Julien Letheulle

La protéinose alvéolaire pulmonaire

Alveolar proteinosis (AP) is a rare disease characterized by alveolar accumulation of surfactant components, which impairs gas exchange. AP is classified into three groups: auto-immune AP defined by the presence of plasma autoantibodies anti-GM-CSF, the most frequent form (90% of all AP); secondary AP, mainly occurring as a consequence of haematological diseases, or following on from toxic inhalation or infections, and genetic AP, which affects almost exclusively children. AP diagnosis is suspected where chest CT-scan demonstrates interstitial lung disease with a crazy paving aspect; and confirmed by bronchoalveolar lavage, which has a milky appearance and contains periodic acid Schiff positive proteinaceous alveolar deposits. The use of surgical lung biopsy to confirm AP is less frequent nowadays. In this context, positive antibodies against GM-CSF indicates an auto-immune etiology of the AP. Concerning management, whole lung lavage is the gold standard therapy. In refractory AP, new treatments are available such as subcutaneous or inhaled GM-CSF supplementation, or rituximab infusions. The clinical course is unpredictable. Spontaneous improvement or even cure can occur, and the 5-year actuarial survival is 95%. The most frequent complications are infectious etiology.

Trends in Prevalence and Prognosis in Subjects With Acute Chronic Respiratory Failure Treated With Noninvasive and/or Invasive Ventilation

BACKGROUND: The pattern and outcome of noninvasive ventilation (NIV) use in patients with acute or chronic respiratory disease other than COPD is not well known. The aims of this study were to investigate trends over time in underlying respiratory diseases, use of NIV, and outcomes in COPD and non-COPD patients with acute respiratory failure. METHODS: We made a retrospective analysis of data recorded prospectively from 1,113 subjects admitted between 1998 and 2012. RESULTS: Subject diagnoses were distributed as follows: COPD, n = 568 (51%); bilateral bronchiectasis, n = 113 (10%); obesity, n = 166 (15%); chronic diffuse interstitial lung disease, n = 131 (12%); restrictive pulmonary disease, n = 113 (10%); and asthma, n = 22 (2%). The proportion of subjects with bilateral bronchiectasis significantly decreased (OR 0.91, 95% CI 0.865–0.951, P < .001), whereas the proportion of subjects with obesity increased (OR 1.03, 95% CI 1.001–1.063, P = .049) over time. The use of NIV (OR 1.05, 95% CI 1.010–1.090, P = .01) and the proportion of subjects initially treated with NIV (OR 1.05, 95% CI 1.013–1.094, P = .009) increased significantly in COPD subjects only. Time trend of mortality was not significant (OR 0.98, 95% CI 0.95–1.01, P = .23), whereas the severity of illness in subjects significantly increased. Transition from NIV to invasive mechanical ventilation (IMV) (OR 2.05, 95% CI 1.36–3.11, P = < .001), IMV (OR 10.49, 95% CI 4.88–10.56, P < .001) and diffuse interstitial lung disease (OR 10.63, 95% CI 5.43–20.83, P < .001) were independently associated with death in the ICU. CONCLUSIONS: Over time, respiratory diseases have changed in non-COPD subjects and trends in the use and efficacy of NIV differ between COPD and non-COPD subjects. Mortality remained stable while the severity of illness in subjects increased. In COPD and non-COPD subjects, transition from NIV to IMV was associated with a poorer prognosis.

At-risk drinking is independently associated with ICU and one-year mortality in critically ill nontrauma patients*.

Objectives:The impact of at-risk drinking on the outcomes of nontrauma patients is not well characterized. The aim of this study was to determine whether at-risk drinking is independently associated with the survival of nontrauma patients in an ICU and within 1 year following ICU discharge. Design:Observational cohort study. Setting:A 21-bed mixed ICU in a university hospital. Patients:A total of 662 patients who experienced an ICU stay of 3 days or more and for whom alcohol consumption could be assessed. Interventions:None. Measurements and Main Results:ICU-related variables were collected prospectively, and a 1-year follow-up was determined retrospectively. Analyses were adjusted based on prognostic determinants of short- and long-term outcomes, as previously described in ICU patients and alcohol abusers. Two hundred and eight patients (33%) were identified as at-risk drinkers according to the National Institute on Alcohol Abuse and Alcoholism criteria. Additionally, 111 patients (17%) died in the ICU, and 97 (15%) died after ICU discharge. From the ICU admission until the end of the 1-year follow-up period, the at-risk drinkers exhibited poorer survival than the non–at-risk drinkers (p = 0.0004, as determined by the log-rank test). More specifically, 50 at-risk drinkers (24%) versus 61 non–at-risk drinkers (13%) died in the ICU (p = 0.0009 for the comparison). After adjustment, at-risk drinking remained independently associated with mortality in the ICU (adjusted odds ratio of 1.83; 95% CI of 1.16–2.89; p = 0.01) and with mortality within the year following ICU discharge (adjusted hazard ratio of 1.70; 95% CI of 1.15–2.52; p = 0.008). The causes of death in the at-risk and non–at-risk drinkers were similar. Conclusions:In this population of critically ill nontrauma patients, at-risk drinking was independently associated with death in the ICU and within the year following ICU discharge.

