Vincent Jounieaux

Effects of nasal positive-pressure hyperventilation on the glottis in normal sleeping subjects

We have previously observed that, in normal awake subjects passively hyperventilated with intermittent positive-pressure ventilation delivered through nasal access (nIPPV), the glottis could interfere with the ventilation. We report on data obtained in the same subjects during stable sleep. In all cases, the glottis was continuously observed through a fiber-optic bronchoscope, and other indexes were also continuously recorded. Mechanical ventilation was progressively increased up to 30 l/min. We have observed during passive nIPPV in stable sleep that increases in delivered minute ventilation (VEd) resulted in progressive narrowing of the glottic aperture, with increases in inspiratory resistance and progressive reductions in the percentage of the delivered tidal volume effectively reaching the lungs. For a given level of VEd, comparisons showed that the glottis was significantly narrower during sleep than during wakefulness and that the glottis was significantly narrower during stage 2 than during stages 3/4 non-rapid-eye-movement sleep. Moreover, when CO2 is added to the inspired air, glottic aperture increased in five of nine trials without changes in sleep stage. We also observed a significant negative correlation between glottic width and the VED, independent of the CO2 level. We conclude that during nIPPV glottis narrowing results in a decrease in the proportion of the delivered tidal volume reaching the lungs.

Assist-control ventilation vs. low levels of pressure support ventilation on sleep quality in intubated ICU patients

ObjectiveTo compare the impact of assist-control ventilation (ACV) and pressure support ventilation with 6 cmH2O inspiratory pressure (low PSV) on sleep quality.DesignProspective randomized cross-over study.PatientsTwenty intubated and mechanically ventilated patients for acute on chronic respiratory failure.MeasurementsPatients were monitored by standard polysomnography at the end of their weaning period. Patients were assigned to receive either ACV from 10 p.m. to 2 a.m. and low PSV from 2 a.m. to 6 a.m. (ACV/low PSV group) or low PSV from 10 p.m. to 2 a.m. and ACV from 2 a.m. to 6 a.m. (low PSV/ACV group).ResultsThere were significant increases in stages 1 and 2 non-rapid eye movement (NREM) sleep and reduction in wakefulness during the first part of the night and significant increases in stages 3 and 4 NREM sleep during the second part of the night were observed with ACV compared to low PSV. A significant negative correlation was observed between the perceived sleep quality and the amount of wakefulness while the amount of stage 2 NREM sleep was positively correlated with perceived sleep quality.ConclusionsACV was significantly associated with a better sleep quality than those recorded during pressure support. The perception of sleep quality appeared to be better with ACV than with low PSV. On the basis of these results we recommend that intubated and mechanically ventilated patients for acute on chronic respiratory failure should be reventilated at night during their weaning period.

Admission of advanced lung cancer patients to intensive care unit: A retrospective study of 76 patients

BackgroundCriteria for admitting patients with incurable diseases to the medical intensive care unit (MICU) remain unclear and have ethical implications.MethodsWe retrospectively evaluated MICU outcomes and identified risk factors for MICU mortality in consecutive patients with advanced lung cancer admitted to two university-hospital MICUs in France between 1996 and 2006.ResultsOf 76 included patients, 49 had non-small cell lung cancer (stage IIIB n = 20; stage IV n = 29). In 60 patients, MICU admission was directly related to the lung cancer (complication of cancer management, n = 30; cancer progression, n = 14; and lung-cancer-induced diseases, n = 17). Mechanical ventilation was required during the MICU stay in 57 patients. Thirty-six (47.4%) patients died in the MICU. Three factors were independently associated with MICU mortality: use of vasoactive agents (odds ratio [OR] 6.81 95% confidence interval [95%CI] [1.77-26.26], p = 0.005), mechanical ventilation (OR 6.61 95%CI [1.44-30.5], p = 0.015) and thrombocytopenia (OR 5.13; 95%CI [1.17-22.5], p = 0.030). In contrast, mortality was lower in patients admitted for a complication of cancer management (OR 0.206; 95%CI [0.058-0.738], p = 0.015). Of the 27 patients who returned home, four received specific lung cancer treatment after the MICU stay.ConclusionsPatients with acute complications of treatment for advanced lung cancer may benefit from MCIU admission. Further studies are necessary to assess outcomes such as quality of life after MICU discharge.

