ventilatory support in cancer patients - oncorea.com rencontre/benoit.pdf · ventilatory support in...
TRANSCRIPT
![Page 1: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/1.jpg)
Ventilatory support in cancer patients
D. Benoit, MD, PhD
Department of Intensive Care Medicine
Ghent University Hospital
![Page 2: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/2.jpg)
![Page 3: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/3.jpg)
![Page 4: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/4.jpg)
![Page 5: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/5.jpg)
La ventilation non-invasive (VNI) réduit le risque d’intubation et la mortalitéchez le cancéreux avec une IRA
Oui
Non
![Page 6: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/6.jpg)
La ventilation non-invasive (VNI) devrait être utiliser d’emblée chez le sujet cancéreux avec une IRA ne présentant pas de contre-indications classiques
Oui
Non
![Page 7: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/7.jpg)
Invasive ……
…. non-invasive mechanical ventilation ?
or
![Page 8: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/8.jpg)
…outside the clearcut indications for NIV :
Acute pulmonary edema
Acute COPD excacerbation
![Page 9: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/9.jpg)
Invasive ……
…. non-invasive mechanical ventilation ?
or
![Page 10: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/10.jpg)
Mortality in ventilated cancer patients
Schuster, 1983 92 52 0 52
Author, year Solid tumors
Haematol. Malign.
Total n. of patients
Hospital mort. (%)
Ewer, 1986 91 46 46 0
Peters, 1988 82 116 0 116
Brunet, 1990 85 111 0 111
Sculier, 1991 80 / 70 64 30 27
Shapira, 1993 75 / 76 54 24 30
Epner, 1996 75 86 0 86
Groeger, 1999 63 / 84 782 305 404
![Page 11: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/11.jpg)
Reluctance for ICU admission
« Patients who require mechanical ventilation longer than 24h are likely to die in the hospital (94% mortality in the largest study). Prognosis should be reassessed at frequent interval with particular attention to the developement of MOF »
Uptodate 2010
![Page 12: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/12.jpg)
Mortality in ventilated cancer patients
Kress, 1999 67 153 95 58
Author, year Solid tumors
Haematol. Malign.
Total n. of patients
Hospital mort. (%)
Azoulay, 2004 75 203 23 180
Massion, 2002 75 48 0 48
Benoit, 2003 68 88 0 88
Depuydt, 2004 71 166 0 166
Soares, 2005 65 / 68463 359 104
Maschmeyer, 2003 73 189 103 86
![Page 13: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/13.jpg)
Duration of mechanical ventilation
100% mortality if duration of MV
> 5 days Schuster, Am J Med 1983
> 6 days Ewer, JAMA 1986
> 4 days* Denardo, Crit Care Med 1989
> 15 days* Huaringa, Crit Care Med 2000
No restriction > most experts in the field
> 7 days* Torrecilla, Crit Care Med 1988
* allo-BMT recipients
![Page 14: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/14.jpg)
Duration of mechanical ventilation
P =0.94
Benoit, unpublished data 2005
alive dead
in hospital mortality
0,00
25,00
50,00
75,00
days of ventilation
A
A
A
A
A
AA AA
A
A
A
A
A
A
A
AA
A
A
A
A
A
A
A
A
A
A
AA
A
A
A
A
A
A
A
A
A
AA
A
A
A
AA
AAA
A
A
A
A
A
AA
A
AAAA
A
A
A
AA
A
AA
A
A
AA
AA
A
AA
A
A
A
A
AA
A
A
A
A
A
A
A
A
AAA
AA
A
A
AA
A
A AA
AA
A
A
A
A
A AA
A
AA
A
A
A
A
A
A
AAAA
AA
A
AA
A
AA
AAA
AA
AA
A
AA
AAA
A
A
A
AAAAA
A
A
A
A
AAAA
A
AAAAA
A
A
AA
AA
AA A
A
A
AAAAAA
A
A
A
A
AAA
AA
AA
A
AAA
A
A
A
AA
A
AA
A
AAA AA
A A
AA
A
A
A
A
AAA A
A
A
A
A
AAA A
A
A
n=66 n=172
![Page 15: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/15.jpg)
Invasive ……
…. non-invasive mechanical ventilation ?
