Noninvasivepositive pressure ventilation vsinvasive mechanical ventilation as first-line therapy for acute hypoxemic respiratory failure in cancer patients

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

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

First-Line Respiratory Support for Children With Hematologic Malignancy and Acute Respiratory Failure

OBJECTIVES

To characterize trends in noninvasive ventilation (NIV) and invasive mechanical ventilation (IMV) use over time in children with hematologic malignancy admitted to the PICU with acute respiratory failure (ARF), and to identify risk factors associated with NIV failure requiring transition to IMV.

DESIGN

Retrospective cohort analysis using the Virtual Pediatric Systems (VPS, LLC) between January 1, 2010 and December 31, 2019.

SETTING

One hundred thirteen North American PICUs participating in VPS.

PATIENTS

Two thousand four hundred eighty children 0-21 years old with hematologic malignancy admitted to participating PICUs for ARF requiring respiratory support.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

There were 3013 total encounters, of which 868 (28.8%) received first-line NIV alone (NIV only), 1544 (51.2%) received first-line IMV (IMV only), and 601 (19.9%) required IMV after a failed NIV trial (NIV failure). From 2010 to 2019, the NIV only group increased from 9.6% to 43.1% and the IMV only group decreased from 80.1% to 34.2% (p < 0.001). The NIV failure group had the highest mortality compared with NIV only and IMV only (36.6% vs. 8.1%, vs. 30.5%, p < 0.001). However, risk-of-mortality (ROM) was highest in the IMV only group compared with NIV only and NIV failure (median Pediatric Risk of Mortality III ROM 8.1% vs. 2.8% vs. 5.5%, p < 0.001). NIV failure patients also had the longest median PICU length of stay compared with the other two study groups (15.2 d vs. 6.1 and 9.0 d, p < 0.001). Higher age was associated with significantly decreased odds of NIV failure, and diagnosis of non-Hodgkin lymphoma was associated with significantly increased odds of NIV failure compared with acute lymphoid leukemia.

CONCLUSIONS

For children with hematologic malignancy admitted to the PICU with ARF, NIV has replaced IMV as the most common initial therapy. NIV failure rate remains high with high-observed mortality despite lower PICU admission ROM.

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.

[Non-invasive Mechanical Ventilation in Acute Respiratory Failure. Clinical Practice Guidelines - on behalf of the German Society of Pneumology and Ventilatory Medicine]

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.

Comparação da Mortalidade entre Pacientes com Neoplasias submetidos à Ventilação Invasiva e não Invasiva: Estudo de Coorte Retrospectiva

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.

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

PURPOSE

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

METHODS

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

RESULTS

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

CONCLUSION

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

Effectiveness of an adapted diving mask (Owner mask) for non-invasive ventilation in the COVID-19 pandemic scenario: study protocol for a randomized clinical trial

Background

Non-invasive ventilation (NIV) is indicated to avoid orotracheal intubation (OTI) to reduce hospital stay and mortality. Patients infected by SARS-CoV2 can progress to respiratory failure (RF); however, in the initial phase, they can be submitted to oxygen therapy and NIV. Such resources can produce aerosol and can cause a high risk of contagion to health professionals. Safe NIV strategies are sought, and therefore, the authors adapted diving masks to be used as NIV masks (called an Owner mask).

Objective

To assess the Owner mask safety and effectiveness regarding conventional orofacial mask for patients in respiratory failure with and without confirmation or suspicion of COVID-19.

Methods

A Brazilian multicentric study to assess patients admitted to the intensive care unit regarding their clinical, sociodemographic and anthropometric data. The primary outcome will be the rate of tracheal intubation, and secondary outcomes will include in-hospital mortality, the difference in PaO₂/FiO₂ ratio and PaCO₂ levels, time in the intensive care unit and hospitalization time, adverse effects, degree of comfort and level of satisfaction of the mask use, success rate of NIV (not progressing to OTI), and behavior of the ventilatory variables obtained in NIV with an Owner mask and with a conventional face mask. Patients with COVID-19 and clinical signs indicative of RF will be submitted to NIV with an Owner mask [NIV Owner COVID Group (n = 63)] or with a conventional orofacial mask [NIV orofacial COVID Group (n = 63)], and those patients in RF due to causes not related to COVID-19 will be allocated into the NIV Owner Non-COVID Group (n = 97) or to the NIV Orofacial Non-COVID Group (n = 97) in a randomized way, which will total 383 patients, admitting 20% for loss to follow-up.

