肿瘤重症患者急性呼吸衰竭专家共识（2023版）

doi:10.24920/004203

Abstract

Objective This consensus aims to provide evidence-based recommendations on common questions in the diagnosis and treatment of acute respiratory failure (ARF) for critically ill cancer patients.
Methods We developed six clinical questions using the PICO (Population, Intervention, Comparison, and Outcome) principle in diagnosis and treatment for critical ill cancer patients with ARF. Based on literature searching and meta-analyses, recommendations were devised. The GRADE (Grading of Recommendation Assessment, Development and Evaluation) method was applied to each question to reach consensus in the expert panel.
Results The panel makes strong recommendations in favor of (1) metagenomic next-generation sequencing (mNGS) tests may aid clinicians in rapid diagnosis in critically ill cancer patients suspected of pulmonary infections; (2) extracorporeal membrane oxygenation (ECMO) therapy should not be used as a routine rescue therapy for acute respiratory distress syndrome in critically ill cancer patients but may benefit highly selected patients after multi-disciplinary consultations; (3) cancer patients who have received immune checkpoint inhibitor therapy have an increased incidence of pneumonitis compared with standard chemotherapy; (4) critically ill cancer patients who are on invasive mechanical ventilation and estimated to be extubated after 14 days may benefit from early tracheotomy; and (5) high-flow nasal oxygen and noninvasive ventilation therapy can be used as a first-line oxygen strategy for critically ill cancer patients with ARFs. A weak recommendation is: (6) for critically ill cancer patients with ARF caused by tumor compression, urgent chemotherapy may be considered as a rescue therapy only in patients determined to be potentially sensitive to the anticancer therapy after multidisciplinary consultations.
Conclusions The recommendations based on the available evidence can guide diagnosis and treatment in critically ill cancer patients with acute respiratory failure and improve outcomes.

Key words: acute respiratory failure, cancer, metagenomic next-generation sequencing, extracorporeal membcane oxygenation, immune checkpoint inhibitor therapy, early tracheotomy, urgent chemotherapy, expert consensus

Funding:

Hai-Jun Wang, Wei Chen, Hong-Zhi Wang, He-Ling Zhao, Dong-Hao Wang, Yun Long, Xue-Zhong Xing, on behalf of the Critical Care Medicine Committee of Beijing Association of Oncology (CCMBAO). Expert Consensus on Acute Respiratory Failure in Critically Ill Cancer Patients (2023)[J].Chinese Medical Sciences Journal, 2023, 38(3): 163-177.

Figures/Tables 8

RECOMMENDATIONS SUMMARY
Recommendation 1. Metagenomic next-generation sequencing (mNGS) may aid clinicians in rapid diagnosis of pulmonary infections in critically ill cancer patients (moderate quality, strong recommendation).
Recommendation 2. Critically ill cancer patients with acute respiratory failure (ARDS) are associated with increased 28-day mortality compared with critically ill non-cancer patients, disregarding whether they receive conventional treatment or extracorpored membrane oxygenation (ECMO) rescue therapy (high quality, strong recommendation). ECMO should not be used as a routine rescue therapy for critically ill cancer patients with ARDS, and only highly selected patients determined after a multi-disciplinary consultation may benefit from ECMO therapy (high quality, strong recommendation).
Recommendation 3. Cancer patients who have received immune checkpoint inhibitor (ICI) therapy have an elevated incidence of pneumonitis compared with standard chemotherapy (high quality, strong recommendation). Intensivists should be alert to ICI-related high-grade pneumonitis (high quality, strong recommendation).
Recommendation 4. Critically ill cancer patients on invasive mechanical ventilation who are estimated to require extubation beyond 14 days may benefit from early tracheotomy (within 3-7 days of intubation). This can lead to reduced 28-day mortality without affecting the duration of mechanical ventilation and the rate of ventilator-associated pneumonia (moderate quality, strong recommendation).
Recommendation 5. For critically ill cancer patients with acute respiratory failure, high-flow nasal oxygen or noninvasive ventilation therapy is superior to standard oxygen therapy with a reduced intubation rate and can be used as a first-line oxygen strategy (moderate quality, strong recommendation).
Recommendation 6. Urgent chemotherapy may be considered for selected critically ill cancer patients with acute respiratory failure caused by tumor compression. The decision should be made after a multidisciplinary consultation, which determines that the tumor is potentially sensitive to anticancer therapy (low quality, weak recommendation).

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Hai-Jun Wang	National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College
Xue-Zhong Xing	National Cancer Center/National Clinical Research Center for Cancer/Cancer Hospital, Chinese Academy of Medical Sciences & Peking Union Medical College
Mei-Li Duan	Beijing Friendship Hospital, Capital Medical University
Shuang-Ling Li	Peking University First Hospital, Peking University
Yuan-Yu Qian	Chinese PLA General Hospital
Zhi-Qiang Wang	Tianjin Medical University General Hospital
Ke-Liang Cui	Key Laboratory of Cancer Prevention and Therapy, National Clinical Research Center of Cancer, Tianjin Medical University Cancer Institute and Hospital
Lan Wang	Dongzhimen Hospital, Beijing University of Chinese Medicine
Zhen-Li Peng	Chui yang liu Hospital affiliated to Tsinghua University
Nian-Fang Lu	Beijing Electric Power Hospital
Yong-Shun Feng	Beijing Coal Group General Hospita
Li-Wei Hua	Affiliated Hospital of Chengde Medical University
Ya-Ling Sun	Changping traditional Chinese Medicine Hospital of Beijing
Lei Li	Fifth Medical Center of the PLA General Hospital
Xiu-Mei Chen	Beijing Miyun Hospital
Xue-Jun Zhou	Beijing Huairou Hospital
Wen-Xian Zhao	Beijing Puren Hospital
Xian-Feng Lu	Beijing Zhongguanchun Hospital
Jun Dong	Peking University Cancer Hospital & Institute
Wei-Shuai Bian	Beijing Shijitan Hospital, Capital Medical University

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