Patients with hematologic malignancy who develop respiratory failure generally have a very poor prognosis. A few such patients, however, enjoy long-term survival. The objective of this study was to identify clinical characteristics of patients with hematologic malignancy and respiratory failure that are predictive of outcome.
Methods
We performed a retrospective chart review of all patients who required mechanical ventilation for acute respiratory failure while on the leukemia or bone marrow transplantation units at the Johns Hopkins Oncology Center between January 1985 and October 1991 (n = 157).
Results
Overall hospital mortality was 83%. Major organ system dysfunction, as measured by the acute physiology score (APS) of the APACHE III prognostic system, was significantly (P < 0.05) related to hospital mortality. Three disease-specific clinical characteristics were predictive of mortality: 1) stage beyond first complete remission, 2) duration of neutropenia greater than 30 days, and 3) treatment with bone marrow transplantation, especially if HLA-mismatched. None of the 15 (10%) patients with neutropenia greater than 30 days or the four patients who underwent HLA-mismatched transplantation survived to discharge. Age was also a significant predictor of hospital mortality.
Conclusions
Overall outcome of patients with hematologic malignancy and acute respiratory failure is poor. A larger prospective study will be required to confirm the relative value of disease-specific variables identified in this study when combined with established predictive variables. In the future, it may be possible to develop a predictive instrument that is specifically tailored for patients with hematologic malignancy who develop respiratory failure.
BrochsteinJA.Critical care issues in bone marrow transplantation. Crit Care Clin1988;4:147–66.
2.
WingardJR, MellitsED, SostrinMB, ChenDY-H, BurnsWH, SantosGW, VriesendorpHM, BeschornerWE, SaralR.Interstitial pneumonitis after allogeneic bone marrow transplantation. Medicine1988;67:175–86.
3.
WingardJR, SostrinMB, VriesendorpHM, MellitsED, SantosGW, FullerDJ, BraineHG, YeagerAM, BurnsWH, SaralR.Interstitial pneumonitis following autologous bone marrow transplantation. Transplantation1988;46:61–5.
4.
WingardJR, ChenDY-H, BurnsWH, FullerDJ, BraineHG, YeagerAM, KaiserH, BurkePJ, GrahamML, SantosGW, SaralR.Cytomegalovirus infection after autologous bone marrow transplantation with comparison to infection after allogeneic bone marrow transplantation. Blood1988;71:1432–7.
5.
NoblePW.The pulmonary complications of bone marrow transplantation in adults. West J Med1989;150:443–9.
6.
HildebrandFL, RosenowECIII, TazelaarHD.Pulmonary complications of leukemia. Chest1990;98:1233–9.
7.
CrawfordSW, SchwartzDA, PetersenFB, ClarkJG.Mechanical ventilation after marrow transplantation. Am Rev Respir Dis1988;137:682–7.
8.
DeesA, LigthartJL, van PuttenWLJ, PlantingAST, StoterG.Mechanical ventilation in cancer patients. Analysis of clinical data and outcome. Neth J Med1990;37:183–8.
9.
Lloyd-ThomasAR, WrightI, ListerTA, HindsCJ.Prognosis of patients receiving intensive care for life-threatening medical complications of haematological malignancy. BMJ1988;296:1025–9.
10.
CrawfordSW, PetersenFB.Long-term survival from respiratory failure after marrow transplantation for malignancy. Am Rev Respir Dis1992;145:510–4.
11.
AfessaB, TefferiA, HoaglandHC, LetendreL, PetersSG.Outcome of recipients of bone marrow transplants who require intensive care unit support. Mayo Clin Proc1992;67:117–22.
12.
SchapiraDV, StudnickiJ, BradhamDD, WolffP, JarrettA.Intensive care, survival, and expense of treating critically ill cancer patients. JAMA1993;269:783–6.
13.
PazHL, CrilleyP, WeinarM, BrodskyI.Outcome of patients requiring medical ICU admission following bone marrow transplantation. Chest1993;104:527–31.
14.
CrawfordSW.Decision making in critically ill patients with hematologic malignancy. West J Med1991;155:488–93.
15.
PetersSG, MeadowsJAIII, GraceyDR.Outcome of respiratory failure in hematologic malignancy. Chest1988;94:99–102.
16.
SchusterDP, MarionJM.Precedents for meaningful recovery during treatment in a medical intensive care unit. Am J Med1983;75:402–8.
17.
LudwigsUG, BaehrendtzS, WanecekM, MatellG.Mechanical ventilation in medical and neurological diseases; 11 years of experience. J Intern Med1991;229:117–24.
