Management of the end stage Management of the end stage lung cancer patients:lung cancer patients:What would the politics be on What would the politics be on the intensive care support?the intensive care support?

Dr Zuhal KarakurtSüreyyapaşa Chest Diseases and Thoracic Surgery Training and Research Hospital,

Respiratory Intensive Care Unit

Admission for ICU: ATS 1999 GuidelinesAdmission for ICU: ATS 1999 Guidelines

Priority 1Priority 1 Priority 2Priority 2 Priority 3Priority 3 Priority 4Priority 4 Category ACategory A Category BCategory B

3. Patients with ARF but have a reduced likelihood of recovery due to underlying diseases.

metastatic malignancy complicated by infection, crdiac tamponade,or airwayobstruction

4. Generally not appropriate for ICU admission

Category A:Too well to benefit from ICU care

Category B: Too sick to benefit from ICU care (severe irreversible: brain damage,organ failure, metastatic cancer unresponsive to CTx& RTx, persistant vegetative state

SOFASOFAOrgansOrgans FindingsFindings

CardiovascularCardiovascular Blood pressure Blood pressure (Sistolic&diastolic), (Sistolic&diastolic), dopamine, dopamine, doputamine, doputamine, NE,AdrenalineNE,Adrenaline

RespiratoryRespiratory PaO2, FiO2PaO2, FiO2

CoagulationCoagulation Platalet countPlatalet count

HepaticHepatic Serum bilirubineSerum bilirubine

RenalRenal Serum creatinine, urine Serum creatinine, urine output/ houtput/ h

NeurologicalNeurological GCSGCS

MODSMODSOrgansOrgans FindingsFindings

CardiovascularCardiovascular

Blood pressure Blood pressure (sistolic&diastolic),heart (sistolic&diastolic),heart rate/min, CVPrate/min, CVP

RespiratoryRespiratory PaO2, FiO2PaO2, FiO2

RenalRenal Serum creatinineSerum creatinine

CoagulationCoagulation Platalet countPlatalet count

HepaticHepatic Serum bilirubineSerum bilirubine

NeurologicalNeurological GCSGCS

MODS score estimate the ICU mortality, hosp. Mortality & MODS score estimate the ICU mortality, hosp. Mortality & lenght of ICU stay.lenght of ICU stay.

www.ICU scores

Multi Organ Disfunctions:Criterias

MildMild SevereSevere

RespiratoryRespiratory MV requirment MV requirment hypoxia & hypoxia & hypercapnia> 3 dayhypercapnia> 3 day

FiO2>0.5, PEEP 8FiO2>0.5, PEEP 8

ARDS ARDS

HepaticHepatic Bilirubine 2-3Bilirubine 2-3 Bilirubine 8-10Bilirubine 8-10

RenalRenal Urine output<35cc/h Urine output<35cc/h DialysisDialysis

CardiovasculCardiovascularar

Reduced EF,Reduced EF,

Capillary leakCapillary leakDopa., doputamine,Dopa., doputamine,

Adrenaline, NEAdrenaline, NE

GISGIS > 5days intolerance > 5days intolerance to gastric feedingto gastric feeding

Stress ulcer, blood Stress ulcer, blood transfusiontransfusion

CogulationCogulation PLT< 100, PLT< 100,

aPTT > N %125aPTT > N %125DICDIC

NeurologicNeurologic Confusion, GKS 8-11Confusion, GKS 8-11 Coma, GKS< 7Coma, GKS< 7

Patients with Cancer:Common reasons of Patients with Cancer:Common reasons of ICU admissionICU admission

Respiratory failure due to CancerRespiratory failure due to Cancer After CTx & bone marrow transplantAfter CTx & bone marrow transplant SepsisSepsis Electrolite disorders (hyponatremia)Electrolite disorders (hyponatremia) Pulmonary edemaPulmonary edema Changes mental statatusChanges mental statatus Acute airway obstructionsAcute airway obstructions Side effects of medical treatmentSide effects of medical treatment Postoperative observationPostoperative observation

Paz H, Chest, 1993

Thomas A Br Med J 1988

Soares, M Chest 2007

Adam AK. ERJ, 2008

Cancer patients with high mortality Cancer patients with high mortality raterate

Bed restricted patientsBed restricted patients Patients with paliative cancer Patients with paliative cancer

teraphyteraphy Mechanical ventilation requirment Mechanical ventilation requirment High SOFA scoresHigh SOFA scores Late stage lung cancerLate stage lung cancer

Lung Cancer: Admission of ICU

ICU admission of patients with ICU admission of patients with newly diagnosed cancernewly diagnosed cancer

Specific organ failure & need Specific organ failure & need for administration of CT.for administration of CT.

