Ventilatory support in critically ill hematology patients with respiratory failure

Abstract

IntroductionHematology patients admitted to the ICU frequently experience respiratory failure and require mechanical ventilation. Noninvasive mechanical ventilation (NIMV) may decrease the risk of intubation, but NIMV failure poses its own risks.MethodsTo establish the impact of ventilatory management and NIMV failure on outcome, data from a prospective, multicenter, observational study were analyzed. All hematology patients admitted to one of the 34 participating ICUs in a 17-month period were followed up. Data on demographics, diagnosis, severity, organ failure, and supportive therapies were recorded. A logistic regression analysis was done to evaluate the risk factors associated with death and NIVM failure.ResultsOf 450 patients, 300 required ventilatory support. A diagnosis of congestive heart failure and the initial use of NIMV significantly improved survival, whereas APACHE II score, allogeneic transplantation, and NIMV failure increased the risk of death. The risk factors associated with NIMV success were age, congestive heart failure, and bacteremia. Patients with NIMV failure experienced a more severe respiratory impairment than did those electively intubated.ConclusionsNIMV improves the outcome of hematology patients with respiratory insufficiency, but NIMV failure may have the opposite effect. A careful selection of patients with rapidly reversible causes of respiratory failure may increase NIMV success.

Outcome of invasive mechanical ventilation after pediatric allogeneic hematopoietic SCT: results from a prospective, multicenter registry

“…18,30,31 NIV is often used as first-line respiratory support in patients with acute respiratory failure, and may decrease mortality rates by avoiding intubation; 32,33 conversely, NIV can have negative effects on outcome by postponing intubation as has been shown in several studies in adult hematology patients. 34,35 Restrictions on use of curative NIV in adults were therefore recently proposed. 36,37 We found nonsignificant better survival in patients who immediately started with IMV (49%) compared with patients who received IMV after failed NIV (63%, P = 0.13).…”

Non-invasive ventilation in immunocompromised patients with acute hypoxemic respiratory failure

“…Simultaneously, there has been an increase in the number of immunocompromised patients with life threatening complications (2)(3)(4), with recent studies showing that 15% of patients with acute leukemia and 20% of bone marrow transplantation recipients require intensive care unit (ICU) admission (5). The main reason for ICU admission in these patient populations is acute hypoxemic respiratory failure (5,6), which is associated with a high mortality rate, particularly when invasive mechanical ventilation is required (2,7). This raises the interest on Perspective Non-invasive ventilation in immunocompromised patients with acute hypoxemic respiratory failure non-invasive ventilation (NIV), a technique that provides ventilator assistance without the use of endotracheal tube.…”

“…Furthermore, although side effects of NIV have been described, including facial skin lesions, gastric distension and patient discomfort related to noise, claustrophobia, nasal or oral dryness and nasal congestion, their incidence is low and largely preventable with proper management of the technique (8). Therefore, applying NIV, and thus avoiding endotracheal intubation and invasive mechanical ventilation with its side effects (9,10), may potentially decrease the mortality rate in immunocompromised patients (5,(11)(12)(13).This perspective reviews the findings from a recent randomized controlled trial (RCT) assessing whether early intermittent respiratory support with NIV has a role in reducing the mortality rate of immunocompromised patients with non-hypercapnic hypoxemic respiratory failure in the context of the current critical care landscape, and in light of recent results from other trials focused on the early management of acute hypoxemic respiratory failure. …”

“…Furthermore, although side effects of NIV have been described, including facial skin lesions, gastric distension and patient discomfort related to noise, claustrophobia, nasal or oral dryness and nasal congestion, their incidence is low and largely preventable with proper management of the technique (8). Therefore, applying NIV, and thus avoiding endotracheal intubation and invasive mechanical ventilation with its side effects (9,10), may potentially decrease the mortality rate in immunocompromised patients (5,(11)(12)(13).…”

Has survival increased in cancer patients admitted to the ICU? No

“…Although non-invasive ventilation (NIV) is assumed to have a beneficial effect on outcome if employed in cancer patients with acute respiratory failure, the failure rate is high yielding a grim prognosis, even worse than that of patients who undergo immediate invasive mechanical ventilation [3]. So only a small proportion of 10-20 % of patients are likely to be successfully managed by NIV [4,5]. As the outcome of invasively mechanically ventilated patients is improving [3,6], new trials are needed to address the current benefits of NIV in this population.…”