Chest
Volume 146, Issue 2, August 2014, Pages 257-266
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Critical Care
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Outcomes for Patients With Cancer Admitted to the ICU Requiring Ventilatory Support: Results From a Prospective Multicenter Study

https://doi.org/10.1378/chest.13-1870Get rights and content

BACKGROUND

This study was undertaken to evaluate the clinical characteristics and outcomes of patients with cancer requiring nonpalliative ventilatory support.

METHODS

This was a secondary analysis of a prospective cohort study conducted in 28 Brazilian ICUs evaluating adult patients with cancer requiring invasive mechanical ventilation (MV) or noninvasive ventilation (NIV) during the first 48 h of their ICU stay. We used logistic regression to identify the variables associated with hospital mortality.

RESULTS

Of 717 patients, 263 (37%) (solid tumors = 227; hematologic malignancies = 36) received ventilatory support. NIV was initially used in 85 patients (32%), and 178 (68%) received MV. Additionally, NIV followed by MV occurred in 45 patients (53%). Hospital mortality rates were 67% in all patients, 40% in patients receiving NIV only, 69% when NIV was followed by MV, and 73% in patients receiving MV only (P < .001). Adjusting for the type of admission, newly diagnosed malignancy (OR, 3.59; 95% CI, 1.28-10.10), recurrent or progressive malignancy (OR, 3.67; 95% CI, 1.25-10.81), tumoral airway involvement (OR, 4.04; 95% CI, 1.30-12.56), performance status (PS) 2 to 4 (OR, 2.39; 95% CI, 1.24-4.59), NIV followed by MV (OR, 3.00; 95% CI, 1.09-8.18), MV as initial ventilatory strategy (OR, 3.53; 95% CI, 1.45-8.60), and Sequential Organ Failure Assessment score (each point except the respiratory domain) (OR, 1.15; 95% CI, 1.03-1.29) were associated with hospital mortality. Hospital survival in patients with good PS and nonprogressive malignancy and without tumoral airway involvement was 53%. Conversely, patients with poor functional capacity and cancer progression had unfavorable outcomes.

CONCLUSIONS

Patients with cancer with good PS and nonprogressive disease requiring ventilatory support should receive full intensive care, because one-half of these patients survive. On the other hand, provision of palliative care should be considered the main goal for patients with poor PS and progressive underlying malignancy.

Section snippets

Design, Setting, and Eligibility Criteria

This study was a secondary analysis of a multicenter prospective cohort study conducted in 28 Brazilian ICUs (e-Appendix 1) between August 1 and September 30, 2007.15 The study was strictly observational, and every clinical decision (including the decision to start, change the modality, or cease the ventilatory support) was at the discretion of attending physicians. The Comitê de Ética em Pesquisa of Instituto Nacional de Câncer (No. 013/07) approved the study, as did local institutional review

Characteristics of the Study Population

Of the 717 patients admitted to the 28 participating ICUs, 263 (37%) fulfilled the eligibility criteria, and these constituted the study population (Fig 1). The median patient inclusion from each center was six (25%-75%, 4-13; range, 1-33). Two hundred twenty-seven patients (86%) had solid tumors, and 36 patients (14%) had hematologic malignancies. Ventilatory support was required more frequently by patients with hematologic malignancies (36 of 50 patients [72%]) than by patients with solid

Discussion

In the current study, we demonstrated that patients with cancer requiring ventilatory support who were admitted to ICUs may have reasonable mortality rates, especially when they have good PS and nonprogressive disease. Moreover, we determined important independent predictors of mortality in these patients, which can assist physicians in decisions relating to patients' management and the counseling of patients and families. ICU refusal of patients merely because of a cancer diagnosis is no

Conclusions

In conclusion, mortality rates in critically ill patients with cancer requiring ventilatory support remain relatively high. Patients with good PS and nonprogressive disease requiring ventilatory support should receive full intensive care, because one-half of these patients survive. On the other hand, the provision of palliative care should be considered the main goal for patients with poor PS and progressive underlying malignancy.

Acknowledgments

Author contributions: M. S. had full access to all data in the study and takes responsibility for the integrity of the data and the accuracy of the analysis. L. C. P. A., J. I. F. S., and M. S contributed to the study conception, data acquisition, analysis, and interpretation, drafting of the manuscript, revision of the manuscript for important intellectual content, and approval of the final copy; P. C. contributed to the study conception, data acquisition, revision of the manuscript for

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    FUNDING/SUPPORT: This article was supported by the Instituto Nacional de Câncer, the National Council for Scientific and Technological Development of Brazil (CNPq), and Fundação Carlos Chagas Filho de Amparo à Pesquisa do Estado do Rio de Janeiro (FAPERJ).

    Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.

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