SciELO - Scientific Electronic Library Online

 
vol.25 número1Dosagens séricas de proteína C-reativa na fase inicial da sepse abdominal e pulmonarTerapia nutricional enteral em pacientes sépticos na unidade de terapia intensiva: adequação às diretrizes nutricionais para pacientes críticos índice de autoresíndice de assuntospesquisa de artigos
Home Pagelista alfabética de periódicos  

Serviços Personalizados

Journal

Artigo

Indicadores

Links relacionados

Compartilhar


Revista Brasileira de Terapia Intensiva

versão impressa ISSN 0103-507X

Rev. bras. ter. intensiva vol.25 no.1 São Paulo jan./mar. 2013

http://dx.doi.org/10.1590/S0103-507X2013000100004 

ORIGINAL ARTICLE - CLINICAL RESEARCH

 

Outcomes for patients with lung cancer admitted to intensive care units

 

 

Alice Mânica MüllerI,II; Marcelo Basso GazzanaI; Denise Rossato SilvaI,II

IHospital de Clínicas de Porto Alegre - HCPA) - Porto Alegre (RS), Brazil
IIPost-Graduate Program in Pneumology Sciences, Universidade Federal do Rio Grande do Sul - UFRGS - Porto Alegre (RS), Brazil

Corresponding author

 

 


ABSTRACT

OBJECTIVE: This study aimed to evaluate the outcomes for patients with lung cancer admitted to intensive care units and assess their clinical and demographic profiles.
METHODS: Retrospective, analytical, observational study, wherein the outcomes for patients diagnosed with lung cancer admitted to the intensive care unit of university hospital from January 2010 until February 2011 were evaluated.
RESULTS: Thirty-four patients' medical records were included. Twenty-six (76.5%) patients received some type of ventilatory support, of whom 21 (61.8%) used invasive mechanical ventilation and 11 (32.4%) used noninvasive ventilation at some point during their stay at the intensive care unit. Regarding mortality, 12 (35.3%) patients died during hospitalization at the intensive care unit, totaling 15 (44.1%) deaths during the entire hospitalization period; 19 (55.9%) patients were discharged from the hospital. The analysis of the variables showed that the patients who died had remained on invasive mechanical ventilation for a longer period 5.0 (0.25 to 15.0) days than the survivors (1.0 (0 to 1.0) days) (p=0.033) and underwent dialysis during their stay at the intensive care unit (p=0.014).
CONCLUSIONS: The mortality of patients with lung cancer admitted to the intensive care unit is associated with the time spent on invasive mechanical ventilation and the need for dialysis.

Keywords: Lung neoplasms/mortality; Intensive care unit; Prognosis


 

 

INTRODUCTION

Lung cancer is one of the most frequent types of cancer in both men and women, and it is also one of the most lethal.(1) Advances in the treatment of tumors have occurred in the last years, enabling a greater probability of disease control or cure. However, these new therapies can cause a number of side effects, affecting almost all organ functions. The cancer itself can also cause clinical complications, with immediate risk to life, directly leading to a greater use of beds at the intensive care unit (ICU).(2-4)

Patients with the chance of curing or controlling cancer with potentially reversible complications are admitted to the ICU, and the intensive care has been shown to contribute to reducing those patients' mortality rate, even in subjects at higher risk, including patients with sepsis or in need of mechanical ventilation (MV).(3,5) The ICU support is sometimes necessary for the immediate relief of symptoms and improved quality of life, even for patients without further therapeutic possibilities of cure.(2)

Acute respiratory failure is one of the most common complications in patients with lung cancer. It implies a worse prognosis and, in most cases, requires the use of MV. Hypoxemic respiratory failure may be due to infectious pneumonia, invasion of the underlying malignancy, acute lung injury due to chemotherapy, cardiogenic or non-cardiogenic pulmonary edema, or diffuse alveolar hemorrhage. Noninvasive ventilation (NIV) should be offered to patients who are stable from the hemodynamic and hematological standpoint.(4,6,7)

Considering that some studies have been performed to characterize patients with lung cancer admitted to the ICU, either based on the high morbidity and mortality or the poor prognosis of those subjects, and considering that advanced cancer requires intensive treatment in most cases, this study aimed to evaluate the outcomes for patients with lung cancer admitted to the ICU.

 

METHODS

A retrospective, analytical, observational study was performed wherein the outcomes for patients diagnosed with lung cancer admitted to the Hospital de Clínicas de Porto Alegre (HCPA) ICU from January 2010 to February 2011 were evaluated. The patients were gathered using the hospital's electronic medical record system. Subsequently, a review of those records was conducted to collect the necessary data.

