Florence Boissier

Risk factors for and prediction by caregivers of extubation failure in ICU patients: a prospective study.

Objective:The influence of delirium, ICU-acquired paresis, and cardiac performance on extubation outcome has never been evaluated together. We aimed to assess the respective role of these factors on the risk of extubation failure and to assess the predictive accuracy of caregivers. Design and Setting:Prospective observational study of all planned extubations in a 13-bed medical ICU of a teaching hospital. Interventions:On the day of extubation, muscle strength of the four limbs, criteria for delirium, cardiac performance, cough strength, and the risk of extubation failure predicted by caregivers were prospectively assessed. Extubation failure was defined as the need for reintubation within the following 7 days. Measurements and Main Results:Over the 18-month study period, 533 patients required intubation. Among the 225 patients intubated for more than 24 hours who experienced a planned extubation attempt, 31 patients (14%) required reintubation within the 7 days following extubation. In multivariate analysis, duration of mechanical ventilation more than 7 days prior to extubation, ineffective cough, and severe systolic left ventricular dysfunction were the three independent factors associated with extubation failure. Although patients considered at high risk for extubation failure had higher reintubation rate, prediction of extubation failure by caregivers at time of extubation had high specificity but low sensitivity. Conclusions:An ineffective cough, a prior duration of mechanical ventilation more than 7 days, and severe systolic left ventricular dysfunction were stronger predictors of extubation failure than delirium or ICU-acquired weakness. Only one-third patients who required reintubation were considered at high risk for extubation failure by caregivers.

Noninvasive Ventilation for Acute Hypercapnic Respiratory Failure: Intubation Rate in an Experienced Unit

BACKGROUND: Failure of noninvasive ventilation (NIV) is common in patients with COPD admitted to the ICU for acute hypercapnic respiratory failure (AHRF). We aimed to assess the rate of NIV failure and to identify early predictors of intubation under NIV in patients admitted for AHRF of all origins in an experienced unit. METHODS: This was an observational cohort study using data prospectively collected over a 3-year period after the implementation of a nurse-driven NIV protocol in a 24-bed medical ICU of a French university hospital. RESULTS: Among 242 subjects receiving NIV for AHRF (PaCO2 > 45 mm Hg), 67 had cardiogenic pulmonary edema (CPE), 146 had acute-on-chronic respiratory failure (AOCRF) (including 99 subjects with COPD and 47 with other chronic respiratory diseases), and 29 had non-AOCRF (mostly pneumonia). Overall, the rates of intubation and ICU mortality were respectively 15% and 5%. The intubation rates were 4% in CPE, 15% in AOCRF, and 38% in non-AOCRF (P < .001). After adjustment, non-AOCRF was independently associated with NIV failure, as well as acidosis (pH < 7.30) and severe hypoxemia (PaO2/FIO2 ≤ 200 mm Hg) after 1 hour of NIV initiation, whereas altered consciousness on admission and ventilatory settings had no influence on outcome. CONCLUSIONS: With a nurse-driven NIV protocol, the intubation rate was reduced to 15% in patients receiving NIV for AHRF, with a mortality rate of only 5%. Whereas the risk of NIV failure is associated with hypoxemia and acidosis after initiation of NIV, it is also markedly influenced by the presence or absence of an underlying chronic respiratory disease.

Pulmonary Vascular Dysfunction and Cor Pulmonale During Acute Respiratory Distress Syndrome in Sicklers.

