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Noninvasive mechanical ventilation as a palliative treatment of acute respiratory failure in patients with end-stage solid cancer

Palliative Care Unit, Fondazione S. Maugeri, IRCCS, Istituto Scientifico di Pavia, Pavia

Monica Delmastro

Piero Ceriana

Stefano Nava

Respiratory Unit, Fondazione S. Maugeri, IRCCS, Istituto Scientifico di Pavia, Pavia

Giorgio Conti

Massimo Antonelli

Emanuele Iacobone

Intensive Care Unit, Universita' Cattolica, Roma

Noninvasive ventilation (NIV) is widely used in the treatment of acute respiratory failure (ARF), but not in patients with end-stage solid cancer in whom any form of mechanical ventilation tends to be avoided. In a prospective study, we investigated the use of NIV in 23 patients with solid malignancies receiving palliative care and who were affected by severe hypoxic or hypercapnic ARF. The most frequent causes of ARF were exacerbations of preexisting pulmonary diseases and pneumonia. After one hour, NIV significantly improved PaO₂/FiO₂ (from 154±48 to 187±55) and the Borg dyspnoea score (from 5.59±1.2 to 2.3±0.3). NIV also improved pH, but only in the subset of hypercapnic patients. Thirteen of 23 (57%) patients were successfully ventilated and discharged alive, while 10/23 patients (43%) met the criteria for intubation or died after an initial trial of NIV. Only two of these patients accepted invasive ventilation. The mortality rate in this subgroup was 9/10 (90%). A higher Simplified Acute Physiology Score (SAPS II) and a lower PaO₂/FiO₂ on admission were associated with a lower probability of survival. Patients with ARF and end-stage solid malignancies have an overall ICU and 1-year mortality rate of 39% and 87%, respectively, but despite this, a consistent subset of patients may still be successfully treated with NIV, if the cause of ARF is reversible.

Key Words: acute respiratory failure • noninvasive ventilation • palliative care • solid cancer

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