A 67-year-old female Caucasian patient, retired teacher, severe cigarette smoker (40 pack-years), with advanced lung cancer (adenocarcinoma cT4N3M1c CS IV), was admitted to the 2nd Department of Lung Diseases and Tuberculosis for oncological treatment. The diagnosis of lung cancer was made in the Department of Internal Medicine of the General Hospital using fine-needle biopsy of metastases to the subcutaneous tissue. No tissue samples were available for molecular diagnostics. Severe acute respiratory syndrome coronavirus-2 infection was ruled out by negative reverse transcription polymerase chain reaction (RT-PCR) on nasopharyngeal swabs.
She had a history of chronic obstructive pulmonary disease (Global Initiative for Chronic Obstructive Lung Disease (GOLD) stage 4D), paroxysmal atrial fibrillation on anticoagulant treatment with apixaban (5 mg, twice a day).
At the time of admission, the patient was in poor condition. The Eastern Cooperative Oncology Group Scale of Performance Status (ECOG PS) was rated at 3. She reported progressive dyspnoea, severe pain in the right scapula and spine of 7/8 points on the numerical rating scale (NRS).
Physical examination revealed tachypnoea (respiration rate 30 breaths per minute), peripheral cyanosis, multiple wheezing and rales on auscultation over the lungs. Oxygen saturation ( SpO 2) was 85% with 6 L per minute oxygen therapy with the nasal cannula (fraction of inspired oxygen ( FiO 2): 0.44).
Laboratory tests have shown elevated levels of C-reactive protein, mild thrombocytopenia. In arterial blood gas (ABG) type 2 RF was found (pH: 7.303; carbon dioxide partial pressure (pCO 2): 67.6 mmHg; oxygen partial pressure (pO 2): 66.2 mmHg, HCO 3: 27.9 mmol/L; SatO 2: 90.5%).
Chest radiograph and computed tomography confirmed a tumor in the lower lobe of the left lung, metastases to the right lung, lymph nodes, bones and subcutaneous tissue ( Figure 1).
NIV was implemented for treatment. The target ventilation settings were: spontaneous/timed (S/T) mode, inspiratory positive airway pressure (IPAP) 16 cmH 2O, expiratory positive airway pressure (EPAP) 7 cmH 2O, VT 450 mL, FiO 2 55%, backup rate 14 breaths per minute. For the first three days it was used around the clock, with breaks only for meals, drinking and care activities, during which passive oxygen therapy was used with a nasal cannula ( FiO 2: 0.3). The therapy was well tolerated. ABG control confirmed systematic, gradual improvement (pH: 7.416; pCO 2: 58.9 mmHg; pO 2: 66.5 mmHg, HCO 3 -: 33.7 mmol/L; SatO 2: 93.0%). During the next seven days, ventilation time was reduced to the night and approximately 4 hours during the day. Oxygen therapy ( FiO 2: 0.28) was administered for the remainder of the day.
FB at NIV support was also performed during hospitalization. A Philips Respironics Trilogy 100 device was used with a Philips Respironics AF531 naso-oral mask and a bronchoscopy elbow (S/T mode, IPAP 20 cmH 2O, EPAP 7 cmH 2O, VT 450 mL, FiO 2: 90-95%, backup rate 18 breaths per minute). The minimum SpO 2 value during the procedure was 85%. A sample was taken by forceps biopsy from a neoplastic mass in the lower lobe of the left lung. Additional molecular testing did not confirm the presence of predictive markers (epidermal growth factor receptor, anaplastic lymphoma kinase, c-ROS oncogene 1) and programmed death receptor-1 expression allowing the use of targeted therapy or immunotherapy.
Pharmacological treatment included broad-spectrum antibiotics (meropenem 3 g intravenously daily, levofloxacin 500 mg twice daily), systemic and inhaled glucocorticosteroids, short acting bronchodilators, mucolytics. Pain management based on NRS was escalated. Combination of non-steroidal anti-inflammatory drugs (ketoprofen 100 mg twice daily), oxycodone with naloxone (20 mg + 10 mg twice daily), fentanyl (50 mug transdermally every 72 hours), pregabalin (150 mg twice daily) and glucocorticosteroid (dexamethasone 8 mg daily) allowed for good pain control (2/3 points on the NRS). Palliative radiotherapy was also performed to the area of the right scapula and surrounding chest wall (a single dose of 8 Gy in one fraction).
Combined pharmacological treatment, NIV and palliative radiotherapy of the chest wall significantly improved the patient's condition. ECOG PS 2 has been achieved. After an acute phase of an infectious exacerbation of COPD complicated with type 2 respiratory failure, the patient was qualified to palliative chemotherapy based on the decision of multi-disciplinary team, initially with pemetrexed as monotherapy. NIV and oxygen therapy were continued on an outpatient basis. A timeline with all relevant data from this clinical case is available in Figure 2.