Alexis Ferré

Passive leg-raising and end-expiratory occlusion tests perform better than pulse pressure variation in patients with low respiratory system compliance.

Objectives:We tested whether the poor ability of pulse pressure variation to predict fluid responsiveness in cases of acute respiratory distress syndrome was related to low lung compliance. We also tested whether the changes in cardiac index induced by passive leg-raising and by an end-expiratory occlusion test were better than pulse pressure variation at predicting fluid responsiveness in acute respiratory distress syndrome patients. Design:Prospective study. Setting:Medical intensive care unit. Patients:We included 54 patients with circulatory shock (63 ± 13 yrs; Simplified Acute Physiology Score II, 63 ± 24). Twenty-seven patients had acute respiratory distress syndrome (compliance of the respiratory system, 22 ± 3 mL/cm H2O). In nonacute respiratory distress syndrome patients, the compliance of the respiratory system was 45 ± 9 mL/cm H2O. Measurements and Main Results:We measured the response of cardiac index (transpulmonary thermodilution) to fluid administration (500 mL saline). Before fluid administration, we recorded pulse pressure variation and the changes in pulse contour analysis-derived cardiac index induced by passive leg-raising and end-expiratory occlusion. Fluid increased cardiac index ≥15% (44% ± 39%) in 30 “responders.” Pulse pressure variation was significantly correlated with compliance of the respiratory system (r = .58), but not with tidal volume. The higher the compliance of the respiratory system, the better the prediction of fluid responsiveness by pulse pressure variation. A compliance of the respiratory system of 30 mL/cm H2O was the best cut-off for discriminating patients regarding the ability of pulse pressure variation to predict fluid responsiveness. If compliance of the respiratory system was >30 mL/cm H2O, then the area under the receiver-operating characteristics curve for predicting fluid responsiveness was not different for pulse pressure variation and the passive leg-raising and end-expiratory occlusion tests (0.98 ± 0.03, 0.91 ± 0.06, and 0.97 ± 0.03, respectively). By contrast, if compliance of the respiratory system was ⩽30 mL/cm H2O, then the area under the receiver-operating characteristics curve was significantly lower for pulse pressure variation than for the passive leg-raising and end-expiratory occlusion tests (0.69 ± 0.10, 0.94 ± 0.05, and 0.93 ± 0.05, respectively). Conclusions:The ability of pulse pressure variation to predict fluid responsiveness was inversely related to compliance of the respiratory system. If compliance of the respiratory system was ⩽30 mL/cm H2O, then pulse pressure variation became less accurate for predicting fluid responsiveness. However, the passive leg-raising and end-expiratory occlusion tests remained valuable in such cases.

Residual pulmonary vascular obstruction and recurrence after acute pulmonary embolism. A single center cohort study

INTRODUCTION Up to 50% of patients with pulmonary embolism (PE) present lung perfusion defects after six months of anticoagulant treatment, suggesting residual pulmonary vascular obstruction (RPVO). The risk of recurrence in patients with RPVO remains unknown. The present study aims to assess the risk of recurrent venous thromboembolism (VTE) in patients with RPVO after a first symptomatic episode of PE. METHODS Consecutive patients who survived a first objectively proven acute PE, treated for at least three months with anticoagulants, were included and followed prospectively. RPVO was defined as a pulmonary vascular obstruction of >10% on ventilation/perfusion lung scan performed at inclusion. Objectively proven VTE recurrences were registered and confirmed by an investigator unaware of the result of the ventilation/perfusion lung scan. RESULTS Among the 310 patients (median age: 61years) included in the study, 60 (19%) had RPVO. During a median follow-up of 51.3months, 66 patients (21.2%, 95% CI [17.5-26.7]) experienced recurrent VTE. In an adjusted cox proportional hazards analysis, we identified RPVO (HR 1.94; 95% CI [1.11-3.39]; p=0.026) and unprovoked PE (HR 3.56; 95% CI [1.79-7.07]; p=0.00051) as independent risk factors for recurrent VTE whereas extended anticoagulation therapy (HR 0.19; 95% CI [0.07-0.55]; p=0.00014) was associated with a low risk of recurrence. CONCLUSION The results suggest that RPVO is an independent risk factor of recurrent VTE after a first PE.

