Elsevier

Critical Care Clinics

Volume 26, Issue 1, January 2010, Pages 21-40
Critical Care Clinics

Acute Respiratory Failure in the Patient with Cancer: Diagnostic and Management Strategies

https://doi.org/10.1016/j.ccc.2009.10.001Get rights and content

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Causes of ARF in patients with cancer

The myriad causes of ARF in critically ill patients with cancer are listed in Table 1. The most frequent causes include pulmonary infections (pneumonia), cardiogenic and noncardiogenic pulmonary edema (ALI/acute respiratory distress syndrome [ARDS]), antineoplastic therapy (chemotherapy, radiation therapy)-induced lung injury, cancer-related medical disorders (such as venous thromboembolism [VTE] and diffuse alveolar hemorrhage [DAH]), direct involvement of the respiratory system by malignancy

Pneumonia

Pulmonary infections are the most common cause of ARF in patients with cancer, especially in those with significant comorbidities (eg, chronic obstructive pulmonary disease, cardiac failure), underlying hematologic malignancies, and in those receiving chemotherapy.34, 35, 36 Several factors increase the risk of infection in these patients, including defects in humoral or cell-mediated immunity, neutropenia, use of corticosteroids, frequent exposure to antibiotics, and prolonged hospitalization.

ALI and ARDS

ALI is a clinical syndrome characterized by the acute onset of severe hypoxemia (as defined by a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen [Pao2/Fio2] <300) and the presence of bilateral alveolar or interstitial infiltrates in the absence of congestive heart failure.55 ARDS is a more severe form of lung injury defined by a Pao2/Fio2 ratio less than 200. Atypical presentation of ARDS with unilateral infiltrates on chest radiograph is noteworthy,

Antineoplastic agent-induced lung injury

Pulmonary toxicity from antineoplastic agents is an important cause of respiratory failure in patients who have cancer. The various clinical syndromes associated with antineoplastic-induced lung injury include acute interstitial pneumonitis, ALI/ARDS, capillary leak syndrome, organizing pneumonia, hypersensitivity reaction, bronchospasm, and DAH. A listing of the most common chemotherapeutic and immunosuppressive agents associated with pulmonary toxicity can be found at http://www.pneumotox.com

VTE

VTE, manifested as either deep venous thrombosis (DVT) or pulmonary embolism (PE), remains an important and major cause of morbidity and mortality in patients with cancer.90, 91 When adjusted for disease prevalence, the malignancies most strongly associated with thrombotic complications are those of the pancreas, ovary, and brain.92 Several factors or conditions increase the risk for DVT and PE in patients with cancer, including intrinsic tumor procoagulant activity, antineoplastic drugs (such

DAH

Alveolar hemorrhage is a frequent cause of respiratory failure in thrombocytopenic patients (platelet counts <50,000/mm3) with acute or chronic leukemias or multiple myeloma. The incidence of DAH in recipients of hematopoietic stem cell transplantation ranges from 2% to 12%.110, 111 Pretransplant intensive chemotherapy, including conditioning regimen, total body irradiation, thoracic irradiation, and old age, are known risk factors for DAH.110 The pathogenesis of DAH in HSCT recipients is

Transfusion-related acute lung injury (TRALI)

Patients with cancer, particularly those with hematologic malignancies and patients undergoing major cancer surgery, frequently require transfusion of fresh frozen plasma, platelets, and packed red blood cells, and thus are susceptible to TRALI. This syndrome usually takes the form of noncardiogenic pulmonary edema and is commonly associated with fever, hypotension, severe hypoxemia, pulmonary hypertension, and bilateral lung infiltrates with normal left ventricular function.116 Similarly,

Radiation-induced lung injury

Radiation-induced lung injury is generally limited to the irradiated lung volume and results in several histopathologic changes, including enlargement and atypia of type II pneumocytes, alveolar wall edema, infiltration of the interstitium by monocytes and fibroblasts, aggregation of alveolar macrophages, and dense collagen fibrosis.119 Significant lung injury from radiation therapy is dependent on the volume of lung irradiated, the total dose, and the dose per fraction used. Although radiation

Paraneoplastic syndromes

Approximately 30% of patients with thymomas develop myasthenia gravis and often the respiratory failure worsens around the time of thymectomy. The diagnosis is confirmed with the finding of improvement in muscle strength after the administration of IV edrophonium (Tensilon) and evidence of decremental response of the muscle action potential to repetitive nerve testing on electromyogram (EMG) studies. Supportive measures, in addition to cholinesterase inhibitors such as pyridostigmine and

Management principles for ARF in the critical care setting

The key management principles for cancer patients who develop ARF include a comprehensive diagnostic work-up including fiberoptic bronchoscopy to identify the cause of the respiratory failure; appropriate and timely use of antimicrobial therapy in those with infectious disorders; and respiratory support including early use of NIPPV rather than invasive MV. The reader is referred to a flow-chart outlining the recommendations for selecting the initial ventilatory strategy in cancer patients with

Prognosis and outcome data

Although MV remains an important life-support modality for many patients who have cancer with ARF, these patients generally have survival rates less than 20%.1, 2, 3, 4, 5, 6, 7, 8, 9, 10, 11, 12, 13, 14, 15 In recent years, however, there has been optimism about improved survival rates in mechanically ventilated patients with cancer.7, 17

In addition to general ICU mortality prediction models (eg, Acute Physiology and Chronic Health Evaluation [APACHE] II and III, Mortality Probability Models,

Summary

The diagnosis and management of ARF in patients with cancer poses special challenges to the intensivist. The clinical presentation of ARF in patients with cancer may be less specific than in patients without cancer. Depending on the type of cancer, the degree of immunosuppression, underlying comorbidities, and the modality of cancer treatment, progression or spread of underlying cancer, and disease- or therapy-associated complications are the most common causes of ARF in these patients. Despite

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