Discussion

This is the first randomized and controlled trial during the COVID-19 pandemic about the safety and effectiveness of the Owner mask compared to the conventional orofacial mask. Experimental studies have shown that the Owner mask enables adequate sealing on the patient’s face and the present study is relevant as it aims to minimize the aerosolization of the virus in the environment and improve the safety of health professionals.

Trial registration

Brazilian Registry of Clinical Trials (ReBEC): RBR – 7xmbgsz. Registered on 15 April 2021.

Prehospital noninvasive positive pressure ventilation for severe respiratory distress in adult patients: An updated meta-analysis

AIM

To compare the effect of prehospital noninvasive positive pressure ventilation (NIPPV) and standard care for severe respiratory distress.

BACKGROUND

Severe respiratory distress is an important cause of death in adult patients. There is a growing body of research exploring the benefits of nasal intermittent positive pressure ventilation (NIPPV) for patients undergoing severe respiratory distress. However, a systematic review is needed to synthesise and summarise this body of knowledge to identify the effectiveness of NIPPV. This is an update of a meta-analysis first published in 2014.

DESIGN

Meta-analysis based on PRISMA guidelines.

METHODS

Databases including PubMed, Embase, Scopus and the Cochrane Library databases were electronically searched to identify randomised controlled trials (RCTs) that reported NIPPV therapy for adult patients with severe respiratory distress. The retrieval time is limited from inception to August 2021. Two reviewers independently screened literature, extracted data and assessed risk bias of included studies. Meta-analysis was performed by using STATA 11.0 software.

RESULTS

A total of 10 studies involving 1465 patients were included. The meta-analysis results showed that compared with standard care, CPAP therapy decreased intubation rate (RR = 0.43, 95% CI: 0.27-0.67, p < .001, I²  = 0.0%), reduced hospital stay (WMD = -4.19, 95% CI: -5.62, -2.77) and ICU stay (WMD = -0.65, 95% CI: -1.09, -0.20) for patients with severe respiratory distress. However, no significant effects of NIPPV were observed on in-hospital mortality (RR = 0.83, 95% CI: 0.64-1.07) and ICU admission rate (RR = 0.93, 95% CI: 0.73-1.19).

CONCLUSIONS

Adult patients with NIPPV treatment for severe respiratory distress had a significantly lower intubation rate and shorter hospital and ICU stay, compared with those with standard care. However, no effect of NIPPV on in-hospital mortality was observed. Further study is needed by enrolling large-sample original studies.

RELEVANCE TO CLINICAL PRACTICE

Among patients with severe respiratory distress, prehospital NIPPV, compared with standard care, was associated with lower intubation rate and shorter hospital and ICU stay in our study. Although our meta-analysis did not find a relationship between prehospital NIPPV and in-hospital mortality and ICU admission rate, which may be limited by the number of studies included and the small sample size. However, our study still suggested that the use of prehospital NIPPV was beneficial to the condition of patients with severe respiratory distress.

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.

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

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

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.

Epidemiology and prognosis of patients with a history of cancer admitted to intensive care. A multicenter observational study

OBJECTIVE

To assess the epidemiology and outcome at discharge of cancer patients requiring admission to the Intensive Care Unit (ICU).

DESIGN

A descriptive observational study was made of data from the ENVIN-HELICS registry, combined with specifically compiled variables. Comparisons were made between patients with and without neoplastic disease, and groups of cancer patients with a poorer outcome were identified.

SETTING

Intensive Care Units participating in ENVIN-HELICS 2018, with voluntary participation in the oncological registry.

PATIENTS

Subjects admitted during over 24 h and diagnosed with cancer in the last 5 years.

