Chest
Volume 126, Issue 4, October 2004, Pages 1299-1306
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Clinical Investigations in Critical Care
Outcome in Noninvasively and Invasively Ventilated Hematologic Patients With Acute Respiratory Failure

https://doi.org/10.1378/chest.126.4.1299Get rights and content

Study objectives:

The survival rate of patients with a hematologic malignancy requiring mechanical ventilation (MV) in the ICU has improved over the last few decades. The objective of this study was to identify the factors affecting the in-hospital mortality of these particular patients, and to assess whether the use of noninvasive positive pressure ventilation (NPPV) was protective in our study population.

Design:

We retrospectively collected variables in 166 consecutive patients with hematologic malignancies who had acute respiratory failure (ARF) requiring MV, and identified factors obtained within 24 h of ICU admission affecting in-hospital mortality in univariate and multivariate stepwise logistic regression analyses. The effect of NPPV on mortality was assessed using a pair-wise matched exposed-unexposed analysis.

Results:

The mean simplified acute physiology score (SAPS) II was 58.9. The in-hospital mortality rate was 71%. In a multivariate logistic regression analysis, the in-hospital mortality rate was predicted by increasing severity of illness, as measured by SAPS II (odds ratio [OR] per point of increase, 1.07; 95% confidence interval [CI], 1.04 to 1.11) and a diagnosis of acute myelogenous leukemia (OR, 2.73; 95% CI, 1.05 to 7.11). Female sex (OR, 0.36; 95% CI, 0.16 to 0.82), endotracheal intubation (ETI) within 24 h of ICU admission (OR, 0.29; 95% CI, 0.11 to 0.78), and recent bacteremia (defined as blood cultures positive for bacteria < 48h before or < 24h after ICU admission) [OR, 0.22; 95% CI, 0.08 to 0.61] were associated with a lower mortality rate. Twenty-seven patients who received NPPV were matched for SAPS II (± 3) with 52 patients who required immediate ETI on a 1:2 basis. The crude in-hospital mortality rate was 65.4% in both groups.

Conclusion:

Although the in-hospital mortality rate in hematologic patients who develop ARF remains high, the reluctance to intubate and start treatment with invasive MV in this population is unjustified, especially when bacteremia has precipitated ICU admission.

Section snippets

Study Location and Subjects

We have studied a cohort of 230 consecutive patients with hematologic malignancies or aplastic anemia who were admitted to the medical ICU of the Ghent University Hospital between January 1, 1997, and June 30, 2002. This 14-bed unit admits critically ill patients who are at least 15 years old. Of these 230 patients, 166 (72.2%) received MV. Twenty-six patients received NPPV. Demographic, clinical, laboratory, and physiologic data were recorded retrospectively in 68 patients (within the period

Patients

A total of 166 patients with a hematologic malignancy received MV in our ICU between January 1, 1997, and June 30, 2002. Patient characteristics, as well as the principal reasons for ICU admission are summarized in Table 1. However, it is important to note that most patients had a combination of ICU admission reasons. The Pao2/Fio2 ratio was < 300 in 141 patients (85%) and < 200 in 118 patients (71%). Data on Paco2 and pH were available in 96 patients. In 35 patients (41%), hypercapnia (ie, Paco

Discussion

The in-hospital mortality rate in our population of hematologic patients with ARF was 70.5%. Although we could not compare this mortality rate with earlier data from our institution, this figure is well in accordance with mortality rates for mechanically ventilated cancer patients that have been reported in the literature.14161824 Those studies illustrate that improving survival in critically ill hematologic patients also reflects a modest gain in survival in those patients who develop ARF

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