413. [PMID: 34608989 DOI: 10.1002/jso.26710] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Revised: 09/24/2021] [Accepted: 09/28/2021] [Indexed: 01/22/2023]
Abstract
BACKGROUND Intensive care unit (ICU) use has increased among patients with cancer. We sought to define factors associated with ICU admissions among patients with pancreatic cancer and characterize trends in mortality among hospital survivors. METHODS The Surveillance, Epidemiology, and End Results (SEER)-Medicare linked database was used to identify patients with pancreatic cancer who underwent resection. Multivariable analyses were conducted to identify factors associated with ICU admission and mortality among hospital survivors. RESULTS Among 6422 Medicare beneficiaries who underwent resection of pancreatic cancer, 2386 (37.1%) had an ICU admission. Patients with ICU admissions were more likely to be younger (10-year increase odds ratio [OR]: 0.83, 95% confidence interval [CI]: 0.77-0.89), male (OR: 1.17, 95% CI 1.05-1.30) and undergo resection at a teaching hospital (OR: 1.19, 95% CI: 1.05-1.36). While the majority of patients survived to hospital discharge (n = 2106; 88.3%), a majority of patients (n = 1296; 54.3%) died within 6 months. Among patients who had subsequent ICU admissions, 1- and 5-year survival was only 31.8% and 11.0%, respectively. CONCLUSIONS Over one-third of patients with pancreatic cancer had an ICU admission. While most patients survived hospitalization, more than one-half of patients died within 6 months of discharge and two-thirds died within 1 year. These data should serve to guide patient-provider discussions around prognosis relative to ICU utilization.
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Affiliation(s)
- Daniel R Rice
- The Ohio State Wexner Medical Center, James Cancer Center, Columbus, Ohio, USA
| | - J Madison Hyer
- The Ohio State Wexner Medical Center, James Cancer Center, Columbus, Ohio, USA
| | | | - Timothy M Pawlik
- The Ohio State Wexner Medical Center, James Cancer Center, Columbus, Ohio, USA
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Kızılgöz D, Akın Kabalak P, Kavurgacı S, İnal Cengiz T, Yılmaz Ü. The success of non-invasive mechanical ventilation in lung cancer patients with respiratory failure. Int J Clin Pract 2021; 75:e14712. [PMID: 34383989 DOI: 10.1111/ijcp.14712] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2021] [Accepted: 07/26/2021] [Indexed: 11/28/2022] Open
Abstract
INTRODUCTION AND AIM Despite the improvement in survival among patients with lung cancer as a result of the development of novel treatment options, acute respiratory failure (ARF), which may occur because of the disease itself, comorbidities or complications in treatment may be life threatening. The most commonly utilised treatment option in cancer patients with ARF is invasive mechanical ventilation (IMV). The prognosis of lung cancer patients admitted to the intensive care unit is poor. The use of non-invasive mechanical ventilation (NIMV) in the setting of ARF not only supports the respiratory muscles and facilitates alveolar ventilation and airway patency, but also reduces the risk of serious complications of IMV, such as ventilator-associated pneumonia. NIMV treatment in the event of respiratory failure has been associated with a high rate of mortality in recently diagnosed or progressive lung cancer with organ failure. However, studies in this regard are limited, and the role of NIMV has yet to be investigated in patients in hospital wards. Accordingly, the present study investigates retrospectively the success of NIMV among patients with lung cancer (including all stages and histopathological types) in a hospital ward setting and the influential factors. MATERIAL AND METHOD The data of 42 patients with lung cancer and respiratory failure who were admitted to the palliative care service and received NIMV between 2014 and 2018 were reviewed retrospectively. Demographic features, comorbidities, respiratory failure types, rate of withdrawal from NIMV, frequencies of tracheostomy and intubation, bacteriologic examination of the airway samples, rate of discharge from hospital and any history of NIMV/USOT use at home were recorded. NIMV success was defined as the discharge of the patient from the hospital, with or without a respiratory support device. The primary end-point of the study was NIMV success, while the secondary end-point was NIMV success with respect to the underlying diagnosis and respiratory failure type. RESULTS A total of 42 patients (38 males and 4 females) were included in the study, with a mean age of 67.4 ± 9.5 years. The rate of discharge from hospital was 71% across the entire study population, among which, 13 (31%) were discharged with USOT and 16 (38.1%) with NIMV. Among the 12 patients under palliative supportive treatment, 8 were discharged from the hospital. The success rates of NIMV in the respiratory failure aetiological subgroups were: 66% (12 patients) in the pneumonia subgroup and 71.4% (15 patients) in the COPD subgroup. The difference between these subgroups was not significant (P = .841). The success rate of NIMV in the hypercapnic and hypoxaemic respiratory failure subgroups was 72.7% (24 patients) and 66.6% (6 patients), respectively. There were no significant differences between the type of respiratory failure subgroups (P = .667). The success rate of NIMV was similar in patients with a positive airway sample microbiology (71.4%, n = 14) and those with no growth identified in the culture (70.3%, n = 28) (P = .834). CONCLUSION In lung cancer patients with no contraindication, NIMV can be used to reduce or postpone the need for ICU admission, independent of disease stage, cellular type and underlying cause.
