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Deng Z, Tang Y, Tu Y, Liu M, Cheng Q, Zhang J, Liu F, Li X. BALF metagenomic next-generation sequencing analysis in hematological malignancy patients with suspected pulmonary infection: clinical significance of negative results. Front Med (Lausanne) 2023; 10:1195629. [PMID: 37457591 PMCID: PMC10338636 DOI: 10.3389/fmed.2023.1195629] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2023] [Accepted: 06/01/2023] [Indexed: 07/18/2023] Open
Abstract
Purpose Metagenomic next-generation sequencing (mNGS) of bronchoalveolar lavage fluid (BALF) is gradually being used in hematological malignancy (HM) patients with suspected pulmonary infections. However, negative results are common and the clinical value and interpretation of such results in this patient population require further analysis. Methods Retrospective analysis of 112 HM patients with suspected pulmonary infection who underwent BALF mNGS and conventional microbiological tests. The final diagnosis, imaging findings, laboratory results and treatment regimen of 29 mNGS-negative patients were mainly analyzed. Results A total of 83 mNGS positive and 29 negative patients (15 true-negatives and 14 false-negatives) were included in the study. Compared to false-negative patients, true-negative patients showed more thickening of interlobular septa on imaging (p < 0.05); fewer true-negative patients had acute respiratory symptoms such as coughing or sputum production (p < 0.05) clinically; On the aspect of etiology, drug-related interstitial pneumonia (6/15, 40%) was the most common type of lung lesion in true-negative patients; on the aspect of pathogenesis, false-negative patients mainly missed atypical pathogens such as fungi and tuberculosis (8/14, 57.1%). Regarding treatment, delayed anti-infection treatment occurred after pathogen missing in mNGS false-negative patients, with the longest median time delay observed for anti-tuberculosis therapy (13 days), followed by antifungal therapy (7 days), and antibacterial therapy (1.5 days); the delay in anti-tuberculosis therapy was significantly longer than that in antibacterial therapy (p < 0.05). Conclusion For HMs patients with imaging showing thickening of interlobular septa and no obvious acute respiratory symptoms, lung lesions are more likely caused by drug treatment or the underlying disease, so caution should be exercised when performing BALF mNGS. If BALF mNGS is negative but infection is still suspected, atypical pathogenic infections should be considered.
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Affiliation(s)
- Zuqun Deng
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yishu Tang
- Department of Emergency, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Yixuan Tu
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Mei Liu
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Qian Cheng
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Jian Zhang
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Feiyang Liu
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
| | - Xin Li
- Department of Hematology, The Third Xiangya Hospital, Central South University, Changsha, Hunan, China
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Mackintosh D, Way M, Reade MC, Dhanani J. Short- and long-term outcomes of neutropenic cancer patients in intensive care according to requirement for invasive ventilation. Intern Med J 2021; 50:603-611. [PMID: 31841270 DOI: 10.1111/imj.14721] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/02/2019] [Revised: 12/08/2019] [Accepted: 12/10/2019] [Indexed: 11/29/2022]
Abstract
BACKGROUND Neutropenic fever is a frequently encountered complication when caring for cancer patients and can lead to intensive care admission, with high mortality rates in those patients who require invasive mechanical ventilation (IMV). Although hospital survival in this population has improved, long-term outcomes of critically ill neutropenic cancer patients have not been well defined. AIMS To evaluate short- and long-term outcomes of neutropenic cancer patients admitted to intensive care, according to requirement for invasive ventilation. Additionally, we aimed to determine predictors of poor clinical outcomes in this group. METHODS A retrospective cohort study of neutropenic cancer patients admitted to our intensive care unit (ICU) from 2008 to 2016. RESULTS We included 192 cancer patients of whom 100 (52.1%) required IMV. Overall ICU mortality was 29.7% and 12-month post-ICU mortality was 61.5%. Patients requiring IMV had significantly higher short- and long-term mortality (P < 0.001). Multivariate analysis determined three variables to be predictors of mortality at ICU discharge in the whole cohort: IMV (OR 13.52), renal replacement therapy (RRT, OR 2.37) and higher APACHE II scores (OR 1.1 for each unit increase). These variables were identical in the subgroup requiring invasive ventilation, with RRT (OR 2.76) and APACHE II scores (OR 1.1 for each unit increase) predicting short-term mortality. CONCLUSION Neutropenic cancer patients admitted to ICU have lower short-term mortality than previously reported in cohort studies, however their mortality rises significantly following discharge from ICU. Those patients who require IMV are at significantly increased risk of both short- and long-term mortality.
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Affiliation(s)
- David Mackintosh
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
| | - Mandy Way
- Department of Biostatistics, Queensland Institute of Medical Research, Brisbane, Queensland, Australia
| | - Michael C Reade
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
| | - Jayesh Dhanani
- Department of Intensive Care Medicine, Royal Brisbane & Women's Hospital, Brisbane, Queensland, Australia
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Parisi GF, Cannata E, Manti S, Papale M, Meli M, Russo G, Di Cataldo A, Leonardi S. Lung clearance index: A new measure of late lung complications of cancer therapy in children. Pediatr Pulmonol 2020; 55:3450-3456. [PMID: 32926567 DOI: 10.1002/ppul.25071] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/19/2020] [Revised: 09/07/2020] [Accepted: 09/10/2020] [Indexed: 11/05/2022]
Abstract
INTRODUCTION Childhood cancer survivors (CSs) might face an increased lifelong risk of lung function impairment. The lung clearance index (LCI) has been described as being more sensitive than spirometry in the early stages of some lung diseases. The aim of this study was to evaluate this index in a cohort of patients with a history of childhood cancer for the first time. MATERIALS AND METHODS We evaluated 57 off-treatment CSs aged 0-18 years old and 50 healthy controls (HCs). We used the multiple-breath washout method to study LCI and spirometry. RESULTS CSs did not show any differences from the controls in ventilation homogeneity (LCI 6.78 ± 1.35 vs. 6.32 ± 0.44; p: not significant [ns]) or lung function (FEV1 99.9 ± 11.3% vs. 103.0 ± 5.9% of predicted; p: ns; FVC 98.2 ± 10.3% vs. 101.1 ± 3.3% of predicted). LCI significantly correlated with the number of years since the last chemotherapy (r = .35, p < .05). CONCLUSIONS Our study describes the trend of LCI in a cohort of CSs and compares it with the results obtained from HCs. The results show that patients maintain both good values of respiratory function and good homogeneity of ventilation during childhood. Moreover, as LCI increases and worsens as the years pass after the end of the treatment could identify the tendency toward pulmonary fibrosis, which is typical of adult CSs, at an earlier time than spirometry.
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Affiliation(s)
- Giuseppe F Parisi
- Pediatric Pulmonology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Emanuela Cannata
- Pediatric Hemato-Oncology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Sara Manti
- Pediatric Pulmonology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Maria Papale
- Pediatric Pulmonology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Mariaclaudia Meli
- Pediatric Hemato-Oncology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Giovanna Russo
- Pediatric Hemato-Oncology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Andrea Di Cataldo
- Pediatric Hemato-Oncology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
| | - Salvatore Leonardi
- Pediatric Pulmonology Unit, Department of Clinical and Experimental Medicine, University of Catania, Catania, Italy
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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. PLoS One 2020; 15:e0234495. [PMID: 32520960 PMCID: PMC7286506 DOI: 10.1371/journal.pone.0234495] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2020] [Accepted: 05/26/2020] [Indexed: 12/15/2022] Open
Abstract
Background Acute respiratory failure (ARF) is a life-threatening complication in onco-hematology patients. Optimal ventilation strategy in immunocompromised patients has been highly controversial over the last decade. Data are lacking on patients presenting with ARF associating isolated cardiac dysfunction or in combination with another etiology. The aim of this study was to assess prognostic impact of initial ventilation strategy in onco-hematology patients presenting ARF with associated cardiac dysfunction. Methods We conducted an observational retrospective study in Institut Paoli-Calmettes, a cancer-referral center, assessing all critically ill cancer patients admitted to the ICU for a ARF with cardiac dysfunction. Results Between 2010–2017, 127 patients were admitted. ICU and hospital mortality were 29% and 57%. Initial ventilation strategy was invasive mechanical ventilation (MV) in 21%. Others ventilation strategies were noninvasive ventilation (NIV) in 50%, associated with oxygen in 21% and high flow nasal oxygen (HFNO) in 29%, HFNO alone in 6% and standard oxygen in 23%. During ICU stay, 48% of patients required intubation. Multivariate analysis identified 3 independent factors associated with ICU mortality: SAPSII at admission (OR = 1.07/point, 95%CI = 1.03–1.11, p<0.001), invasive fungal infection (OR = 7.65, 95%CI = 1.7–34.6, p = 0.008) and initial ventilation strategy (p = 0.015). Compared to NIV, HFNO alone and standard oxygen alone were associated with an increased ICU mortality, with respective OR of 19.56 (p = 0.01) and 10.72 (p = 0.01). We realized a propensity score analysis including 40 matched patients, 20 in the NIV arm and 20 receiving others ventilation strategies, excluding initial MV patients. ICU mortality was lower in patients treated with NIV (10%), versus 50% in the other arm (p = 0.037). Conclusion In onco-hematology patients admitted for ARF with associated cardiac dysfunction, severity at ICU admission, invasive fungal infections and initial ventilation strategy were independently associated with ICU mortality. NIV was a protective factor on ICU mortality.