PRIMARY ENDPOINTS

The general epidemiological endpoints of the ENVIN-HELICS registry and cancer-related variables.

RESULTS

Of the 92 ICUs with full data, a total of 11,796 patients were selected, of which 1786 (15.1%) were cancer patients. The proportion of cancer patients per Unit proved highly variable (1%-48%). In-ICU mortality was higher among the cancer patients than in the non-oncological subjects (12.3% versus 8.9%; p < .001). Elective postoperative (46.7%) or emergency admission (15.3%) predominated in the cancer patients. Patients with medical disease were in more serious condition, with longer stay and greater mortality (27.5%). The patients admitted to the ICU due to nonsurgical disease related to cancer exhibited the highest mortality rate (31.4%).

CONCLUSIONS

Great variability was recorded in the percentage of cancer patients in the different ICUs. A total of 46.7% of the patients were admitted after undergoing scheduled surgery. The highest mortality rate corresponded to patients with medical disease (27.5%), and to those admitted due to cancer-related complications (31.4%).

Oxygenation Strategy During Acute Respiratory Failure in Critically-Ill Immunocompromised Patients

OBJECTIVES

To assess the response to initial oxygenation strategy according to clinical variables available at admission.

DESIGN

Multicenter cohort study.

SETTING

Thirty French and Belgium medical ICU.

SUBJECTS

Immunocompromised patients with hypoxemic acute respiratory failure.

INTERVENTIONS

None.

MEASUREMENTS AND MAIN RESULTS

Data were extracted from the Groupe de Recherche en Reanimation Respiratoire du patient d'Onco-Hématologie database. Need for invasive mechanical ventilation was the primary endpoint. Secondary endpoint was day-28 mortality. Six-hundred forty-nine patients were included. First oxygenation strategies included standard oxygen (n = 245, 38%), noninvasive ventilation (n = 285; 44%), high-flow nasal cannula oxygen (n = 55; 8%), and noninvasive ventilation + high-flow nasal cannula oxygen (n = 64; 10%). Bilateral alveolar pattern (odds ratio = 1.67 [1.03-2.69]; p = 0.04), bacterial (odds ratio = 1.98 [1.07-3.65]; p = 0.03) or opportunistic infection (odds ratio = 4.75 [2.23-10.1]; p < 0.001), noninvasive ventilation use (odds ratio = 2.85 [1.73-4.70]; p < 0.001), Sequential Organ Failure Assessment score (odds ratio = 1.19 [1.10-1.28]; p < 0.001), and ratio of PaO2 and FIO2 less than 100 at ICU admission (odds ratio = 1.96 [1.27-3.02]; p = 0.0002) were independently associated with intubation rate. Day-28 mortality was independently associated with bacterial (odds ratio = 2.34 [1.10-4.97]; p = 0.03) or opportunistic infection (odds ratio = 4.96 [2.11-11.6]; p < 0.001), noninvasive ventilation use (odds ratio = 2.35 [1.35-4.09]; p = 0.003), Sequential Organ Failure Assessment score (odds ratio = 1.19 [1.10-1.28]; p < 0.001), and ratio of PaO2 and FIO2 less than 100 at ICU admission (odds ratio = 1.97 [1.26-3.09]; p = 0.003). High-flow nasal cannula oxygen use was neither associated with intubation nor mortality rates.

CONCLUSIONS

Some clinical characteristics at ICU admission including etiology and severity of acute respiratory failure enable to identify patients at high risk for intubation.

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

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

Factors associated with non-invasive mechanical ventilation failure in patients with hematological neoplasia and their association with outcomes

Background

The usefulness of non-invasive mechanical ventilation (NIMV) in oncohematological patients is still a matter of debate.

Aim

To analyze the rate of noninvasive ventilation failure and the main characteristics associated with this endpoint in oncohematological patients with acute respiratory failure (ARF).

Methods

A ventilatory support protocol was developed and implemented before the onset of the study. According to the PaO₂/FiO₂ (P/F) ratio and clinical judgment, patients received supplementary oxygen therapy, NIMV, or invasive mechanical ventilation (IMV).

