Introduction
Respiratory insufficiency
Prognostic importance of invasive mechanical ventilation
Definitions, causes and diagnostics
Imaging studies | Chest radiograph |
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High-resolution computed tomography | |
Echocardiography | Exclusion of pulmonary congestion |
Sputum examination | Bacteria |
Fungi | |
Tuberculosis | |
Induced sputum | P. jirovecii |
Nasopharyngeal aspirates | Respiratory viruses |
Blood cultures | |
Polymerase chain reaction test | Herpes viridae |
Cytomegalovirus | |
Circulating Galactomanan | Aspergillus |
Serologic tests | Chlamydia pneumoniae |
Mycoplasma pneumoniae | |
Legionella pneumophila | |
Urine antigen | Legionella pneumophila |
Streptococcus pneumoniae |
Noninvasive ventilation as measure to avoid intubation?
Risk factors for NIV failure in cancer patients with hypoxic ARF | |
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Prior to NIV | Vasopressor need |
Multiple organ failure | |
Airway involvement by malignancy | |
Acute respiratory distress syndrome | |
Unknown etiology for ARF | |
Delayed onset of ARF | |
During NIV | Patient not tolerating NIV |
No improvement of ABG within 6 hours | |
Respiratory rate > 30/minute | |
NIV dependency ≥ 3 days | |
Clinical or respiratory deterioration | |
Unknown etiology for ARF |
Sepsis
Other important conditions
Possible admission criteria
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A “full code management” without restrictions is advisable in patients in remission of their malignant disease, newly diagnosed malignancies with favorable life expectation (> 1 year), availability of curative therapeutic options (e. g. hematologic malignancies during induction or consolidation therapy), complications of autologous stem cell transplantation, in certain cases of low grade hematologic malignancies, in multiple myeloma with partial remission, as well as in patients with advanced stages of solid malignancies, if available therapeutic options still allow for long-term survival.
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The term “ICU trial” describes an initial “full code management” for three to five days followed by a thorough re-evaluation of the therapeutic strategy. This approach seems to be adequate in patients who do not fulfill the above stated criteria, but for whom the option of a potentially life-extending therapy is available. In patients of this category with at least two organ failure including IMV, Lecuyer et al. showed that no clinical sign at ICU admission correlates with hospital outcome [30]. Only after the third ICU day the severity level of organ dysfunction differed between survivors and nonsurvivors. The mortality in these very ill patients was as high as 80 %. No patient requiring an additional intensive care therapy measure (intubation, renal replacement therapy, vasopressors) after the third ICU day survived.
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According to the available literature, patients with no life-extending therapy option for their underlying malignant disease, with uncontrolled or refractory graft-versus-host-disease after allogeneic stem cell transplantation, unfavorable cancer-related life-expectation (< 1 year), and patients who were bedridden most of the time within the last three months should not receive aggressive ICU therapies. However, ICU admissions for management of a specific acute problem together with primary therapy limitations (such as do-not-intubate orders) may be suitable in selected patients [31].
Unanswered questions
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How effective is communication and collaboration between intensivists and hemato/oncologists with regard to clinical decision-making?
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What is the impact on outcome if no hemato/oncologist is available due to the institutional structure?
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What are the specific needs of critically ill cancer patients’ families?
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How can we optimize the transition from full code ICU management to palliative care, if indicated?
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Early ICU admissions seem to be associated with a favorable outcome in cancer patients with ARF. However, if this applies to other organ dysfunctions remains unclear. Moreover, a recent publication suggested that treating patients with acute leukemia with hematological risk of early death in the ICU even in the absence of a manifest organ failure is associated with improved survival [32].
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How can we establish effective structures to identify patients in the wards who would profit from ICU admission?
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How safe and effective is the administration of intensive care measures in the setting of a normal ward?
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What would be the benefits of hemato/oncologic intermediate care units?