How to ventilate critical children with cancer?Jesus Dominguez-Rojas M.D.1, Silvio Fabio Torres Godoy M.D.2, Lupe Nataly Mora Robles MD3, Ale Méndez Aceituno MD4.1. Medico Pediatra Intensivista. Instituto Nacional de Salud del Niño. Lima – Perú2. Médico Pediatra Intensivista. Unidad de Cuidados Intensivos Pediátricos del Hospital Universitario Austral – Argentina.3. Medico Pediatra Intensivista, Tratante de UCIP SOLCA, Hospital José Carrasco Arteaga – Ecuador.4. Unidad de Cuidados Intensivos Pediátricos, Unidad Nacional de Oncología Pediátrica (UNOP), Ciudad de Guatemala, Guatemala.Correspondence: Jesús Domínguez-Rojas, [email protected], Fray Angelico 238 Departamento 103, San Borja – Lima, phone: +51953907559Text word count 1075;Key words: Cuidados Intensivos, oncologia pediatrica, hematologia pediatricaTables: 0Figures: 1Mr. Editor, there is currently concern about the choice of how to ventilate an oncohematologic patient when presenting with severe respiratory failure, severe hypoxemia, since the use of invasive mechanical ventilation is associated with a higher mortality rate. It is worth mentioning that children with malignant neoplasms usually have low priority for admission to Pediatric Intensive Care Units (PICU), since the allocation of beds to these children with cancer is considered to have a poor prognosis. It is for this reason that the usefulness of invasive mechanical ventilation (IMV) or noninvasive ventilation (NIV) in early stages should be investigated in larger clinical studies, since oncohematological patients with hypoxemic respiratory failure are the first reason for admission to the PICU, and the decision to choose IMV or NIV as the first respiratory support in early stages can reduce in most cases the lethality in this group of patients. (1) Respiratory support in the form of NIV and humidified oxygen with high-flow nasal cannula (HFNC) are very attractive alternatives in patients with malignant neoplasms. The benefits of NIV in immunocompromised patients in children have been documented. (2) In children, a ventilation strategy incorporating very high levels of carbon dioxide to allow low tidal volumes and limited inspiratory pressures is feasible. This strategy could increase survival in immunocompromised children with severe ARDS, although there are no guidelines on how to ventilate this group of critically ill oncohematologic patients, so individualization of these patients is of fundamental consideration. Guidelines of the Second Pediatric Acute Lung Injury Consensus Conference (PALICC-2) lacks of recomendations for ventilatory management in children with cancer, therefore, the line of research should be focused on this susceptible group. (3) The prognosis of acute respiratory failure (ARF) in immunocompromised children remains guarded, regardless of the initial success or failure of NIV, due to the high rate of recurrent ARF. (4) The application of NIV is feasible and well tolerated in immunocompromised children with ARDS. A brief trial of NIV can be used to test the usefulness of the technique. (5) NIV should be considered a favorable therapeutic approach to avoid endotracheal intubation, as long as children with cancer presenting with acute respiratory distress improve and when clinical and gasometric improvement can be achieved and objectively assessed. In a small report of cases, Ofer Schiller et al. in 12 of 16 BiPAP interventions (75 %; 11 patients), children survived to discharge from the pediatric intensive care unit (PICU) without invasive ventilation. No major complications were observed during bi-level positive pressure ventilation (BiPAP). Thus, two-level positive airway pressure ventilation is well tolerated in pediatric oncology patients presenting with acute respiratory failure and may offer better outcomes sed opportunely and with correct monitoring previously. (6)Another researchion by Piastra et al. noted that children with NIV had a shorter period of hospitalization and PICU. In addition, the success of NIV decreased the number of hours of NIV use as well as the length of stay in the PICU in children with cancer. It appears to be a viable initial option in children with malignancies with acute respiratory failure.The decision to start mechanical ventilation in cancer patients is frequently questioned, because respiratory failure could be a terminal manifestation of their disease. Something that is very controversial when there is lung or airway collapse due to the presence of tumor, space occupying masses in the thoracic cavity (typical of teratoma and ganglioneuroma) or due to the presence of partial or complete obstruction of the upper airway (nasal fibroma, hemangioma, fibromatosis or adenopathy in case of ALL or lymphoma), is to decide whether to start chemotherapy first to debulk the tumor and avoid orotracheal intubation or secure the airway initially, due to the restrictive pattern in case of ALL or lymphoma, fibromatosis or adenopathy in case of ALL or lymphoma) or urgent surgery. (7) Children with hematologic malignancies fare worse than children with solid tumors.Historically it was not clear whether the use of IMV as a therapeutic option in oncology patients had a real clinical benefit. The use of IMV in oncology patients with advanced disease raises not only the question of clinical benefit, but also psychosocial issues. When invasive treatments such as IMV fail, the outcome is often one of considerable suffering for both the patient and their families.Indeed, in view of the increased survival of cancer patients and the evolution of intensive care in the last decade, the place of IMV in this context needs to be reconsidered. We agree with recent literature that the idea that patients with metastases are not ideal candidates for intensive and invasive procedures should be revisited. This is particularly true in the context of modern oncology, which incorporates new and revolutionary treatments that have been a true paradigm shift in the overall survival and quality of life of many cancer patients. However, most of the available studies on noninvasive ventilation have been conducted in high-income countries, which do not match low- and middle-income countries (LMIC) in terms of resource availability, staffing and disease characteristics. Therefore, the disease profile, severity at the time of hospital arrival, vailability of age-appropriate equipment, competence of healthcare professionals to treat patients with noninvasive ventilation, and cost-benefit ratio need to be taken into account.A recent prospective study indicated that mortality rates may be reduced in pediatric NIV patients. Relative to others, the mortality rate (93.33%) was high among patients with hemodynamic instability in this group in whom NIV failed. (8) Pancera et al. reported that most patients with impaired hemodynamic status failed NIV. (9) There are currently no comparative studies of the superiority of high-flow nasal cannula in children with cancer versus noninvasive ventilation. (Figure 1) Research by Garcia et al, in their study of 88 pediatric oncohematologic patients, reported that the first respiratory support on admission to the PICU was, in decreasing order of frequency, high-flow nasal oxygen cannula (HFNC; 50/88), noninvasive ventilation (NIV; 13/88) and nasal oxygen cannula (16/88). MV was required in 47/88 episodes, 38/47 after other respiratory support. In 18/28 children with initial NIV, MV was subsequently required. (10)The usefulness of HFNC or early NIV in children with cancer needs to be investigated in larger clinical studies.We conclude that the use of NIV with good age-appropriate pediatric interface and/or HFNC should be implemented in our pediatric oncologic intensive care units as first-line treatment in children with malignancies who develop acute respiratory failure, except in those with severe hemodynamic status.