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Acute respiratory distress syndrome in patients with malignancies

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Abstract

Purpose

Little attention has been given to ARDS in cancer patients, despite their high risk for pulmonary complications. We sought to describe outcomes in cancer patients with ARDS meeting the Berlin definition.

Methods

Data from a cohort of patients admitted to 14 ICUs between 1990 and 2011 were used for a multivariable analysis of risk factors for hospital mortality.

Results

Of 1,004 included patients (86 % with hematological malignancies and 14 % with solid tumors), 444 (44.2 %) had neutropenia. Admission SOFA score was 12 (10–13). Etiological categories were primary infection-related ARDS (n = 662, 65.9 %; 385 bacterial infections, 213 invasive aspergillosis, 64 Pneumocystis pneumonia); extrapulmonary septic shock-related ARDS (n = 225, 22.4 %; 33 % candidemia); noninfectious ARDS (n = 76, 7.6 %); and undetermined cause (n = 41, 4.1 %). Of 387 (38.6 %) patients given noninvasive ventilation (NIV), 276 (71 %) subsequently required endotracheal ventilation. Hospital mortality was 64 % overall. According to the Berlin definition, 252 (25.1 %) patients had mild, 426 (42.4 %) moderate and 326 (32.5 %) severe ARDS; mortality was 59, 63 and 68.5 %, respectively (p = 0.06). Mortality dropped from 89 % in 1990–1995 to 52 % in 2006–2011 (p < 0.0001). Solid tumors, primary ARDS, and later admission period were associated with lower mortality. Risk factors for higher mortality were allogeneic bone-marrow transplantation, modified SOFA, NIV failure, severe ARDS, and invasive fungal infection.

Conclusions

In cancer patients, 90 % of ARDS cases are infection-related, including one-third due to invasive fungal infections. Mortality has decreased over time. NIV failure is associated with increased mortality. The high mortality associated with invasive fungal infections warrants specific studies of early treatment strategies.

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Acknowledgments

French Ministry of Health.

Conflicts of interest

Elie Azoulay is in the board of Gilead and has received research grant from MSD and Pfizer.

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Correspondence to Elie Azoulay.

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Take home message:

Pulmonary and extrapulmonary infections were responsible for 90 % of ARDS cases in patients with solid or hematological malignancies. One-third of the underlying infections were due to opportunistic pathogens. Survival improved significantly over time. Noninvasive ventilation was attempted in 30 % of patients but failed in 70 %, and failure was associated with increased mortality. The particularly high mortality among patients with invasive fungal infections indicates a pressing need for specific studies on early antifungal therapy in high-risk patients.

On behalf of the Groupe de Recherche Respiratoire en Réanimation Onco-Hématologique (Grrr-OH).

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Azoulay, E., Lemiale, V., Mokart, D. et al. Acute respiratory distress syndrome in patients with malignancies. Intensive Care Med 40, 1106–1114 (2014). https://doi.org/10.1007/s00134-014-3354-0

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