Azoulay Elie, Schlemmer Benoît
Service de Réanimation Médicale, Hôpital Saint-Louis et Université Paris 7, Paris, France.
Intensive Care Med. 2006 Jun;32(6):808-22. doi: 10.1007/s00134-006-0129-2. Epub 2006 Apr 29.
Nearly 15% of cancer patients experience acute respiratory failure (ARF) requiring admission to the intensive care unit, where their mortality is about 50%. This review focuses on ARF in cancer patients. The most recent literature is reviewed, and emphasis is placed on current controversies, most notably the risk/benefit ratio of fiberoptic bronchoscopy and BAL in patients with severe hypoxemia.
Fiberoptic bronchoscopy with bronchoalveolar lavage (BAL) is the cornerstone of the causal diagnosis. However, the low diagnostic yield of about 50%, related to the widespread use of broad-spectrum antimicrobial therapy in cancer patients, has generated interest in high-resolution computed tomography (HRCT) and primary surgical lung biopsy. In patients with hypoxemia, bronchoscopy and BAL may trigger a need for invasive mechanical ventilation, thus considerably decreasing the chances of survival.
The place for recently developed, effective, noninvasive diagnostic tools (tests on sputum, blood, urine, and nasopharyngeal aspirates) needs to be determined. The prognosis is not markedly influenced by cancer characteristics; it is determined chiefly by the cause of ARF, need for mechanical ventilation, and presence of other organ failures. Although noninvasive ventilation reduces the need for endotracheal intubation and diminishes mortality rate, its prolonged use in patients with severe disease may preclude optimal diagnostic and therapeutic management. The appropriateness of switching to endotracheal mechanical ventilation in patients who fail noninvasive ventilation warrants evaluation.
This review discusses risks and benefits from invasive and non invasive diagnostic and therapeutic strategies in critically ill cancer patients with acute respiratory failure. Avenues for research are also suggested in order to improve survival in these very high risk patients.
近15%的癌症患者会发生急性呼吸衰竭（ARF），需要入住重症监护病房，其死亡率约为50%。本综述聚焦于癌症患者的ARF。对最新文献进行了综述，并重点关注当前的争议问题，最显著的是纤维支气管镜检查和支气管肺泡灌洗（BAL）在严重低氧血症患者中的风险/效益比。
纤维支气管镜检查联合支气管肺泡灌洗（BAL）是病因诊断的基石。然而，由于癌症患者广泛使用广谱抗菌治疗，导致诊断阳性率约为50%较低，这引发了人们对高分辨率计算机断层扫描（HRCT）和原发性外科肺活检的兴趣。在低氧血症患者中，支气管镜检查和BAL可能会引发有创机械通气的需求，从而显著降低生存几率。
需要确定最近开发的有效非侵入性诊断工具（痰液、血液、尿液和鼻咽抽吸物检测）的作用。预后不受癌症特征的显著影响；主要由ARF的病因、机械通气的需求以及其他器官功能衰竭的存在决定。虽然无创通气减少了气管插管的需求并降低了死亡率，但在重症患者中长时间使用可能会妨碍最佳的诊断和治疗管理。对于无创通气失败的患者转为气管内机械通气的适宜性值得评估。
本综述讨论了重症癌症急性呼吸衰竭患者侵入性和非侵入性诊断及治疗策略的风险和益处。还提出了研究途径，以提高这些高风险患者的生存率。