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Affiliation(s)
- Derya Kızılgöz
- Atatürk Chest Diseases and Thoracic Surgery Education and Research Hospital, Ankara, Turkey
| | - Pınar Akın Kabalak
- Atatürk Chest Diseases and Thoracic Surgery Education and Research Hospital, Ankara, Turkey
| | - Suna Kavurgacı
- Atatürk Chest Diseases and Thoracic Surgery Education and Research Hospital, Ankara, Turkey
| | - Tuba İnal Cengiz
- Atatürk Chest Diseases and Thoracic Surgery Education and Research Hospital, Ankara, Turkey
| | - Ülkü Yılmaz
- Atatürk Chest Diseases and Thoracic Surgery Education and Research Hospital, Ankara, Turkey
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Dumas G, Lemiale V, Rathi N, Cortegiani A, Pène F, Bonny V, Salluh J, Albaiceta GM, Soares M, Soubani AO, Canet E, Hanane T, Kouatchet A, Mokart D, Lebiedz P, Türkoğlu M, Coudroy R, Jeon K, Demoule A, Mehta S, Caruso P, Frat JP, Yang KY, Roca O, Laffey J, Timsit JF, Azoulay E, Darmon M. Survival in Immunocompromised Patients Ultimately Requiring Invasive Mechanical Ventilation: A Pooled Individual Patient Data Analysis. Am J Respir Crit Care Med 2021; 204:187-196. [PMID: 33751920 DOI: 10.1164/rccm.202009-3575oc] [Citation(s) in RCA: 25] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Rationale: Acute respiratory failure (ARF) is associated with high mortality in immunocompromised patients, particularly when invasive mechanical ventilation is needed. Therefore, noninvasive oxygenation/ventilation strategies have been developed to avoid intubation, with uncertain impact on mortality, especially when intubation is delayed. Objectives: We sought to report trends of survival over time in immunocompromised patients receiving invasive mechanical ventilation. The impact of delayed intubation after failure of noninvasive strategies was also assessed. Methods: Systematic review and meta-analysis using individual patient data of studies that focused on immunocompromised adult patients with ARF requiring invasive mechanical ventilation. Studies published in English were identified through PubMed, Web of Science, and Cochrane Central (2008-2018). Individual patient data were requested from corresponding authors for all identified studies. We used mixed-effect models to estimate the effect of delayed intubation on hospital mortality and described mortality rates over time. Measurements and Main Results: A total of 11,087 patients were included (24 studies, three controlled trials, and 21 cohorts), of whom 7,736 (74%) were intubated within 24 hours of ICU admission (early intubation). The crude mortality rate was 53.2%. Adjusted survivals improved over time (from 1995 to 2017, odds ratio [OR] for hospital mortality per year, 0.96 [0.95-0.97]). For each elapsed day between ICU admission and intubation, mortality was higher (OR, 1.38 [1.26-1.52]; P < 0.001). Early intubation was significantly associated with lower mortality (OR, 0.83 [0.72-0.96]), regardless of initial oxygenation strategy. These results persisted after propensity score analysis (matched OR associated with delayed intubation, 1.56 [1.44-1.70]). Conclusions: In immunocompromised intubated patients, survival has improved over time. Time between ICU admission and intubation is a strong predictor of mortality, suggesting a detrimental effect of late initial oxygenation failure.