Results

Eighty-two patients were included, average age between 52.1 ± 16 years old; 44 (53.6%) were male. The tested protocol was followed in 95.1% of cases. Six patients (7.3%) received IMV, 59 (89.7%) received NIMV, and 17 (20.7%) received oxygen therapy. ICU mortality rates were significantly higher in the IMV (83.3%) than in the NIMV (49.2%) and oxygen therapy (5.9%) groups (P < 0.001). Among the 59 patients who initially received NIMV, 30 (50.8%) had to eventually be intubated. Higher SOFA score at baseline (1.35 [95% CI = 1.12-2.10], P = 0.007), higher respiratory rate (RR) (1.10 [95% CI = 1.00-1.22], P = 0.048), and sepsis on admission (16.9 [95% CI = 1.93-149.26], P = 0.011) were independently associated with the need of orotracheal intubation among patients initially treated with NIMV. Moreover, NIMV failure was independently associated with ICU (P < 0.001) and hospital mortality (P = 0.049), and mortality between 6 months and 1 year (P < 0.001).

Conclusion

The implementation of a NIMV protocol is feasible in patients with hematological neoplasia admitted to the ICU, even though its benefits still remain to be demonstrated. NIMV failure was associated with higher SOFA and RR and more frequent sepsis, and it was also related to poor prognosis.

Epidemiology and prognosis of patients with a history of cancer admitted to intensive care. A multicenter observational study

OBJECTIVE

To assess the epidemiology and outcome at discharge of cancer patients requiring admission to the Intensive Care Unit (ICU).

DESIGN

A descriptive observational study was made of data from the ENVIN-HELICS registry, combined with specifically compiled variables. Comparisons were made between patients with and without neoplastic disease, and groups of cancer patients with a poorer outcome were identified.

SETTING

Intensive Care Units participating in ENVIN-HELICS 2018, with voluntary participation in the oncological registry.

PATIENTS

Subjects admitted during over 24hours and diagnosed with cancer in the last 5 years.

PRIMARY ENDPOINTS

The general epidemiological endpoints of the ENVIN-HELICS registry and cancer-related variables.

RESULTS

Of the 92 ICUs with full data, a total of 11,796 patients were selected, of which 1786 (15.1%) were cancer patients. The proportion of cancer patients per Unit proved highly variable (1-48%). In-ICU mortality was higher among the cancer patients than in the non-oncological subjects (12.3% versus 8.9%; P<.001). Elective postoperative (46.7%) or emergency admission (15.3%) predominated in the cancer patients. Patients with medical disease were in more serious condition, with longer stay and greater mortality (27.5%). The patients admitted in ICU due to nonsurgical disease related to cancer exhibited the highest mortality rate (31.4%).

CONCLUSIONS

Great variability was recorded in the percentage of cancer patients in the different ICUs. A total of 46.7% of the patients were admitted after undergoing scheduled surgery. The highest mortality rate corresponded to patients with medical disease (27.5%), and to those admitted due to cancer-related complications (31.4%).

The chimeric antigen receptor-intensive care unit (CAR-ICU) initiative: Surveying intensive care unit practices in the management of CAR T-cell associated toxicities

PURPOSE

A task force of experts from 11 United States (US) centers, sought to describe practices for managing chimeric antigen receptor (CAR) T-cell toxicity in the intensive care unit (ICU).

MATERIALS AND METHODS

Between June-July 2019, a survey was electronically distributed to 11 centers. The survey addressed: CAR products, toxicities, targeted treatments, management practices and interventions in the ICU.

RESULTS

Most centers (82%) had experience with commercial and non-FDA approved CAR products. Criteria for ICU admission varied between centers for patients with Cytokine Release Syndrome (CRS) but were similar for Immune Effector Cell Associated Neurotoxicity Syndrome (ICANS). Practices for vasopressor support, neurotoxicity and electroencephalogram monitoring, use of prophylactic anti-epileptic drugs and tocilizumab were comparable. In contrast, fluid resuscitation, respiratory support, methods of surveillance and management of cerebral edema, use of corticosteroid and other anti-cytokine therapies varied between centers.

