Table 2 Common triggers of ALI/ARDS in cancer
From: Acute Respiratory Distress Syndrome in Cancer Patients
| Â | Clinical clues/risk factors | Clinical features and imaging findings | Diagnostic testing | Treatment |
|---|---|---|---|---|
Infection/pneumonia | Productive cough, pleuritic pain, fever, chills, shortness of breath | Pulmonary infiltrates may be lobar, multi-lobar, diffuse, or bilateral areas of consolidation and/or ground-glass change. Air bronchograms may be seen | Gram stain/cultures obtained on sputum or bronchoscopically; blood cultures; WBC may be elevated, normal, or decreased | Antibiotics, supportive care, ventilatory support, as indicated |
Aspiration | Witnessed aspiration or high risk for aspiration; bronchial erythema, food, lipid-laden macrophages seen on bronchoscopy; low-grade fever | Infiltrates on chest imaging usually involving dependent pulmonary segments | Presumptive diagnosis with negative cultures | Supportive, ventilatory support; supplemental oxygen, antibiotics |
Pancreatitis | Presence of risk factors – gallstones, drugs/alcohol, viral infection. Persistent abdominal pain, nausea/vomiting; elevated amylase and lipase, with or without abnormal imaging | Dyspnea due to diaphragmatic inflammation/ARDS; unexplained hypotension (5–10%); small pleural effusions | Elevated lipase, amylase | Supportive; IV fluid resuscitation, antibiotics, ventilatory support, oxygen, vasopressor support, dietary modifications, remove offending drugs |
TRALI | History of transfused blood products within 6Â h of clinical signs/symptoms: dyspnea, hypoxemia, fever, hypotension, cyanosis | Bilateral pulmonary infiltrates with normal cardiac silhouette | Diagnosis of exclusion; infiltrates, hypoxemia occurring within 6Â h of blood/blood product transfusion that meets criteria for ARDS is designated transfusion-related ARDS; exclude hemolytic transfusion reactions | Supportive: oxygen supplementation, noninvasive respiratory support with continuous positive airway pressure (CPAP) or bi-level positive airway pressure (BiPAP) may be sufficient in less severe cases, endotracheal intubation with invasive mechanical ventilation if severe |
Sepsis/shock | Fever, hypotension, lactic acidosis, DIC; infectious source not identified in all cases; CRP >2 SD above normal; plasma prolactin >2 SD above normal; thrombocytopenia; CBC may demonstrate leukocytosis, leukopenia, or normal WBC with bandemia | Signs/symptoms of organ damage: nephritis, transaminitis, adrenal insufficiency, altered mental status | Appropriate clinical context and positive cultures | Supportive; IV fluid resuscitation, antibiotics, ventilatory support, oxygen, vasopressor support |
HSCT | History of HSCT | Variable, diffuse infiltrates, nodules, consolidation; evidence of graft-versus-host disease (allogeneic transplants) | Diagnosis of exclusion | Supportive; antibiotics ventilatory support, oxygen, vasopressor support |
Drug toxicity | History of exposure to offending agent or radiation; BAL may demonstrate nonspecific findings of predominant lymphocytosis, eosinophils, or foamy macrophages, depending on the suspected culprit | Bilateral subpleural reticulation; ground-glass changes or consolidation | Diagnosis of exclusion, lung biopsy occasionally helpful | Discontinue offending agent; supportive care, antibiotics, ventilatory support, oxygen, vasopressor support |
Thoracic surgery | History of surgery, intraoperative ventilation, intraoperative transfusion | Elevated hemidiaphragm due to postoperative diaphragmatic dysfunction; partial/complete opacification of the ipsilateral thorax depending on the extent of resection and time interval postsurgery. Bronchopleural fistula formation with persistent air leak, depending on the type of surgery | Diagnosis of exclusion | Supportive; antibiotics, ventilatory support, oxygen, vasopressor support |