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Schmidt H, Das A, Nam H, Yang A, Ison MG. Epidemiology and outcomes of hospitalized adults with respiratory syncytial virus: A 6-year retrospective study. Influenza Other Respir Viruses 2019; 13:331-338. [PMID: 30977284 PMCID: PMC6586178 DOI: 10.1111/irv.12643] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2018] [Revised: 02/25/2019] [Accepted: 02/26/2019] [Indexed: 01/01/2023] Open
Abstract
Objectives Respiratory syncytial virus (RSV) is an important cause of morbidity and mortality in adults. Existing studies are limited by the number of seasons studied and most have focused on the immunocompromised. Methods A retrospective cohort study was conducted on all adults (≥18 years) with a positive RSV molecular test admitted from 2009 to 2015 to one hospital in Chicago, IL. Epidemiologic and outcomes data were collected after IRB approval. Results Of the 489 eligible patients, 227 had RSV A and 262 had RSV B. Patients had a median age of 61 years and comorbidity (eg, chronic lung disease [40.6%], obesity [37.8%], and cardiac disease [34.3%]). On presentation, most had cough (86.5%), fever (42.4%), and shortness of breath (38.2%). Severe disease was present in 27.6% of patients. Antibiotic was used in 76.3% inpatients and 45.8% at discharged despite few patients (4.7%) having documented bacterial infections. Supplemental oxygen and mechanical ventilation were utilized in 44.6% and 12.3%, respectively, while ICU level care was required in 26.9%. Most patients were discharged home (82.7%). Most deaths (68.4%, 13/19) were attributed to pneumonia or hypoxemia likely from RSV. Most fatal cases were seen in those with recent cancer treatment and older adults. Conclusions Respiratory syncytial virus in hospitalized adults is associated with significant morbidity and mortality with 26.9% requiring ICU level care. Antibiotics are commonly prescribed to patients with documented RSV, and antibiotics are frequently continued after diagnosis. Novel antiviral therapies are needed for RSV to improve outcomes and potentially improve antibiotic stewardship in patients without a bacterial infection.
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Affiliation(s)
- Henry Schmidt
- Florida Atlantic University Schmidt College of Medicine, Boca Raton, Florida
| | - Arighno Das
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Hannah Nam
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Amy Yang
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Michael G Ison
- Northwestern University Feinberg School of Medicine, Chicago, Illinois
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Hilbert G, Vargas F. My paper 20 years later: NIV in immunocompromized patients. Intensive Care Med 2018; 44:2225-2228. [DOI: 10.1007/s00134-018-5155-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/18/2017] [Accepted: 03/28/2018] [Indexed: 11/30/2022]
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Predictors of outcome in patients with hematologic malignancies admitted to the intensive care unit. Hematol Oncol Stem Cell Ther 2018; 11:206-218. [PMID: 29684341 DOI: 10.1016/j.hemonc.2018.03.003] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2017] [Revised: 01/02/2018] [Accepted: 03/10/2018] [Indexed: 12/25/2022] Open
Abstract
PURPOSE Several studies showed conflicting results about prognosis and predictors of outcome of critically ill patients with hematological malignancies (HM). The aim of this study is to determine the hospital outcome of critically ill patients with HM and the factors predicting the outcome. METHODS AND MATERIALS All patients with HM admitted to MICU at a tertiary academic medical center were enrolled. Clinical data upon admission and during ICU stay were collected. Hospital, ICU, and 6 months outcomes were documented. RESULTS There were 130 HM patients during the study period. Acute Leukemia was the most common malignancy (31.5%) followed by Non-Hodgkin's Lymphoma (28.5%). About 12.5% patients had autologous HSCT and 51.5% had allogeneic HSCT. Sepsis was the most common ICU diagnosis (25.9%). ICU mortality and hospital mortality were 24.8% and 45.3%, respectively. Six months mortality (available on 80% of patients) was 56.7%. Hospital mortality was higher among mechanically ventilated patients (75%). Using multivariate analysis, only mechanical ventilation (OR of 19.0, CI: 3.1-117.4, P: 0.001) and allogeneic HSCT (OR of 10.9, CI: 1.8-66.9, P: 0.01) predicted hospital mortality. CONCLUSION Overall hospital outcome of critically ill patients with HM is improving. However those who require mechanical ventilation or underwent allogeneic HSCT continue to have poor outcome.
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Helviz Y, Einav S. A Systematic Review of the High-flow Nasal Cannula for Adult Patients. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:71. [PMID: 29558988 PMCID: PMC5861611 DOI: 10.1186/s13054-018-1990-4] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2018. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2018. Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901.
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Affiliation(s)
- Yigal Helviz
- The Intensive Care Unit, Shaare Zedek Medical Centre, Jerusalem, Israel
| | - Sharon Einav
- The Intensive Care Unit, Shaare Zedek Medical Centre, Jerusalem, Israel. .,The Faculty of Medicine, Hebrew University, Jerusalem, Israel.
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Huang HB, Peng JM, Weng L, Liu GY, Du B. High-flow oxygen therapy in immunocompromised patients with acute respiratory failure: A review and meta-analysis. J Crit Care 2017; 43:300-305. [PMID: 28968525 DOI: 10.1016/j.jcrc.2017.09.176] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/04/2017] [Revised: 09/03/2017] [Accepted: 09/21/2017] [Indexed: 02/07/2023]
Abstract
PURPOSE Acute respiratory failure remains a common hazardous complication in immunocompromised patients and is associated with increased mortality rates when endotracheal intubation is need. We aimed to evaluate the effect of high-flow nasal cannula oxygen therapy (HFNC) compared with other oxygen technique for this patient population. METHODS We searched Cochrane library, Embase, PubMed databases before Aug. 15, 2017 for eligible articles. A meta-analysis was performed for measuring short-term mortality (defined as ICU, hospital or 28-days mortality) and intubation rate as the primary outcomes, and length of stay in ICU as the secondary outcome. RESULTS We included seven studies involving 667 patients. Use of HFNC was significantly association with a reduction in short-term mortality (RR 0.66; 95% CI, 0.52 to 0.84, p=0.0007) and intubation rate (RR 0.76, 95% CI 0.64 to 0.90; p=0.002). In addition, HFNC did not significant increase length of stay in ICU (MD 0.15days; 95% CI, -2.08 to 2.39; p=0.89). CONCLUSIONS The results of current meta-analysis suggest that use of HFNC significantly improve outcomes of acute respiratory failure in immunocompromised patients. Owing to the quality of the included studies, further adequately powered randomized controlled trials are needed to confirm our results.
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Affiliation(s)
- Hui-Bin Huang
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Peking, China; Department of Critical Care Medicine, The First Affiliated Hospital of Fujian Medical University, Fuzhou, China
| | - Jin-Min Peng
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Peking, China
| | - Li Weng
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Peking, China
| | - Guang-Yun Liu
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Peking, China
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, Peking, China.
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Abstract
Advances in cancer treatment and patient survival are associated with increasing number of these patients requiring intensive care. Over the last 2 decades, there has been a steady improvement in the outcomes of critically ill patients with cancer. This review provides data on the use of the intensive care unit (ICU) and short and long-term outcomes of critically ill patients with cancer, the ICU system practices that influence patients outcomes, and the role of the different clinical variables in predicting the prognosis of these patients.
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Affiliation(s)
- Ayman O Soubani
- Division of Pulmonary, Critical Care and Sleep Medicine, Wayne State University School of Medicine, 3990 John R- 3 Hudson, Detroit, MI 48201, USA.
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11
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Huang HB, Xu B, Liu GY, Lin JD, Du B. Use of noninvasive ventilation in immunocompromised patients with acute respiratory failure: a systematic review and meta-analysis. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2017; 21:4. [PMID: 28061910 PMCID: PMC5219799 DOI: 10.1186/s13054-016-1586-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/13/2016] [Accepted: 12/08/2016] [Indexed: 12/15/2022]
Abstract
Background Acute respiratory failure (ARF) remains a common hazardous complication in immunocompromised patients and is associated with increased mortality rates when endotracheal intubation is needed. We aimed to evaluate the effect of early noninvasive ventilation (NIV) compared with oxygen therapy alone in this patient population. Methods We searched for relevant studies in MEDLINE, EMBASE, and the Cochrane database up to 25 July 2016. Randomized controlled trials (RCTs) were included if they reported data on any of the predefined outcomes in immunocompromised patients managed with NIV or oxygen therapy alone. Results were expressed as risk ratio (RR) and mean difference (MD) with accompanying 95% confidence interval (CI). Results Five RCTs with 592 patients were included. Early NIV significantly reduced short-term mortality (RR 0.62, 95% CI 0.40 to 0.97, p = 0.04) and intubation rate (RR 0.52, 95% CI 0.32 to 0.85, p = 0.01) when compared with oxygen therapy alone, with significant heterogeneity in these two outcomes between the pooled studies. In addition, early NIV was associated with a shorter length of ICU stay (MD −1.71 days, 95% CI −2.98 to 1.44, p = 0.008) but not long-term mortality (RR 0.92, 95% CI 0.74 to 1.15, p = 0.46). Conclusions The limited evidence indicates that early use of NIV could reduce short-term mortality in selected immunocompromised patients with ARF. Further studies are needed to identify in which selected patients NIV could be more beneficial, before wider application of this ventilator strategy. Electronic supplementary material The online version of this article (doi:10.1186/s13054-016-1586-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Hui-Bin Huang
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China.,Department of Critical Care Medicine, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350000, People's Republic of China
| | - Biao Xu
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China.,Critical Care Medicine Center, the PLA 302 Hospital, No. 100 Xisihuanzhong Road, Fengtai District, Beijing, 100039, People's Republic of China
| | - Guang-Yun Liu
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China
| | - Jian-Dong Lin
- Department of Critical Care Medicine, the First Affiliated Hospital of Fujian Medical University, 20 Chazhong Road, Fuzhou, 350000, People's Republic of China
| | - Bin Du
- Medical ICU, Peking Union Medical College Hospital, Peking Union Medical College and Chinese Academy of Medical Sciences, 1 Shuai Fu Yuan, Beijing, 100730, People's Republic of China.