Apparent Absence of Pneumocystis jirovecii in Healthy Subjects

We prospectively investigated 30 healthy subjects with normal CD4+ T cell counts in blood and normal findings of spirometry and chest radiography for the presence of Pneumocystis jirovecii, by performing polymerase chain reaction on sputum specimens. Fifty patients with chronic obstructive pulmonary disease were investigated at the same time in the same manner; this group was used as controls for the diagnosis of pulmonary colonization with P. jirovecii. None of the healthy subjects had positive test results, whereas the fungus was detected in 8 patients with chronic obstructive pulmonary disease. The results suggest that in our region (Amiens, France), P. jirovecii is apparently uncommon in healthy subjects and that this population, therefore, plays a minor role in circulation of the fungus within human communities.

Bacterial infection profiles in lung cancer patients with febrile neutropenia

BackgroundThe chemotherapy used to treat lung cancer causes febrile neutropenia in 10 to 40% of patients. Although most episodes are of undetermined origin, an infectious etiology can be suspected in 30% of cases. In view of the scarcity of data on lung cancer patients with febrile neutropenia, we performed a retrospective study of the microbiological characteristics of cases recorded in three medical centers in the Picardy region of northern France.MethodsWe analyzed the medical records of lung cancer patients with neutropenia (neutrophil count < 500/mm3) and fever (temperature > 38.3°C).ResultsThe study included 87 lung cancer patients with febrile neutropenia (mean age: 64.2). Two thirds of the patients had metastases and half had poor performance status. Thirty-three of the 87 cases were microbiologically documented. Gram-negative bacteria (mainly enterobacteriaceae from the urinary and digestive tracts) were identified in 59% of these cases. Staphylococcus species (mainly S. aureus) accounted for a high proportion of the identified Gram-positive bacteria. Bacteremia accounted for 60% of the microbiologically documented cases of fever. 23% of the blood cultures were positive. 14% of the infections were probably hospital-acquired and 14% were caused by multidrug-resistant strains. The overall mortality rate at day 30 was 33% and the infection-related mortality rate was 16.1%. Treatment with antibiotics was successful in 82.8% of cases. In a multivariate analysis, predictive factors for treatment failure were age >60 and thrombocytopenia < 20000/mm3.ConclusionGram-negative species were the most frequently identified bacteria in lung cancer patients with febrile neutropenia. Despite the success of antibiotic treatment and a low-risk neutropenic patient group, mortality is high in this particular population.

Respiratory-gated 18F-FDG PET imaging in lung cancer: effects on sensitivity and specificity.

Background Respiratory motion is known to deteriorate positron emission tomography (PET) images and may lead to potential diagnostic errors when a standardized uptake value (SUV) cut-off threshold is used to discriminate between benign and malignant lesions. Purpose To evaluate and compare ungated and respiratory-gated 18F-fluorodeoxyglucose PET/computed tomography (CT) methods for the characterization of pulmonary nodules. Material and Methods The list-mode acquisition during respiratory-gated PET was combined with a short breath-hold CT scan to form the CT-based images. We studied 48 lesions in 43 patients. PET images were analyzed in terms of the maximum SUV (SUVmax) and the lesion location. Results Using receiver-operating characteristic (ROC) curves, the optimal SUV cut-off thresholds for the ungated and CT-based methods were calculated to be 2.0 and 2.2, respectively. The corresponding sensitivity values were 83% and 92%, respectively, with a specificity of 67% for both methods. The two methods gave equivalent performance levels for the upper and middle lobes (sensitivity 93%, specificity 62%). They differed for the lower lobes, where the CT-based method outperformed the ungated method (sensitivity values of 90% and 70%, respectively, and a specificity of 73% with both methods) – especially for lesions smaller than 15 mm. Conclusion The CT-based method increased sensitivity and did not diminish specificity, compared with the ungated method. It was more efficient than the ungated method for imaging the lower lobes and smallest lesions, which are most affected by respiratory motion.

Relationships between exercise-induced pulmonary hypertension and nocturnal desaturation.

