Antoine Parrot

An integrated approach to diagnosis and management of severe haemoptysis in patients admitted to the intensive care unit: a case series from a referral centre

BackgroundLimited data are available concerning patients admitted to the intensive care unit (ICU) for severe haemoptysis. We reviewed a large series of patients managed in a uniform way to describe the clinical spectrum and outcome of haemoptysis in this setting, and better define the indications for bronchial artery embolisation (BAE).MethodsA retrospective chart review of 196 patients referred for severe haemoptysis to a respiratory intermediate care ward and ICU between January 1999 and December 2001. A follow-up by telephone interview or a visit.ResultsPatients (148 males) were aged 51 (± sd, 16) years, with a median cumulated amount of bleeding averaging 200 ml on admission. Bronchiectasis, lung cancer, tuberculosis and mycetoma were the main underlying causes. In 21 patients (11%), no cause was identified. A first-line bronchial arteriography was attempted in 147 patients (75%), whereas 46 (23%) received conservative treatment. Patients who underwent BAE had a higher respiratory rate, greater amount of bleeding, persistent bloody sputum and/or evidence of active bleeding on fiberoptic bronchoscopy. When completed (n = 131/147), BAE controlled haemoptysis in 80% of patients, both in the short and long (> 30 days) terms. Surgery was mostly performed when bronchial arteriography had failed and/or bleeding recurred early after completed BAE. Bleeding was controlled by conservative measures alone in 44 patients. The ICU mortality rate was low (4%).ConclusionPatients with evidence of more severe or persistent haemoptysis were more likely to receive BAE rather than conservative management. The procedure was effective and safe in most patients with severe haemoptysis, and surgery was mostly reserved to failure of arteriography and/or early recurrences after BAE.

Surgical lung resection for severe hemoptysis.

BACKGROUNDnThe role of surgical lung resection in the management of severe hemoptysis has evolved after advances in interventional radiology. We sought to describe the indications for surgical lung resection in such patients and to identify predictive factors of postoperative complications.nnnMETHODSnThis study is a retrospective analysis (May 1995 to July 2006) of consecutive patients referred to the intensive care unit of a tertiary hospital for severe hemoptysis who underwent surgical lung resection.nnnRESULTSnAmong 813 patients referred for severe hemoptysis, 111 underwent surgical lung resection. Interventional radiology had been first attempted in 87 patients (78%); 68 underwent surgery because of a failed procedure (n = 28) or bleeding persistence or recurrence within 72 hours despite a completed procedure (n = 40); 19 patients underwent surgery after bleeding control. The remaining 24 patients (22%) were directly referred to the surgeon (5 for emergency surgery). Overall, surgery was performed in emergency (n = 48), scheduled after bleeding control (n = 48), or planned after discharge (n = 15). The main indications for surgery were mycetoma, cancer, bronchiectasis, and active tuberculosis. Surgery for mycetoma (odds ratio, 9.4; 95% confidence interval, 2.8 to 32), emergency surgery (odds ratio, 5.3; 95% confidence interval, 1.8 to 16), and pneumonectomy (odds ratio, 4.7; 95% confidence interval, 1.2 to 18) independently predicted complications. Fifteen patients died in the intensive care unit, of whom 14 underwent emergency surgery. Chronic alcoholism (odds ratio, 4.6; 95% confidence interval, 1.1 to 19), the need for mechanical ventilation or vasoactive drugs on admission (odds ratio, 8.2; 95% confidence interval, 1.9 to 35), and blood transfusion before surgery (odds ratio, 8; 95% confidence interval, 1.5 to 42) predicted mortality.nnnCONCLUSIONSnAttempting at controlling bleeding with first-line nonsurgical approaches appears necessary to optimize the operative conditions and improve outcome of patients with severe hemoptysis.

