Moussa Riachy

Prediction of the survival and functional ability of severe stroke patients after ICU therapeutic intervention

BackgroundThis study evaluated the benefits and impact of ICU therapeutic interventions on the survival and functional ability of severe cerebrovascular accident (CVA) patients.MethodsSixty-two ICU patients suffering from severe ischemic/haemorrhagic stroke were evaluated for CVA severity using APACHE II and the Glasgow coma scale (GCS). Survival was determined using Kaplan-Meier survival tables and survival prediction factors were determined by Cox multivariate analysis. Functional ability was assessed using the stroke impact scale (SIS-16) and Karnofsky score. Risk factors, life support techniques and neurosurgical interventions were recorded. One year post-CVA dependency was investigated using multivariate analysis based on linear regression.ResultsThe study cohort constituted 6% of all CVA (37.8% haemorrhagic/62.2% ischemic) admissions. Patient mean(SD) age was 65.8(12.3) years with a 1:1 male: female ratio. During the study period 16 patients had died within the ICU and seven in the year following hospital release.The mean(SD) APACHE II score at hospital admission was 14.9(6.0) and ICU mean duration of stay was 11.2(15.4) days. Mechanical ventilation was required in 37.1% of cases. Risk ratios were; GCS at admission 0.8(0.14), (p = 0.024), APACHE II 1.11(0.11), (p = 0.05) and duration of mechanical ventilation 1.07(0.07), (p = 0.046). Linear coefficients were: type of CVA – haemorrhagic versus ischemic: -18.95(4.58) (p = 0.007), GCS at hospital admission: -6.83(1.08), (p = 0.001), and duration of hospital stay -0.38(0.14), (p = 0.40).ConclusionTo ensure a better prognosis CVA patients require ICU therapeutic interventions. However, as we have shown, where tests can determine the worst affected patients with a poor vital and functional outcome should treatment be withheld?

Validation de la version arabe de l’échelle de somnolence d’Epworth : étude multicentrique

OBJECTIVES The Epworth Sleepiness Scale (ESS) is a self-completion questionnaire developed in the English language and used for the evaluation of sleepiness. The objective of this study was to develop an Arabic version of ESS (AESS) and to investigate its reliability and the validity. METHODS The AESS was created according to the recommendations of the ISPOR Task Force for Translation and Cultural Adaptation with bilingual individuals. It was applied to 91 patients referred to three sleep Lebanese centers for suspicion of sleep-related breathing diseases, and to 166 controls in good health. AESS scores of 60 patients were compared to 60 matched controls according to their age, sex and body mass index. Reproducibility was tested in 30 controls. The treatment response was tested among 15 patients after one month of CPAP treatment. RESULTS Principal component analysis showed convergence towards only one latent factor. The AESS had a good internal consistency (Cronbachs alpha 0.76, intraclass correlation coefficient of 0.85 (IC95%: 0.76-0.92), Spearman 0.97, P<0.001). An increase in the severity of sleep apnea was accompanied by an increase in the score on the AESS (P<0.001). AESS scores improved significantly after CPAP. CONCLUSION The AESS, a reliable and valid instrument for the evaluation of daytime sleepiness, is a valuable tool for clinical practice and multicenter research.

Hémothorax iatrogène massif jugulé par injection intercostale de lidocaïne-adrénaline

Resume Introduction Un hemothorax abondant est une complication peu frequente d’une ponction ou d’un drainage pleural. Il est principalement secondaire a une rupture vasculaire intercostale. Il necessite un drainage evacuateur, voire une thoracotomie d’hemostase lorsqu’il persiste. Observation Ce cas clinique rapporte la survenue, dans les suites d’un premier drainage pleural, d’un hemothorax grave avec etat de choc franc, persistant malgre un drainage evacuateur, chez une patiente âgee de 72 ans, a haut risque operatoire d’une thoracotomie d’hemostase. Le saignement a pu etre jugule par injection intercostale de lidocaine-adrenaline. Conclusion Cette observation suggere une indication d’injection intercostale premiere de vasoconstricteurs lors d’une hemorragie pleurale persistante par lesion vasculaire intercostale.

Streptococcus pneumoniae causing septic arthritis with shock and revealing multiple myeloma

The authors present the case of a 43-year-old male who presented at the emergency department, with a mean arterial pressure of 48 mm of Hg, a sinus tachycardia of 142/min and shallow breathing at 30/min. Two days previously, he started a high-grade fever with a concomitant reddish and painful left knee and right elbow, without any treatment. Septic shock was diagnosed and the patient was started on empiric antibiotics combining ceftriaxone and vancomycin and vasopressors (norepinephrine). The painful knee and elbow joints were aspirated and cultures grew Streptococcus pneumoniae. The patient’s clinical condition improved progressively and after investigation, the diagnosis of multiple myeloma was concluded. Pneumococcal septic arthritis, an extraordinary cause of septic arthritis, is a manifestation of an underlying disease and can be responsible for septic shock. Its diagnosis should direct further investigations. It can occur in patients with joint disease but should emphasise the search of systemic immunosuppression.