Management of acute exacerbations of chronic obstructive pulmonary disease (COPD). Guidelines from the Société de pneumologie de langue française (summary)

Chronic obstructive pulmonary disease (COPD) is the chronic respiratory disease with the most important burden on public health in terms of morbidity, mortality and health costs. For patients, COPD is a major source of disability because of dyspnea, restriction in daily activities, exacerbation, risk of chronic respiratory failure and extra-respiratory systemic organ disorders. The previous French Language Respiratory Society (SPLF) guidelines on COPD exacerbations were published in 2003. Using the GRADE methodology, the present document reviews the current knowledge on COPD exacerbation through 4 specific outlines: (1) epidemiology, (2) clinical evaluation, (3) therapeutic management and (4) prevention. Specific aspects of outpatients and inpatients care are discussed, especially regarding assessment of exacerbation severity and pharmacological approach.

Knowledge of the diagnostic algorithm for pulmonary embolism in primary care

BACKGROUND Diagnostic algorithms for pulmonary embolism (PE) have been validated in patients attending hospital emergency departments. However, general practitioners (GPs) are often the professionals of first resort for the majority of non-critical cases of PE. AIM To evaluate the knowledge of the diagnostic algorithm for PE among GPs in France. DESIGN AND SETTING Questionnaire-based survey of GPs with a private practice. METHOD All GPs in the study area were sent a questionnaire including several questions on the diagnosis of PE and two clinical cases scenario with suspected PE. Factors associated with knowledge of the diagnostic algorithm were analysed by univariate and multivariate analyses. RESULTS Five-hundred and eight questionnaires were distributed and 155 (30.5%) were available for analysis. Only 55% of the GPs did know about clinical scores for the assessment of clinical probability of PE and 42% of the GPs were aware that clinical probability is needed to interpret the result of D-dimer testing. Forty GPs (26%) gave valid responses to both clinical cases, 54 GPs (35%) had one valid case out of the two and 61 (39%) gave invalid responses to both clinical cases. Participation in specific training on PE was significantly associated with valid responses to the two clinical cases in multivariate analysis (p<0.017). CONCLUSION The majority of GPs were unaware of the diagnostic algorithm for PE. Clinical probability was rarely assessed and knowledge about D-dimers was poor. Specific training on PE and greater awareness of clinical probability scores may promote knowledge of PE algorithm diagnosis.

Antibiotics against Pseudomonas aeruginosa for COPD exacerbation in ICU: a 10-year retrospective study

Summary Chronic obstructive pulmonary disease (COPD) is a frequent source of hospitalization. Antibiotics are largely prescribed during COPD exacerbation. Our hypothesis is that large broad-spectrum antibiotics are more and more frequently prescribed. Our results confirm this trend and highlight that the increase in large broad-spectrum use in COPD exacerbation is largely unexplained. Background Acute COPD exacerbation (AECOPD) is frequently due to respiratory tract infection, and the benefit of antipseudomonal antibiotics (APA) is still debated. Health care–associated pneumonia (HCAP) was defined in 2005 and requires broad-spectrum antibiotherapy. The main objectives are to describe the antibiotic use for AECOPD in intensive care unit and to identify factors associated with APA use and AECOPD prognosis. Methods We conducted a monocentric, retrospective study on all AECOPDs in the intensive care unit treated by antibiotics for respiratory tract infection. Treatment failure (TF) was defined by death, secondary need for mechanical ventilation, or secondary systemic steroid treatment. A multivariate analysis was used to assess factors associated with APA prescription and TF. Results From January 2000 to December 2011, 111 patients were included. Mean age was 69 years (±12), mean forced expiratory volume 38% of theoretic value (±13). Thirty-five (31%) patients were intubated, and 52 (47%) were treated with noninvasive ventilation. From 107 patients, 8 (7%) cases of Pseudomonas aeruginosa were documented. APAs were prescribed in 21% of patients before 2006 versus 57% after (P=0.001). TF prevalence was 31%. Risk factors for P. aeruginosa in COPD and HCAP diagnosis did not influence APA, whereas the post-2006 period was independently associated with APA prescription (odds ratio 6.2; 95% confidence interval 1.9–20.3; P=0.0013). APA did not improve TF (odds ratio 1.09; 95% confidence interval 0.37–3.2). Conclusion HCAP guidelines were followed by an increase in APA use in AECOPD, without an improvement in prognosis. HCAP prevalence cannot account for the increasing APA trend. Time effect reveals a drift in practices. The microbiological effect of such a drift must be evaluated.