18.
TorrecillaC, CortésJL, ChamorroC, RubioJJ, GaldosP, Dominguez de VillotaE.Prognostic assessment of the acute complications of bone marrow transplantation requiring intensive therapy. Intensive Care Med1988;14:393–98.
19.
EstopaR, MartiAT, KastanosN, RivesA, Agusti-VidalA, RozmanC.Acute respiratory failure in severe hematologic disorders. Crit Care Med1984;12:26–8.
20.
DenardoSJ, OyeRK, BellamyPE.Efficacy of intensive care for bone marrow transplant patients with respiratory failure. Crit Care Med1989;17:4–6.
21.
BrunetF, LanoreJJ, DhainautJF, DreyfusF, VaxelaireJF, NouiraS, GiraudT, ArmoganidisA, MonsallierJF.Is intensive care justified for patients with haematological malignancies?Intensive Care Med1990;16:291–7.
22.
Lloyd-ThomasAR, DhaliwalHS, ListerTA, HindsCJ.Intensive therapy for life-threatening medical complications of haematological malignancy. Intensive Care Med1986;12:317–24.
23.
KnausWA, WagnerDP, LynnJ.Short-term mortality predictions for critically ill hospitalized adults: science and ethics. Science1991;254:389–94.
24.
MurphyDJ, BurrowsD, SantilliS, KempAW, TennerS, KrelingB, TenoJ.The influence of probability of survival on patients’ preferences regarding cardiopulmonary resuscitation. N Engl J Med1994;330:545–9.
25.
JayesRL, ZimmermanJE, WagnerDP, DraperEA, KnausWA.Do-not-resuscitate orders in intensive care units. JAMA1993;270:2213–7.
26.
KnausWA, DraperEA, WagnerDP, ZimmermanJE.APACHE II: a severity of disease classification system. Crit Care Med1985;13:818–29.
27.
LemeshowS, Le GallJ-R. Modeling the severity of illness of ICU patients. JAMA1994;272:1049–55.
WongDT, KnausWA.Predicting outcome in critical care: the current status of APACHE prognostic scoring system. Can J Anaesth1991;38:374–83.
30.
JohnsonMH, GordonPW, FitzgeraldFT.Stratification of prognosis in granulocytopenic patients with hematologic malignancies using the APACHE - II severity of illness score. Crit Care Med1986;14:693–7.
31.
LemeshowS, TeresD, KlarJ, AvruninJS, GehlbachSH, RapoportJ.Mortality Probability Model (MPM II) based on an international cohort of intensive care unit patients. JAMA1993;270:2478–86.
32.
GellerRB, BurkePJ, KarpJE, HemphreyRL, BraineHG, TuckerRW, FoxMG, ZahurakM, MorrellL, HallKL, et al. A two-step timed sequential treatment for acute myelocytic leukemia. Blood1989;74:1499–506.
33.
GellerRB, SaralR, PiantadosiS, ZahurakM, VogelsongGB, WingardJR, AmbinderRF, BeschornerWB, BraineHG, BurnsWH, et al. Allogeneic bone marrow transplantation after high-dose busulfan and cyclophosphamide in patients with acute nonlymphocytic leukemia. Blood1989;73:2209–18.
34.
ChalfinDB, CarlonGC.Age and utilization of intensive care unit resources of critically ill cancer patients. Crit Care Med1990;18:694–8.
CarlonGC.Admitting cancer patients to the intensive care unit. Crit Care Clin1988;4:183–92.
37.
ReedEC, BowdenRA, DandlikerPS, LillebyKE, MeyersJD.Treatment of cytomegalovirus pneumonia with ganciclovir and intravenous cytomegalovirus immunoglobulin in patients with bone marrow transplants. Ann Intern Med1988;109:783–8.
38.
SchmidtGM, HorakDA, NilandJC, DuncanSR, FormanSJ, ZaiaJA.A randomized, controlled trial of prophylactic ganciclovir for cytomegalovirus pulmonary infection in recipients of allogeneic bone marrow transplants. N Engl J Med1991;324:1005–11.
39.
ElfenbeinGJ, SiddiquiT, RandKH, Graham-PoleJ, MarcusRB, MendenhallNP, GoedertTM, Wikle-FisherT, GrossSA, WeinerRS.Successful strategy for prevention of cytomegalovirus interstitial pneumonia after human leukocyte antigen-identical bone marrow transplantation. Reviews of Infectious Diseases2 (7 Suppl):1990;S805–10.
