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Dr Zuhal Karakurt Süreyyapaşa Chest Diseases and Thoracic Surgery Training and Research Hospital,

Management of the end stage lung cancer patients: What would the politics be on the intensive care support?. Dr Zuhal Karakurt Süreyyapaşa Chest Diseases and Thoracic Surgery Training and Research Hospital, Respiratory Intensive Care Unit. Priority 1 Priority 2 Priority 3 Priority 4

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Dr Zuhal Karakurt Süreyyapaşa Chest Diseases and Thoracic Surgery Training and Research Hospital,

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  1. Management of the end stage lung cancer patients:What would the politics be on the intensive care support? Dr Zuhal Karakurt Süreyyapaşa Chest Diseases and Thoracic Surgery Training and Research Hospital, Respiratory Intensive Care Unit

  2. Priority 1 Priority 2 Priority 3 Priority 4 Category A Category 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 Admission for ICU: ATS 1999 Guidelines

  3. SOFA

  4. MODS www.ICU scores

  5. Multi Organ Disfunctions:Criterias

  6. Patients with Cancer:Common reasons of ICU admission • Respiratory failure due to Cancer • After CTx & bone marrow transplant • Sepsis • Electrolite disorders (hyponatremia) • Pulmonary edema • Changes mental statatus • Acute airway obstructions • Side effects of medical treatment • Postoperative observation Paz H, Chest, 1993 Thomas A Br Med J 1988 Soares, M Chest 2007 Adam AK. ERJ, 2008

  7. Cancer patients with high mortality rate • Bed restricted patients • Patients with paliative cancer teraphy • Mechanical ventilation requirment • High SOFA scores • Late stage lung cancer

  8. Lung Cancer: Admission of ICU ICU admission of patients with newly diagnosed cancer Specific organ failure & need for administration of CT. Mortality: * need for vasopressor * need for mechanical ventilation * hepatic failure Darmon M. Crit Care Med. 2005; 33:2488

  9. NSCLC (939 pts) Severe dispnea %32 Severe pain %28 Short term effectiveness MV%19 Tube feeding %18 CPR %7.5 COPD (1008 pts) % 56 %21 %70 %38 %25 Terminal Cancer & COPD patients Claessens MT .Dying with lung cancer or chronic obstructive pulmonary diseases: insights from SUPPORT.. J Am Geriatr Soc. 2000.:48 (5 Supp) 146

  10. Metastatic colon cancer: 316 stage III-IV lung cancer: 747 1. Severity of dieases (APACHE) 2. Activities of daily life (ADLs) score, 3. Physical and emotinal symptoms (pain, depretion, anxiety) 4. Patients preference for care 5. 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 Terminal colon & lung (NSCLC)cancer:three days before death McCarthy EP. Dying with cancer:patient’s function, symptoms, and care preferences as death approaches. JAm Geriatry Soc.2000; 48 (5 Suppl): 110

  11. Results of patients with lung cancer in the ICU

  12. Lung cancer cases NSCLC, stageIV,entubated on admission: 49 y M, 6th.day exitus, hypoxic cardiac arrest Diagnosed in ICU: 59 y, F, NSCLC& invazive aspergillosis, MOF ( 31st day eksitus)

  13. Acute respiratory failure due to lung cancer: • Cancer related atelectasis • Cardiac pulmonary edema, • Pulmonary infection, • COPD exacerbation, 19.04.08 Noninvasive mechanical ventilation WHERE ???

  14. ICU indications for lung cancer patients September 07 April 08 Endobronchial stent aplications and observations Postop prolonged MV

  15. NIMV on wards Acute respiratory failure in 23 solid cancer 13 succesfull 10 failure 4 BİPAP intolerance 6 rapidly detoriate 6 exitus 3 exitus 13 alive 1 alive Cuomo A. Palliative Med 2004: 18: 602.

  16. Newly diagnosed cases Presence of infections COPD acute exacerbations Post-op prolonged MV Organ functions failure ( > 4 organs mortality % 100) high mortality for unresponsive Ctx ve RTx in metastatic cases. Approachment for admission to ICU

  17. Sign & symptoms Increase the pain, anxiety, Fear from death, Respiratory distress Rapidly detoriation in general status Unresponsive to CTx ve RTx What can we do? Oxygen NIMV **(wards) Sedation Analgesia** Place: ICU if patient request (priority 4, Category B) CONCLUSIONS3 days left for end of life! McCarthy Ep. JAM Geriatry Soc. 2000:48 (Supp).:110 Stefano Nava, ERS 2007 Oral prentation)**

  18. Thanks

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