A randomized double-blind controlled trial comparing three sedation regimens during flexible bronchoscopy: Dexmedetomidine, alfentanil and lidocaine

No standardized sedation protocol is available for flexible bronchoscopy (FB).

Single or repetitive lung recruitment manoeuvres after cardiac valve replacement surgery

Cardiopulmonary bypass surgery has been implicated in causing atelectasis; a major cause of intrapulmonary shunting and hypoxemia postoperatively. This study investigated if repetitive lung recruitment manoeuvres (RRM), before and after extubation, could reduce intrapulmonary shunting for a longer period post-extubation than only one standardized recruitment manoeuvre (SRM), Forty cardiac valve replacement patients were randomised after SRM into two groups: RRM group (n=20): Total vital capacity manoeuvre at surgery end and repeated every 4 hours until extubation; SC group (n=20): Standard care with SRM. Intrapulmonary shunts (Qs/Qt) were measured after anaesthesia induction, at surgery termination and every 4 hours until 24 hours post-extubation. Time to extubation was recorded. Lung function was measured every 12 hours until discharge. A 24 hour post-extubation ANOVA showed no Qs/Qt significant differences between RRM and SC group (4.5 ± 3.3% and 5.3 ± 2.4%). At surgery end, Qs/Qt increased in RRM group (7.3 ± 3.2% to 13.5 ± 3.7%; p<10-3) but was significantly less (p<0.02) compared to SC group (7.3 ± 3.7% to 16.1 ± 6%; p<10-3). Time to extubation was 8.8 ± 4.2 h in RRM group versus 10.4 ± 4.3 h SC group (p<0.2, ns). No significant difference in vital capacity was seen in the RRM group (3.17 ± 1.2 to 1.9 ± 1 l) compared to SC group (3.4 ± 0.8 to 2.1 ± 0.9 l). In valve replacement surgery, RRM is only beneficial in the short-term period and does not assure a better intrapulmonary shunt benefit than one SRM applied at the end of surgery. Correspondence to: Moussa Riachy, Department of Pulmonary and Critical Care Hotel Dieu de France, Beirut, Lebanon, E-mail: riachy@dm.net.lb Received: May 04, 2017; Accepted: May 17, 2017; Published: May 20, 2017 Introduction Pulmonary complications are relatively frequent after cardiac surgery and remain the major cause of morbidity and mortality in the post-surgery period [1-10]. Pulmonary atelectasis (condition of deflated alveoli/collapsed lung) is the most common complication after this type of surgery [2,4,11]. The incidence of atelectasis varies between 20 to 75% (12). A scannographic study showed that atelectasis affects 24% of the pulmonary surface and predisposes patients to pulmonary infections and to other problems, such as difficulty in weaning patients from the ventilator in the post-surgery period [13]. Atelectasis explains 67% of the pulmonary shunt effect, which is considered the major pathophysiological mechanism for post-surgical arterial hypoxemia [7,11,14]. Tschernko et al. have proved that pulmonary shunt increases to around 16.8 ± 6.7% at the end of cardiopulmonary bypass (CPB), and continues to increase in the post-extubation period [15]. Four hours after extubation, the shunt was shown to be around 25.6 ± 8.1%. This result was confirmed by a recent study which showed the shunt as 30.3 ± 14.1% [16]. Moreover, Bender et al. showed that the pulmonary shunt can still be high at 24 hours after extubation (29 ± 12.3%) [17]. Several types of medical intervention are employed to decrease the risk of atelectasis [18-24]. currently the most widespread used method is incentive spirometry, although the majority of studies do not show it to have a significant effect (21). Another post-operative intervention to recruit collapsed alveoli is the multiple hyperinflation technique, which is sub-divided into 2 groups: low pressure techniques (CPAP; BiPAP) and high pressure (IPPB [19,20,22,23,25]. However, in spite of their tempting concept and their effectiveness in small open studies, meta-analysis of randomized and controlled studies has not found a significant benefit [23]. In recent years at the end of cardiopulmonary bypass (CPB) surgery and before patient extubation, alveolar recruitment manoeuvres were shown to have some benefit on post-surgical hypoxia and allowed an earlier extubation in the treated group [5,15,18,22,26-28]. The total vital capacity manoeuvre (TVCM) is standardized and is the most commonly used. It consists of inflating the lungs for 15 seconds’ duration and maintaining the airway pressure to a level of 40 cm H2O [29]. The studies were restricted by the limited number of patients and short term benefits gained [5,15,27,28]. Minkovich et Coll showed that two consecutive recruitment manoeuvres result in a better arterial oxygenation extending from the immediate postoperative period to approximately 24 hours after surgery [26]. In a recent study, Leme et al demonstrated that the use of an intensive vs a moderate alveolar recruitment strategy resulted in less severe pulmonary complications [18]. This study assesses the efficacy of a new therapeutic approach, which aims to prevent deterioration of pulmonary function secondary Riachy M (2017) Single or repetitive lung recruitment manoeuvres after cardiac valve replacement surgery Volume 1(1): 2-8 Lung Breath J, 2017 doi: 10.15761/LBJ.1000103 Applied methods Both groups: Patients were premedicated with hydroxyzine 1 mg kg-1. General anaesthesia was induced using propofol 2 mg kg-1, fentanyl 1μg kg-1 and succinylcholine 1 mg kg-1. After tracheal intubation, anaesthesia was maintained with one MAC (minimum alveolar concentration) sevoflurane and fentanyl 1-2 μg kg-1 h-1 .Neuromuscular blockade was obtained by cisatracurium with a loading dose of 0.2 mg kg-1 followed by a continuous infusion of 2-4 μg kg-1 h-1 .Anaesthesia drugs were calculated on an ideal body weight basis. Intraoperative monitoring included five-lead electrocardiography, invasive radial arterial pressure, pulmonary artery catheter, pulse oximetry, capnography, urine output and rectal temperature. All patients were mechanically ventilated (Datex-ohmeda Aestiva/5; Helsinski, Finland) with a tidal volume of 8 ml kg-1 of ideal body weight, an inspiratory/ expiratory time ratio of 0.4 and a mixture of oxygen (O2) and air adjusted to have a fixed inspired oxygen concentration of 40%. End-tidal carbon dioxide (ETCO2) was continuously monitored and respiratory rate was subsequently adjusted to maintain ETCO2 at a level of 30-35 mm Hg. At the end of surgery (I) and before separation from CPB, a standard recruitment manoeuvre (SRM) was applied at the end of surgery in both groups and before sternum closure. SRM was standardized to receive sustained manual inflation for a period of eight seconds at a pressure of 40 cm H2O. The SRM was followed by a passive expiration without pause, and repeated three times. The study procedural timeline is shown in Table 1. After surgery, all patients were transferred from the operating room to the ICU while receiving manual ventilation using an Ambu-type resuscitation bag (Ambu SPUR; Ambu Inc, Lithicum, MD, USA). On ICU admission, mechanical ventilation of the lungs was started with a 7600 Ventilator System (Nellcor Puritan Bennett Inc, Pleasanton, CA, USA) using assist-control mode. Initial ventilator parameters were set at a tidal volume of 8 ml kg-1, a respiratory rate of 14 /min, PEEP of 5 cm Hg, an inspiratory trigger of 0.3 cm H2O and an FiO2 of 0.4. Pressure support mode of ventilation (PSV) was applied to wean all patients from mechanical ventilation. Extubation was performed if to atelectasis and thereby limits pulmonary complications after cardiac surgery, compared to a standard approach. This new therapeutic approach called repetitive recruitment manoeuvre (RRM) begins directly at the end of the surgery, after closing the sternum, and is maintained until 24 hours post-extubation. It aims to prolong the gas exchange benefit of a standard care including standard recruitment manoeuvre (SRM) applied before separation from CPB. Our primary objective was to study the benefit of RRM on postoperative hypoxemia using pulmonary shunt. Additionally, the alveolo-arterial oxygen gradient, the effects of RRM on the time to extubation, lung function aqnd pulmonary complications were determined. Materials and methods