Approach to diagnosis and pathological examination in bronchial Dieulafoy disease: a case series

BackgroundThere are limited series concerning Dieulafoy disease of the bronchus. We describe the clinical presentation of a series of 7 patients diagnosed with Dieulafoy disease of the bronchus and provide information about the pathological diagnosis approach.Patients and methodsA retrospective review of patients who underwent surgery for massive and unexplained recurrent hemoptysis in a referral center during a 11-year period.ResultsSeven heavy smoker (49 pack years) patients (5 males) mean aged 54 years experienced a massive hemoptysis (350–1000 ml) unrelated to a known lung disease and frequently recurrent. Bronchial contrast extravasation was observed in 3 patients, combining both CT scan and bronchial arteriography. Efficacy of bronchial artery embolization was achieved in 40% of cases before surgery. Pathological examination demonstrated a minute defect in 3 cases and a large and dysplasic superficial bronchial artery in the submucosa in all cases.ConclusionDieulafoy disease should be suspected in patients with massive and unexplained episodes of recurrent hemoptysis, in order to avoid hazardous endoscopic biopsies and to alert the pathologist if surgery is performed.

Shock complicating successful bronchial artery embolization for severe hemoptysis.

Bronchial artery embolization (BAE) complications are uncommon. We describe three patients who had a shock related to splenic infarction after a successful BAE.

Images in cardiovascular medicine. Large pulmonary artery aneurysm rupture in Hughes-Stovin syndrome: multidetector computed tomography pattern and endovascular treatment.

A 42-year-old man with a history of recurrent pulmonary embolism was admitted to the respiratory intensive care unit of our hospital for massive hemoptysis (600 mL in one time). The multidetector computed tomography angiography (MDCTA) showed a large aneurysm originating from the middle lobe pulmonary artery with an air bubble in the aneurysm sac (Figure, A) and enlargement of systemic bronchial and nonbronchial arteries (Figure, B). The MDCTA showed 5 aneurysms of the pulmonary arteries at the right lower lobe …A 42-year-old man with a history of recurrent pulmonary embolism was admitted to the respiratory intensive care unit of our hospital for massive hemoptysis (600 mL in one time). The multidetector computed tomography angiography (MDCTA) showed a large aneurysm originating from the middle lobe pulmonary artery with an air bubble in the aneurysm sac (Figure, A) and enlargement of systemic bronchial and nonbronchial arteries (Figure, B). The MDCTA showed 5 aneurysms of the pulmonary arteries at the right lower lobe …

Description and predictive factors of infection in patients with chronic kidney disease admitted to the critical care unit

OBJECTIVESnTo describe the spectrum of infection and multidrug-resistant bacterial colonization, and to identify early predictors of infection in patients with chronic kidney disease (CKD) admitted to the critical care unit (CCU).nnnMETHODSnA 7-month observational prospective single-centre study in a French university hospital.nnnRESULTSn791 patients were admitted to the CCU, 135 of whom (17%) had severe CKD. Among these, 41 (30%) were infected on admission. Infection was microbiologically documented in 32 patients (78%), of which 7 (22%) were related to Pseudomonas aeruginosa. There was no infection related to extended-spectrum β-lactamase-producing enterobacteriaceae despite a 12% carriage rate on admission. A temperature ≥37.6 °C and a leukocyte count >12.000/mm³ were specific but poorly sensitive of infection (91% and 80%, and 45% and 39%, respectively). Using the threshold of 0.85 ng/ml, procalcitonin was a strong independent predictor of infection on admission (OR 12.8, 95% CI 4.4-37.3). Age (≥60 years) and the cause of CKD were two other predictors.nnnCONCLUSIONSnInfection accounts for one-third of CCU admissions in CKD patients, with a high prevalence of P. aeruginosa. The usual diagnostic criteria are inaccurate for diagnosing infection in this population. A procalcitonin ≥0.85 ng/ml might be helpful for early identifying CKD patients with infection.

