P. Nesme

Devenir des patients BPCO traités par ventilation non invasive prolongée à domicile

Resume Introduction Les benefices de la Ventilation Non Invasive (VNI) restent controverses dans la BPCO hypercapnique stable. Methodes Etude retrospective des patients BPCO traites par VNI au long cours entre 1990 et 2002, soit au decours d’une exacerbation aigue, soit en raison d’une hypercapnie chronique. Resultats 37 patients sous oxygenotherapie longue duree (50 ± 47 mois) ont ete inclus. A l’inclusion : VEMS 27 ± 9% th, Capacite Inspiratoire 45 ± 14 % th, PaO2 en air ambiant 50 ± 10 mm Hg, PaCO2 en air ambiant 53 ± 8 mm Hg, PaCO2 sous oxygene 60 ± 9 mm Hg. La mediane de survie en VNI a ete de 41 mois. Le taux de survie a ete de 92% a 1 an, de 62% a 3 ans, de 24% a 5 ans. Apres 12 mois de VNI a domicile, les PaCO2 en air ambiant et sous oxygene sont significativement diminuees (respectivement 47 ± 8 mm Hg, p = 0,028 et 53 ± 8 mm Hg, p = 0,005), la Capacite Inspiratoire est significativement augmentee (54 ± 18% th, p = 0,033). Conclusion Cette etude suggere que la VNI a domicile permet une stabilisation physiologique durable de certains patients BPCO, particulierement dans les formes avancees, en reduisant l’hypercapnie et en ameliorant la Capacite Inspiratoire.

Épanchement pleural gauche massif révélateur d’une péricardite constrictive idiopathique

Introduction Nous presentons l’observation d’une pericardite constrictive initialement revelee par un epanchement pleural gauche de grande abondance chez une patiente dyspneique sans autres signes cliniques associes. Cas clinique Seul le catheterisme cardiaque a pose le diagnostic de certitude par l’aspect caracteristique en dip-plateau du ventricule droit. Apres bilan, aucune etiologie n’a ete retrouvee a cette pericardite constrictive. Conclusion Suite a la mise en place d’un traitement par corticoides, l’evolution est a ce jour favorable.

Diffuse Interstitial Lung Disease Linked to Vandetanib

Introduction Vandetanib inhibits vascular endothelial growth factor receptor (VEGFR) 2 tyrosine kinase activity in endothelial cells and, to a lesser degree, endothelial growth factor receptor (EGFR) tyrosine kinase activity in tumor cells. Vandetanib has been developed for the treatment of non–small-cell lung cancer (NSCLC), either alone or in combination with second-line chemotherapy. We describe a case of interstitial lung disease (ILD) in a patient who received vandetanib in a randomized, controlled, double-blind trial by comparing a pemetrexed combination with either vandetanib or placebo.

Quantitative Analysis of Acid-Base Disorders in Patients with Acute on Chronic Respiratory Failure and Acute Respiratory Distress Syndrome. A Prospective, One Center Study

Background: With Stewart approach, pH depends on strong ion difference (SIDe), PaCO2 and non volatile weak acids (Atot). This approach might detect complex acid-base disorders undetected by conventional approach. We de- signed this study to describe acid-base disorders with both Stewart and conventional approaches and to compare the diagnostic performance in patients with chronic respiratory failure (CRF) in acute respiratory failure (ARF) or with acute respiratory distress syndrome (ARDS) because they are expected to have complex acid-base disorders. Conventional ap- proach was based on standardized base excess (SBE), bicarbonate (HCO3 - ) and anion gap (AG). Working hypotheses were that in CRF, metabolic alkalosis was associated with respiratory acidosis and in ARDS, Stewart approach was able to identify metabolic acidosis not detected with the conventional approach. Methods: Observational study in a medical ICU of a University hospital on 36 patients with obstructive CRF (CRFo), 36 with non obstructive CRF (CRFno) and 28 with ARDS prospectively included over 8 months. Measurements were per- formed on ICU admission, day 1 and day 2 after admission. Results: Metabolic alkalosis occurred in less than 5% of samples in CRF patients and in 0 ARDS patient. As compared to CRF patients, ARDS patients exhibited lower SBE, higher AG, lower SIDe and lower Atot. In ARDS, low SIDe was pri- marily due to elevated unidentified anions. Hypoalbuminemia was present in more than 75% of patients without dif- ference between groups. Normal values of SBE, HCO3 - and AG were very common. Stewart approach detected low SIDe in 13% of samples with normal SBE, in 13.8% of samples with normal HCO3 - , and in 11% of samples with normal AG corrected for abnormal albumin concentration, without difference between CRF and ARDS. Conclusions: In these selected critically ill patients, Stewart approach exceeded the diagnostic performance of the conven- tional approach even when AG corrected was taken into account. Further studies in CRF patients with chronic hypercap- nia and elevated bicarbonatemia are required to assess the incidence of associated metabolic alkalosis.