Aérosolthérapie : tests de provocation, risques infectieux, bronchiolites et pathologie ORL. Aérosolstorming du GAT, Paris 2011

Communications from the 2011 meeting of the GAT are reported in this second article on the practical management of bronchial provocation tests and infectious risks associated with the use of nebulization. Recent advances on the role of nebulized hypertonic saline in the treatment of acute bronchiolitis in infants and of the nebulization in sinusal diseases are also reported.

Outcomes after extracorporeal membrane oxygenation for the treatment of high-risk pulmonary embolism: a multicentre series of 52 cases

Aims The role of extracorporeal membrane oxygenation (ECMO) remains ill defined in pulmonary embolism (PE). We investigated outcomes in patients with high-risk PE undergoing ECMO according to initial therapeutic strategy. Methods and results From 01 January 2014 to 31 December 2015, 180 patients from 13 Departments in nine centres with high-risk PE were retrospectively included. Among those undergoing ECMO, we compared characteristics and outcomes according to adjunctive treatment strategy (systemic thrombolysis, surgical embolectomy, or no reperfusion therapy). Primary outcome was all-cause 30-day mortality. Secondary outcome was 90-day major bleeding. One hundred and twenty-eight patients were treated without ECMO; 52 (mean age 47.6 years) underwent ECMO. Overall 30-day mortality was 48.3% [95% confidence interval (CI) 41-56] (87/180); 43% (95% CI 34-52) (55/128) in those treated without ECMO vs. 61.5% (95% CI 52-78) (32/52) in those with ECMO (P = 0.008). In patients undergoing ECMO, 30-day mortality was 76.5% (95% CI 57-97) (13/17) for ECMO + fibrinolysis, 29.4% (95% CI 51-89) (5/17) for ECMO + surgical embolectomy, and 77.7% (95% CI 59-97) (14/18) for ECMO alone (P = 0.004). Among patients with ECMO, 20 (38.5%, 95% CI 25-52) had a major bleeding event in-hospital; without significant difference across groups. Conclusion In patients with high-risk PE, those with ECMO have a more severe presentation and worse prognosis. Extracorporeal membrane oxygenation in patients with failed fibrinolysis and in those with no reperfusion seems to be associated with particularly unfavourable prognosis compared with ECMO performed in addition to surgical embolectomy. Our findings suggest that ECMO does not appear justified as a stand-alone treatment strategy in PE patients, but shows promise as a complement to surgical embolectomy.

Un angiosarcome mimant une embolie pulmonaire récidivante

INTRODUCTION Pulmonary artery sarcoma is a rare disease with non-specific symptoms. The clinical and radiological presentation can mimic pulmonary embolism with chronic thromboembolic pulmonary hypertension. Management is essentially surgical but the prognosis remains poor. CASE REPORT A patient presented with symptoms of pulmonary embolism. Despite vitamin K antagonist therapy, he suffered from extension of the endovascular defects and his pulmonary hypertension increased. Suspicious results of positron emission tomography suggested the diagnosis of pulmonary artery sarcoma that was confirmed by surgery. However, the outcome was unfavourable, leading to death of the patient. CONCLUSION This case reinforces the idea that the clinical and tomodensitometric presentations of pulmonary arterial sarcoma and chronic thromboembolic pulmonary hypertension are similar. The positron emission tomography seems to be a key to distinguishing these two diagnoses.

