Respiration/Mechanical Ventilation
The impact of the initial ventilatory strategy on survival in hematological patients with acute hypoxemic respiratory failure

https://doi.org/10.1016/j.jcrc.2009.02.016Get rights and content

Abstract

Purpose

The aim of this study was to assess the impact of the 3 types of initial respiratory support (noninvasive positive pressure ventilation vs invasive positive pressure ventilation vs supplemental oxygen only) in hematological patients with acute hypoxemic respiratory failure (ARF).

Materials and Methods

This study is a retrospective analysis of a cohort of hematological patients admitted to the intensive care unit (ICU) of a tertiary care hospital between January 1, 2002, and June 30, 2006.

Results

One hundred thirty-seven hematological patients were admitted at the ICU with ARF (defined as Pao2/Fio2 <200): within the first 24 hours, 24 and 67 patients received noninvasive positive pressure ventilation and invasive positive pressure ventilation, respectively, and 46 received supplemental oxygen only. Intensive care unit mortality in the 3 patient categories was 71%, 63%, and 32%, respectively (P = .001), and in-hospital mortality was 75%, 80%, and 47%, respectively (P = .001). In multivariate regression analysis, increasing cancer-specific severity-of-illness score upon admission and more organ failure after 24 hours of ICU admission, but not the type of initial respiratory support, were significantly associated with ICU or in-hospital mortality.

Conclusions

Intensive care unit and in-hospital mortality in our population of hematological patients with hypoxemic ARF was determined by severity of illness and not by the type of initial respiratory support.

Introduction

Prognosis of hematological malignancy has improved in the last decades because of advances in diagnosis and therapy [1], [2], [3], [4], [5]. However, this therapeutic intensification, coupled with longer survival time, has led to an increased occurrence of potential life-threatening complications in these profoundly immunosuppressed patients [6], [7], [8]. Acute respiratory failure (ARF) is known to occur in up to 50% of hematological patients and to be associated with a rather grim prognosis, as up to 70% to 75% patients requiring mechanical ventilation eventually die in the hospital. However, the general trend toward increased survival in critically ill cancer and hematological patients [6], [7], [8] has also been observed in those patients with ARF [9], [10], [11], [12], [13] as well as in other severely ill subgroups [14], [15], [16], [17], [18], [19]. Since the publication of studies describing improved outcome associated with the use of noninvasive positive pressure ventilation (NIPPV) in hematological and solid cancer patients with ARF [12], [20], including a randomized controlled trial [20], NIPPV has been advocated as a preferable initial mode of respiratory support. In contrast to this, we have observed that NIPPV was not linked with outcome in a cohort of hematological patients requiring mechanical ventilation [10]. However, this study was, in part, based on retrospectively collected data, included patients treated with continuous positive airway pressure rather than NIPPV, and covered a period before the publication of the aforementioned randomized controlled trial of Hilbert et al [20] and of the British Thoracic Society guidelines for the use of NIPPV [21]. In the current report, we have updated on the impact of the initial type of respiratory support (NIPPV vs invasive positive pressure ventilation [IPPV] vs supplemental oxygen only, within the first 24 hours of intensive care unit [ICU] admission) on outcome in hematological patients admitted to the ICU with severe hypoxemic ARF (defined as a Pao2/Fio2 <200 at ICU admission).

Section snippets

Patients and methods

This retrospective study includes all consecutive patients with a hematological malignancy admitted to the medical ICU of the Ghent University Hospital between January 1, 2002, and June 30, 2006. Demographic, clinical, laboratory, and physiological data were recorded prospectively in all patients. The study was approved by the Ethical Committee of the Ghent University Hospital, and informed consent was waived due to the observational nature of the study.

Since 2002, hematological patients

Results

During the study period, 239 adult patients with a hematological malignancy were admitted to the ICU. One hundred thirty-seven (57%) of these had hypoxemic ARF, as defined as a Pao2/Fio2 <200 within the first 24 hours of ICU admission, and were included in the analysis. Mechanical ventilatory support was provided to 91 patients: in 24, NIPPV was the initial mode of mechanical ventilation. In 46 patients, respiratory support within the first 24 hours consisted of supplemental oxygen only.

Discussion

In our hematological patients with severe hypoxic ARF, the use of NIPPV within 24 hours of ICU admission, as compared with IPPV or supplemental oxygen, was not associated with better outcome. Guided by the article of Hilbert et al [20] and the general indications and contraindications for NIPPV [21], we selected approximately a fifth of hematological patients with severe ARF for a NIPPV trial. However, NIPPV failed in 75% of these patients.

The high rate of NIPPV failure in our patients requires

Acknowledgments

The authors wish to thank Renaat Pelemaan, MD, PhD (Department of Internal Medicine, Ghent University Hospital) for his contribution to establishing the ICU admission diagnosis in patients with hypoxemic ARF.

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