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Fee-Mulhearn A, Nana-Sinkam P. Acute Pulmonary Manifestations of Hematologic Malignancies. Respir Med 2017. [DOI: 10.1007/978-3-319-41912-1_7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
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13
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Shimabukuro-Vornhagen A, Böll B, Kochanek M, Azoulay É, von Bergwelt-Baildon MS. Critical care of patients with cancer. CA Cancer J Clin 2016; 66:496-517. [PMID: 27348695 DOI: 10.3322/caac.21351] [Citation(s) in RCA: 88] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
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.
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Affiliation(s)
- Alexander Shimabukuro-Vornhagen
- Consultant, Medical Intensive Care Program, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Member, Cologne-Bonn Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
- Founding Member, Intensive Care in Hemato-Oncologic Patients (iCHOP), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Boris Böll
- Member, Cologne-Bonn Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
- Founding Member, Intensive Care in Hemato-Oncologic Patients (iCHOP), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Head of Medical Intensive Care Program, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Matthias Kochanek
- Member, Cologne-Bonn Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
- Founding Member, Intensive Care in Hemato-Oncologic Patients (iCHOP), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Program Director, Medical Intensive Care Program, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
| | - Éli Azoulay
- Director, Medical Intensive Care Unit, St. Louis Hospital, Paris, France
- Professor of Medicine, Teaching and Research Unit, Department of Medicine, Paris Diderot University, Paris, France
- Chair, Study Group for Respiratory Intensive Care in Malignancies, St. Louis Hospital, Paris, France
| | - Michael S von Bergwelt-Baildon
- Founding Member, Intensive Care in Hemato-Oncologic Patients (iCHOP), Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Program Director, Medical Intensive Care Program, Department I of Internal Medicine, University Hospital of Cologne, Cologne, Germany
- Professor, Cologne-Bonn Center for Integrated Oncology, University Hospital of Cologne, Cologne, Germany
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Lemiale V, Resche-Rigon M, Mokart D, Pène F, Rabbat A, Kouatchet A, Vincent F, Bruneel F, Nyunga M, Lebert C, Perez P, Meert AP, Benoit D, Chevret S, Azoulay E. Acute respiratory failure in patients with hematological malignancies: outcomes according to initial ventilation strategy. A groupe de recherche respiratoire en réanimation onco-hématologique (Grrr-OH) study. Ann Intensive Care 2015; 5:28. [PMID: 26429355 PMCID: PMC4883632 DOI: 10.1186/s13613-015-0070-z] [Citation(s) in RCA: 31] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2015] [Accepted: 09/14/2015] [Indexed: 12/15/2022] Open
Abstract
BACKGROUND In patients with hematological malignancies and acute respiratory failure (ARF), noninvasive ventilation was associated with a decreased mortality in older studies. However, mortality of intubated patients decreased in the last years. In this study, we assess outcomes in those patients according to the initial ventilation strategy. METHODS We performed a post hoc analysis of a prospective multicentre study of critically ill hematology patients, in 17 intensive care units in France and Belgium. Patients with hematological malignancies admitted for ARF in 2010 and 2011 and who were not intubated at admission were included in the study. A propensity score-based approach was used to assess the impact of NIV compared to oxygen only on hospital mortality. RESULTS Among 1011 patients admitted to ICU during the study period, 380 met inclusion criteria. Underlying diseases included lymphoid (n = 162, 42.6 %) or myeloid (n = 141, 37.1 %) diseases. ARF etiologies were pulmonary infections (n = 161, 43 %), malignant infiltration (n = 65, 17 %) or cardiac pulmonary edema (n = 40, 10 %). Mechanical ventilation was ultimately needed in 94 (24.7 %) patients, within 3 [2-5] days of ICU admission. Hospital mortality was 32 % (123 deaths). At ICU admission, 142 patients received first-line noninvasive ventilation (NIV), whereas 238 received oxygen only. Fifty-five patients in each group (NIV or oxygen only) were matched according the propensity score. NIV was not associated with decreased hospital mortality [OR 1.5 (0.62-3.65)]. CONCLUSIONS In hematology patients with acute respiratory failure, initial treatment with NIV did not improve survival compared to oxygen only. CLINICAL TRIAL gov number NCT 01172132.
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Affiliation(s)
- Virginie Lemiale
- AP-HP, Hôpital Saint-Louis, Medical ICU, 1 avenue Claude Vellefaux, 75010, Paris, France.
| | | | | | | | - Antoine Rabbat
- Respiratory Unit, Cochin Teaching Hospital, Paris, France.
| | | | | | | | | | | | | | | | | | - Sylvie Chevret
- Biostatistics Department, Saint Louis Teaching Hospital, Paris, France.
| | - Elie Azoulay
- AP-HP, Hôpital Saint-Louis, Medical ICU, 1 avenue Claude Vellefaux, 75010, Paris, France.
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Acker SN, Gonzales D, Ross JT, Dishop MK, Deterding RR, Partrick DA. Factors that increase diagnostic yield of surgical lung biopsy in pediatric oncology patients. J Pediatr Surg 2015; 50:1490-2. [PMID: 25957864 DOI: 10.1016/j.jpedsurg.2015.03.064] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/19/2014] [Revised: 03/13/2015] [Accepted: 03/21/2015] [Indexed: 10/23/2022]
Abstract
PURPOSE Recent data demonstrate that surgical lung biopsy in immunocompromised children, including oncology patients, alters therapy in only 50% of cases. We hypothesized that there are factors identifiable preoperatively which can predict the patients who will or will not benefit from surgical biopsy. METHODS We reviewed the medical records of all children with malignancy who underwent surgical lung biopsy between 2004 and 2013 at a single institution, excluding those children who had previously undergone a solid organ or bone marrow transplant. RESULTS Eighty lung wedge biopsies were performed (median age 13 years, IQR 5.25-16; 63% male, n=50) 53 (66%) of which led to a change in patient management. The majority of biopsies were performed to diagnose a new mass or differentiate infection from metastases (mass group) (n=68, 85%), and 12 biopsies (15%) were performed to diagnose a known infection for antibiotic guidance (infection group). Children in the infection group were more likely to be febrile preoperatively, were more likely to be an inpatient preoperatively, and had a lower absolute neutrophil count at the time of biopsy. Patients in the infection group had higher postoperative mortality rates and higher rates of major complications. CONCLUSION In pediatric oncology patients, surgical lung biopsy has a lower diagnostic yield and higher complication rate when performed for antibiotic guidance. Prior to proceeding with biopsy in this high-risk patient population, surgeons and oncologists should carefully weigh the potential risks and benefits.
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Affiliation(s)
- Shannon N Acker
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Danielle Gonzales
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
| | - James T Ross
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Megan K Dishop
- Department of Pediatric Pathology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
| | - Robin R Deterding
- Department of Pediatric Pulmonology, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
| | - David A Partrick
- Department of Pediatric Surgery, Children's Hospital Colorado, University of Colorado School of Medicine, Aurora, CO, USA.
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Chellapandian D, Lehrnbecher T, Phillips B, Fisher BT, Zaoutis TE, Steinbach WJ, Beyene J, Sung L. Bronchoalveolar lavage and lung biopsy in patients with cancer and hematopoietic stem-cell transplantation recipients: a systematic review and meta-analysis. J Clin Oncol 2015; 33:501-9. [PMID: 25559816 DOI: 10.1200/jco.2014.58.0480] [Citation(s) in RCA: 83] [Impact Index Per Article: 9.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
PURPOSE The objective of this study was to describe the diagnostic yield and complication rate of bronchoalveolar lavage (BAL) and lung biopsy in the evaluation of pulmonary lesions in patients with cancer and recipients of hematopoietic stem-cell transplantation (HSCT). METHODS We conducted a systematic literature review and performed electronic searches of Ovid MEDLINE, EMBASE, and Cochrane Central Register of Controlled Trials. Studies were included if patients had cancer or were recipients of HSCT, and if they underwent BAL or lung biopsy for the evaluation of pulmonary lesions. Only English language publications were included. RESULTS In all, 14,148 studies were screened; 72 studies of BAL and 31 of lung biopsy were included. The proportion of procedures leading to any diagnosis was similar by procedure type (0.53 v 0.54; P = .94) but an infectious diagnosis was more common with BAL compared with lung biopsy (0.49 v 0.34; P < .001). Lung biopsy more commonly led to a noninfectious diagnosis (0.43 v 0.07; P < .001) and was more likely to change how the patient was managed (0.48 v 0.31; P = .002) compared with BAL. However, complications were more common with lung biopsy (0.15 v 0.08; P = .006), and procedure-related mortality was four-fold higher for lung biopsy (0.0078) compared with BAL (0.0018). CONCLUSION BAL may be the preferred diagnostic modality for the evaluation of potentially infectious pulmonary lesions because of lower complication and mortality rates; thus, choice of procedure depends on clinical suspicion of infection. Guidelines to promote consistency in the approach to the evaluation of lung infiltrates may improve clinical care of patients.
