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 Table of Contents  
CONSENSUS REPORT
Year : 2019  |  Volume : 1  |  Issue : 1  |  Page : 4-6

Combining Therapy of Octreotide and Glucocorticoid in the Treatment of a Lung Adenocarcinoma Patient with Acute Respiratory Distress Syndrome


Department of Intensive Care Unit, Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, Beijing, China

Date of Web Publication4-Jan-2019

Correspondence Address:
Prof. Xue-Zhong Xing
Department of Intensive Care Unit, Cancer Hospital, Chinese Academy of Medical Sciences, Peking Union Medical College, 17, Panjiayuan Nanli, Chaoyang District, Beijing 100021
China
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DOI: 10.4103/jtccm.jtccm_8_18

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  Abstract 


A 63-year-old male who was diagnosed with adenocarcinoma of the right lower lobe presented with 1 week of fever, cough, and progressive dyspnea and admitted to the Intensive Care Unit (ICU). After intubation, physical examination revealed copious, light bloody sputum and diffuse crackles and rales on lung auscultation. The patient was diagnosed as Stage IV adenocarcinoma, septic shock (lung infection), and acute respiratory distress syndrome. His oxygenation failed to improve despite sedation, restrictive fluid therapy, and methylprednisolone, antimicrobials therapy, protective ventilation, plasma supplement, and anticoagulation. Respiratory secretions suctioned from her endotracheal tube averaged 1.0 L daily. On day 2 after admission, octreotide was infused to control sputum volume. The patient's respiratory secretions decreased significantly, and on day 8, the ventilator mode was changed to pressure support ventilation, and the patient was extubated and dismissed from ICU.

Keywords: Acute respiratory distress syndrome, adenocarcinoma, bronchorrhea, octreotide


How to cite this article:
Xing XZ, Wang HJ, Qu SN, Huang CL. Combining Therapy of Octreotide and Glucocorticoid in the Treatment of a Lung Adenocarcinoma Patient with Acute Respiratory Distress Syndrome. J Transl Crit Care Med 2019;1:4-6

How to cite this URL:
Xing XZ, Wang HJ, Qu SN, Huang CL. Combining Therapy of Octreotide and Glucocorticoid in the Treatment of a Lung Adenocarcinoma Patient with Acute Respiratory Distress Syndrome. J Transl Crit Care Med [serial online] 2019 [cited 2021 Dec 2];1:4-6. Available from: http://www.tccmjournal.com/text.asp?2019/1/1/4/249339




  Introduction Top


The cornerstone of acute respiratory distress syndrome (ARDS) treatment is protective ventilation. Octreotide has been reported to treat ARDS in animal studies. In addition, octreotide had also reported to control bronchorrhea successfully in lung adenocarcinoma and bronchioloalveolar cell carcinoma patients. Here, we presented a case who was diagnosed as lung adenocarcinoma and manifested bronchorrhea and ARDS. We hypothesized that octreotide may decrease sputum and inhibit inflammation simultaneously.


  Case Report Top


A 63-year-old man presented with 1 week of fever, cough, and progressive dyspnea. He was diagnosed with adenocarcinoma of the right lower lobe with negative epidermal growth factor receptor mutation and multiple metastases involving contralateral lung [Figure 1]. He presented to a cancer hospital. He developed dyspnea while waiting for chemotherapy. He admitted to the Intensive Care Unit (ICU) because of acute respiratory failure.
Figure 1: Chest computed tomography showed adenocarcinoma of the right lower lobe and multiple metastases involving contralateral lung

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The patient presented in respiratory distress. His temperature was 37°C; pulse rate was 150 beats/min; blood pressure was 130/(80 mmHg with norepinephrine infusion at a rate of 0.15 μg/kg min); respiratory rate was 30 breaths/min; and arterial oxygen saturation was 80% on 6 L/min facial mask oxygen. The patient received intubation and mechanical ventilation (FIO2 of 90% and positive end-expiratory pressure [PEEP] of 10 cm H2O). After intubation, physical examination revealed copious, light bloody sputum and diffuse crackles and rales on lung auscultation. Electrocardiography showed multiple premature ventricular contractions. Arterial blood gas showed hypoxemia and hypercapnia (PaO2:72 mmHg; PaCO2:56 mmHg; and pH: 7.23). Laboratory testing revealed leukocytosis with 16.15 × 109 cells/L, FIB: 0.51 g/L (1.88–4.35), APTT: 23.5 s (20.9–34.6), and DD: 8.51 mg/L (0–0.55).

The initial chest X-ray revealed bilateral lung infiltrates [Figure 2]. Results of sputum microbiology tests were negative for bacteria.
Figure 2: Chest X-ray showed bilateral lung infiltrates

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The patient was diagnosed as Stage IV adenocarcinoma, septic shock (lung infection), ARDS, and disseminated intravascular coagulation.

The patient received sedation with midazolam, propofol and dexmedetomidine, restrictive fluid therapy, methylprednisolone (80 mg, q12 h), and antimicrobials with meropenem, linezolid, fluconazole, protective ventilation, plasma supplement, and anticoagulation with low-weight heparin. However, his oxygenation failed to improve despite these measures. Respiratory secretions suctioned from her endotracheal tube averaged 1.0 L daily.