Factors determining continuous positive airway pressure (CPAP) compliance in obstructive sleep apnea (OSA)

Background: CPAP device is the gold standard therapy for OSA, though CPAP compliance remains problematic. Aims and Objectives: We aimed at evaluating the compliance to CPAP and at exploring potential predictors of compliance. Methods: This was a retrospective study at Hotel Dieu de France Hospital where we followed all patients diagnosed with OSA in the sleep center and treated for at least one day by CPAP between June 2008 and December 2014. Dropout events were noted. The Kaplan-Meier curve was used to estimate the median compliance time. Cox proportional hazards models were applied to determine independent predictive factors for short-term (3 months) and long-term compliance. Results: We followed 374 OSA patients. Mean apnea-hypopnea index (AHI) was 32.7±24.1/hour and mean sleep efficiency was 81.6±13.9%. Median compliance time was 957 days. 70.3% of patients were compliant at 6 months, but only 49.3% remained compliant at the end of the study. Cox models showed that use of nasal masks (HR 0.48 p 0.048) and higher oxygen desaturation index (ODI) (HR 0.98 p 0.048) were independently associated with short-term CPAP compliance. Buying the CPAP device (HR 0.18 p Conclusion: Short-term CPAP compliance was significantly associated with polysomnographic severity and mask type usage whereas long-term compliance was related to provider services and reported improvement. These attributes should be targeted in order to increase CPAP compliance in OSA patients. NCT02301923.