Background: Acute chest syndrome (ACS) is the most common cause of death among sickle cell disease (SCD) adult patients. Pulmonary vascular dysfunction (PVD) and acute cor pulmonale (ACP) are common during acute respiratory distress syndrome (ARDS) and their prevalence may be even more important during ARDS related to ACS (ACS-ARDS). The objective of this study was to evaluate the prevalence and prognosis of PVD and ACP during ACS-ARDS. Patients and Methods: This was a retrospective analysis over a 10-year period of patients with moderate-to-severe ARDS. PVD and ACP were assessed by echocardiography. ARDS episodes were assigned to ACS-ARDS or nonACS-ARDS group according to whether the clinical insult was ACS or not, respectively. To evaluate independent factors associated with ACP, significant univariable risk factors were examined using logistic regression and propensity score analyses. Results: A total of 362 patients were analyzed, including 24 ACS-ARDS. PVD and ACP were identified, respectively, in 24 (100%) and 20 (83%) ACS-ARDS patients, as compared with 204 (60%) and 68 (20%) nonACS-ARDS patients (P < 0.0001). The mortality did not differ between ACS-ARDS and nonACS-ARDS patients. Both the crude (odds ratio [OR], 19.9; 95% confidence interval [CI], 6.6–60; P < 0.0001), multivariable adjustment (OR, 27.4; 95% CI, 8.2–91.5; P < 0.001), and propensity-matched (OR, 11.7; 95% CI, 1.2–110.8; P = 0.03) analyses found a significant association between ACS-ARDS and ACP. Conclusions: All SCD patients presenting with moderate-to-severe ARDS as a consequence of ACS experienced PVD and more than 80% of them exhibited ACP. These results suggest a predominant role for PVD in the pathogenesis of severe forms of ACS.

Bedside Lung Ultrasound During Acute Chest Syndrome in Sickle Cell Disease.

AbstractLung ultrasound (LU) is increasingly used to assess pleural and lung disease in intensive care unit (ICU) and emergency unit at the bedside. We assessed the performance of bedside chest radiograph (CR) and LU during severe acute chest syndrome (ACS), using computed tomography (CT) as the reference standard.We prospectively explored 44 ACS episodes (in 41 patients) admitted to the medical ICU. Three imaging findings were evaluated (consolidation, ground-glass opacities, and pleural effusion). A score was used to quantify and compare loss of lung aeration with each technique and assess its association with outcome.A total number of 496, 507, and 519 lung regions could be assessed by CT scan, bedside CR, and bedside LU, respectively. Consolidations were the most common pattern and prevailed in lung bases (especially postero-inferior regions). The agreement with CT scan patterns was significantly higher for LU as compared to CR (&kgr; coefficients of 0.45 ± 0.03 vs 0.30 ± 0.03, P < 0.01 for the parenchyma, and 0.73 ± 0.08 vs 0.06 ± 0.09, P < 0.001 for pleural effusion). The Bland and Altman analysis showed a nonfixed bias of −1.0 (P = 0.12) between LU score and CT score whereas CR score underestimated CT score with a fixed bias of −5.8 (P < 0.001). The specificity for the detection of consolidated regions or pleural effusion (using CT scan as the reference standard) was high for LU and CR, whereas the sensitivity was high for LU but low for CR. As compared to others, ACS patients with an LU score above the median value of 11 had a larger volume of transfused and exsanguinated blood, greater oxygen requirements, more need for mechanical ventilation, and a longer ICU length of stay.LU outperformed CR for the diagnosis of consolidations and pleural effusion during ACS. Higher values of LU score identified patients at risk of worse outcome.

Severe but not mild hypercapnia affects the outcome in patients with severe cardiogenic pulmonary edema treated by non-invasive ventilation