On day 2 after admission, an octreotide infusion at 0.05 mg/h was initiated. Twenty-four hours later, the patient's respiratory secretions decreased from 1.0 L to 300 mL daily, with reductions in FIO2 from 0.9 to 0.7. On day 3, respiratory secretions decreased from 300 mL to 200 mL daily and FIO2 from 0.7 to 0.5. Octreotide was discontinued on day 4 after admission, respiratory secretions decreased from 200 mL to 100 mL daily and FIO2 from 0.5 to 0.4 with PEEP 10 cm H2O [Figure 3]. On day 6, methylprednisolone was reduced from 80 mg to 60 mg, q12 h. On day 8, the ventilator mode was changed to pressure support ventilation, and the patient was extubated and dismissed from ICU to ward to receive further anticancer treatment.
Figure 3: Use of octreotide and change of sputum volume and PaO2/FiO2 ratio

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  Discussion Top


The cornerstone of ARDS treatment is protective ventilation which consists of low tidal volume and plateau pressure <30 cm H2O.[1] In addition, restrictive fluid therapy is useful in decreasing the duration of mechanical ventilation although it may not improve survival. Recently, prone positioning ventilation in patients with a PaO2/FIO2 ratio <150 mmHg was reported to be associated with a significant survival benefit[2] and was recommended by the American Thoracic Society and other societies. Pharmacologic therapies such as glucocorticoid may have value in decrease mortality in early ARDS, whereas others such as β2 agonists, statins, and keratinocyte growth factor, which targeted pathophysiologic alterations in ARDS, were not beneficial and demonstrated possible harm.[1]

Octreotide has been reported to treat bronchorrhea in lung adenocarcinoma patients successfully in several cases.[3],[4],[5] In 2006, octreotide was first reported to treat bronchorrhea in a patient with adenocarcinoma of the lung.[3] Bronchorrhea was termed as the production of sputum of >100 mL/day. In this patient, the sputum volume was >1 L/day. After infusion of octreotide at 0.3 mg/day for 2 days, the sputum volume decreased to 150 mL. In another patient with bronchioloalveolar cell carcinoma, watery sputum production was also decreased from 1 L/day to 150 mL daily after 2-day infusion of octreotide 0.425 mg/day and remained minimal after discontinuation of octreotide.[4] Recently, Roeder reported that a lung adenocarcinoma patient presented to the ICU with respiratory secretions averaged 2.5 L/day. The patient received octreotide infusion with 0.6 mg/day, and respiratory secretions decreased from 2.5 L to 300 mL daily in 24 h. Reduction in bronchorrhea persisted after discontinuation of octreotide.[5]

Octreotide has been reported to treat ARDS in animal studies.[6],[7] Liu reported that in rat model of ARDS induced by paraguat, three drugs including somatostatin, octreotide, and dexamethasone were infused separately.[6] Compared with control group, infusion with somatostatin, octreotide, or dexamethasone was associated with mitigation of pulmonary inflammatory responses including the improvement in lung ventilation, increase in PaO2 level, and decrease in PaCO2 level, suggesting that somatostatin and octreotide may be used as adjuvant therapy in ARDS patients. Zhang reported that in rat model of acute lung injury (ALI) induced by cecal ligation puncture, administration of somatostatin was associated with improved PaO2 level compared with controls. In addition, results of JAK-STAT-signaling pathways microarray chip evaluation showed that, of the 128 cDNA clones on the chip, 57 known unique genes in ALI group were upregulated as compared with controls. Altogether, these results demonstrated that somatostatin and its analog octreotide were effective in reducing inflammation of ARDS and thus may be used as potential pharmaceutical therapy in ARDS patients.

In our case, the patient was a lung adenocarcinoma patient with ARDS. He presented with respiratory secretions averaged 1.0 L daily. On prior literature results, we decided to provide the patient with octreotide which may decrease sputum and inhibit inflammation simultaneously. Surprisingly, the sputum production decreases greatly from 1 L to 100 mL per day. Besides, the patient's oxygenation improved with the application of octreotide and glucocorticoid which reflected the alleviation of alveoli inflammatory. It is a pity that we could not ascertain the anti-inflammatory action which was due to combined octreotide and glucocorticoid or any single agent.

To the best of our knowledge, this is the first report of octreotide in the treatment of bronchorrhea and ARDS in lung adenocarcinoma patient. We found that octreotide is effective in the treatment of bronchorrhea in lung adenocarcinoma patient, and octreotide may have a role in the treatment of ARDS with or without glucocorticoid.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Fan E, Brodie D, Slutsky AS. Acute respiratory distress syndrome: Advances in diagnosis and treatment. JAMA 2018;319:698-710.  Back to cited text no. 1
    
2.
Munshi L, Del Sorbo L, Adhikari NKJ, Hodgson CL, Wunsch H, Meade MO, et al. Prone position for acute respiratory distress syndrome. A Systematic review and meta-analysis. Ann Am Thorac Soc 2017;14:S280-8.  Back to cited text no. 2
    
3.
Hudson E, Lester JF, Attanoos RL, Linnane SJ, Byrne A. Successful treatment of bronchorrhea with octreotide in a patient with adenocarcinoma of the lung. J Pain Symptom Manage 2006;32:200-2.  Back to cited text no. 3
    
4.
Pahuja M, Shepherd RW, Lyckholm LJ. The use of octreotide to manage symptoms of bronchorrhea: A case report. J Pain Symptom Manage 2014;47:814-8.  Back to cited text no. 4
    
5.
Roeder NL, Marshall JD, Britto CJ. A woman in her 60s with lung adenocarcinoma presents with copious watery sputum and respiratory failure. Chest 2017;152:e143-6.  Back to cited text no. 5
    
6.
Liu R, Wang CH, Huang MH, Li X, Qiang O, Tang CW, et al. Therapeutic effect of somatostatin on acute respiratory distress syndrome in experimental rats. Sichuan Da Xue Xue Bao Yi Xue Ban 2006;37:412-5.  Back to cited text no. 6
    
7.
Zhang L. The Protective Effects and Mechanism of Somatostatin on Acute Lung Injury Induced by Sepsis [D]. Guangzhou: Southern Medical University; 2008.  Back to cited text no. 7
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]



 

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