or
![Page 16: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/16.jpg)
-30%
![Page 17: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/17.jpg)
-30%
![Page 18: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/18.jpg)
-60%
![Page 19: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/19.jpg)
![Page 20: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/20.jpg)
![Page 21: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/21.jpg)
![Page 22: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/22.jpg)
Matched-cohort analysis (1:2)
NIV (n=26) IMV (n=52) P-value
age 44 (35-63) 58 (41-69) 0.06
Variables
AML 9 (35 %) 13 (25 %) 0.64
Leukopenia 6 (23 %) 9 (17 %) 0.55
SAPS II 46 46 0.99
Active disease 7 (27 %) 12 (23 %) 0.78
Pa02 / Fi02 72 (56-86) 147 (78-201) <0.001
PEEP level 5 (5-8) 5 (5-10) 0.17
Vasopressor need 7 (27) 25 (48) 0. 09
Dialysis 0.08
Hospital mortality 17 (65 %) 34 (65 %) 0.99
4 (15) 18 (35)
Conditional logistic regression analysis: NIV OR 1.08; 95% CI, 0.34-3.38)
Depuydt, Chest 2004
![Page 23: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/23.jpg)
![Page 24: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/24.jpg)
![Page 25: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/25.jpg)
Matched-cohort analysis (1:2)
NIV (n=26) IMV (n=52) P-value
age 44 (35-63) 58 (41-69) 0.06
Variables
AML 9 (35 %) 13 (25 %) 0.64
Leukopenia 6 (23 %) 9 (17 %) 0.55
SAPS II 46 46 0.99
Active disease 7 (27 %) 12 (23 %) 0.78
Pa02 / Fi02 72 (56-86) 147 (78-201) <0.001
PEEP level 5 (5-8) 5 (5-10) 0.17
Vasopressor need 7 (27) 25 (48) 0. 09
Dialysis 0.08
Hospital mortality 17 (65 %) 34 (65 %) 0.99
4 (15) 18 (35)
Conditional logistic regression analysis: NIV OR 1.08; 95% CI, 0.34-3.38)
Depuydt, Chest 2004
Too sick… too late..?
![Page 26: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/26.jpg)
Alive (n=48) Died (n=118) P-value
Male gender 23 (48 %) 77 (65 %) 0.054
Variables
AML 8 (17 %) 36 (30 %) 0.08
Leukopenia 7 (15 %) 38 (32 %) 0.02
SAPS II 50 ±14 62 ±19 <0.001
Active disease 8 (17 %) 42 (35 %) 0.016
Intubation < 24 h 36 (75 %) 84 (72 %) 0.70
Non-invasive ventilation 9 (19 %) 17 (14 %) 0.25
PEEP level 5 (5-8) 5 (5-8) 0.76
Pa02 / Fi02 143 (67-274) 112 (76-206) 0.58
Bacteremia 13 (27 %) 16 (14 %) 0.04
*
40/463 (9.0 %) Soares, Crit care Med 2005
26/166 (15.6 %) Depuydt, Chest 2004
![Page 27: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/27.jpg)
![Page 28: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/28.jpg)
Non-invasive ventilation…
Start «early » …
![Page 29: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/29.jpg)
NIV or IMV ?
1) Can the absolute risk reduction in mortality of 30% in the RCT’s be attributed to the ventilation mode only ?
2) Explanation why non invasive mechanical ventilation is associated with a lower mortality ?
![Page 30: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/30.jpg)
NIV or IMV ?
1) Can the absolute risk reduction in mortality of 30% in the RCTs be attributed to the ventilation mode only ?
Very small groups in a heterogeneous population
High probability of imbalances in baseline charactheristics
Per definition not well randomized….
![Page 31: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/31.jpg)
Study Author Journal N Mortality
Goal-directe therapy in severe sepsis and
septic shock
Rivers N NEJM 2001 263 30.5 % vs. 46.5 % (p=0.009)
Activated protein C Prowess trial (aPC)
Bernard NEJM 2001 1728 24.7 % vs. 30.8 %
(p=0.005)
ARDS network study low tidal volume
NIH NEJM 2000 861 31 % vs. 39.8 %
(p=0.007)
Low dose corticosteroids in septic shock
Annane JAMA 2002 300 53 % vs. 63 %
(p=0.02)
Tight glycemia control in the ICU
Van den Berghe
NEJM 2001 1548 4.6 % vs. 8 %
(p=0.04)
![Page 32: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/32.jpg)
Ventilatory mode
Cause(s) of ARF
Mortality
![Page 33: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/33.jpg)
Ventilatory mode
Cause(s) of ARF
Mortality
![Page 34: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/34.jpg)
« Successful » NIV trial…
= surrogate marker for rapidly reversible and therefore per definition succesfull treatment of the underlying cause of ARF ?