Reliability of Tidal Volume in Average Volume Assured Pressure Support Mode

BACKGROUND: Remote monitoring is increasingly used in patients who receive home mechanical ventilation. The average volume assured pressure support mode is a target volume pressure preset mode that delivers a given tidal volume (VT) within a range of controlled inspiratory pressures. In a mode such as this, it is important to verify that the VT value retrieved from the ventilator SD card is accurate. METHODS: A lung model was set with C (Compliance) 0.075 L/cm H2O and RI (Inspiratory resistance)-RE (Expiratory resistance) 15–25 cm H2O/L/s (model 1) or with C 0.050 L/cm H2O and RI 6 cm H2O/L/s (model 2) and 6 cm H2O effort. Three home-care ventilators (A40, PrismaST30, and Vivo40) were set to average volume assured pressure support mode with 0.3 and 0.6 L VT each at PEEP 5 and 10 cm H2O, and were connected to the lung model with and without nonintentional leak. The reference airway pressure and flow were measured by a data logger. VT was expressed in body temperature and pressure saturated. We assessed the difference in VT between the ventilator SD card and a data logger relative to set VT and factors associated with its magnitude. RESULTS: For A40, PrismaST30, and Vivo40, the adjusted mean VT differences between the ventilator SD card and the data logger were −0.053 L (95% CI −0.067 to −0.039 L) (P < .001), −0.002 L (95%CI −0.022 to 0.019 L) (P = .86), and −0.067 L (95% CI −0.007 to 0.127 L) (P = .03), respectively. The partial Spearman correlation coefficients between the ventilator SD card and a data logger were 0.89 (P < .001), 0.59 (P < .001), and 0.78 (P < .001), respectively to the ventilators. The relative variations in measured VT from the set VT were 16.0, −12.0, and 6.7% for the ventilator SD card, and were −2.5, −7.5, and −27.2% for the data logger, respectively. The discrepancy in ventilator between SD card and data logger were influenced by PEEP for the PrismaST30 ventilator, nonintentional leak for the Vivo40 ventilator and PEEP, nonintentional leak, and underlying disease, the effect of each depending on the levels of the other factors, for the A40 ventilator. CONCLUSIONS: In the 3 home-care ventilators, the ventilator SD card underestimated VT. Factors involved in this difference differed among the ventilators.

Sleep apnea in patients with heart failure: Could cardiac resynchronization therapy be the first line treatment?

Adaptive servo-ventilation as well as continuous and bi-level positive airway pressure seems to effectively treat sleep apnea syndrome (SAS) in patients with chronic heart failure (CHF), and to improve left ventricular function. However, no randomized data show a significant impact of ventilation on survival in patients with CHF. By contrast, there is overwhelming evidence that cardiac resynchronization therapy (CRT) improves outcomes in patients with CHF. CRT also provides a clinically significant decrease in SAS severity in patients with CHF. Consequently, CRT eligibility criteria should always be searched for in patients with severe CHF having SAS.

A successful new method for removal of a large foreign body from the airways of an ARDS patient

Sir: Extracting a foreign body (FB) from the bronchial tree may be difficult, depending on the size and location of the FB, and on the training of the operator as well. When FB aspiration occurs in a severely hypoxemic patient, extraction using bronchoscopy may be harmful because of the risk of hypoventilation during the procedure. We report the successful removal of a dental crown from the right bronchial tree with an unusual new method in a patient with severe acute respiratory distress syndrome (ARDS). A 58-year-old man underwent out-of-hospital cardiac arrest from ventricular fibrillation. Return to sinus cardiac rhythm was obtained after the first electric shock delivered by a semi-automated external defibrillator. Emergency tracheal intubation via the oral route was complicated by dental injury and pulmonary aspiration of gastric content leading to severe hypoxemia. Chest X-ray demonstrated a FB in the right main bronchus and bilateral infiltrates (Fig. 1a). The diagnosis of severe ARDS was established from PaO2/FiO2 \100 and normal left atrial pressure assessed by echocardiography. Ventilatory settings included FiO2 0.7, tidal volume 6 ml/ kg predicted body weight and positive end-expiratory pressure 12 cm H2O. Several attempts performed by a pulmonologist to remove the FB using either a suction device attached to a flexible fiberscope (LF-GPOlympus,Germany), biopsy forceps, wire basket or wire loop snare were unsuccessful. Due to the ongoing severe ARDS, rigid bronchoscopy was not performed because it would have required patient extubation and interruption of mechanical ventilation during the whole procedure, which was thought to be much too hazardous.