Diagnostic Strategy for Hematology and Oncology Patients with Acute Respiratory Failure

Abstract

FO-BAL performed in the intensive care unit did not significantly increase intubation requirements in critically ill cancer patients with ARF. Noninvasive testing alone was not inferior to noninvasive testing plus FO-BAL for identifying the cause of ARF. Clinical trial registered with www.clinicaltrials.gov (NCT00248443).

Critically ill allogeneic hematopoietic stem cell transplantation patients in the intensive care unit: reappraisal of actual prognosis

“…89 High acute illness severity at ICU admission can be explained by different factors, mainly represented by diagnostic difficulties and suboptimal evaluation in wards, resulting in underestimation of disease severity followed by an unexpected clinical deterioration. An early ICU management may translate into better survival, allowing the use of noninvasive diagnostic strategies, 90,91 reducing the number of patients admitted with MOF and initiating early organ failure support. Five recent studies demonstrated the benefit of early ICU admission in the context of cancer patients with ARF, 89 newly diagnosed AML, 92 septic shock of pulmonary origin, 93 cancer patients admitted to the ICU 94 and for patients with hematologic malignancies admitted to the ICU.…”

Non-invasive mechanical ventilation in hematology patients with hypoxemic acute respiratory failure: a false belief?

“…Also, in-ICU prophylactic NIV could be a way to safely perform non-invasive or invasive diagnostic strategy. 5,13,17 In summary, we believe that the following 10 reasons warrant additional randomized trials of prophylactic NIV in hematology patients with respiratory events. (1) No controlled trial on NIV use in only hematology patients is available; (2) no trial of prophylactic NIV in hematology patients is available; (3) only one randomized controlled trial from a single ICU has evaluated prophylactic NIV in 30 hematology patients; (4) benefit from NIV comes from studies with high mortality rates of intubated patients; (5) no study has formally distinguished prophylactic from curative NIV; (6) data from cohort studies suggest that early intubation offers survival benefits to hematology patients; (7) data from cohort studies raise concerns about late failure from NIV in hematology patients with ARF; (8) according to each hospital, technical requirements as well as nurse/physician to patient ratio may be insufficient to safely use NIV in patients with ARF; (9) conflicting results come from two studies on NIV outside of the ICU in hematology patients with respiratory events but no respiratory distress; (10) in patients who receive palliative NIV, cancer patients are the least likely to benefit.…”

“…Corresponding figures nowadays would be up to 60 and 15%. 13 Therefore, we are convinced that the current literature has witnessed important advances over the last decades, at a time where most of the hematology patients requiring intubation and mechanical ventilation were dying. However, we also believe that the same studies remain inconclusive now that a substantial number of patients survive to life-sustaining therapies, more particularly mechanical ventilation.…”

“…In such a trial, great care should be taken to undertake appropriate diagnostic tests so as to identify the precise cause of the ARF, which can be a major confounding factor when analysing survival in immunocompromized patients with pulmonary involvement. 12,13 …”

Improved outcome of critically ill patients with hematological malignancies: what’s next?

“…Such interventions may include testing and assessing specific admission and discharge criteria, the outcome of different ventilatory strategies, including noninvasive ventilation, and diagnostic and therapeutic strategies. Few of such interventional studies have been conducted to date [11]. Future studies should also include representation from countries around the world, including developing countries, in order to improve our understanding of the attitudes, obstacles and outcomes in the care of such patients in healthcare systems that may have much fewer resources, thereby necessitating more difficult choices in patient care.…”