Sedation regimens comparison during flexible bronchoscopy: Dexmedetomidine, alfentanil and lidocaine

Background: Bronchoscopy tolerance varies significantly between patients, and no standardized protocol for sedation during bronchoscopy is currently available. Aims and Objectives: This study aimed at evaluating the efficacy and safety of three regimens: Dexmedetomidine (D) or Alfentanil (A) combined with local anesthesia, and local anesthesia alone (C). Methods: This randomized double-blind controlled trial included 162 patients undergoing bronchoscopy. Patients received 15 ml of lidocaine 1% alone (C) or combined with dexmedetomidine 0.5 mcg/kg (D) or alfentanil 10 mcg/kg (A). Lidocaine and midazolam were added as needed. Tolerance was assessed using the bronchoscopy score (BS), and level of sedation was assessed using the Nursing Instrument for the Communication of Sedation (NICS). Safety was evaluated in terms of pulmonary function and vital signs. Results: BS were identical in all groups. Group D subjects were the most sedated (p 0.013) whereas group A subjects were the least agitated. Linear regression showed a negative association between BS and age in A (β=-0.07, p 0.003). Male gender (β=2.47, p 0.001) and longer procedure (β=-0.12, p 0.010), and obesity (β=-2.23, p 0.026) and shorter procedure (β=0.08, p 0.020) were positive predictors of BS in D C respectively. Desaturation was most prevalent in A compared to D and C respectively (p 0.006). Hypotension was mostly observed in D. Conclusion: Though there were no consistent differences in efficacy and safety between the three regimens, results suggest that dexmedetomidine would be a better option in males and longer procedures, alfentanyl in elderly and lidocaine alone in obese patients and shorter procedures. [NCT02301923][1]. [1]: /lookup/external-ref?link_type=CLINTRIALGOV&access_num=NCT02301923&atom=%2Ferj%2F46%2Fsuppl_59%2FPA321.atom

Acquired haemophilia secondary to ivabradine presenting with acute respiratory distress syndrome

The authors present the case of a 72-year-old patient who presented with severe dyspnoea, scant haemoptysis, pronounced desaturation and bilateral haematomas on the upper limbs. Chest radiography showed bilateral infiltrates mainly in the lower lobes. The patient’s prothrombin time, and platelet count were normal. However, the activated partial thromboplastin time showed a prolongation that was not reversed on a correction study. Factor VIII (FVIII) levels were very low and evidence of FVIII inhibitor was found. The patient had started taking ivabradine 2 months earlier, and the diagnosis of idiosyncratic acquired haemophilia was established. The patient was treated with volume expansion therapy, high levels of oxygen, multiple transfusions, methylprednisolone, desmopressine and rituximab. On the 3rd day, the patient showed progressive amelioration of his dyspnoea, oxygen needs and chest infiltrates. On the 7th day, the patient was discharged.

PCR use in miliary tuberculosis presenting with acute respiratory distress syndrome

A 30-year-old pregnant woman admitted to the hospital for rapidly progressive dyspnoea, non-productive cough and altered general status evolving over 1-month period. Her vital signs showed a low blood pressure 90/60 mm Hg, pulse rate 100 beats/min, respiratory rate 32 breaths/min and oxygen saturation on room air of 88%. Laboratory findings showed haemoglobin 9.7 g/dl, white blood cells 15 000/mm3 (neutrophils 82%), C reactive protein 74 mg/l, alkaline phosphatase 320 U/l, alanine aminotransferase 62 IU/l, aspartate aminotransferase 120 IU/l, γ glutamyl transpeptidase 125 U/l; brain natriuretic peptide 25.4 pg/ml, procalcitonine >2, lactate dehydrogenase 1618 U/l. Chest radiographics showed diffuse bilateral micronodular pulmonary infiltrates and CT of the chest confirmed 1–3 mm diffuse bilateral micronodular infiltrates with ground glass opacities. Complete investigation including bronchoalveolar lavage (BAL) for any viral, bacteriologic, acid-fast bacilli and full serum antibodies panel were all negative. DNA amplification for mycobacterium using PCR on the BAL rapidly rectified the diagnosis of tuberculosis.