CONCLUSIONS

This survey identified areas of investigation that could improve outcomes in CAR T-cell recipients such as fluid and vasopressor selection in CRS, management of respiratory failure, and less common complications such as hemophagocytic lymphohistiocytosis, infections and stroke. The variability in specific treatments for CAR T-cell toxicities, needs to be considered when designing future outcome studies of critically ill CAR T-cell patients.

ISCCM Guidelines for the Use of Non-invasive Ventilation in Acute Respiratory Failure in Adult ICUs

A. ACUTE HYPERCAPNIC RESPIRATORY FAILURE A1. Acute Exacerbation of COPD: Recommendations: NIV should be used in management of acute exacerbation of COPD in patients with acute or acute-on-chronic respiratory acidosis (pH = 7.25-7.35). (1A) NIV should be attempted in patients with acute exacerbation of COPD (pH <7.25 & PaCO2 ≥ 45) before initiating invasive mechanical ventilation (IMV) except in patients requiring immediate intubation. (2A). Lower the pH higher the chance of failure of NIV. (2B) NIV should not to be used routinely in normo- or mildly hyper-capneic patients with acute exacerbation of COPD, without acidosis (pH > 7.35). (2B) A2. NIV in ARF due to Chest wall deformities/Neuromuscular diseases: Recommendations: NIV may be used in patients of ARF due to chest wall deformity/Neuromuscular diseases. (PaCO2 ≥ 45) (UPP) A3. NIV in ARF due to Obesity hypoventilation syndrome (OHS): Recommendations: NIV may be used in AHRF in OHS patients when they present with acute hypercapnic or acute on chronic respiratory failure (pH 45). (3B) NIV/CPAP may be used in obese, hypercapnic patients with OHS and/or right heart failure in the absence of acidosis. (UPP) B. NIV IN ACUTE HYPOXEMIC RESPIRATORY FAILURE: B1. NIV in Acute Cardiogenic Pulmonary Oedema: Recommendations: NIV is recommended in hospital patients with ARF, due to Cardiogenic pulmonary edema. (1A). NIV should be used in patients with acute heart failure/ cardiogenic pulmonary edema, right from emergency department itself. (1B) Both CPAP and BiPAP modes are safe and effective in patients with cardiogenic pulmonary edema. (1A). However, BPAP (NIV-PS) should be preferred in cardiogenic pulmonary edema with hypercapnia. (3A) B2. NIV in acute hypoxemic respiratory failure: Recommendations: NIV may be used over conventional oxygen therapy in mild early acute hypoxemic respiratory failure (P/F ratio <300 and >200 mmHg), under close supervision. (2B) We strongly recommend against a trial of NIV in patients with acute hypoxemic failure with P/F ratio <150. (2A) B3. NIV in ARF due to Chest Trauma: Recommendations: NIV may be used in traumatic flail chest along with adequate pain relief. (3B) B4. NIV in Immunocompromised Host: Recommendations: In Immunocompromised patients with early ARF, we may consider NIV over conventional oxygen. (2B). B5. NIV in Palliative Care: Recommendations: We strongly recommend use of NIV for reducing dyspnea in palliative care setting. (2A) B6. NIV in post-operative cases: Recommendations: NIV should be used in patients with post-operative acute respiratory failure. (2A) B6a. NIV in abdominal surgery: Recommendations: NIV may be used in patients with ARF following abdominal surgeries. (2A) B6b. NIV in bariatric surgery: Recommendations: NIV may be used in post-bariatric surgery patients with pre-existent OSA or OHS. (3A) B6c. NIV in Thoracic surgery: Recommendations: In cardiothoracic surgeries, use of NIV is recommended post operatively for acute respiratory failure to improve oxygenation and reduce chance of reintubation. (2A) NIV should not be used in patients undergoing esophageal surgery. (UPP) B6d. NIV in post lung transplant: Recommendations: NIV may be used for shortening weaning time and to avoid re-intubation following lung transplantation. (2B) B7. NIV during Procedures (ETI/Bronchoscopy/TEE/Endoscopy): Recommendations: NIV may be used for pre-oxygenation before intubation. (2B) NIV with appropriate interface may be used in patients of ARF during Bronchoscopy/Endoscopy to improve oxygenation. (3B) B8. NIV in Viral Pneumonitis ARDS: Recommendations: NIV cannot be considered as a treatment of choice for patients with acute respiratory failure with H1N1 pneumonia. However, it may be reasonable to use NIV in selected patients with single organ involvement, in a strictly controlled environment with close monitoring. (2B) B9. NIV and Acute exacerbation of Pulmonary Tuberculosis: Recommendations: Careful use of NIV in patients with acute Tuberculosis may be considered, with effective infection control precautions to prevent air-borne transmission. (3B) B10. NIV after planned extubation in high risk patients: Recommendation: We recommend that NIV may be used to wean high risk patients from invasive mechanical ventilation as it reduces re-intubation rate. (2B) B11. NIV for respiratory distress post extubation: Recommendations: We recommend that NIV therapy should not be used to manage respiratory distress post-extubation in high risk patients. (2B) C. APPLICATION OF NIV: Recommendation: Choice of mode should be mainly decided by factors like disease etiology and severity, the breathing effort by the patient and the operator familiarity and experience. (UPP) We suggest using flow trigger over pressure triggering in assisted modes, as it provides better patient ventilator synchrony. Especially in COPD patients, flow triggering has been found to benefit auto PEEP. (3B) D. MANAGEMENT OF PATIENT ON NIV: D1. Sedation: Recommendations: A non-pharmacological approach to calm the patient (Reassuring the patient, proper environment) should always be tried before administrating sedatives. (UPP) In patients on NIV, sedation may be used with extremely close monitoring and only in an ICU setting with lookout for signs of NIV failure. (UPP) E. EQUIPMENT: Recommendations: We recommend that portable bilevel ventilators or specifically designed ICU ventilators with non-invasive mode should be used for delivering Non–invasive ventilation in critically ill patients. (UPP) Both critical care ventilators with leak compensation and bi-level ventilators have been equally effective in decreasing the WOB, RR, and PaCO2. (3B) Currently, Oronasal mask is the most preferred interface for non-invasive ventilation for acute respiratory failure. (3B) F. WEANING: Recommendations: We recommend that weaning from NIV may be done by a standardized protocol driven approach of the unit. (2B)

