46 ciddi solunum yetmezliği olan hastalarda NİMV ile İMV uygulamalarının karşılaştırıldığında mortalite üzerine benzer etkileri olduğu saptandı. Bununla birlikte NİMV uygulamasının başarısız olduğu durumlarda mortalite oranı çok daha yüksek olduğu yapılan çalışmalarda bulunmuştur. Bunun başlıca nedeni hastalara yeterli solunum desteği uygulanamamasıdır. Yapılan çalışmalarda agresif solunum desteği ihtiyacı olan hastalarda ilk 24 saat içinde İMV uygulamasının mortalite üzerine olumlu etkileri saptanmıştır.91 Bizim yaptığımız çalışmada da benzer olarak sadece NIMV uygulanan grupta mortalite en iyi olarak saptanırken NIMV sonrası İMV uygulanan grupta mortalite oranları en kötü olarak bulundu. NIMV uygulaması prognozu etkileyen bağımsız risk faktörü olarak bulunmamasının başlıca nedeni hastalara uygulanacak solunum tipi belirlenirken birçok parametrenin göz önünde bulundurulmasıdır. Bizim çalışmamızda APACHE, SOFA gibi prognostik skorlara ulaşılamadığı için NIMV uygulamasının bağımsız faktör olarak değerlendirilmesi uygun görünmemektedir. Solunum desteği uygulandığı sıradaki pH > 7.35 olmasının olumlu prognoza işaret eden bağımsız faktör olarak saptanmıştır ve hastalık şiddetinin daha az olduğunu gösteren bir bulgu olarak değerlendirilmelidir.
Yapılan çalışmalarda solunum desteği uygulamasının akut lösemilerde hastalık durumundan bağımsız olarak kötü prognostik bir belirteç olduğu bilinmektedir. Şu ana kadar yapılan tüm çalışmalarda mortalite oranını % 75 – 100 arasında değişen değerlerde tespit edilmiştir.1,92 Bizim çalışmamızda bulduğumu 60 günlük total sağ kalım oranının % 5,5 olması da literatür verilerine uygun olarak saptanmıştır.
47 başlanması, erken yoğun bakım kabulü veya yoğun bakıma kolay transfer olabilecek bir serviste takip edilmesi gibi mortalite oranını azaltıcı yaklaşımlarda bulunabilinir.
Solunum destek ihtiyacı geliştikten sonra NİMV uygulamalarının mortalite, morbidite ve İMV uygulamasında azalmaya neden olduğu bilinmektedir. Bununla birlikte NİMV uygulamasının başarısız olduğu durumlarda mortalite oranı çok daha yüksek olması ve hematolojik hastalarda NIMV başarısızlığının yaklaşık % 50 oranında görülmesi nedeniyle tüm hastalara NİMV uygulanmasında ziyade sadece seçilmiş ve fayda görecek hastalara NİMV uygulanması esastır.
Daha önceleri yüksek mortalite oranı nedeniyle hematoloji hastalarının yoğun bakım ünitelerinde takibi düşük oranda gerçekleşirken son zamanlarda tedavi ve destek hizmetlerinde gelişme neticesinde beklenen hayat beklentisinde uzama olmuştur. Bu nedenlerle solunum desteği ihtiyacı olan ve olabilecek yüksek riskli tüm hastaların yoğun bakım ünitelerinde takip edilmesi uygun olacaktır.
48 6. SONUÇ VE ÖNERİLER
Akut lösemi olgularında solunum desteği ihtiyacının sıklığı, risk faktörleri ve prognostik faktörleri belirlemeyi amaçladığımız çalışmanın sonucu şu şekilde özetlenebilir:
1. Akut lösemi hastalarında % 30 oranında solunum desteği uygulandığını saptandı.
2. Enfeksiyonlar solunum yetmezliğinin en sık nedeni olarak saptanırken bakteriyel nedenlere en sık etken olarak bulundu.
3. Antibiyotik profilaksisi uygulanmaması, pulmoner infiltrasyonların varlığı ve diffüz dağılımı, 40 yaşın üzerinde olmak, kötü performans durumu ve indüksiyon–reindüksiyon rejimlerini almak solunum yetmezliği gelişimi için bağımsız risk faktörü olarak saptandı. Solunum destek ihtiyacı gelişimini predikte etmek için yeni bir model geliştirildi; 6 ve üzeri puan alanlar solunum yetmezliği gelişimi için yüksek riskli kabul edildi.
4. Solunum desteği başlangıcı sırasındaki pH’nın 7,35’in üzerinde olması düzelme için olumlu bağımsız faktör olarak saptandı.
5. Solunum desteği uygulanan hastalardaki 60 günlük total sağ kalım oranı % 5,5 olarak saptandı.
Akut lösemi olgularında solunum yetmezliği gelişimi tahmin edilenden daha sık olarak görülebilmektedir. Yüksek mortalite oranına sahip olması nedeniyle solunum desteği ihtiyacı olabilecek hastaların erken tespiti ve erken önlemlerin alınması mortalite üzerine olumlu etkileri olabilir.
Yaptığımız bu çalışma retrospektif bir çalışma olduğu için tüm verilere ulaşılamadı. Bu yüzden APACHE II, SOFA skoru gibi prognostik skorlarında dâhil edildiği geniş prospektif çalışmalar yapılabilir.
Solunum desteği ihtiyacını predikte etmek için oluşturduğumuz modelin gerçek hayat verileri ve Hosmer – Lemeshow testi ile doğruluğu tespit edilse de prospektif olarak validasyonu yapılamamıştır. Bu yüzde bu modellerin prospektif olarak validasyonunun yapılmasına ihtiyaç vardır.
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