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Affiliation(s)
- DeepakBabu Chellapandian
- DeepakBabu Chellapandian, Joseph Beyene, and Lillian Sung, The Hospital for Sick Children, Toronto; Joseph Beyene, McMaster University, Hamilton, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; Bob Phillips, Centre for Reviews and Dissemination, University of York, York, United Kingdom; Brian T. Fisher and Theoklis E. Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; and William J. Steinbach, Duke University Medical Center, Durham, NC
| | - Thomas Lehrnbecher
- DeepakBabu Chellapandian, Joseph Beyene, and Lillian Sung, The Hospital for Sick Children, Toronto; Joseph Beyene, McMaster University, Hamilton, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; Bob Phillips, Centre for Reviews and Dissemination, University of York, York, United Kingdom; Brian T. Fisher and Theoklis E. Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; and William J. Steinbach, Duke University Medical Center, Durham, NC
| | - Bob Phillips
- DeepakBabu Chellapandian, Joseph Beyene, and Lillian Sung, The Hospital for Sick Children, Toronto; Joseph Beyene, McMaster University, Hamilton, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; Bob Phillips, Centre for Reviews and Dissemination, University of York, York, United Kingdom; Brian T. Fisher and Theoklis E. Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; and William J. Steinbach, Duke University Medical Center, Durham, NC
| | - Brian T Fisher
- DeepakBabu Chellapandian, Joseph Beyene, and Lillian Sung, The Hospital for Sick Children, Toronto; Joseph Beyene, McMaster University, Hamilton, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; Bob Phillips, Centre for Reviews and Dissemination, University of York, York, United Kingdom; Brian T. Fisher and Theoklis E. Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; and William J. Steinbach, Duke University Medical Center, Durham, NC
| | - Theoklis E Zaoutis
- DeepakBabu Chellapandian, Joseph Beyene, and Lillian Sung, The Hospital for Sick Children, Toronto; Joseph Beyene, McMaster University, Hamilton, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; Bob Phillips, Centre for Reviews and Dissemination, University of York, York, United Kingdom; Brian T. Fisher and Theoklis E. Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; and William J. Steinbach, Duke University Medical Center, Durham, NC
| | - William J Steinbach
- DeepakBabu Chellapandian, Joseph Beyene, and Lillian Sung, The Hospital for Sick Children, Toronto; Joseph Beyene, McMaster University, Hamilton, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; Bob Phillips, Centre for Reviews and Dissemination, University of York, York, United Kingdom; Brian T. Fisher and Theoklis E. Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; and William J. Steinbach, Duke University Medical Center, Durham, NC
| | - Joseph Beyene
- DeepakBabu Chellapandian, Joseph Beyene, and Lillian Sung, The Hospital for Sick Children, Toronto; Joseph Beyene, McMaster University, Hamilton, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; Bob Phillips, Centre for Reviews and Dissemination, University of York, York, United Kingdom; Brian T. Fisher and Theoklis E. Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; and William J. Steinbach, Duke University Medical Center, Durham, NC
| | - Lillian Sung
- DeepakBabu Chellapandian, Joseph Beyene, and Lillian Sung, The Hospital for Sick Children, Toronto; Joseph Beyene, McMaster University, Hamilton, Ontario, Canada; Thomas Lehrnbecher, Johann Wolfgang Goethe University, Frankfurt, Germany; Bob Phillips, Centre for Reviews and Dissemination, University of York, York, United Kingdom; Brian T. Fisher and Theoklis E. Zaoutis, Children's Hospital of Philadelphia, Philadelphia, PA; and William J. Steinbach, Duke University Medical Center, Durham, NC.
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Pneumonien. DIE INTENSIVMEDIZIN 2015. [PMCID: PMC7153163 DOI: 10.1007/978-3-642-54953-3_60] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Luo J, Wang MY, Zhu H, Liang BM, Liu D, Peng XY, Wang RC, Li CT, He CY, Liang ZA. Can non-invasive positive pressure ventilation prevent endotracheal intubation in acute lung injury/acute respiratory distress syndrome? A meta-analysis. Respirology 2014; 19:1149-57. [PMID: 25208731 DOI: 10.1111/resp.12383] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/01/2013] [Revised: 03/26/2014] [Accepted: 07/07/2014] [Indexed: 02/05/2023]
Abstract
The role of non-invasive positive pressure ventilation (NIPPV) in acute lung injury (ALI)/acute respiratory distress syndrome (ARDS) is controversial. The aim of this study was to investigate whether NIPPV could prevent endotracheal intubation and decrease mortality rate in patients with ALI/ARDS. Randomized controlled trials (RCT) which reported endotracheal intubation and mortality rate in patients with ALI/ARDS treated by NIPPV were identified in Pubmed, Medline, Embase, Central Cochrane Controlled Trials Register, Chinese National Knowledge Infrastructure, reference lists and by manual searches. Fixed- and random-effects models were used to calculate pooled relative risks. This meta-analysis included six RCT involving 227 patients. The results showed that endotracheal intubation rate was lower in NIPPV (95% confidence interval (CI): 0.44-0.80, z = 3.44, P = 0.0006), but no significant difference was found either in intensive care unit (ICU) mortality (95% CI: 0.45-1.07, z = 1.65, P = 0.10) or in hospital mortality (95% CI: 0.17-1.58, z = 1.16, P = 0.25). Only two studies discussed the aetiology of ALI/ARDS as pulmonary or extra-pulmonary, and neither showed statistical heterogeneity (I(2) = 0%, χ(2) = 0.31, P = 0.58), nor a significant difference in endotracheal intubation rate (95% CI: 0.35-9.08, z = 0.69, P = 0.49). In conclusion, the early use of NIPPV can decrease the endotracheal intubation rate in patients with ALI/ARDS, but does not change the mortality of these patients.
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Affiliation(s)
- Jian Luo
- Department of Respiratory and Critical Care Medicine, West China School of Medicine and West China Hospital, Sichuan University, Chengdu, China
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Tridente A, Browett K, Hall J, Sorour Y, Snowden J, Webber S. Predictors of outcome in patients with haematological malignancies admitted to critical care. Crit Care 2014. [PMCID: PMC4068804 DOI: 10.1186/cc13231] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
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Fruchter O, Fridel L, Rosengarten D, Rahman NAE, Kramer MR. Transbronchial cryobiopsy in immunocompromised patients with pulmonary infiltrates: a pilot study. Lung 2013; 191:619-24. [PMID: 24071930 DOI: 10.1007/s00408-013-9507-z] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/22/2013] [Accepted: 08/30/2013] [Indexed: 11/24/2022]
Abstract
BACKGROUND In immunocompromised patients with pulmonary infiltrates, transbronchial lung biopsies (TBB) obtained by forceps has been shown to increase the diagnostic yield over simple bronchoalveolar lavage. Cryo-TBB is a novel modality for obtaining lung biopsies. We aimed to evaluate for the first time the efficacy and safety of cryo-TBB in immunocompromised patients. METHODS Fifteen immunocompromised patients with pulmonary infiltrates underwent cryo-TBB. During the procedure two to three biopsy samples were taken. Procedure characteristics, complications, and the diagnostic yield were retrospectively evaluated. RESULTS Most patients (n = 11) were immunocompromised due to hematological malignancies. The remaining four patients were receiving chronic immunosuppressive treatment due to previous solid-organ transplantation (n = 2) or collagen-vascular disease (n = 2). No major complications occurred in the cryo-TBB group. The mean surface area of the specimen taken by cryo-TBB was 9 mm(2). The increase in surface area and quality of biopsy samples translated to a high percentage of alveolated tissue (70 %) that enabled a clear histological detection of the following diagnoses: noncaseating granulomatous inflammation (n = 2), acute interstitial pneumonitis consistent with drug reaction (n = 5), nonspecific interstitial pneumonia fibrotic variant (n = 1), diffuse alveolar damage (n = 3), organizing pneumonia (n = 3), and pulmonary cryptococcal pneumonia (n = 1). Diagnostic information obtained by cryo-TBB led to change in the management of 12 patients (80 %). CONCLUSION Cryo-TBB in immunocompromised patients with pulmonary infiltrates provides clinically important diagnostic data with a low complication rate. These advantages should be further compared with traditional forceps TBB in a prospective randomized trial.
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Affiliation(s)
- Oren Fruchter
- The Pulmonary Division, Rabin Medical Center, Beilinson Hospital, 49100, Petah Tikva, Israel,
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Risk factors for ICU admission and ICU survival after allogeneic hematopoietic SCT. Bone Marrow Transplant 2013; 49:62-5. [PMID: 24056739 DOI: 10.1038/bmt.2013.141] [Citation(s) in RCA: 51] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2012] [Revised: 07/31/2013] [Accepted: 08/06/2013] [Indexed: 01/08/2023]
Abstract
A considerable number of patients undergoing allogeneic hematopoietic SCT (HSCT) develop post-transplant complications requiring intensive care unit (ICU) treatment. Whereas the indications and the outcome of ICU admission are well known, the risk factors leading to ICU admission are less well understood. We performed a retrospective single-center study on 250 consecutive HSCT patients analyzing the indications, risk factors and outcome of ICU admission. Of these 250 patients, 33 (13%) were admitted to the ICU. The most common indications for admission to the ICU were pulmonary complications (11, 33%), sepsis (8, 24%), neurological disorders (6, 18%) and cardiovascular problems (2, 6%). Acute GvHD and HLA mismatch were the only significant risk factors for ICU admission in multivariate analysis. Among patients admitted to the ICU, the number of organ failures correlated negatively with survival. Twenty-one (64%) patients died during the ICU stay and the 6-month mortality was 85% (27 out of 33). SAPS II score underestimated the mortality rate. In conclusion, acute GvHD and HLA mismatch were identified as risk factors for ICU admission following allogeneic HSCT. Both, short- and long-term survival of patients admitted to the ICU remains dismal and depends on the number of organ failures.