Mortality:Mortality:

* need for vasopressor * need for vasopressor

* need for mechanical * need for mechanical

ventilationventilation

* hepatic failure* hepatic failure

Darmon M. Crit Care Med. 2005; 33:2488

Terminal Cancer & COPD Terminal Cancer & COPD patientspatients

NSCLC (939 pts)NSCLC (939 pts)

Severe dispnea %32Severe dispnea %32

Severe pain %28Severe pain %28

Short term effectiveness MVShort term effectiveness MV %19%19

Tube feeding %18Tube feeding %18

CPR %7.5CPR %7.5

COPD (1008 pts)COPD (1008 pts)

% 56% 56

%21%21

%70%70

%38%38

%25%25

Claessens MT .Dying with lung cancer or chronic obstructive pulmonary diseases: insights from SUPPORT.. J Am Geriatr Soc. 2000.:48 (5 Supp) 146

Metastatic colon cancer: 316 stage III-IV lung cancer: 7471. Severity of dieases (APACHE) 2. Activities of daily life (ADLs)

score,3. Physical and emotinal

symptoms (pain, depretion, anxiety)

4. Patients preference for care5. Financial impact on patient’s

families

3 days before death 4 or more impairments. More pain (%40) confusion, decrease

mood,anxiety. 2/3 patients forego

resuscitation.

3-6 month before death: 25% suffer pain, Families incurred significant

financial burdens

McCarthy EP. Dying with cancer:patient’s function, symptoms, and care preferences as

death approaches. JAm Geriatry Soc. 2000; 48 (5 Suppl): 110

Terminal colon & lung (NSCLC)cancer:three days before death

FindingsFindings Number of Number of ptspts

stagestage ICU etio?ICU etio?

(%)(%)MV MV

mortalitmortalityy

MortalityMortality

Our centerOur center

2001-2001-04.200804.2008

7272 %60%60

IVIVPulm (70)Pulm (70)

Postop Postop (30)(30)

%59%59 %50 ICU%50 ICU

Adam A.Adam A.

ERJ 2008ERJ 2008139139

(% 69 (% 69 NSCLC)NSCLC)

%62%62

IVIVPulm (49)Pulm (49)

Cardio Cardio (25)(25)

%38 ICU%38 ICU

%53 %53 HospHosp

% 22 ICU,% 22 ICU,

% 40 Hosp% 40 Hosp

Reicher A, Reicher A,

Chest 2006Chest 20064848

(%83 (%83 NSCLC)NSCLC)

%64 %64

IVIVPulm (57), Pulm (57),

Sepsis Sepsis (15)(15)

% 75% 75

(%86 )(%86 )%43 ICU%43 ICU

%60 Hosp%60 Hosp

Lin YCLin YC

Respir 2004Respir 20048181 ?? Pulm Pulm %85%85 %85 ICU%85 ICU

Jennens RRJennens RR

Lung C 2002Lung C 200220 , 20 ,

SCLC newSCLC new?? PulmPulm ------ 7 m 2 pts7 m 2 pts

4 m 17 pts4 m 17 pts

40 day 1 40 day 1 ptspts

Boussat SBoussat S

ICM 2000ICM 200056 56 ?? PulmPulm %66%66 %66 ICU%66 ICU

%75 Hosp%75 Hosp

Ewer MSEwer MS

JAMA 1986JAMA 19864646 IVIV Pulm (100)Pulm (100) %100%100 %100 ICU%100 ICU

Results of patients with lung cancer in the ICU

0102030405060708090100

%

1 2mortality in MV General Mortality

Mortality in ICU according to years

1986

2000

2002

2004

2008

Lung cancer casesLung cancer cases

Diagnosed in ICU: 59 y, F, NSCLC& invazive aspergillosis, MOF ( 31st day eksitus)

NSCLC, stageIV,entubated on admission: 49 y M, 6th.day exitus, hypoxic cardiac arrest

Acute respiratory failure due to lung cancer:

Cancer related Cancer related atelectasisatelectasis

Cardiac pulmonary Cardiac pulmonary edema,edema,

Pulmonary Pulmonary infection,infection,

COPD COPD exacerbation,exacerbation,Noninvasive mechanical

ventilation

19.04.08

WHERE ???

ICU indications for lung cancer ICU indications for lung cancer patientspatients

Endobronchial stent aplications and observations

Postop prolonged MV

September 07

April 08

NIMV on wardsNIMV on wards

Acute respiratory failure in 23 solid cancer

13 succesfull

10 failure

4 BİPAP

intolerance

6 rapidly detoriate

6 exitus3 exitus

13 alive 1 alive

Cuomo A. Palliative Med 2004: 18: 602.

Approachment for admission to ICUApproachment for admission to ICU

Newly diagnosed Newly diagnosed casescases

Presence of Presence of infectionsinfections

COPD acute COPD acute exacerbationsexacerbations

Post-op prolonged Post-op prolonged MVMV

Organ functions Organ functions failurefailure

( > 4 organs ( > 4 organs mortality % 100)mortality % 100)

high mortality for high mortality for unresponsive Ctx unresponsive Ctx ve RTx in ve RTx in metastatic cases.metastatic cases.

CONCLUSIONSCONCLUSIONS3 days left for end of life!3 days left for end of life!

Sign & symptomsSign & symptoms Increase the pain, Increase the pain, anxiety, anxiety, Fear from death, Fear from death, Respiratory Respiratory

distressdistress Rapidly Rapidly

detoriation in detoriation in general status general status

Unresponsive to Unresponsive to CTx ve RTx CTx ve RTx

What can we do?What can we do? OxygenOxygen NIMV **(wards)NIMV **(wards) Sedation Sedation Analgesia**Analgesia**

Place: ICU if patient Place: ICU if patient requestrequest

(priority 4, Category B)

McCarthy Ep. JAM Geriatry Soc. 2000:48 (Supp).:110

Stefano Nava, ERS 2007 Oral prentation)**

Thanks