BackgroundPatients with severe cardiogenic pulmonary edema (CPE) are frequently hypercapnic, possibly because of associated underlying chronic lung disease (CLD). Since hypercapnia has been associated with outcome, we aimed to identify factors associated to hypercapnia and its role on outcome of patients with CPE and no underlying CLD.MethodsObservational cohort study using data prospectively collected over a 3-year period. After excluding patients with any CLD or obstructive sleep apneas, all patients treated by non-invasive ventilation (NIV) for severe CPE were included. Hypercapnia was defined as PaCO2 >45 mmHg and non-rapid favorable outcome was defined as the need for intubation or continuation of NIV for more than 48 h.ResultsAfter excluding 60 patients with underlying CLD or sleep apneas, 112 patients were studied. The rates of intubation and of prolonged NIV were 6.3 % (n = 7) and 21.4 % (n = 24), respectively. Half of the patients (n = 56) had hypercapnia upon admission. Hypercapnic patients were older, more frequently obese, and were more likely to have a respiratory tract infection than non-hypercapnic patients. Hypercapnia had no influence on intubation rate or the need for prolonged NIV. However, patients with severe hypercapnia (PaCO2 >60 mmHg) needed longer durations of NIV and intensive care unit (ICU) stay than the others.ConclusionsAmong the patients admitted for severe CPE without CLD, half of them had hypercapnia at admission. Hypercapnic patients were older and more frequently obese but their outcome was similar compared to non-hypercapnic patients. Patients with severe hypercapnia needed longer durations of NIV than the others without increase in intubation rate.

Acute respiratory distress and shock secondary to complicated diaphragmatic hernia

Dear Editor, The efficacy and safety of radiofrequency ablation (RFA) in patients with small hepatocellular carcinoma (HCC) is recognized [1]. However, major complications occur in 2.2% of cases, including abdominal bleeding or infection, biliary tract injury, vascular damage to the liver, liver abscess, visceral damage, skin burn, tumor seeding, pleural effusion, pneumothorax and diaphragmatic injury [2]. In some rare cases, these complications lead to acute respiratory failure and shock, and the need for hospitalization of the patient in the intensive care unit (ICU). We report the first case to our knowledge of a life-threatening incarcerated trans-diaphragmatic hernia (DH) with colon perforation into the pleural space. A 65-year-old woman was admitted to our ICU for acute respiratory failure and shock. Her medical history was significant for alcoholic cirrhosis Child-Pugh A, complicated by a nodule of HCC in segment VIII. Percutaneous sonography-guided RFA had been performed 7 months previously. The patient complained of a dorsal pain thereafter. A month previously, a second RFA procedure was performed for a nodule in segment V. One week before admission, she developed a right chest pain with dyspnea, abdominal pain and nausea. Upon admission, laboratory tests showed acute renal failure and lactic acidosis. Emergency plain radiography of the chest was performed because of the respiratory symptoms and showed a right pleural effusion, with a suspicion of pneumoperitoneum (Fig. 1a). A CT scan revealed a DH of the right colon, complicated by volvulus, pneumatosis, pneumothorax and pleural effusion (Fig. 1b). Fluid expansion and antibiotics were administered and an emergency laparotomy was performed. An incarcerated, necrotic and perforated DH of the right colon was present, associated with stercoral pleural effusion. A right colectomy was performed. The diaphragmatic defect (Fig. 1c) was repaired with a vicryl patch. Escherichia coli and Bacteroides thetaiotaomicron were identified in the pleural effusion and blood cultures, and treated over 4 weeks. The patient gradually improved and was discharged from hospital on day 27. Only a few cases of DH complicating RFA have been described previously. In three of the patients DH was associated with a nonstercoral pleural effusion. Hernia was complicated by ileus in only one of the patients [3]. Surgery was required in all patients. The main mechanism of DH related to RFA is diaphragmatic injury, secondary to thermal damage or mechanical damage by the needle itself [3, 4]. This complication is particularly feared if the tumor is abutting the diaphragm [4]. Diaphragmatic injury (thickening or collection) has been found in 55% of systematic CT scans performed after RFA [4]. The symptoms are often delayed, ranging in onset from 3 to 18 months. This period of latency could be explained by the fact that a small diaphragmatic defect expands progressively. In our patient, the causal relationship between RFA and DH was assumed because DH was not present on the CT scan performed

Early Identification of Acute Respiratory Distress Disorder in the Absence of Positive Pressure Ventilation: Implications for Revision of the Berlin Criteria for Acute Respiratory Distress Syndrome

