Muriel Fartoukh

High-Flow Oxygen through Nasal Cannula in Acute Hypoxemic Respiratory Failure

BACKGROUND Whether noninvasive ventilation should be administered in patients with acute hypoxemic respiratory failure is debated. Therapy with high-flow oxygen through a nasal cannula may offer an alternative in patients with hypoxemia. METHODS We performed a multicenter, open-label trial in which we randomly assigned patients without hypercapnia who had acute hypoxemic respiratory failure and a ratio of the partial pressure of arterial oxygen to the fraction of inspired oxygen of 300 mm Hg or less to high-flow oxygen therapy, standard oxygen therapy delivered through a face mask, or noninvasive positive-pressure ventilation. The primary outcome was the proportion of patients intubated at day 28; secondary outcomes included all-cause mortality in the intensive care unit and at 90 days and the number of ventilator-free days at day 28. RESULTS A total of 310 patients were included in the analyses. The intubation rate (primary outcome) was 38% (40 of 106 patients) in the high-flow-oxygen group, 47% (44 of 94) in the standard group, and 50% (55 of 110) in the noninvasive-ventilation group (P=0.18 for all comparisons). The number of ventilator-free days at day 28 was significantly higher in the high-flow-oxygen group (24±8 days, vs. 22±10 in the standard-oxygen group and 19±12 in the noninvasive-ventilation group; P=0.02 for all comparisons). The hazard ratio for death at 90 days was 2.01 (95% confidence interval [CI], 1.01 to 3.99) with standard oxygen versus high-flow oxygen (P=0.046) and 2.50 (95% CI, 1.31 to 4.78) with noninvasive ventilation versus high-flow oxygen (P=0.006). CONCLUSIONS In patients with nonhypercapnic acute hypoxemic respiratory failure, treatment with high-flow oxygen, standard oxygen, or noninvasive ventilation did not result in significantly different intubation rates. There was a significant difference in favor of high-flow oxygen in 90-day mortality. (Funded by the Programme Hospitalier de Recherche Clinique Interrégional 2010 of the French Ministry of Health; FLORALI ClinicalTrials.gov number, NCT01320384.).

Inhaled nitric oxide as a screening agent for safely identifying responders to oral calcium-channel blockers in primary pulmonary hypertension

In a subset of patients with primary pulmonary hypertension (PPH), high doses of oral calcium-channel blockers (CCB) produce a sustained clinical and haemodynamic improvement. However, significant side-effects have been reported during acute testing with CCB. Therefore, to identify accurately patients who may benefit from long-term CCB therapy, there is a need for a safe, potent and short-acting vasodilator. The aim of this study was to compare the acute response to inhaled nitric oxide (NO) and oral high doses of CCB in 33 consecutive patients with PPH. A significant acute vasodilator response was defined by a fall in both mean pulmonary artery pressure and total pulmonary resistance by >20%. Ten patients responded acutely to NO, nine of whom responded acutely to CCB, without any complications. The 23 other patients failed to respond to NO and CCB. In these nonresponders, nine serious adverse events were observed with CCB (38%). There was no clinical or baseline haemodynamic feature predicting acute vasodilator response. Long-term oral treatment with CCB was restricted to the nine acute responders and a sustained clinical and haemodynamic improvement was observed in only six patients. In primary pulmonary hypertension, the acute response rate to high doses of calcium-channel blockers is low (27%). Serious adverse reactions to high doses of calcium-channel blockers during acute testing are frequently observed in nonresponders. It is concluded that nitric oxide may be used as a screening agent for safely identifying patients with primary pulmonary hypertension who respond acutely to calcium-channel blockers and may benefit from long-term treatment with these agents.

Short-term and long-term epoprostenol (prostacyclin) therapy in pulmonary hypertension secondary to connective tissue diseases: results of a pilot study

Continuous intravenous epoprostenol improves exercise capacity, haemodynamics, and survival in severe primary pulmonary hypertension. Pulmonary hypertension can also be life-threatening in patients with connective tissue diseases. In a prospective open monocentre uncontrolled study, the effects of epoprostenol were evaluated in patients with severe pulmonary hypertension secondary to connective tissue diseases who were unresponsive to oral vasodilators (including calcium channel blockers) and continued to be in the New York Heart Association (NYHA) functional class III or IV despite conventional medical therapy. Seventeen patients received epoprostenol administered by a portable infusion pump associated with conventional therapy (oral anticoagulants, diuretics, supplemental oxygen). During the first six weeks of therapy, two (12%) patients died, of pulmonary oedema (n = 1) and severe sepsis (n = 1). In the fifteen remaining subjects, clinical and haemodynamic parameters improved significantly at six weeks. These patients were subsequently monitored for 80+/-48 (range 14-154) weeks after initiation of epoprostenol. Five (33%) patients died, of right heart failure (n = 2), severe sepsis (n = 2) or syncope (n = 1) and two patients were successfully transplanted 24 and 52 weeks after initiation of epoprostenol. Seven of the remaining eight patients had a persistent clinical improvement. Short-term epoprostenol therapy is effective in some patients with connective tissue diseases as demonstrated by better clinical status and haemodynamics at six weeks. However, this study reports several cases of early and late major complications including severe sepsis and pulmonary oedema. Additional information is needed to evaluate the benefit: risk ratio of long-term epoprostenol therapy in pulmonary hypertension secondary to connective tissue diseases.

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.

