Incidence and prognostic value of respiratory events in acute leukemia

Abstract

Acute respiratory failure and infectious pneumonia are the major causes of death during induction chemotherapy of acute leukemia. However, the causes, incidence and prognostic value of all respiratory events (REs) occurring in this context have never been assessed prospectively. We recruited 65 consecutive patients with newly diagnosed acute leukemia into a 1-year prospective study (December 2000-November 2001 to evaluate the incidence and prognostic value of these events. REs were frequent: 38 were recorded in 30 patients. There was a significant relationship between REs and pre-existing respiratory disease and/or smoking. REs were caused by infection in 34% of cases, by an established cause other than infection in 42% and had an undetermined cause in 24%. Poor early outcome (death within 45 days of starting induction chemotherapy) in patients experiencing an RE was independently associated with a 425/min respiratory rate (P ¼ 0.003) and the nonachievement of complete remission (CR) (Po0.0001). Predictors of overall survival in the entire patient population were the absence of CR (Po0.0001), REs (P ¼ 0.02) and a X2 performance status (P ¼ 0.03). In conclusion, REs are frequent during induction chemotherapy of acute leukemia and represent an independent prognostic factor of poor outcome, regardless of their cause.

Commentary

“…Pulmonary findings were due to infection in 56.6% of cases and to another cause in 24.5%. These results and the rate of pulmonary events with undetermined etiologies were consistent with similar studies from different groups such as Chaoui et al and Rano et al [2,3].…”

“…In conclusion, irrespective of their etiology, respiratory events are of a major prognostic significance [2]. Moreover, leukemic pulmonary involvement should be considered in AML patients with noninfectious lung infiltration.…”

Is BAL useful in patients with acute myeloid leukemia admitted in ICU for severe respiratory complications?

“…Third, the prolonged neutropenia observed in AML patients leads to a higher incidence of pulmonary aspergillosis than in previous studies. 2,3,8,26 FOB-BAL diagnostic yield regarding Aspergillus species is low and we might have underestimated some cases of invasive aspergillosis in our patients. Indeed, Saito et al 12 compared the results obtained with BAL to autopsy results.…”

“…Noninfectious etiologies of pulmonary infiltrates include a large panel of pulmonary diseases such as pulmonary leukostasis, acute lysis pneumonitis, pulmonary edema related to hydration, transfusion-related acute lung injury and all-trans-retinoic acid-related syndrome. 3,6,16 These complications may present with a typical radioclinical pattern and may respond rapidly to a specific treatment without the need for FOB-BAL. 16 Such complications are infrequent in lymphoid malignancies and absent after complete remission.…”

“…[1][2][3] PC are related to a large spectrum of infectious and noninfectious etiologies [4][5][6][7] and, in case of acute respiratory failure (ARF), early identification of the cause of PC is associated with a better outcome. 8 Fiberoptic bronchoscopy with bronchoalveolar lavage (FOB-BAL) is usually considered as the cornerstone of diagnostic procedures in immunocompromised patients with pulmonary infiltrates.…”