How to cite this article: Chawla R, Dixit SB, Zirpe KG, Chaudhry D, Khilnani GC, Mehta Y, et al. ISCCM Guidelines for the Use of Non-invasive Ventilation in Acute Respiratory Failure in Adult ICUs. Indian J Crit Care Med 2020;24(Suppl 1):S61–S81.

Noninvasive Oxygen Therapies in Oncologic Patients

Acute hypoxemic respiratory failure (ARF) is the most common cause of critical illness in oncologic patients. Despite significant advancements in survival of oncologic patients who develop critical illness, mortality rates in those requiring invasive mechanical ventilation have improved but remain high. Avoiding intubation is paramount to the management of oncologic patients with ARF. There are important differences between the oncologic patient with ARF compared to the general ICU population that likely underlie the increased mortality once intubated. Noninvasive oxygen modalities have been recognized as an important therapeutic approach to prevent intubation. Continuous low-flow oxygen therapy, noninvasive ventilation, and high-flow nasal cannula are the most commonly used noninvasive oxygen therapies in recent years. They have unique physiologic properties. The data surrounding their efficacy in the general ICU population and oncologic population has evolved over time reflecting the changes in the oncologic population. This chapter reviews the three different noninvasive oxygen modalities, their physiologic impact, and evidence surrounding their effectiveness.