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Kim IK, Rhee CK, Yeo CD, Kang HH, Lee DG, Lee SH, Kim JW. Effect of tyrosine kinase inhibitors, imatinib and nilotinib, in murine lipopolysaccharide-induced acute lung injury during neutropenia recovery. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2013; 17:R114. [PMID: 23787115 PMCID: PMC4056323 DOI: 10.1186/cc12786] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/20/2012] [Accepted: 06/20/2013] [Indexed: 11/28/2022]
Abstract
Introduction Neutrophil recovery has been implicated in deterioration of oxygenation and exacerbation of preexisting acute lung injury (ALI). The aim of this study was to investigate whether imatinib or nilotinib was effective on lipopolysaccharide (LPS)-induced ALI during neutropenia recovery in mice. Methods Mice were rendered neutropenic with cyclophosphamide prior to the intratracheal instillation of LPS. Imatinib or nilotinib was administrated by oral gavage during neutropenia recovery. In order to study the effects of drugs, mice were killed on day 5 and blood, bronchoalveolar lavage (BAL) fluid and lung tissue samples were obtained. The lung wet/dry weight ratio and protein levels in the BAL fluid or lung tissue were determined. Results Treatment with imatinib or nilotinib significantly attenuated the LPS-induced pulmonary edema, and this result was supported by the histopathological examination. The concentrations of tumor necrosis factor-α, interleukin (IL)-1β, IL-6 and myeloperoxidase in BAL fluid were significantly inhibited by imatinib or nilotinib in mice of ALI during neutropenia recovery. The mRNA expressions of platelet-derived growth factor receptor-β and c-KIT in imatinib or nilotinib group were significantly lower than LPS group. Conclusions Our data indicated that imatinib or nilotinib effectively attenuated LPS-induced ALI during neutropenia recovery. These results provide evidence for the therapeutic potential of imatinib and nilotinib in ALI during neutropenia recovery.
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Razlaf P, Pabst D, Mohr M, Kessler T, Wiewrodt R, Stelljes M, Reinecke H, Waltenberger J, Berdel WE, Lebiedz P. Non-invasive ventilation in immunosuppressed patients with pneumonia and extrapulmonary sepsis. Respir Med 2012; 106:1509-16. [PMID: 22944604 DOI: 10.1016/j.rmed.2012.08.007] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/09/2012] [Revised: 07/13/2012] [Accepted: 08/13/2012] [Indexed: 11/24/2022]
Abstract
PURPOSE International guidelines recommend the use of noninvasive ventilation in immunocompromised patients with acute respiratory failure (ARF). We analyzed failure rates and risk factors for NIV failure in immunocompromised patients. METHODS We retrospectively analyzed 120 immunodeficient patients treated with NIV in our medical ICU from 2005 to 2011. We compared the clinical course and NIV failure rates. Furthermore, we compared patients with secondary respiratory failure due to those with Systemic Inflammatory Response Syndrome (SIRS) of other than pulmonary origin to those with primary pulmonary infiltrations. RESULTS Regression analyses revealed high APACHE II score (p < 0.01), need for catecholamines (p < 0.05) and low paO(2)/FIO(2) ratio (p < 0.05) as risk factors for NIV failure. Regarding the underlying diseases, we could not find differences in NIV duration (p = 0.07) and outcome (p = 0.44). 59.2% suffered from ARF due to lung infiltrations whereas 40.8% had secondary ARF caused by sepsis of extrapulmonary origin. Patients with lung infiltrations had a longer stay on ICU (16.3 vs 13.2 days; p = 0.047) and showed a trend toward longer NIV duration (87 ± 102 h vs 65.6 ± 97.8 h; p = 0.056). The SIRS patients compared to pneumonia patients showed a trend toward higher serum creatinine (1.63 mg/dL to 1.51 mg/dL; p = 0.059), a higher rate of renal failure (p < 0.01), higher APACHE II score (30.6-25.7, p < 0.01) and more frequently needed catecholamines (p < 0.01). NIV failure rate (overall 55%) was not different. CONCLUSIONS Almost 50% of the immunocompromised patients treated with NIV did not require intubation independent of the etiology of ARF. High APACHE II scores and severity of oxygenation failure were associated with NIV failure.
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Affiliation(s)
- Peter Razlaf
- Department of Cardiology und Angiology, University Hospital of Muenster, Muenster, Germany
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García Salido A, Nieto Moro M, Casado Flores J. Dificultad respiratoria en el niño sometido a trasplante de médula ósea. Med Intensiva 2011; 35:569-77. [DOI: 10.1016/j.medin.2011.06.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2011] [Accepted: 06/09/2011] [Indexed: 12/28/2022]
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Respiratory failure in patients undergoing allogeneic hematopoietic SCT--a randomized trial on early non-invasive ventilation based on standard care hematology wards. Bone Marrow Transplant 2011; 47:574-80. [PMID: 21927036 DOI: 10.1038/bmt.2011.160] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
The prognosis of patients suffering from respiratory failure (RF) after allogeneic hematopoietic SCT (HSCT) is poor. However, early treatment for using non-invasive ventilation (NIV) may be of benefit. We conducted a randomized trial to prove the impact of early NIV in patients in the early post-transplant period. A total of 526 patients undergoing HSCT in a single center were monitored for signs of RF. Patients with RF were enrolled into either treatment arm A (oxygen supply only) or treatment arm B (oxygen+intermittent NIV). RF had to be diagnosed in 86 patients (16%). RF was an independent risk factor for both short-term (100 day mortality/ OR 2.76; P<0.001) and long-term survival (OR 1.57; P<0.01). Although early RF treatment with NIV was associated with a decreased rate of failure to achieve sufficient oxygenation (39% in arm A vs 24% in arm B, P=0.17), neither intensive care unit admission rate, nor need for intubation or survival parameters were affected by the treatment strategy. An early interventional strategy using NIV was not associated with improvement of the prognosis of the patients. The limited influence of NIV may be related to the study design allowing for switching of treatment in case of unsatisfactory efficacy.
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Palliative noninvasive ventilation in patients with acute respiratory failure. Intensive Care Med 2011; 37:1250-7. [DOI: 10.1007/s00134-011-2263-8] [Citation(s) in RCA: 63] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/21/2010] [Accepted: 04/16/2011] [Indexed: 11/26/2022]
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Azoulay E. What Has Been Learned from Postmortem Studies? PULMONARY INVOLVEMENT IN PATIENTS WITH HEMATOLOGICAL MALIGNANCIES 2011. [PMCID: PMC7123032 DOI: 10.1007/978-3-642-15742-4_20] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
Infectious and noninfectious pulmonary diseases are commonly found on postmortem autopsy studies in patients with hematological malignancy. Despite the technological advances in diagnostic testing and imaging modalities, obtaining an accurate clinical diagnosis remains difficult and often not possible until autopsy. Major diagnostic discrepancies between clinical premortem diagnoses and postmortem autopsy findings have been reported in these patients. The most common missed diagnoses are due to opportunistic infections and cardiopulmonary complications. These findings underscore the importance of enhanced surveillance, monitoring and treatment of infections and cardiopulmonary disorders in these patients. Autopsies remain important in determining an accurate cause of death and for improved understanding of diagnostic deficiencies, as well as for medical education and quality assurance.
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Affiliation(s)
- Elie Azoulay
- Service de Réanimation Médicale, Hôpital Saint Louis, Avenue Claude Vellefaux 1, Paris, 75010 France
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Roze des Ordons AL, Chan K, Mirza I, Townsend DR, Bagshaw SM. Clinical characteristics and outcomes of patients with acute myelogenous leukemia admitted to intensive care: a case-control study. BMC Cancer 2010; 10:516. [PMID: 20920175 PMCID: PMC2955611 DOI: 10.1186/1471-2407-10-516] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2010] [Accepted: 09/28/2010] [Indexed: 11/26/2022] Open
Abstract
Background There is limited epidemiologic data on patients with acute myelogenous (myeloid) leukemia (AML) requiring life-sustaining therapies in the intensive care unit (ICU). Our objectives were to describe the clinical characteristics and outcomes in critically ill AML patients. Methods This was a retrospective case-control study. Cases were defined as adult patients with a primary diagnosis of AML admitted to ICU at the University of Alberta Hospital between January 1st 2002 and June 30th 2008. Each case was matched by age, sex, and illness severity (ICU only) to two control groups: hospitalized AML controls, and non-AML ICU controls. Data were extracted on demographics, course of hospitalization, and clinical outcomes. Results In total, 45 AML patients with available data were admitted to ICU. Mean (SD) age was 54.8 (13.1) years and 28.9% were female. Primary diagnoses were sepsis (32.6%) and respiratory failure (37.3%). Mean (SD) APACHE II score was 30.3 (10.3), SOFA score 12.6 (4.0) with 62.2% receiving mechanical ventilation, 55.6% vasoactive therapy, and 26.7% renal replacement therapy. Crude in-hospital, 90-day and 1-year mortality was 44.4%, 51.1% and 71.1%, respectively. AML cases had significantly higher adjusted-hazards of death (HR 2.23; 95% CI, 1.38-3.60, p = 0.001) compared to both non-AML ICU controls (HR 1.69; 95% CI, 1.11-2.58, p = 0.02) and hospitalized AML controls (OR 1.0, reference variable). Factors associated with ICU mortality by univariate analysis included older age, AML subtype, higher baseline SOFA score, no change or an increase in early SOFA score, shock, vasoactive therapy and mechanical ventilation. Active chemotherapy in ICU was associated with lower mortality. Conclusions AML patients may represent a minority of all critically ill admissions; however, are not uncommonly supported in ICU. These AML patients are characterized by high illness severity, multi-organ dysfunction, and high treatment intensity and have a higher risk of death when compared with matched hospitalized AML or non-AML ICU controls. The absence of early improvement in organ failure may be a useful predictor for mortality for AML patients admitted to ICU.
