Azoulay E, de Miranda S, Bèle N, Schlemmer B
Service de Réanimation médicale, Hôpital Saint-Louis, Université Paris Diderot, Assistance Publique Hôpitaux de Paris, 1 avenue Claude Vellefaux, Paris, France.
Rev Mal Respir. 2008 Apr;25(4):433-49. doi: 10.1016/s0761-8425(08)71584-5.
About 15% of patients with haematological malignancy develop acute respiratory failure (ARF), necessitating admission to intensive care where their mortality is of the order of 50%.
The prognosis of these patients is not determined by the pathological characteristics of the malignancy but by the cause of the acute respiratory failure. In effect, the need to resort to mechanical ventilation in the presence of dysfunction of other organs dominates the prognosis. Even if the use of non-invasive ventilation in these patients has reduced the need for intubation and reduced the mortality, its prolonged use in the most severely affected patients prevents the optimal diagnostic and therapeutic management.
Fibreoptic bronchoscopy with broncho-alveolar lavage (BAL) is considered the cornerstone of aetiological diagnosis but its diagnostic effectiveness is poor, at best 50%, and this has led to increasing interest in high resolution CT scanning and regularly reawakens a transitory enthusiasm for surgical lung biopsy. Furthermore, in hypoxaemic patients, fibreoptic bronchoscopy with BAL may be the origin of the resort to mechanical ventilation, and thus increased mortality. The place of recently developed non-invasive tools is under evaluation. In effect, though the individual performance of diagnostic molecular techniques on sputum, blood, urine or naso- pharyngeal secretions has been established, the combination of these tools as an alternative to BAL has not yet been reported.
This review deals with acute respiratory failure in patients with haematological malignancy. It includes a review of the recent literature and considers the current controversies, in particular the risk-benefit balance of fibreoptic bronchoscopy with BAL in severely hypoxaemic patients.
约15%的血液系统恶性肿瘤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%。
这些患者的预后并非由恶性肿瘤的病理特征决定，而是由急性呼吸衰竭的病因决定。实际上，在其他器官功能障碍的情况下需要进行机械通气这一点对预后起主导作用。即使在这些患者中使用无创通气减少了插管需求并降低了死亡率，但在病情最严重的患者中长期使用无创通气会妨碍最佳的诊断和治疗管理。
纤维支气管镜检查联合支气管肺泡灌洗（BAL）被认为是病因诊断的基石，但其诊断有效性较差，最高仅为50%，这导致人们对高分辨率CT扫描的兴趣日益增加，并时常重新燃起对手术肺活检的短暂热情。此外，在低氧血症患者中，纤维支气管镜检查联合BAL可能是导致采用机械通气的原因，从而增加死亡率。目前正在评估近期开发的无创工具的作用。实际上，尽管已经确定了诊断分子技术在痰液、血液、尿液或鼻咽分泌物方面的个体性能，但尚未有将这些工具联合起来替代BAL的报道。
本综述探讨了血液系统恶性肿瘤患者的急性呼吸衰竭。它包括对近期文献的综述，并考虑了当前的争议，特别是在严重低氧血症患者中纤维支气管镜检查联合BAL的风险效益平衡。