Acute Respiratory Failure in the Oncologic Patient: New Era, New Issues

Recent decades have seen an increase in the number of patients living with cancer. This trend has resulted in an increase in intensive care unit (ICU) utilization across this population [1]. Acute respiratory failure is the most frequent medical complication leading to critical illness in oncologic patients [2–4]. Historically, there had been a reluctance to admit cancer patients to the ICU given their poor outcomes, particularly in the setting of hematologic malignancy and invasive mechanical ventilation [5]. ICU treatment limitations or refusal of admission was advocated [6]. Major advances in oncologic care, critical care and more meticulous attention to where the conditions overlap, have resulted in marked improvement in short-term survival in this population [1, 7, 8]. Despite these major advances, acute respiratory failure in this population remains complex with unique challenges surrounding diagnosis and management compared to the general ICU population. This chapter provides a comprehensive overview of acute respiratory failure in the oncologic population and highlights specific considerations for the intensivist. We will focus on the important differences between the immunocompromised oncologic patient and general intensive care population, the spectrum of causes of acute respiratory failure with a specific focus on toxicities related to newer cancer therapies, diagnostic approach, management and an up-to-date overview of prognosis.

Non-invasive positive pressure ventilation in lung transplant recipients with acute respiratory failure: Beyond the perioperative period

PURPOSE

The purpose of this study is to evaluate outcomes in MICU lung transplant recipients with acute respiratory failure treated with non-invasive positive pressure ventilation (NPPV) and identify factors associated with NPPV failure (need for intubation).

METHODS

Retrospective chart review of all lung transplant recipients who were admitted with acute respiratory failure to the MICU from January 2009-August 2016 was completed. Logistic regression analysis was performed to determine which factors were independently associated with NPPV failure.

RESULTS

Of 156 patients included in the study, 125 (80.1%) were tried on NPPV. Sixty-eight (54.4%) were managed successfully with NPPV with a hospital survival rate of 94.1%. Subjects who failed NPPV had higher hospital mortality, similar to those intubated from the outset (15 [48.3%]; 22 [38.6%], p = .37). In multivariate analyses, APACHE III scores >78 (9.717 [3.346, 28.22]) and PaO2/FiO2 ≤ 151 (4.54 [1.72, 11.99]) were associated with greater likelihood of NPPV failure. There was no difference in NPPV failure based on the presence of BOS. In patients with high severity of illness, there was no difference in mortality between initial IMV and NPPV failure when stratified on the basis of hypoxemia (PaO2/FiO2 > 151, p-value 0.34; PaO2/FiO2 ≤ 151, p-value 0.99).

CONCLUSIONS

NPPV is a viable option for lung transplant recipients with acute respiratory failure. Extreme caution should be exercised when used in patients with high severity of illness (APACHE III >78) and/or severe hypoxemia (PaO2/FiO2 ≤ 151).

Prognostic factors of noninvasive mechanical ventilation in lung cancer patients with acute respiratory failure

Introduction

Few studies have reported outcomes of lung cancer patients with acute respiratory failure (RF) using noninvasive positive pressure ventilation (NIPPV). The aim of this study was to investigate the prognostic factors in these patients.

Materials and methods

This retrospective observational study included all hospitalized lung cancer patients who received NIPPV for acute RF. It was conducted at a tertiary medical center in Taiwan from 2005 to 2010. The primary outcome was all cause mortality at 28 days after the initiation of NIPPV. Secondary outcomes included all-cause in-hospital mortality, weaning from NIPPV, intubation rate, tracheostomy rate, duration of NIPPV, hospital stay and intensive care unit stay.

Results

The all-cause mortality rate at day 28 of the enrolled 58 patients was 39.66%. The 90-day and 1-year mortality rates were 63.79% and 86.21%, respectively. NIPPV as the first line therapy for RF had higher 28-day mortality rate than it used for post-extubation RF (57.6% versus 16.0%, p<0.05). Independent predictors of mortality at 28 days were progressive disease or newly diagnosed lung cancer (OR 14.02 95% CI 1.03–191.59, p = 0.048), combined with other organ failure (OR 18.07 95% CI 1.87–172.7, p = 0.012), and NIPPV as the first line therapy for RF (OR 35.37 95% CI 3.30–378.68, p = 0.003).

Conclusion

Lung cancer patients using NIPPV with progressive or newly diagnosed cancer disease, combined with other organ failure, or NIPPV as the first line therapy for respiratory failure have a poor outcome.

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.