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Affiliation(s)
- Amanda L Roze des Ordons
- Division of Critical Care Medicine, Faculty of Medicine and Dentistry, University of Alberta Hospital, Edmonton, Alberta, T6G2B7 Canada
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Azoulay E. Epidemiology of Acute Respiratory Failure in Patients with HM (ICU Only). PULMONARY INVOLVEMENT IN PATIENTS WITH HEMATOLOGICAL MALIGNANCIES 2010. [PMCID: PMC7123526 DOI: 10.1007/978-3-642-15742-4_5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/15/2023]
Abstract
Pulmonary complications are common in hematological patients, particularly those receiving a hematological stem cell transplant (HSCT), and a significant percentage of them will require intensive care unit (ICU) admission. Acute respiratory failure in these patients is a threatening event, with a very poor outcome, particularly when mechanical ventilation (MV) is required. For many years, oncologists and intensivists had a pessimistic vision of the dismal outcome of those hematological patients requiring admission to the ICU. The bleak experience in this population led some authors to suggest early withdrawal of support, or even withholding the option of mechanical ventilation altogether. However, over the last years this vision seems to be changing. Great progress has been made in stem cell transplantation that can be ascribed to a better understanding of the human leukocyte antigen (HLA) system for donor selection, more effective and less toxic immunosupression for prevention and treatment of graft-versus host disease (GVHD), and significant advances in infectious disease therapy. Also improvements in ventilatory and supportive care, such as the early implantation of noninvasive ventilation (NIV), may avoid intubation in a significant percentage of patients suffering from acute respiratory failure. As a result of all this, the proportion of both hematological patients requiring management in the ICU and those requiring MV is decreasing. Also the survival rate of HSCT recipients admitted to the ICU has been steadily improving. In this chapter we will report on the epidemiology of acute respiratory failure in patients with hematological malignancies.
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Affiliation(s)
- Elie Azoulay
- Service de Réanimation Médicale, Hôpital Saint Louis, Avenue Claude Vellefaux 1, Paris, 75010 France
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Abstract
Acute respiratory failure with the need for mechanical ventilation is a severe and frequent complication, and a leading reason for admission to the intensive care unit (ICU) in patients with malignancies. Nevertheless, improvements in patient survival have been observed over the last decade. This article reviews the epidemiology of adult patients with malignancies requiring ventilatory support. Criteria used to assist decisions to admit a patient to the ICU and to select the initial ventilatory strategy are discussed.
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Abstract
An estimated 50,000 to 60,000 patients undergo hematopoietic stem cell transplantation (HSCT) worldwide annually, of which 15.7% are admitted to the intensive care unit (ICU). The most common reason for ICU admission is respiratory failure and almost all develop single or multiorgan failure. Most HSCT recipients admitted to ICU receive invasive mechanical ventilation (MV). The overall short-term mortality rate of HSCT recipients admitted to ICU is 65%, and 86.4% for those receiving MV. Patient outcome has improved over time. Poor prognostic indicators include advanced age, poor functional status, active disease at transplant, allogeneic transplant, the severity of acute illness, and the development of multiorgan failure. ICU resource limitations often lead to triage decisions for admission. For HSCT recipients, the authors recommend (1) ICU admission for full support during their pre-engraftment period and when there is no evidence of disease recurrence; (2) no ICU admission for patients who refuse it and those who are bedridden with disease recurrence and without treatment options except palliation; (3) a trial ICU admission for patients with unknown status of disease recurrence with available treatment options.
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Affiliation(s)
- Bekele Afessa
- Division of Pulmonary and Critical Care Medicine, Mayo Clinic College of Medicine, 200 First Street SW, Rochester, MN 55905, USA.
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Burghi G, Lemiale V, Bagnulo H, Bódega E, Azoulay E. [Invasive pulmonary aspergillosis in a hematooncological patient in the intensive care units. A review of the literature]. Med Intensiva 2010; 34:459-66. [PMID: 20096960 DOI: 10.1016/j.medin.2009.11.010] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2009] [Revised: 11/16/2009] [Accepted: 11/24/2009] [Indexed: 11/26/2022]
Abstract
Invasive aspergillosis is a common condition in patients with hematologic malignancies. Symptoms are extremely non-specific, and therefore it is necessary to be familiar with the diagnostic tests for early diagnosis. This review has attempted to clarify the current evidence regarding the following areas: clinical presentation, methods of study and treatment of this condition in hemato-oncological critical patients.
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Affiliation(s)
- G Burghi
- Unidad de Cuidados Intensivos, Hospital Maciel, Montevideo, Uruguay.
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Hill QA. Intensify, resuscitate or palliate: Decision making in the critically ill patient with haematological malignancy. Blood Rev 2010; 24:17-25. [DOI: 10.1016/j.blre.2009.10.002] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Ñamendys-Silva SA, Hernández-Garay M, Herrera-Gómez A. Noninvasive Ventilation in Immunosuppressed Patients. Am J Hosp Palliat Care 2009; 27:134-8. [DOI: 10.1177/1049909109346833] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/06/2023] Open
Abstract
In immunosuppressed patients (ISP) with acute respiratory failure (ARF), invasive mechanical ventilation (IMV) is associated with high mortality rate. Noninvasive ventilation (NIV) is a type of mechanical ventilation that does not require an artificial airway. It has seen increasing use in critically ill patients to avoid endotracheal intubation. Acute respiratory failure due to pulmonary infections is an important cause of illness in ISP and their treatment. Immunosuppressive treatments have showed an increase not only in the survival but also in the susceptibility to infection. Several authors have underlined the worst prognosis for neutropenic patients with ARF requiring endotracheal intubation and IMV. The NIV seems to be an interesting alternative in ISP because of the lower risk of complications; it prevents endotracheal intubation and its associated complications with survival benefits in this population.
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Affiliation(s)
- Silvio A. Ñamendys-Silva
- Department of Critical Care Medicine, Instituto Nacional de Cancerología and Instituto Nacional de Ciencias Médicas y Nutrición Salvador Zubirán, Mexico City, Mexico,
| | | | - Angel Herrera-Gómez
- Deparment of Oncology Surgery, Instituto Nacional de Cancerología, México City, Mexico
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Hampshire PA, Welch CA, McCrossan LA, Francis K, Harrison DA. Admission factors associated with hospital mortality in patients with haematological malignancy admitted to UK adult, general critical care units: a secondary analysis of the ICNARC Case Mix Programme Database. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2009; 13:R137. [PMID: 19706163 PMCID: PMC2750195 DOI: 10.1186/cc8016] [Citation(s) in RCA: 123] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/28/2009] [Revised: 05/12/2009] [Accepted: 08/25/2009] [Indexed: 01/20/2023]
Abstract
Introduction Patients with haematological malignancy admitted to intensive care have a high mortality. Adverse prognostic factors include the number of organ failures, invasive mechanical ventilation and previous bone marrow transplantation. Severity-of-illness scores may underestimate the mortality of critically ill patients with haematological malignancy. This study investigates the relationship between admission characteristics and outcome in patients with haematological malignancies admitted to intensive care units (ICUs) in England, Wales and Northern Ireland, and assesses the performance of three severity-of-illness scores in this population. Methods A secondary analysis of the Intensive Care National Audit and Research Centre (ICNARC) Case Mix Programme Database was conducted on admissions to 178 adult, general ICUs in England, Wales and Northern Ireland between 1995 and 2007. Multivariate logistic regression analysis was used to identify factors associated with hospital mortality. The Acute Physiology and Chronic Health Evaluation (APACHE) II score, Simplified Acute Physiology Score (SAPS) II and ICNARC score were evaluated for discrimination (the ability to distinguish survivors from nonsurvivors); and the APACHE II, SAPS II and ICNARC mortality probabilities were evaluated for calibration (the accuracy of the estimated probability of survival). Results There were 7,689 eligible admissions. ICU mortality was 43.1% (3,312 deaths) and acute hospital mortality was 59.2% (4,239 deaths). ICU and hospital mortality increased with the number of organ failures on admission. Admission factors associated with an increased risk of death were bone marrow transplant, Hodgkin's lymphoma, severe sepsis, age, length of hospital stay prior to intensive care admission, tachycardia, low systolic blood pressure, tachypnoea, low Glasgow Coma Score, sedation, PaO2:FiO2, acidaemia, alkalaemia, oliguria, hyponatraemia, hypernatraemia, low haematocrit, and uraemia. The ICNARC model had the best discrimination of the three scores analysed, as assessed by the area under the receiver operating characteristic curve of 0.78, but all scores were poorly calibrated. APACHE II had the highest accuracy at predicting hospital mortality, with a standardised mortality ratio of 1.01. SAPS II and the ICNARC score both underestimated hospital mortality. Conclusions Increased hospital mortality is associated with the length of hospital stay prior to ICU admission and with severe sepsis, suggesting that, if appropriate, such patients should be treated aggressively with early ICU admission. A low haematocrit was associated with higher mortality and this relationship requires further investigation. The severity-of-illness scores assessed in this study had reasonable discriminative power, but none showed good calibration.
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Affiliation(s)
- Peter A Hampshire
- Royal Liverpool University Hospital, Prescot Street, Liverpool, L7 8XP, UK.
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Abstract
Non-invasive mechanical ventilation has been increasingly used to avoid or serve as an alternative to intubation. Compared with medical therapy, and in some instances with invasive mechanical ventilation, it improves survival and reduces complications in selected patients with acute respiratory failure. The main indications are exacerbation of chronic obstructive pulmonary disease, cardiogenic pulmonary oedema, pulmonary infiltrates in immunocompromised patients, and weaning of previously intubated stable patients with chronic obstructive pulmonary disease. Furthermore, this technique can be used in postoperative patients or those with neurological diseases, to palliate symptoms in terminally ill patients, or to help with bronchoscopy; however further studies are needed in these situations before it can be regarded as first-line treatment. Non-invasive ventilation implemented as an alternative to intubation should be provided in an intensive care or high-dependency unit. When used to prevent intubation in otherwise stable patients it can be safely administered in an adequately staffed and monitored ward.