Scompenso respiratorio delle broncopneumopatie croniche ostruttive

La broncopneumopatia cronica ostruttiva (BPCO) e un problema importante di salute pubblica sia per la morbilita e la mortalita che per i costi sanitari che essa genera. Tenuto conto delle frequenti comorbilita (in particolare cardiovascolari), la gestione deve essere multidisciplinare. L’evoluzione di questa malattia e costellata di episodi acuti che aggravano la prognosi a lungo termine e che, nei casi piu gravi, mettono in gioco la prognosi vitale. Il trattamento sintomatico degli scompensi e stato oggetto di numerose raccomandazioni basate, per la maggior parte, su degli studi disomogenei, il cui elemento piu dibattuto resta quello dei corticosteroidi sistemici. Viceversa, i broncodilatatori per via inalata hanno dimostrato la loro efficacia. Il trattamento del fattore eziologico dello scompenso e fondamentale: il fattore piu frequente e un’infezione respiratoria. L’utilizzo degli antibiotici e ampiamente diffuso, ma deve limitarsi ai casi di polmoniti o di riacutizzazioni di BPCO con sovrainfezione nei pazienti agli stadi GOLD (global initiative for chronic obstructive lung disease) piu gravi (stadi definiti in funzione del volume espiratorio massimo durante il primo secondo [VEMS]). Diversi lavori si interessano ai dosaggi di bioindicatori per orientare la prescrizione della terapia antibiotica; nessuno e consigliato di routine a tutt’oggi. A proposito degli scompensi piu gravi che giustificano un ricovero in terapia intensiva, l’avvento della ventilazione non invasiva da piu di due decenni ha trasformato la gestione e la prognosi di questi pazienti. Essa deve restare la metodica di assistenza ventilatoria di elezione, sempre rispettando le sue indicazioni e controindicazioni per non ritardare l’instaurazione di una ventilazione invasiva, in caso di necessita. L’esperienza delle equipe che praticano queste tecniche e garanzia della loro efficacia. Infine, dopo la fase acuta, occorrera pensare all’implementazione di un follow-up e dei mezzi di prevenzione delle esacerbazioni e, all’occorrenza, a una riabilitazione respiratoria nel quadro di una gestione globale e multidisciplinare.

Descompensación respiratoria de la enfermedad pulmonar obstructiva crónica

La enfermedad pulmonar obstructiva cronica (EPOC) es un grave problema de salud publica, tanto por la morbilidad y la mortalidad como por los costes que genera. Debido a las comorbilidades frecuentes (sobre todo cardiovasculares), el tratamiento debe ser multidisciplinario. La evolucion de la enfermedad incluye episodios agudos que agravan el pronostico a largo plazo y que, en los casos mas graves, comprometen el pronostico vital. El tratamiento sintomatico de las descompensaciones ha sido objeto de numerosas recomendaciones que, en su mayoria, se basan en estudios heterogeneos cuyo punto mas controvertido sigue siendo la corticoterapia sistemica. En cambio, los broncodilatadores por inhalacion han demostrado ser eficaces. Tratar el factor etiologico de la descompensacion es primordial: el factor mas frecuente es una infeccion respiratoria. El uso de los antibioticos esta ampliamente extendido, pero debe limitarse a las neumonias o a las exacerbaciones de la EPOC con otra infeccion anadida en los pacientes de los estadios GOLD (global initiative for chronic obstructive lung disease) mas graves (estadios definidos en funcion del volumen espiratorio maximo en el primer segundo [VEMS]). Existen varios trabajos relativos a la determinacion de la concentracion de biomarcadores para guiar la prescripcion de la antibioticoterapia, pero hasta ahora ninguno de ellos se recomienda de rutina. En lo que se refiere a las descompensaciones mas graves que justifican la hospitalizacion en cuidados intensivos, la disponibilidad de la ventilacion no invasiva desde hace mas de dos decadas ha modificado el tratamiento y el pronostico. Debe seguir siendo el metodo de asistencia ventilatoria de eleccion, respetando las indicaciones y las contraindicaciones para no retrasar, llegado el caso, el comienzo de la ventilacion invasiva. La experiencia de los equipos que usan estas tecnicas garantiza su eficacia. Por ultimo, despues de la fase aguda, habra que pensar en el seguimiento, los medios de prevencion de las exacerbaciones y, si fuera necesario, la rehabilitacion respiratoria en el contexto de un tratamiento general y multidisciplinario.