The patients were evaluated regarding their demographic and clinical profile, the reason for ICU admission, length of stay, whether ventilatory support was used, mortality, complications, prognosis, and treatment (medical and/or surgical), according to the data collected from the evaluation questionnaire for patients with lung cancer admitted to the ICU.

All patients diagnosed with lung cancer and admitted to the adult ICU of HCPA, from January 2010 to February 2011, of both genders, varying age, whether under treatment for cancer or not, were included in the study. Patients who did not meet the inclusion criteria, including patients with other tumors and/or diseases not diagnosed as lung cancer, were excluded.

The study was approved by the Ethics and Research Committee of the HCPA. The Informed Consent Form was waived because it was a retrospective study analyzing medical records.

The modified form of the Brazilian Research in Intensive Care Network (BRICNet),(8) with demographic and clinical data characteristic of the cancer, cause of ICU admission and reason for the use or non-use of MV, Acute Physiology and Chronic Health Evaluation II (APACHE II) prognostic score, mortality, and treatment, was used for data collection.

Statistical analysis

The data collected were entered into the Microsoft® Excel 2000 database software and were processed and analyzed using the Statistical Package for the Social Sciences (SPSS) software, version 17.0. A descriptive analysis was performed for the study variables. The quantitative data were shown as the mean±standard deviation (SD) and/or as the median and interquartile range (IQR). The frequency data were expressed as the number of subjects (N) and the percentage (%) of cases. The comparison between survivors and non-survivors, regarding the continuous variables, was performed using the Student t test for normally distributed data or the nonparametric Mann-Whitney test for data that are not normally distributed. The chi-square or Fisher's exact (if the expected counts in one group were below 5) tests were used for the two groups with respect to categorical variables. Differences were considered statistically significant at p<0.05.

 

RESULTS

A total of 34 patients diagnosed with lung cancer were admitted to the ICU of HCPA from January 2010 to February 2011. The patients' demographic and clinical characteristics are shown in table 1. There was a predominance of females and a mean age of 63.3±11.2 years. The histologic type epidermoid cancer prevailed in 13 (38.2%) patients. There were distant metastases in 13 (38.2%) patients and recently diagnosed active cancer in 29 (85.3%) patients. Regarding treatment, 22 (64.7%) patients underwent non-surgical and 12 (35.3%) surgical treatments.

 

 

Twenty-nine (85.3%) of the 34 patients were admitted to the clinical ICU and only 5 (14.7%) to the elective surgical ICU. Seventeen (50%) came from the infirmary, 5 (14.7%) from the emergency room, 8 (23.5%) from the surgical center, 3 (8.8%) from the recovery room, and only 1 (2.9%) from the outpatient clinic.

The main reasons for admission to the ICU were respiratory failure in 16 patients (47.1%), sepsis in 6 (17.6%), and postoperative monitoring in 5 (14.7%). During the ICU stay, 21 (61.8%) patients had some type of infection, and pneumonia was the most prevalent, occurring in 16 (47%) patients, followed by sepsis in 8 (23.5%). Fifteen patients (44.1%) used vasoactive drugs, and only 3 (8.8%) required dialysis. Only 1 (2.9%) patient was treated with chemotherapy at the ICU.

Twenty-six (76.5%) of the 34 patients received some form of ventilatory support: 21 (61.8%) used IMV, and 11 (32.4%) used NIV at some point during the ICU stay. Two (5.9) of these had NIV failure, and 3 (8.8%) had difficulty weaning from the IMV (Table 1).

Concerning the patient mortality, 12 (35.3%) patients died during the period of the ICU stay, with a total of 15 (44.1%) deaths during hospitalization (ICU and infirmary), and 19 (55.9%) were discharged from the hospital. The decision of therapeutic obstinacy occurred in 11 (32.4%) patients. Twelve (35.3%) patients did not receive any physical therapy.

Univariate analyses of quantitative variables, associated with the primary outcome, which is mortality, were performed. The results of the univariate analyses are shown in tables 2 and 3. The analysis of variables showed that the patients who died remained on IMV for a longer period than the survivors (p=0.033) and underwent dialysis during the ICU stay (p=0.014). The other variables, including gender, treatment, infection, use of vasoactive drugs, NIV and performing physical therapy were not statistically significant regarding mortality.