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Affiliation(s)
- Stefano Nava
- Respiratory Intensive Care Unit, Fondazione S Maugeri Istituto Scientifico di Pavia, IRCCS, Pavia, Italy.
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38
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Noninvasive pressure-support ventilation in immunocompromised children with ARDS: a feasibility study. Intensive Care Med 2009; 35:1420-7. [DOI: 10.1007/s00134-009-1558-5] [Citation(s) in RCA: 79] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2008] [Accepted: 06/09/2009] [Indexed: 11/28/2022]
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Wu YK, Huang YC, Huang SF, Huang CC, Tsai YH. Acute respiratory distress syndrome caused by leukemic infiltration of the lung. J Formos Med Assoc 2008; 107:419-23. [PMID: 18492627 DOI: 10.1016/s0929-6646(08)60108-4] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/18/2022] Open
Abstract
Respiratory distress syndrome resulting from leukemic pulmonary infiltrates is seldom diagnosed antemortem. Two 60- and 80-year-old women presented with general malaise, progressive shortness of breath, and hyperleukocytosis, which progressed to acute respiratory distress syndrome (ARDS) after admission. Acute leukemia with pulmonary infection was initially diagnosed, but subsequent examinations including open lung biopsy revealed leukemic pulmonary infiltrates without infection. In one case, the clinical condition and chest radiography improved initially after combination therapy with chemotherapy for leukemia and aggressive pulmonary support. However, new pulmonary infiltration on chest radiography and hypoxemia recurred, which was consistent with acute lysis pneumopathy. Despite aggressive treatment, both patients died due to rapidly deteriorating condition. Leukemic pulmonary involvement should be considered in acute leukemia patients with non-infectious diffusive lung infiltration, especially in acute leukemia with a high blast count.
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Affiliation(s)
- Yao-Kuang Wu
- Division of Pulmonary and Critical Care Medicine, Buddhist Tzu Chi General Hospital, Taipei, Taiwan
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40
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Azoulay E, de Miranda S, Bèle N, Schlemmer B. [Diagnostic strategy for acute respiratory failure in patients with haematological malignancy]. Rev Mal Respir 2008; 25:433-49. [PMID: 18536628 DOI: 10.1016/s0761-8425(08)71584-5] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
INTRODUCTION About 15% of patients with haematological malignancy develop acute respiratory failure (ARF), necessitating admission to intensive care where their mortality is of the order of 50%. STATE OF THE ART The prognosis of these patients is not determined by the pathological characteristics of the malignancy but by the cause of the acute respiratory failure. In effect, the need to resort to mechanical ventilation in the presence of dysfunction of other organs dominates the prognosis. Even if the use of non-invasive ventilation in these patients has reduced the need for intubation and reduced the mortality, its prolonged use in the most severely affected patients prevents the optimal diagnostic and therapeutic management. PERSPECTIVES Fibreoptic bronchoscopy with broncho-alveolar lavage (BAL) is considered the cornerstone of aetiological diagnosis but its diagnostic effectiveness is poor, at best 50%, and this has led to increasing interest in high resolution CT scanning and regularly reawakens a transitory enthusiasm for surgical lung biopsy. Furthermore, in hypoxaemic patients, fibreoptic bronchoscopy with BAL may be the origin of the resort to mechanical ventilation, and thus increased mortality. The place of recently developed non-invasive tools is under evaluation. In effect, though the individual performance of diagnostic molecular techniques on sputum, blood, urine or naso- pharyngeal secretions has been established, the combination of these tools as an alternative to BAL has not yet been reported. CONCLUSION This review deals with acute respiratory failure in patients with haematological malignancy. It includes a review of the recent literature and considers the current controversies, in particular the risk-benefit balance of fibreoptic bronchoscopy with BAL in severely hypoxaemic patients.
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Affiliation(s)
- E Azoulay
- Service de Réanimation médicale, Hôpital Saint-Louis, Université Paris Diderot, Assistance Publique Hôpitaux de Paris, 1 avenue Claude Vellefaux, Paris, France.
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Abstract
We evaluated the frequency, etiologic factors, outcome, and the comorbid conditions affecting the morbidity and mortality of pulmonary complications in acute childhood leukemia. Sixty-six (40.4%) out of 163 patients developed 79 pulmonary complications. Infectious etiology was the leading cause (92.4%). The most identified infectious agents were Gram (-) bacteria, followed by fungi. Acute respiratory distress syndrome, leukostasis, lymphomatoid granulomatosis, pulmonary edema, and pneumothorax were among the noninfectious causes. The pulmonary complications in the induction and consolidation phase of leukemia therapy were more severe and the mortality rate was higher. Tachypnea, shock, oxygen and mechanical ventilation requirement, disseminated intravascular coagulation, involvement of other organs or systems, cytopenias, requirement of modification in antimicrobial drugs were found to be related with increased mortality risk. The mortality rate of pulmonary complications was 8.9%. Pulmonary infections in the maintenance phase of the therapy were frequently treated with oral antibiotics, and they were generally rapidly taken under control. In conclusion, pulmonary complications are frequent in children with acute leukemia, and early diagnosis and appropriate management are important to avoid mortality owing to pulmonary complications, especially in neutropenic patients receiving induction or consolidation phase of chemotherapy.
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42
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Cuthbertson BH, Rajalingam Y, Harrison S, McKirdy F. The Outcome of Haematological Malignancy in Scottish Intensive Care Units. J Intensive Care Soc 2008. [DOI: 10.1177/175114370800900208] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
To study the prognostic indicators and outcome in patients with haematological malignancy requiring intensive care, we identified 714 adult patients and analysed their clinical audit data. Mean APACHE II score was 24. Main admitting diagnoses were acute lymphoma (43%) and acute leukaemia (28%). There was a high requirement for acute organ support. Intensive care unit (ICU) mortality was 39% and hospital mortality 55%, with a standardised mortality rate of 1.05 (0.98–1.13). Factors predictive of outcome after multivariate analysis were: cardiopulmonary resuscitation (CPR) in the 24-hours before ICU admission, inotropic support in the first 24-hours, APACHE II score and requirement for ventilatory support immediately prior to, or at admission to the ICU. Neutropaenia was not an independent predictor. Patients with neutropaenic septic shock and multiorgan failure left hospital. Hospital mortality for this group is comparable to that of non-cancer patients admitted with multi-organ system failure. The reluctance to admit such patients to ICU may be unjustified.
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Affiliation(s)
| | - Yadhu Rajalingam
- Department of Intensive Care, Royal Free Hampstead NHS Trust, London
| | | | - Fiona McKirdy
- Scottish Intensive Care Society Audit Group, Victoria Infirmary, Glasgow
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43
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Tomicic V, Montalván C, Espinoza M, Graf J, Martínez E, Umaña A, Torres J. [Pumpless extracorporeal pulmonary care: an alternative in the treatment of persistent acute respiratory distress syndrome]. Med Intensiva 2008; 32:253-7. [PMID: 18570836 DOI: 10.1016/s0210-5691(08)70948-3] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
A 34-year old woman who developed persistent and severe acute respiratory distress syndrome with underlying myelomonocytic leukemia (M4FAB) is described. After ruling out the most common causes of pulmonary infiltration in this type of patient and one week of broad spectrum antibiotics and steroids therapy, we proposed leukemic pulmonary infiltration as etiological diagnosis. Despite using a protective ventilatory strategy, recruitment maneuvers, prone position and high frequency oscillatory ventilation, her gas exchange became worse. Under this condition we used a Pumpless-Extracorporeal life assist (PELA) and begun chemotherapy. The method, arterial blood gases, hemodynamic parameters and ventilatory mechanics before and after its use are described. The patient remained on P-ELA for nine days; one week later she was extubated and ten days after she was discharged from the Intensive Care Unit the patient left the hospital in good health condition.
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Affiliation(s)
- V Tomicic
- Departamento de Paciente Crítico, Clínica Alemana de Santiago, Facultad de Medicina Clínica Alemana, Universidad del Desarrollo, Santiago de Chile, Chile.
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Mendoza V, Lee A, Marik PE. The hospital-survival and prognostic factors of patients with solid tumors admitted to an ICU. Am J Hosp Palliat Care 2008; 25:240-3. [PMID: 18539768 DOI: 10.1177/1049909108315523] [Citation(s) in RCA: 32] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
The decision to admit a patient with cancer to the intensive care unit (ICU) is complex. There are limited data as to the outcome and prognostic factors of patients with solid tumors admitted to the ICU. A retrospective chart review was undertaken to evaluate this issue. Over an 18-month period, 147 patients with solid tumors were admitted to our ICU. Lung, colorectal, and breast were the commonest sites of the primary tumors, with 52% of patients having metastatic disease. A total of 79 (54%) patients survived to hospital discharge, with 50 (34%) patients being discharged to home. Metastatic disease and the requirement for vasopressor agents were independent predictors of poor outcome. The relatively high survival rate of this cohort of patients should prompt a reevaluation of the ICU admission criteria for patients with solid tumors who become critically ill.