Objectives: To assess whether patients breathing spontaneously under standard oxygen could be recognized early as acute respiratory distress syndrome patients according to the current Berlin definition. Design: A post hoc analysis from two prospective studies. Setting: Twenty-three French ICUs. Patients: All patients admitted for acute hypoxemic respiratory failure and treated with noninvasive ventilation were analyzed. Patients with cardiogenic pulmonary edema, acute exacerbation of chronic obstructive pulmonary disease, or hypercapnia were excluded. Interventions: None. Measurements and Main Results: The PaO2/FIO2 ratio was estimated at admission under standard oxygen and then under noninvasive ventilation 1 hour after initiation and within the first 24 hours. Among the 219 patients treated with noninvasive ventilation for acute hypoxemic respiratory failure, 180 (82%) had bilateral infiltrates including 161 patients with PaO2/FIO2 less than or equal to 300 mm Hg under standard oxygen. Among them, 127 were treated with positive end-expiratory pressure of at least 5 cm H2O, and 120 (94%) fulfilled criteria for acute respiratory distress syndrome within the first 24 hours. The mortality rate of patients with bilateral infiltrates and PaO2/FIO2 less than or equal to 300 mm Hg under standard oxygen was 29%, a rate very close to that of intubated patients with acute respiratory distress syndrome in the Berlin definition. Conclusions: Almost all patients with pulmonary bilateral infiltrates and a PaO2/FIO2 less than or equal to 300 mm Hg under standard oxygen fulfilled the acute respiratory distress syndrome criteria under noninvasive ventilation within the first 24 hours. Their mortality rate was similar to that reported in the Berlin definition of acute respiratory distress syndrome. Therefore, spontaneous breathing patients with the acute respiratory distress syndrome criteria could be identified early without positive pressure ventilation.

Echocardiographic detection of transpulmonary bubble transit during acute respiratory distress syndrome

BackgroundTranspulmonary bubble transit (TPBT) detected with contrast echocardiography is reported as a sign of intrapulmonary shunt during cirrhosis or exercise in healthy humans. However, its physiological meaning is not clear during acute respiratory distress syndrome (ARDS). Our aim was to determine the prevalence, significance, and prognosis of TPBT detection during ARDS.MethodsThis was a prospective observational study in an academic medical intensive care unit in France. Two hundred and sixteen consecutive patients with moderate-to-severe ARDS underwent transesophageal echocardiography with modified gelatine contrast. Moderate-to-large TPBT was defined as right-to-left passage of at least ten bubbles through a pulmonary vein more than three cardiac cycles after complete opacification of the right atrium. Patients with intra-cardiac shunt through patent foramen ovale were excluded.ResultsThe prevalence of moderate-to-large TPBT was 26% (including 42 patients with moderate and 15 with large TPBT). Patients with moderate-to-large TPBT had higher values of cardiac index and heart rate as compared to those without TPBT. There was no significant difference in PaO2/FIO2 ratio between groups, and TPBT was not influenced by end-expiratory positive pressure level in 93% of tested patients. Prevalence of septic shock was higher in the group with moderate-to-large TPBT. Patients with moderate-to-large TPBT had fewer ventilator-free days and intensive care unit-free days within the first 28 days, and higher in-hospital mortality as compared to others.ConclusionsModerate-to-large TPBT was detected with contrast echocardiography in 26% of patients with ARDS. This finding was associated with a hyperdynamic and septic state, but did not influence oxygenation.

At the Critical Time of Deciding on Extubation, It Is Too Late to Assess Patient Breathlessness

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Septic shock complicating Plasmodium falciparum malaria in a pregnant patient with low parasitemia.

hoc septique compliquant un paludisme a Plasmodium falciparum associe a une parasitemie faible chez une femme enceinte F. Boissier a,∗, C. Vermersch a, S. Spagnolo a, F. Bruneel b, C. Brun-Buisson a, N. de Prost a a Service de reanimation medicale, hopital Henri-Mondor, 51, avenue de Lattre-de-Tassigny, 94010 Creteil, France b Service de reanimation medico-chirurgicale, centre hospitalier de Versailles, Le Chesnay, France