To the Editors: We read with interest the excellent article by Christensen et al . 1, which failed to show a consistent relationship between hypoxaemia and pulmonary hypertension (PH) during exercise equivalent to activities of daily living (ADL) in chronic obstructive pulmonary disease (COPD) patients. This important observation prompted us to report here the results of a prospective study that we conducted during the 1990s, which has only been published in abstract form 2. Nine male COPD patients with mild hypoxaemia at rest (six current and three ex-smokers) were included in the study (age: 66.9±5.8 yrs, forced expiratory volume in one second/forced vital capacity: 43.2±15.5% predicted, arterial oxygen tension ( P a,O2): 8.66±0.47 kPa (65.1±3.5 mmHg), carbon dioxide arterial tension ( P a,CO2): 5.93±0.77 kPa (44.6±5.8 mmHg)). Haemodynamic …

Comparison of 2 maintenance doses (100 μg vs 200 μg) in Hymenoptera venom immunotherapy: influence of the maintenance dose on the immunologic response

Background In Hymenoptera venom immunotherapy, the maintenance dose is usually 100 μg. However, persistent systemic reactions to sting challenges could be treated by an increase in the maintenance dose to 200 μg with success, suggesting greater efficiency. Objective To compare the effects of 2 monthly maintenance doses (100 μg vs 200 μg) on skin test sensitivity and venom specific IgE antibody levels. Methods Twenty-two patients receiving Vespula venom immunotherapy were enrolled in this retrospective study. After rush therapy, the 100-μg maintenance dose initially administered was maintained (group 1, n=13) or was increased to 200 μg (group 2, n=9). Results Levels of venom specific IgE antibody and skin test results measured before the onset of immunotherapy were comparable in both groups. Unlike in group 1, a maintenance dose of 200 μg resulted in significant decreases in venom specific IgE antibody levels and skin test sensitivity. Conclusions Increasing the monthly maintenance dose to 200 μg results in a greater degree of change in venom specific IgE antibody levels and skin test sensitivity than when maintaining a 100-μg dose. Our data strengthen those of previous clinical studies showing the usefulness of a 200-μg maintenance dose in the case of clinical failure of a 100-μg dose.

Pneumothorax et inhalation volontaire de protoxyde d'azote

Resume Cas clinique Un homme de 21 ans est admis aux urgences pour douleur thoracique gauche. La radiographie thoracique revele un pneumothorax gauche complet non compressif. L’evolution est favorable apres drainage thoracique. La reprise de l’interrogatoire revelera une utilisation repetee et reguliere de protoxyde d’azote par inhalation, pour ses effets hilarants et psychodysleptiques, dans les rave-party. Discussion Les principaux effets indesirables de l’exposition repetee au protoxyde d’azote sont hematologiques, neuropsychiatriques et teratogenes. Les rares cas de pneumothorax decrits avec ce gaz sont des accidents d’anesthesie ou de coelioscopie par diffusion du gaz de la cavite peritoneale vers la cavite pleurale. La toxicomanie au protoxyde d’azote est rare et touchait jusqu’a present le personnel medical. En s’etendant au grand public, elle expose a la survenue d’accidents et d’effets indesirables non connus. Conclusion L’inhalation de protoxyde d’azote peut reveler un pneumothorax asymptomatique en l’aggravant. Les consequences peuvent etre dramatiques lors de son utilisation frauduleuse en milieu extra-hospitalier par meconnaissance de ses effets secondaires.

Hémangioendothéliome épithélioïde pulmonaire: à propos de trois cas et revue de la littérature

INTRODUCTION Pulmonary epithelioid haemangioendothelioma (PEH) is a rare vascular tumour of intermediate malignancy that predominantly affects women. CLINICAL CASE REPORTS We report three cases of PEH. Though all three diagnoses were confirmed by surgical biopsy, it is notable that, in one case, a tracheal biopsy by flexible bronchoscopy was contributory. Two patients had undergone positron emission tomography, which showed the lesions to be well established. The three cases show that the evolution of this pathology can be very varied. In the first case, the disease was multifocal and needed to be treated with several pulmonary resections. In the second case no recurrence has been observed after surgery; in the third case the patient died following a haemothorax. CONCLUSION The discovery of a PEH is usually fortuitous. The diagnosis is confirmed by immuno-chemical analysis of a lung biopsy. No standard treatment has been validated and no treatment is necessary if the disease is asymptomatic. If there is only one nodule, surgery is the treatment of choice. The prognosis is variable. Usually the evolution is slow except when the disease is complicated by haemoptysis, pleural effusion, haemothorax, mediastinal lymphadenopathy or hepatic spread.