Large Pulmonary Artery Aneurysm Rupture in Hughes-Stovin Syndrome Multidetector Computed Tomography Pattern and Endovascular Treatment

A 42-year-old man with a history of recurrent pulmonary embolism was admitted to the respiratory intensive care unit of our hospital for massive hemoptysis (600 mL in one time). The multidetector computed tomography angiography (MDCTA) showed a large aneurysm originating from the middle lobe pulmonary artery with an air bubble in the aneurysm sac (Figure, A) and enlargement of systemic bronchial and nonbronchial arteries (Figure, B). The MDCTA showed 5 aneurysms of the pulmonary arteries at the right lower lobe …A 42-year-old man with a history of recurrent pulmonary embolism was admitted to the respiratory intensive care unit of our hospital for massive hemoptysis (600 mL in one time). The multidetector computed tomography angiography (MDCTA) showed a large aneurysm originating from the middle lobe pulmonary artery with an air bubble in the aneurysm sac (Figure, A) and enlargement of systemic bronchial and nonbronchial arteries (Figure, B). The MDCTA showed 5 aneurysms of the pulmonary arteries at the right lower lobe …

Clinical Features of Patients with Diffuse Alveolar Hemorrhage due to Negative-Pressure Pulmonary Edema

Purpose Diffuse alveolar hemorrhage (DAH) with negative-pressure pulmonary edema (NPPE) is an uncommon yet life-threatening condition. We aimed at describing the circumstances, clinical, radiological, and bronchoscopic features, as well as the outcome of patients with NPPE-related DAH.MethodsWe performed a retrospective, observational cohort study, using data prospectively collected over 35xa0years in an intensive care unit (ICU).ResultsOf the 149 patients admitted for DAH, we identified 18 NPPE episodes in 15 patients, one admitted four times for recurrent NPPE-related DAH. The patients were primarily young, male, and athletic. The NPPE setting was postoperative (nxa0=xa012/18, 67%) or following generalized tonic–clonic seizures (nxa0=xa06/18, 33%). Hemoptysis was almost constant (nxa0=xa017/18, 94%), yet rarely massive (>200xa0cc, nxa0=xa01/18, 6%), with anemia observed in 10 (56%) episodes. The DAH triad (hemoptysis, anemia, and pulmonary infiltrates) was observed in 50% of episodes (nxa0=xa09/18), and acute respiratory failure in 94% (nxa0=xa017/18). Chest computed tomography revealed diffuse bilateral ground glass opacities (nxa0=xa010/10, 100%), while bronchoscopy detected bilateral hemorrhage (nxa0=xa012/12, 100%) and macroscopically bloody bronchoalveolar lavage, with siderophage absence in most (nxa0=xa07/8, 88%), indicating acute DAH. While one episode proved fatal, the other 17 recovered rapidly, with a mean ICU stay lasting 4.6 (2–15)xa0days. Typically, the evolution was rapidly favorable under supportive care.ConclusionNPPE-related DAH is a rare life-threatening condition occurring primarily after tonic–clonic generalized seizure or generalized anesthesia. Clinical circumstances are a key to its diagnosis. Early diagnosis and recognition likely allow for successful management of this potentially serious complication, whereas ictal-DAH appears ominous in epileptic patients.

Hémorragie intra-alvéolaire et syndrome pneumo-rénal

L’eventualite d’une hemorragie intra-alveolaire (HIA) entrainant la venue aux urgences d’un adulte non immunodeprime est rare. Elle doit neanmoins etre connue dans la mesure ou l’HIA engage alors le pronostic vital et justifie des le passage aux urgences une prise en charge adaptee a sa gravite et a son mecanisme presume: immun ou non immun.

Severe Refractory Hypoxemia 16 Years After a Gunshot Injury Multidetector CT-Angiography Pattern and Endovascular Treatment

A 53-year-old man presented with a history of depressant syndrome. He had been hospitalized 16 years previously because of penetrating traumatic injury of the left hemithorax by bullet secondary to a suicide attempt. Recently, he came to the emergency department for an illness leading to the discovery of severe hypoxemia refractory to nasal oxygen therapy. The arterial blood gas measurements revealed a pH of 7.41, a Paco2 of 41 mm Hg, a Pao2 of 45 mm Hg, and O2 saturation of 83% on ambient air; the Pao2 increased to 85 mm Hg on inspired oxygen of 100%. resulting in a shunt of 30%. Multidetector computed tomography–angiography of the chest showed clearly a giant proximal pulmonary arteriovenous fistula (Figure 1A and B and …