![Page 35: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/35.jpg)
I.Treatable and often rapidly reversible admission diagnosis
Acute pulmonary edema
COPD excacerbation
II. Treatable and potentially reversible admission diagnosis
Documented or clinically suspected bacterial infection
Pneumocystis jerovicii pneumonia
III. Difficult to treat and/or often slowly reversible admission diagnosis
IV. Difficult to treat and often irreversible admission diagnosis
Cause of ARF and mortality
Viral pneumonia
Invasive pulmonary aspergillosis
No diagnosis, solid tumor invasion, idiopathic fibrosis…
Invasion of hematological malignancy
0%
20%
50%
80%
90%
![Page 36: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/36.jpg)
Non-invasive ventilation…
NIV P-value
Intubation
ICU mortality
(n=26) (n=26)
Immunocompromised patients with respiratory failure (n=52)
Standard
Final diagnosis 11 (42%)
Hospital mortality
Hilbert, N Engl J Med 2001
17 (65%) 0.09
12 (46%) 17 (77%)
10 (38%) 18 (69%)
13 (50%) 21 (81%)
0.03
0.03
0.02
![Page 37: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/37.jpg)
Final diagnosis P-value
Fungi
ICU mortality
(n=31) (n=21)
Immunocompromised patients with respiratory failure (n=52)
No final diagnosis
Bacteria -
Hilbert, N Engl J Med 2001
15
7 -
12 (38%) 16 (76%) 0.007
Bacteria + fungi -3
CMV / PCP 6 -
4 (26%)
2 (67%)
2 (28%)
4 (67%)
0.01
0.03
24/37 (65%)4/15 (27%)
6/18 (30%) 22/34 (65%)
Non-invasive ventilation…
![Page 38: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/38.jpg)
![Page 39: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/39.jpg)
![Page 40: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/40.jpg)
![Page 41: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/41.jpg)
![Page 42: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/42.jpg)
![Page 43: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/43.jpg)
![Page 44: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/44.jpg)
![Page 45: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/45.jpg)
Causes ??
![Page 46: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/46.jpg)
NIV or IMV ?
1) Can the absolute risk reduction in mortality of 30% in the RCT’s be attributed to the ventilation mode only ?
Very small groups in a heterogeneous population
Imbalances in baseline charactheristics
Discrepancies with results in general ICU population
Only effective in well-known indications
Weaning protocol / short-acting drugs in IMV group ?
No !!
![Page 47: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/47.jpg)
NIV or IMV ?
1) Can the absolute risk reduction in mortality of 30% in the RCT’s be attributed to the ventilation mode only ?
2) Explanation why non invasive mechanical ventilation is associated with a lower mortality ?
No !!
![Page 48: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/48.jpg)
![Page 49: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/49.jpg)
![Page 50: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/50.jpg)
How many patients died directly because of nosocomial infection ….?
Time of onset ….?
Did nosocomial infection indirectly increased mortality by increasing the duration of ventilation ?
![Page 51: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/51.jpg)
![Page 52: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/52.jpg)
![Page 53: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/53.jpg)
NIV or IMV ?
1) Can the absolute risk reduction in mortality of 30% in the RCT’s be attributed to the ventilation mode only ?
2) Explanation why non invasive mechanical ventilation is associated with a lower mortality ?
No !!
?
![Page 54: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/54.jpg)
![Page 55: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/55.jpg)
Ventilatory mode
Cause(s) of ARF
Mortality
!
![Page 56: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/56.jpg)
![Page 57: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/57.jpg)
I.Treatable and often rapidly reversible admission diagnosis
Acute pulmonary edema
COPD excacerbation
II. Treatable and potentially reversible admission diagnosis
Documented or clinically suspected bacterial infection
Pneumocystis jerovicii pneumonia
III. Difficult to treat and/or often slowly reversible admission diagnosis
IV. Difficult to treat and often irreversible admission diagnosis
Admission diagnosis and mortality
Viral pneumonia
Invasive pulmonary aspergillosis
No diagnosis, solid tumor invasion, idiopathic fibrosis…
Invasion of hematological malignancy
0%
20%
50%
80%
90%
![Page 58: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/58.jpg)
Non-invasive ventilation…
Start « early » …
… for a potentially rapidly reversible complication…
![Page 59: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/59.jpg)
NIV or IMV ?
NIV trial: for how long ?
![Page 60: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/60.jpg)
![Page 61: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/61.jpg)
![Page 62: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/62.jpg)
![Page 63: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/63.jpg)
![Page 64: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/64.jpg)
Non-invasive ventilation…
Start « early » …
… for a potentially rapidly reversible complication…
… for a couple of hours !
= 10-15 % of the population..!
![Page 65: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/65.jpg)
![Page 66: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/66.jpg)
Conclusion
![Page 67: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/67.jpg)
La ventilation non-invasive (VNI) réduit le risque d’intubation et la mortalitéchez le cancereux avec une IRA
Oui
Non
![Page 68: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/68.jpg)
La ventilation non-invasive (VNI) devrait être utiliser d’emblé chez le sujet cancereux avec une IRA ne présentant pas de contre-indications classiques
Oui
Non
![Page 69: Ventilatory support in cancer patients - Oncorea.com Rencontre/Benoit.pdf · Ventilatory support in cancer patients D. Benoit, MD, PhD ... Explanation why non invasive mechanical](https://reader036.vdocuments.mx/reader036/viewer/2022062603/5f0efd0a7e708231d441ee8e/html5/thumbnails/69.jpg)
Medicine is learned by the bedside and not in the classroom. Let not your conceptions of disease come from words heard in the lecture room or read from the book. See, and then reason, and compare and control. But see first
Sir William Osler – 1904