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Affiliation(s)
- Guillaume Dumas
- Medical ICU, Saint-Louis Teaching Hospital, Paris, France.,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Université de Paris, Paris, France
| | - Virginie Lemiale
- Medical ICU, Saint-Louis Teaching Hospital, Paris, France.,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Université de Paris, Paris, France
| | - Nisha Rathi
- Department of Critical Care, MD Anderson Cancer Center, Houston, Texas
| | - Andrea Cortegiani
- Department of Surgical, Oncological and Oral Sciences, University of Palermo, Palermo, Italy
| | - Frédéric Pène
- Medical ICU, Cochin Teaching Hospital, Paris, France
| | - Vincent Bonny
- Medical ICU, Saint-Louis Teaching Hospital, Paris, France.,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Université de Paris, Paris, France
| | - Jorge Salluh
- The Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Guillermo M Albaiceta
- Instituto de Investigación Sanitaria del Principado de Asturias, Unidad de Cuidados Intensivos Cardiológicos, Hospital Universitario Central de Asturias, Instituto Universitario de Oncología del Principado de Asturias, Oviedo, Spain.,CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain
| | - Marcio Soares
- The Department of Critical Care and Graduate Program in Translational Medicine, D'Or Institute for Research and Education, Rio de Janeiro, Brazil
| | - Ayman O Soubani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, Detroit, Michigan
| | | | - Tarik Hanane
- Department of Critical Care, Cleveland Clinic, Cleveland, Ohio
| | | | | | - Pia Lebiedz
- ICU, Evangelisches Krankenhaus, Oldenburg, Germany
| | - Melda Türkoğlu
- Medical ICU, Gazi University School of Medicine, Ankara, Turkey
| | - Rémi Coudroy
- CHU de Poitiers, Médecine Intensive Réanimation, Poitiers, France.,INSERM CIC1402, groupe ALIVE, Université de Poitiers, Poitiers, France
| | - Kyeongman Jeon
- Department of Critical Care Medicine and.,Division of Pulmonary and Critical Care Medicine, Department of Medicine, Samsung Medical Center, Sungkyunkwan University School of Medicine, Irwon-ro, Gangnam-gu, Seoul, Korea
| | - Alexandre Demoule
- APHP Sorbonne Université site Pitié-Salpêtrière, Service de Pneumologie, Médecine Intensive et Réanimation (Département R3S) and INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Sorbonne Université, Paris, France
| | - Sangeeta Mehta
- Medical Surgical ICU, Mount Sinai Hospital, University of Toronto, Toronto, Ontario, Canada
| | - Pedro Caruso
- Intensive Care Unit, AC Camargo Cancer Center, São Paulo, Brazil
| | - Jean-Pierre Frat
- CHU de Poitiers, Médecine Intensive Réanimation, Poitiers, France.,INSERM CIC1402, groupe ALIVE, Université de Poitiers, Poitiers, France
| | - Kuang-Yao Yang
- Department of Chest Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.,School of Medicine, National Yang-Ming University, Taipei, Taiwan
| | - Oriol Roca
- CIBER Enfermedades Respiratorias, Instituto de Salud Carlos III, Madrid, Spain.,Servei de Medicina Intensiva, Hospital Universitari Vall d'Hebron, Institut de Recerca Vall d'Hebron, Barcelona, Spain.,Departament de Medicina, Universitat Autònoma de Barcelona, Bellaterra, Spain
| | - John Laffey
- Department of Anesthesia and.,Department of Intensive Care Medicine, NUI Galway, Ireland; and
| | - Jean-François Timsit
- Medical and Infectious Diseases ICU, Bichat-Claude Bernard Hospital, UMR 1137 Inserm, Université de Paris, IAME, Paris, France
| | - Elie Azoulay
- Medical ICU, Saint-Louis Teaching Hospital, Paris, France.,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Université de Paris, Paris, France
| | - Michael Darmon
- Medical ICU, Saint-Louis Teaching Hospital, Paris, France.,ECSTRA Team, Biostatistics and Clinical Epidemiology, UMR 1153 (Center of Epidemiology and Biostatistics Sorbonne Paris Cité, CRESS), INSERM, Université de Paris, Paris, France
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9
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Arranz M, Jacob J, Sancho-Ramoneda M, Lopez À, Navarro-Sáez MC, Cousiño-Chao JR, López-Altimiras X, López I Vengut F, García-Trallero O, German A, Farré-Cerdà J, Zorrilla J. Characteristics and Prognosis of Patients Who Receive Noninvasive Ventilation and Present Limitation of Life Support Treatment: The LLST-NIVCat Multicenter Cohort Study. J Emerg Med 2020; 59:477-484. [PMID: 32684380 DOI: 10.1016/j.jemermed.2020.06.012] [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: 01/11/2020] [Revised: 05/16/2020] [Accepted: 06/01/2020] [Indexed: 06/11/2023]
Abstract