 

 

 

 

The Mann-Whitney test could not be performed regarding the duration of dialysis because only three patients underwent dialysis, and all died; therefore, no patient remained in the group of survivors, and the test could not be performed using an empty group.

 

DISCUSSION

The results of this study suggest a worse outcome for patients with lung cancer admitted to the ICU, with a 44.1% in-hospital mortality rate and 35.3% ICU mortality rate.

These data are in accordance with the overall mean mortality in the ICU, similar to other recently published studies, which showed overall ICU mortality ranging from 22 to 51% and in-hospital mortality ranging from 46 to 66%.(9-17) Conversely, the study by Lin(6) showed an 85.2% hospital mortality rate.

The patients' epidemiological profile coincides with the profiles reported in previous studies, wherein the female gender and the mean age group above 60 years predominate, and the histological types epidermoid and adenocarcinoma, recently diagnosed active cancer and disease with distant metastasis were further prevalent.(6,9,18) Approximately 40% of patients with non-small cell lung cancer (NSCLC) were in an advanced disease stage, with metastasis or locally advanced involvement.(19)

According to some studies,(9-13) patients admitted to the ICU with lung cancer have NSCLC in a more advanced disease stage, and the admission is directly related to lung cancer. The use of the ICU for patients with advanced lung cancer has increased. The performance status and ability to control tumor growth are key factors assessed upon patient admission to the ICU, where the overall mortality is 40-50%, with reductions in mortality attributed to advances in ICU care.(20)

Infectious complications, from localized to generalized infections with sepsis and septic shock, are the most common reasons for ICU admission among the indications for intensive therapy in patients with cancer.(2,6,10,13,14) In this study, the most frequent reasons were respiratory failure (47%) and sepsis (17.6%). A total of 61.8% of the patients were found to have some type of infection during the ICU stay. Similar results were found in earlier studies.(6,9,10) Typically, cancer patients admitted to the ICU with infection are unresponsive to the initial therapy and show signs of spread of the infectious agent.(2) This tendency leads to longer ICU stays, MV, and the use of vasoactive drugs.

Most patients included in this study received some type of ventilatory support during the ICU stay. The data in this study corroborate prior research studies, which showed the use of IMV during the ICU stay of most cancer patients.(12-15)

This study also showed that the need for dialysis and the duration of IMV use were factors significantly associated with mortality. D'Avila showed that an MV duration longer than 6 days was associated with higher mortality risk.(21) Other studies also showed a direct correlation between lethality and longer stays on IMV and dialysis.(6,21) Roques et al.(9) showed an association between mortality and admission to the ICU for acute respiratory failure, cancer progression, vasopressor use, IMV use, and APACHE II.(18)

Although it is known that patients using vasoactive drugs or IMV and patients suffering from infections during hospitalization have an increased risk of mortality, no significant association was found in this study, most likely because of the reduced sample size, but some other studies do show that correlation.(9,12,18)

The current study had some limitations. First, the main study limitation is its sample size, which makes it practically descriptive, as the interpretation of associations considering only univariate analyses is very limited and compromises the associations between variables and the main outcome. Second, the study was based on data collected from a single center, which might have potential biases given the target population's characteristics, including access to health services, for example. New studies with more patients are needed to confirm those results and relate other factors and outcomes.

 

CONCLUSION

Although patients with lung cancer may benefit from intensive care in the ICU because many therapeutic advances have been pursued that can increase their survival and improve their quality of life, this study showed a high mortality rate in such patients, related to the time of use of IMV and the use of dialysis.

 

REFERENCES

1. Castro MS, Vieira VA, Assunção RM. Padrões espaço-temporais da mortalidade por câncer de pulmão no Sul do Brasil. Rev Bras Epidemiol. 2004;7(2):131-43.         [ Links ]

2. Sapolnik R. Suporte de terapia intensiva no paciente oncológico. J Pediatr (Rio J). 2003;79(Supl 2):S231-42.         [ Links ]

3. Salluh JI, Soares M. Políticas de admissão de pacientes oncológicos na UTI: hora de rever os conceitos. Rev Bras Ter Intensiva. 2006;18(3):217-8.         [ Links ]

4. Benoit DD, Depuydt PO. Outcome in critically ill cancer patients: past and present. Rev Bras Ter Intensiva. 2008;20(1):82-7.         [ Links ]

5. Soares M. Quando o tratamento oncológico pode ser fútil? Do ponto de vista do intensivista. Rev Bras Cancerol. 2008;54(4):389-92.         [ Links ]

