Aurélie Lefebvre

Prognosis of patients with acute myeloid leukaemia admitted to intensive care

This retrospective study assessed the prognostic factors associated with early and long‐term outcome in consecutive patients with acute myeloid leukaemia (AML) admitted to the intensive care unit (ICU) over a 9‐year period. A total of 83 patients were studied (age 48 ± 16 years), among whom 60% were neutropenic on admission. For 68%, admission occurred within the first month following diagnosis of AML. The main reason for ICU admission was an acute respiratory disease in 82% of cases. Mechanical ventilation (MV) was required in 57% of patients. In‐ICU mortality was 34%. Among patients discharged alive from ICU, 49% died within a year after discharge. Factors significantly associated with in‐ICU death in multivariate analysis were simplified acute physiology score II and need for invasive MV (IMV). Age, performance status, AML3 subtype and complete remission were significantly associated with 1‐year survival. Patients with acute respiratory failure initially supported with non‐invasive MV had significantly better ICU outcome than patients initially supported with IMV. In conclusion, ICU admission is justified for selected patients with AML. The ICU mortality rate is highly predictable by the acute illness severity score. A 1‐year survival is predicted by haematological prognostic factors.

Prise en charge des exacerbations aiguës de BPCO

Exacerbations of COPD are common and cause a considerable burden to the patient and the healthcare system. To optimize the hospital care of patients with exacerbations of COPD, clinicians should be aware of some key points: management of exacerbations is broadly based on clinical features and severity. Initial clinical evaluation is crucial to define those patients requiring hospital admission and those who could be managed as outpatients. In hospitalized patients, the appropriate level of care should be determined by the initial severity and response to initial medical treatment. Medical treatment should follow recent recommendations, including rest, titrated oxygen therapy, inhaled or nebulized short-acting bronchodilators (Beta2-agonists and anticholinergic agents), DVT prevention with LMWH, steroids in most severely ill patients, unless there are contraindications and antibiotics in the case of a clear bacterial infectious aetiology. Severe exacerbations may lead to acute hypercapnic respiratory failure. Unless contraindicated, non-invasive ventilation (NIV) should be the first line ventilatory support for these patients. NIV should be commenced early, before severe acidosis ensues, to avoid the need for endotracheal intubation and to reduce mortality and treatment failures. Several randomised controlled clinical trials support the use of NIV in the management of acute exacerbations of COPD, demonstrating a decreased need for mechanical ventilation and an improved survival. In most severe cases, NIV should be provided in ICU. Although it has been shown that for less severe patients (with pH values>7.30), NIV can be administered safely and effectively on general medical wards, a lead respiratory consultant and trained nurses are mandatory. Mechanical ventilation through an endotracheal tube should be considered when patients have contraindications to the use of NIV or fail to improve on NIV. The duration of mechanical ventilation should be shortened as much as possible by an early weaning process, including preventive post-extubation NIV in hypercapnic patients. hospital stay could be shortened by non-invasive treatments. Future exacerbations should be avoided by respiratory specialist management of the patients, including education, optimization of long-term medical treatment, vaccinations, nutritional support, and pulmonary rehabilitation.

Acute Respiratory Failure in a Patient Presenting T-cell Prolymphocytic Leukemia: Specific Leukemic Lung Involvement?

A 36-year old patient with relapsing T-cell prolymphocytic leukemia was admitted in intensive care unit for acute respiratory failure and pulmonary infiltrates. A flexible bronchoscopy with bronchoalveolar lavage was performed while the patient was under noninvasive ventilation. Cytological examination and immunophenotyping of BAL lymphoid cells confirmed the diagnosis of lung infiltration with prolymphocytic T-cell leukemia. An associated organized pneumonia was suspected. The rapid clinical and radiological response to corticosteroids followed by immunotherapy with alemtuzumab strengthened our hypothesis. To our knowledge, this is the first reported case of prolymphocytic T-cell leukemia with a specific pulmonary lung involvement associated with an organized pneumonia.

Nasal high flow oxygen therapy after extubation: the road is open but don’t drive too fast!

Mechanical ventilation (MV) is necessary for many patients admitted in intensive care unit (ICU). In intubated patients, weaning from invasive MV is a major event during their ICU stay (1,2). Delayed extubation increases the risks associated with IMV and extubation failure is associated with prolonged ICU and hospital stays and increased mortality, particularly attributable to nosocomial infection (3-5).