Role of MDCT in Identification of the Bleeding Site and the Vessels Causing Hemoptysis

OBJECTIVE MDCT has improved the management of hemoptysis by providing more precise depiction of bronchial and nonbronchial systemic arteries than conventional CT. The purpose of this article is to review the role of MDCT in the identification of the bleeding site and the vessels causing hemoptysis. CONCLUSION Identification of the origin of the involved systemic arteries (bronchial and nonbronchial) or involved pulmonary artery on MDCT enables the interventional radiologist to treat them, especially in elderly patients with a tortuous aorta and atheroma.

Nonsteroidal Antiinflammatory Drugs May Affect the Presentation and Course of Community-Acquired Pneumonia

BACKGROUND Nonsteroidal antiinflammatory drugs (NSAIDs) are commonly used as antipyretics and analgesics and may affect the host response to acute infection. We investigated the potential influence of NSAIDs on the presentation and short-term outcomes of nonimmunocompromised inpatients with community-acquired pneumonia (CAP) admitted to the ICU. METHODS All consecutive patients with CAP admitted to the ICU or step-down unit of a university hospital during a 4-year period were prospectively included, except when receiving long-term NSAIDs or steroids. Drug exposures, presentation, and hospital course were recorded. RESULTS Of the 90 patients included, 32 (36%) had taken NSAIDs prior to hospital referral. Compared with nonexposed patients, they were younger and had fewer comorbidities but similar severity of disease at presentation, despite a longer duration of symptoms before referral. However, they more often developed pleuropulmonary complications, such as pleural empyema and lung cavitation (37.5% vs 7%; P = .0009), and had a trend to more-invasive disease, with a higher frequency of pleural empyema (25% vs 5%, P = .014) and bacteremia, especially in those not having received concomitant antibiotics (69% vs 27%, P = .009). Nevertheless, the patients in the NSAID group had no more severe systemic inflammation or remote organ dysfunction. In multivariable analyses, NSAID exposure was independently associated with the occurrence of pleuropulmonary complications (OR, 8.1; 95% CI, 2.3-28). CONCLUSIONS Our findings suggest that NSAID exposure at the early stage of CAP is associated with a more complicated course but a blunted systemic response, which may be associated with a delayed diagnosis and a protracted course.

Extracorporeal life support for patients with acute respiratory distress syndrome: report of a Consensus Conference

The influenza H1N1 epidemics in 2009 led a substantial number of people to develop severe acute respiratory distress syndrome and refractory hypoxemia. In these patients, extracorporeal membrane oxygenation was used as rescue oxygenation therapy. Several randomized clinical trials and observational studies suggested that extracorporeal membrane oxygenation associated with protective mechanical ventilation could improve outcome, but its efficacy remains uncertain. Organized by the Société de Réanimation de Langue Française (SRLF) in conjunction with the Société Française d’Anesthésie et de Réanimation (SFAR), the Société de Pneumologie de Langue Française (SPLF), the Groupe Francophone de Réanimation et d’Urgences Pédiatriques (GFRUP), the Société Française de Perfusion (SOFRAPERF), the Société Française de Chirurgie Thoracique et Cardiovasculaire (SFCTV) et the Sociedad Española de Medecina Intensiva Critica y Unidades Coronarias (SEMICYUC), a Consensus Conference was held in December 2013 and a jury of 13 members wrote 65 recommendations to answer the five following questions regarding the place of extracorporeal life support for patients with acute respiratory distress syndrome: 1) What are the available techniques?; 2) Which patients could benefit from extracorporeal life support?; 3) How to perform extracorporeal life support?; 4) How and when to stop extracorporeal life support?; 5) Which organization should be recommended? To write the recommendations, evidence-based medicine (GRADE method), expert panel opinions, and shared decisions taken by all the thirteen members of the jury of the Consensus Conference were taken into account.

Surgical lung resection for severe hemoptysis.

BACKGROUND The 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. METHODS This 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. RESULTS Among 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. CONCLUSIONS Attempting at controlling bleeding with first-line nonsurgical approaches appears necessary to optimize the operative conditions and improve outcome of patients with severe hemoptysis.

Diffuse alveolar haemorrhage: factors associated with in-hospital and long-term mortality

Diffuse alveolar haemorrhage (DAH) is a feature of several immune and nonimmune disorders. Reported prognosis is poor, with in-hospital mortality ranging from 20% to 100%. Early identification of prognostic factors may be useful in the initiation of appropriate treatment. We retrospectively analysed the charts of all patients referred to a university hospital for DAH between 1980 and 2008. Variables associated with in-hospital and long-term mortality were determined using a logistic regression model and the Kaplan–Meier method, respectively. Immunosuppressed patients were excluded. Overall, 97 patients were included in the study. In-hospital mortality was 24.7%. Factors associated with in-hospital mortality were shock (OR 77.5, 95% CI 8.9–677.2), glomerular filtration rate <60 mL·min−1 (OR 11.2, 95% CI 1.8–68.4) and plasmatic lactate dehydrogenase level more than twice the normal value (OR 12.1, 95% CI 1.7–84.3). Mortality among discharged patients was 16.4% with a median follow-up duration of 34 months. Factors associated with increased long-term mortality in univariate analysis were age over 60 yrs (p = 0.026), cardiovascular comorbidity (p = 0.027) and end-stage renal failure with dependence on haemodialysis (p = 0.026). Patients with immune and nonimmune DAH had similar outcomes. Early outcome depended on nonpulmonary organ failures. Conversely, late outcome was related to age, cardiac comorbidities and the need for haemodialysis.

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.