Iterative Thoracentesis as First-Line Treatment of Complicated Parapneumonic Effusion

Rationale Optimal management of complicated parapneumonic effusions (CPPE) remains controversial. Objectives to assess safety and efficacy of iterative therapeutic thoracentesis (ITTC), the first-line treatment of CPPE in Rennes University Hospital. Methods Patients with CPPE were identified through our computerized database. We retrospectively studied all cases of CPPE initially managed with ITTC in our institution between 2001 and 2010. ITTC failure was defined by the need for additional treatment (i.e. surgery or percutaneous drainage), or death. Results Seventy-nine consecutive patients were included. The success rate was 81% (n = 64). Only 3 patients (4%) were referred to thoracic surgery. The one-year survival rate was 88%. On multivariate analysis, microorganisms observed in pleural fluid after Gram staining and first thoracentesis volume ≥450 mL were associated with ITTC failure with adjusted odds-ratios of 7.65 [95% CI, 1.44–40.67] and 6.97 [95% CI, 1.86–26.07], respectively. The main complications of ITTC were iatrogenic pneumothorax (n = 5, 6%) and vasovagal reactions (n = 3, 4%). None of the pneumothoraces required chest tube drainage, and no hemothorax or re-expansion pulmonary edema was observed. Conclusions Although not indicated in international recommendations, ITTC is safe and effective as first-line treatment of CPPE, with limited invasiveness.

Le syndrome des ongles jaunes : présentation de cinq cas

INTRODUCTION The yellow nail syndrome is a rare disorder described for the first time in 1964. The pathophysiology remains unclear. Its definition is based on a clinical triad of yellow nails, lymphoedema and chronic respiratory disorders including pleural effusions and bronchiectasis. CASES REPORTS We describe a retrospective series of five patients diagnosed with the yellow nail syndrome. All the patients were male, aged from 52 to 71 years (median=56). Three patients were diagnosed with the classic triad, whereas the other two had only yellow nails and bronchiectasis. Yellow nails and chronic sinusitis were present in all five patients. We also report atypical manifestations such as a transudative pleural effusion and facial oedema. The yellow nail syndrome was associated with cancer in two cases. CONCLUSION More common alternative diagnoses must be excluded. The association with cancer should be explored. The treatment is only symptomatic.

Constipation is independently associated with delirium in critically ill ventilated patients.

Delirium is a central nervous system (CNS) dysfunction reported in up to 80 % of intensive care unit (ICU) patients associated with negative short- and long-term outcomes [1, 2]. Gastrointestinal motility disorders are frequent in ICU patients leading to frequent delayed passage of stools [3]. Because there is a bi-directional communication between the CNS and the digestive tract [4], we believed it relevant to test the hypothesis that constipation and delirium are related in ICU patients.

Extracorporeal Membrane Oxygenation in Pregnancy.

Adult respiratory distress syndrome (ARDS) may pose specific challenges in pregnant women, including the need for prone decubitus ventilation and extracorporeal membrane oxygenation (ECMO). We present our experience with ECMO during pregnancy and review the literature on this topic.

Internet use by family members of intensive care unit patients: a pilot study.

Dear Editor, The next of kin of critically ill patients experience stress during the intensive care unit (ICU) stay and may develop posttraumatic stress disorder [1, 2], which could be related to a lack of understanding between families and doctors [2, 3]. The Internet represents the most easily accessible source of medical information, and 60–80 % of adults have already searched the Internet for medical information [4]. Internet use by family members has already been assessed for patients from specialities other than intensive care medicine [5], but no study has ever focused on families of ICU patients. Before analyzing the impact of medical information research on the Internet on the physician–family relationship, it is necessary to estimate the proportion of families who resort to the Internet and their characteristics. For this purpose, we conducted a monocentric observational study between May 2012 and April 2013. The study was approved by the hospital’s review board. Patients with ICU length of stay longer than 48 h were prospectively identified. All next of kin visiting the patient were

Massive Intra-Alveolar Hemorrhage Caused by Leptospira Serovar Djasiman in a Traveler Returning From Laos

Leptospirosis is one of the most common pathogens responsible for life-threatening tropical disease in travelers. We report a case of massive intra-alveolar hemorrhage caused by Leptospira serovar Djasiman in a 38-year-old man returning from Laos, who was cured with antibiotics and salvage treatment with extra-corporeal membrane oxygenation.

Repeated therapeutic thoracentesis to manage complicated parapneumonic effusions.

Purpose of review In complicated parapneumonic effusion (CPPE), antibiotics and evacuation of the infected pleural fluid are mandatory. The first-line evacuation treatment is still controversial. The aim of this article is to highlight the usefulness of repeated therapeutic thoracentesis (RTT) as a first-line treatment. Recent findings In the most recent study on RTT in CPPE, disposable pleural needles were used and the median number of thoracentesis was 3. The success rate was 81%, and only 4% of the patients were referred for thoracic surgery. The 1-year survival rate was 88%. On multivariate analysis, the observation of microorganisms in the pleural fluid after Gram staining and first thoracentesis volume at least 450 ml was associated with a higher risk of RTT failure. RTT is less invasive and can target different loculated pleural collections. Patients are less confined to beds between each procedure, and could even be ambulatory managed. The use of intrapleural fibrinolytics in association with DNase could most likely enhance the efficacy of RTT. Summary RTT is efficient and well tolerated in the management of CPPE, including pleural empyema, and could be proposed as a first-line therapy for CPPE. This technique could be used in association with intrapleural fibrinolytics and DNase.