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Affiliation(s)
- Vinia Mendoza
- Department of Internal Medicine, Thomas Jefferson University, Philadelphia, PA 19107, USA
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45
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Is BAL useful in patients with acute myeloid leukemia admitted in ICU for severe respiratory complications? Leukemia 2008; 22:1361-7. [PMID: 18432262 DOI: 10.1038/leu.2008.100] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
In patients with hematological malignancy (HM) developing acute respiratory failure (ARF) bronchoalveolar lavage (BAL) is considered as a major diagnostic tool. However, the benefit/risk ratio of this invasive procedure is probably lower in the subset of patients with acute myeloid leukemia (AML). The study was to analyze the yield of BAL performed in HM patients (n=175) with AML or lymphoid malignancies (LM) admitted in intensive care unit (ICU) for ARF and pulmonary infiltrates. BAL was performed in 121 patients (53/73 AML patients (73%) and 68/102 LM patients (67%)) without a definite diagnosis at admission or contraindication for fiberoptic bronchoscopy. Life-threatening complications were noticed in 12/121 patients (10%). The overall diagnostic yield of BAL was 47% (25/53) in AML patients and 50% (34/68) in LM patients. A microorganism was recovered from BAL in 23% (12/53) of AML patients and 41% (28/68) of LM patients (P<0.005). BAL results induced significant therapeutic changes in 17% (9/53) of AML patients vs 35% (24/68) of LM patients (P=0.039). This study underlines the rather low diagnostic yield of BAL for infectious diagnosis and the low rate of therapeutic changes induced by its results in AML patients with ARF admitted in ICU.
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46
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Pneumonien. DIE INTENSIVMEDIZIN 2008. [PMCID: PMC7122425 DOI: 10.1007/978-3-540-72296-0_38] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Die heute gebräuchlichen Definitionen der unterschiedlichen Formen der Pneumonie haben nicht nur eine begrifflich ordnende Funktion, sondern bezeichnen jeweils spezifische ätiopathogenetische, diagnostische und therapeutische Konzepte. Es kommt ihnen somit ein klinisch handlungsanweisender Wert zu.
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Diagnostic yield of bronchoscopy with bronchoalveolar lavage in febrile patients with hematologic malignancies and pulmonary infiltrates. Ann Hematol 2007; 87:291-7. [PMID: 17932672 DOI: 10.1007/s00277-007-0391-6] [Citation(s) in RCA: 62] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2007] [Accepted: 09/13/2007] [Indexed: 10/22/2022]
Abstract
Infectious complications are a major cause of morbidity and mortality in immunosuppressed patients. Febrile patients with hematologic malignancies and pulmonary infiltrates have high mortality rates, especially if mechanical ventilation is required. The diagnostic value of fiberoptic bronchoscopy (FOB) with bronchoalveolar lavage (BAL) in these patients is controversial. We retrospectively analyzed the microbiological results of BAL samples obtained during 249 FOB examinations from 199 febrile patients with hematologic malignancies and pulmonary infiltrates (underlying diseases: acute leukemia 103 patients, lymphoma 84 patients, other malignancies 12 patients). Two hundred forty-six examinations could be evaluated. Seventy-three out of 246 BAL samples were sterile; 55 samples showed microbiological findings classified as contamination or colonization. One hundred eighteen samples showed positive microbiological results of bacteria and/or fungi classified as causative pathogens. Thereof, in 70 samples, only bacterial pathogens were detectable (Gram-positive, 35; Gram-negative, 30; mixed Gram-positive and Gram-negative, 5). Thirteen samples showed both fungi and bacterial pathogens. In 33 samples, only fungi were detectable, thereof, in 15 samples Aspergillus species, in 16 samples Candida species, and in 2 both. In two samples, a viral pathogen could be detected. Three nonlethal complications (bleeding, arrhythmia) occurred that required early termination of FOB. In 94 (38.2%) patient episodes, antibiotic treatment was modified as a result of microbiological findings in BAL samples. Our results show that FOB with BAL is a valuable diagnostic tool with low complication rates in high-risk febrile patients with hematologic malignancies and pulmonary infiltrates, contributing crucial results for the individual case, and also improving epidemiologic knowledge.
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48
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Marik PE. Noninvasive Positive-Pressure Ventilation in Patients With Malignancy. Am J Hosp Palliat Care 2007; 24:417-421. [DOI: 10.1177/1049909107307370] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/30/2023] Open
Abstract
Noninvasive positive-pressure ventilation (NIPPV) is now accepted as the treatment of choice for subgroups of patients with acute respiratory failure. Noninvasive positive-pressure ventilation has traditionally not been considered in the management strategy of patients with malignancy; however, this mode of ventilatory support may be appropriate in some specific situations. Noninvasive positive-pressure ventilation is the preferred initial mode of ventilatory support in patients with hematologic malignancies or after bone marrow transplantation who develop acute respiratory failure. In these patients, NIPPV should be initiated early; severe respiratory distress and altered mental status require conventional mechanical ventilation. Noninvasive positive-pressure ventilation should be considered in select patients with cancer who develop respiratory failure and have a do-not-intubate code status. In rare instances, NIPPV may have a role in treating patients with advanced cancer who have intractable dyspnea; however, NIPPV should not be used for the sole purpose of prolonging life in patients with terminal respiratory failure.
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Affiliation(s)
- Paul E. Marik
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Thomas Jefferson University, Philadelphia, Pennsylvania,
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49
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Boersma WG, Erjavec Z, van der Werf TS, de Vries-Hosper HG, Gouw ASH, Manson WL. Bronchoscopic diagnosis of pulmonary infiltrates in granulocytopenic patients with hematologic malignancies: BAL versus PSB and PBAL. Respir Med 2007; 101:317-25. [PMID: 16774815 DOI: 10.1016/j.rmed.2006.04.021] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/30/2005] [Revised: 04/22/2006] [Accepted: 04/24/2006] [Indexed: 10/24/2022]
Abstract
BACKGROUND Treatment of patients with hematologic malignancies is often complicated by severe respiratory infections. Bronchoscopy is generally to be used as a diagnostic tool in order to find a causative pathogen. OBJECTIVES In a prospective study the combination of protected specimen brush (PSB) and protected bronchoalveolar lavage (PBAL) was compared with bronchoalveolar lavage (BAL) for evaluated feasibility and diagnostic yield in granulocytopenic patients with hematologic malignancies and pulmonary infiltrates. METHODS All specimens from 63 bronchoscopic procedures (35 BAL and 28 PSB-PBAL) were investigated by cytological examination and various microbiological tests. If clinically relevant and feasible, based on the clinical condition and/or the presence of thrombocytopenia, lung tissue samples were obtained. RESULTS The majority of the 58 included patients were diagnosed as having acute myeloid leukaemia and developed a severe neutropenia (BAL-group: 27 days; PSB-PBAL group: 30 days). Microbiological and cytological examination of 63 bronchoscopic procedures (35 BAL and 28 PSB-PBAL) yielded causative pathogens in 9 (26%) patients of the BAL-group and 8 (29%) patients of the PSB-PBAL group (PSB and PBAL 4 each). Aspergillus fumigatus was the pathogen most frequently (13%) detected. Using all available examinations including the results of autopsy, a presumptive diagnosis was established in 43% of the patients in the BAL group and 57% of those in the PSB-PBAL group; in these cases microbial aetiology was correctly identified in 67% and 57%, respectively. The complication rate was of these procedures were low, and none of the patients experienced serious complications due to the invasive techniques. CONCLUSIONS Our results showed that modern bronchoscopic techniques such as PSB and PBAL did not yield better diagnostic results compared to BAL in granulocytopenic patients with hematologic malignancies and pulmonary infiltrates. In approximately half of the cases a presumptive diagnosis was made by bronchoscopic procedures.
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Affiliation(s)
- Wim G Boersma
- Department of Pulmonary Diseases, Medical Center Alkmaar, 1800 AM Alkmaar, The Netherlands.
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50
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Armenian SH, La Via WV, Siegel SE, Mascarenhas L. Evaluation of persistent pulmonary infiltrates in pediatric oncology patients. Pediatr Blood Cancer 2007; 48:165-72. [PMID: 16411212 DOI: 10.1002/pbc.20747] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
PURPOSE To evaluate the role of bronchoalveolar lavage (BAL), computed-tomography-guided biopsy (CTB), and open lung biopsy (OLB) in the management of persistent pulmonary infiltrates in pediatric oncology patients. METHODS Retrospective review of clinical records of pediatric oncology patients who underwent BAL, CTB, and OLB over a 7-year period. Data was compared across the three procedures using chi-square analysis. Logistic regression was used to adjust potential confounding variables for diagnostic yield. RESULTS There were 113 consecutive patients who underwent 140 separate procedures during their hospitalization. Thirty (26%) patients had a previous BMT. BALs were more likely to occur as the first line of investigation (98% vs. 47%, 45%; P < 0.01) and in patients with diffuse infiltrates (64% vs. 6%, 26%; P < 0.01) when compared to CTB and OLB, respectively. OLBs were performed less frequently in neutropenic patients (26% vs. 53%, 54%; P < 0.05), more often led to change in management directly because of procedure (61% vs. 12%, 33%; P < 0.01), and had higher diagnostic yield (61% vs. 24%, 36%; P < 0.01) when compared to CTB and BAL, respectively. Diagnostic yield of OLB was significantly higher regardless of diffuse or focal nature of infiltrate. Major adverse events after a procedure were not significantly different across the three procedures. Logistic regression demonstrated that having an OLB was independently associated with identifying the cause of pulmonary infiltrate. CONCLUSION OLB appears to be safe, has the best diagnostic yield, and leads to change in management more often than CTB or BAL in pediatric oncology patients with persistent pulmonary infiltrates.
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Affiliation(s)
- Saro H Armenian
- Division of Hematology/Oncology, Childrens Hospital Los Angeles, Los Angeles, California 90027, USA
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