Management strategy for hematological malignancy patients with acute respiratory failure

Li Jiang,Hongbing Ma,Qunfang Wan

doi:10.1186/s40001-021-00579-7

Abstract

Acute respiratory failure (ARF) is still the major cause of intensive care unit (ICU) admission for hematological malignancy (HM) patients although the advance in hematology and supportive care has greatly improved the prognosis. Clinicians have to make decisions whether the HM patients with ARF should be sent to ICU and which ventilation support should be administered. Based on the reported investigations related to management of HM patients with ARF, we propose a selection procedure to manage this population and recommend hematological ICU as the optimal setting to recuse these patients, where hematologists and intensivists can collaborate closely and improve the outcomes. Moreover, noninvasive ventilation (NIV) still has its own place for selected HM patients with ARF who have mild hypoxemia and reversible causes. It is also crucial to monitor the efficacy of NIV closely and switch to invasive mechanical ventilation at appropriate timing when NIV shows no apparent improvement. Otherwise, early IMV should be initiated to HM with ARF who have moderate and severe hypoxemia, adult respiratory distress syndrome, multiple organ dysfunction, and unstable hemodynamic. More studies are needed to elucidate the predictors of ICU mortality and ventilatory mode for HM patients with ARF.

Highlights

Hematologic malignancy (HM) is neoplastic myeloid or lymphoid disease, including acute and chronic leukemia, lymphoma, myeloma, as well as myelodysplastic syndrome and myeloproliferative neoplasm [1, 2]
Confronting HM patients with acute respiratory failure (ARF) in clinical setting, the clinicians have to make decisions about the procedures. Do they need treatment in an intensive care unit (ICU)? Which kind of respiratory support should be selected for the patients, noninvasive ventilation (NIV) or invasive mechanical ventilation (IMV)? In this review, based on the results of different investigations related to management of HM patients with ARF, which is defined as PaO2 < 60 mmHg, or tachypnea > 30/min, or SpO2 < 90% on room air, or the ratio of arterial oxygen partial pressure to fractional inspired oxygen (PO2/ FiO2) < 300, or labored breathing, or respiratory distress, or dyspnea at rest [7–10]we propose a selection strategy to help manage this population and hopefully improve their outcomes
PaO2 arterial oxygen tension, FiO2 fraction of inspired oxygen, RR respiratory rate, IMV invasive mechanical ventilation, NIV noninvasive ventilation, RCTrandomized control trial, HM hematological malignancy, ARF acute respiratory failure, Sequential Organ Failure Assessment (SOFA) sequential organ assessment, N/A not available, BiPAP bi-level positive airway pressure in NIV group was significantly lower than immediate IMV and IMV after NIV failure (42% vs. 69% and 77%, respectively)

Summary

Introduction

Hematologic malignancy (HM) is neoplastic myeloid or lymphoid disease, including acute and chronic leukemia, lymphoma, myeloma, as well as myelodysplastic syndrome and myeloproliferative neoplasm [1, 2]. Some investigators hold that the admission of HM patients to ICU should be determined by objective mortality prediction model rather than clinical experience [18]. An ideal ICU for HM with ARF patients should be hematologic ICU, where hematologist, intensivist and respiratory therapist can collaborate closely to provide the optimal critical care [15, 25]. The hematologists are good at addressing HM and related complications, while intensivists and respiratory therapists are accomplished in respiration and circulation support to stabilize patients [15, 18]. They can discuss and make decisions together for HM patients without time and space limitations.

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