Non-invasive ventilation indication for critically ill cancer patients admitted to the intensive care unit for acute respiratory failure (ARF) with associated cardiac dysfunction: Results from an observational study

High-flow nasal cannula failure in critically ill cancer patients with acute respiratory failure: Moving from avoiding intubation to avoiding delayed intubation

Background

High-flow nasal cannula (HFNC) is increasingly used in critically ill cancer patients with acute respiratory failure (ARF) to avoid mechanical ventilation (MV). The objective was to assess prognostic factors associated with mortality in ICU cancer patients requiring MV after HFNC failure, and to identify predictive factors of intubation.

Methods

We conducted a retrospective study from 2012–2016 in a cancer referral center. All consecutive onco-hematology adult patients admitted to the ICU treated with HFNC were included. HFNC failure was defined by intubation requirement.

Results

202 patients were included, 104 successfully treated with HFNC and 98 requiring intubation. ICU and hospital mortality rates were 26.2% (n = 53) and 42.1% (n = 85) respectively, and 53.1% (n = 52) and 68.4% (n = 67) in patients requiring MV. Multivariate analysis identified 4 prognostic factors of hospital mortality after HFNC failure: complete/partial remission (OR = 0.2, 95%CI = 0.04–0.98, p<0.001) compared to patients with refractory/relapse disease (OR = 3.73, 95%CI = 1.08–12.86), intubation after day 3 (OR = 7.78, 95%CI = 1.44–41.96), number of pulmonary quadrants involved on chest X-ray (OR = 1.93, 95%CI = 1.14–3.26, p = 0.01) and SAPSII at ICU admission (OR = 1.06, 95%CI = 1–1.12, p = 0.019). Predictive factors of intubation were the absence of sepsis (sHR = 0.32, 95%CI = 0.12–0.74, p = 0.0087), Sp02<95% 15 minutes after HFNC initiation (sHR = 2.05, 95%CI = 1.32–3.18, p = 0.0014), number of quadrants on X-ray (sHR = 1.73, 95%CI = 1.46–2.06, p<0.001), Fi02>60% at HFNC initiation (sHR = 3.12, 95%CI = 2.06–4.74, p<0.001) and SAPSII at ICU admission (sHR = 1.03, 95%CI = 1.02–1.05, p<0.01).

Conclusion

Duration of HFNC may be predictive of an excess mortality in ARF cancer patients. Early warning scores to predict HFNC failure are needed to identify patients who would benefit from early intubation.

Management strategy for hematological malignancy patients with acute respiratory failure

Acute respiratory failure (ARF) is still the major cause of intensive care unit (ICU) admission for hematological malignancy (HM) patients although the advance in hematology and supportive care has greatly improved the prognosis. Clinicians have to make decisions whether the HM patients with ARF should be sent to ICU and which ventilation support should be administered. Based on the reported investigations related to management of HM patients with ARF, we propose a selection procedure to manage this population and recommend hematological ICU as the optimal setting to recuse these patients, where hematologists and intensivists can collaborate closely and improve the outcomes. Moreover, noninvasive ventilation (NIV) still has its own place for selected HM patients with ARF who have mild hypoxemia and reversible causes. It is also crucial to monitor the efficacy of NIV closely and switch to invasive mechanical ventilation at appropriate timing when NIV shows no apparent improvement. Otherwise, early IMV should be initiated to HM with ARF who have moderate and severe hypoxemia, adult respiratory distress syndrome, multiple organ dysfunction, and unstable hemodynamic. More studies are needed to elucidate the predictors of ICU mortality and ventilatory mode for HM patients with ARF.