BACKGROUND Patients who receive noninvasive ventilation (NIV) in the emergency department (ED) sometimes have a limitation of life support treatment (LLST). The characteristics and prognosis in these patients may be worse, however, few studies have been carried out in this respect. OBJECTIVE Analyze the differences between patients receiving NIV in the ED with LLST (NIV-LLST) or without LLST (NIV-noLLST) and their impact on in-hospital mortality, as well as investigate in-hospital mortality in the NIV-LLST group. METHOD We performed a secondary analysis of data from the NIVCat registry. This was a prospective, multicenter, analytical cohort study with consecutive inclusion of patients receiving NIV from February to March 2015 in 11 hospital EDs in Spain. Data on the baseline characteristics, the acute episode, and final patient destination were collected. The dependent variable was all-cause in-hospital mortality. RESULTS We analyzed 152 cases receiving NIV, 66 (43.4%) of whom had NIV-LLTS. Age ≥ 75 years was associated with NIV-LLST. In-hospital mortality was higher in the NIV-LLST group, with an adjusted hazard ratio of 2.50 (95% confidence interval [CI] 1.03-6.06). Patients with NIV-LLST presenting an exacerbation of chronic obstructive pulmonary disease (COPD) presented the lowest mortality, with an odds ratio of 0.27 (95% confidence interval 0.08-0.93), compared with the remaining patients. CONCLUSION In our cohort of patients receiving NIV in the ED, the presence of LLST is frequent and is associated with high hospital mortality. The NIV-LLST patients with a COPD exacerbation have a better prognosis than NIV-LLST patients with other diseases.
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Affiliation(s)
- María Arranz
- Emergency Department, Hospital de Viladecans, Barcelona, Spain
| | - Javier Jacob
- Emergency Department, Hospital Universitari de Bellvitge, L'Hospitalet de Llobregat, Barcelona, Spain
| | | | - Àngels Lopez
- Sistema d'Emergències Mèdiques, Barcelona, Spain
| | | | | | | | - Francesc López I Vengut
- Emergency Department, Parc sanitari Sant Joan de Déu, Sant Boi de Llobregat, Barcelona, Spain
| | | | - Antonio German
- Emergency Department, Hospital Universitari Mútua de Terrassa, Barcelona, Spain
| | - Jaume Farré-Cerdà
- Emergency Department, Hospital Sant Pau i Santa Tecla, Tarragona, Spain
| | - José Zorrilla
- Emergency Department, Xarxa Assistencial de Manresa, Fundació Althaia, Barcelona, Spain
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10
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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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11
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Pinsolle J, Terzi N, Ferrer L, Giaj Levra M, Toffart AC, Moro-Sibilot D. Les avancées dans la prise en charge des cancers bronchopulmonaires : ce qui change pour le réanimateur. MEDECINE INTENSIVE REANIMATION 2019. [DOI: 10.3166/rea-2019-0091] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
Abstract
Le cancer bronchopulmonaire (CBP) est la première cause de mortalité par cancer en France et dans le monde, mais son pronostic tend à s’améliorer depuis une dizaine d’années grâce à de nouvelles classes de traitements : l’immunothérapie et les thérapies ciblées. L’immunothérapie stimule le système immunitaire afin d’engendrer une réponse antitumorale. Ces molécules peuvent être prescrites chez la plupart des patients avec un CBP non à petites cellules (CBNPC) métastatique et entraînent parfois des réponses tumorales majeures et durables pouvant dépasser les 24 mois. Toutefois, cette efficacité concerne entre 20 et 50 % des patients selon la ligne de traitement. Les thérapies ciblées sont des traitements oraux visant les cellules tumorales porteuses d’anomalies génétiques spécifiques (addictions oncogéniques) et intéressent moins de 15 % des patients avec CBNPC, majoritairement les non-fumeurs. Les deux principales sont les mutations du gène de l’epithelial growth factor receptor (EGFR) et les réarrangements d’anaplastic lymphoma kinase (ALK). Ces anomalies peuvent être diagnostiquées en quelques jours, parfois sur un prélèvement sanguin (biopsie liquide pour détecter les mutations EGFR). Les thérapies ciblées améliorent la survie globale des patients dont la médiane dépasse les 30 mois. Toutefois, ces deux classes de traitement entraînent des toxicités spécifiques, fréquentes mais souvent bénignes. Les hospitalisations en réanimation des patients porteurs de CBNPC sont croissantes. L’amélioration du pronostic de ces patients est à prendre en compte lors de la discussion d’admission en réanimation sans conduire à des prises en charge déraisonnables.
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