6. Lin YC, Tsai YH, Huang CC, Hsu KH, Wang SW, Tsao TC, et al. Outcome of lung cancer patients with acute respiratory failure requiring mechanical ventilation. Respir Med. 2004;98(1):43-51.         [ Links ]

7. Meert AP, Berghmans T, Hardy M, Markiewicz E, Sculier JP. Non-invasive ventilation for cancer patients with life-support techniques limitation. Support Care Cancer. 2006;14(2):167-71.         [ Links ]

8. Brasil. Ministério da Saúde. Avaliação de pacientes com câncer de pulmão internados em unidade de terapia intensiva. BRICNet - Brazilian Research Intensive Care Network. Instituto Nacional de Câncer - INCA [Internet]. 2009 [citado 2011 Mai 15]. Disponível em: http://198.170.82.216/Bricnet%20Estudo%20Cancer/Ficha_de_coleta_de_dados.pdf        [ Links ]

9. Roques S, Parrot A, Lavole A, Ancel PY, Gounant V, Djibre M, et al. Six-month prognosis of patients with lung cancer admitted to the intensive care unit. Intensive Care Med. 2009;35(12):2044-50.         [ Links ]

10. Reichner CA, Thompson JA, O'Brien S, Kuru T, Anderson ED. Outcome and code status of lung cancer patients admitted to the medical ICU. Chest. 2006;130(3):719-23.         [ Links ]

11. Adam AK, Soubani AO. Outcome and prognostic factors of lung cancer patients admitted to the medical intensive care unit. Eur Respir J. 2008;31(1):47-53.         [ Links ]

12. Andréjak C, Terzi N, Thielen S, Bergot E, Zalcman G, Charbonneau P, et al. Admission of advanced lung cancer patients to intensive care unit: a retrospective study of 76 patients. BMC Cancer. 2011;11:159.         [ Links ]

13. Soares M, Darmon M, Salluh JI, Ferreira CG, Thiéry G, Schlemmer B, et al. Prognosis of lung cancer patients with life-threatening complications. Chest. 2007;131(3):840-6.         [ Links ]

14. Soares M, Salluh JI, Rocco JR, Spector N. Fatores prognósticos em pacientes com neoplasias hematológicas gravemente enfermos. Rev Bras Ter Intensiva. 2005;17(3):170-5.         [ Links ]

15. Soares M, Salluh JI, Spector N, Rocco JR. Characteristics and outcomes of cancer patients requiring mechanical ventilatory support for >24 hrs. Crit Care Med. 2005;33(3):520-6.         [ Links ]

16. Maniate JM, Navaratnam S, Cheang M, Math M, Sharma S. Outcome of lung cancer patients admitted to the intensive care unit. Clin Pulm Med. 2007;14(5):281-5.         [ Links ]

17. Slatore CG, Cecere LM, Letourneau JL, O'Neil ME, Duckart JP, Wiener RS, et al. Intensive care unit outcomes among patients with lung cancer in the surveillance, epidemiology, and end results-medicare registry. J Clin Oncol. 2012;30(14):1686-91.         [ Links ]

18. Toffart AC, Minet C, Raynard B, Schwebel C, Hamidfar-Roy R, Diab S, et al. Use of intensive care in patients with nonresectable lung cancer. Chest. 2011;139(1):101-8.         [ Links ]

19. Thatcher N. First- and second-line treatment of advanced metastatic non-small-cell lung cancer: a global view. BMC Proc. 2008;2 Suppl 2:S3.         [ Links ]

20. Boyd M, Ie S, Rubio E. Lung cancer in the ICU: a review of utilization and outcomes. Clin Pulm Med. 2011;18(5):238-42.         [ Links ]

21. D'Avila DO, Traezel M, Glock L. Insuficiência renal aguda tratada por diálise em unidade de tratamento intensivo (análise de 124 pacientes consecutivos). J Bras Nefrol. 1997;19(1):21-31.         [ Links ]

 

 

Corresponding author:
Alice Mânica Müller
Rua Ramiro Barcelos, 2.350, sala 2.050
CEP: 90035-903 - Porto Alegre (RS), Brazil
E-mail: alicemm26@hotmail.com

Submitted on November 20, 2012
Accepted on February 28, 2013
Conflicts of interest: None.

 

 

This study was conducted at Hospital de Clínicas de Porto Alegre - HCPA - Porto Alegre (RS), Brazil

Creative Commons License Todo o conteúdo deste periódico, exceto onde está identificado, está licenciado sob uma Licença Creative Commons