Y. Le Tulzo

Survie à long terme des bronchopathes chroniques obstructifs après la réanimation

OBJECTIVE To compare the one year survival after discharge from ICU of patients with chronic obstructive pulmonary disease (COPD) admitted for acute hypercapnic respiratory failure and who required mechanical ventilation. METHODS Retrospective cohort study on 130 patients, 52 patients were treated with non-invasive ventilation (NIV) and 78 patients with conventional mechanical ventilation (CMV). RESULTS In 73 patients the cause for respiratory failure could not be identified. Long-term survival was significantly better following NIV than with CMV (p=0.02 by log-rank testing), but the better prognosis associated with use of NIV was not found in patients with no documented cause for the respiratory failure. After adjusting for male gender, age>65 years, simplified acute physiology score II>35, prior long-term home oxygen therapy, treatment with steroids, FEV1<30% of predicted value, body-mass index<21 kg/m2, albumin level<30 g/L, right ventricular failure, ventilator-associated pneumonia and cause of respiratory failure, NIV remained independently associated with better outcomes (adjusted hazard ratio 0.55; 95% CI 0.31-0.97; p=0.04). CONCLUSIONS Our results suggest that in COPD patients requiring mechanical ventilation and who survived after an ICU stay, the use of NIV is an independent factor associated with a better long-term survival, especially in those with a documented cause of respiratory failure.

Syndrome de détresse respiratoire aiguë sur hémorragie intra-alvéolaire révélant une vascularite

Intra-alveolar hemorrhage (IAH) could be revealed by acute respiratory failure. The classic association of hemoptysis - anemia - radiological infiltrates is suggestive and has to be confirmed by broncho-alveolar lavage with Golde score. Etiologies included immune and non-immune diseases, with specific treatment for each. We report a case of IAH revealed by acute respiratory distress syndrome and anemia (3 g/dL), related to pulmonary and cerebral vasculitis without renal involvement. The patient was efficiently treated with corticosteroids and cyclophosphamide. This case highlights the critical role of BAL cytological analysis with Golde score, and the need for a rapid and accurate diagnosis in order to guide specific treatment. If histology is needed, renal biopsy even without renal involvement, or surgical lung biopsy is possible.

Acute severe hypoxaemia after mechanical ventilation in a patient with an Ebstein anomaly requiring extracorporeal membrane oxygenation

case, however, which demonstrates that this technique can be used safely despite multiple traumatic thoracic injuries, including complex sternal fractures and a flail segment. Several of the key studies of prone ventilation specifically excluded patients with severe chest wall injuries 7 or intracranial hypertension. 8 We believe this case illustrates that this treatment may, with care, be considered for such patients and also suggest that they should not be excluded from further studies in this field.

Q-04 Infections à SARM producteurs de la leucocidine de Panton-Valentine : description d’un clone émergent parmi une population toxicomane

Introduction et objectifs La propagation de SARM communautaires est decrite a travers le monde depuis le milieu des annees 1990. La plupart des souches produisent la leucocidine de Panton-Valentine (LPV) et presentent des specificites liees entre autres a l’existence de populations a risques. Nous rapportons ici la description d’un clone ST8 different d’USA300, responsable d’infections chez des patients presentant, pour la plupart, une toxicomanie active. Materiels et methodes Des souches de S. aureus isolement resistantes a la meticilline ont ete identifiees entre janvier 2007 et janvier 2009 comme responsables de suppurations chez 9 patients. Les donnees demographiques et cliniques ont ete recueillies, les caracteristiques moleculaires des souches determinees a des fins de comparaison. Resultats Ces infections sont survenues chez 6 hommes et 3 femmes, âge moyen 33 ans, dont 6 etaient toxicomanes et 2 vivaient dans des conditions precaires. Tous habitaient dans une zone geographique correspondant au centre et au nord de l’Illeet-Vilaine et a l’est des Cotes-d’Armor. Un lien de clonalite entre les souches a ete confirme par les caracteristiques moleculaires qui ont permis d’identifier un clone ST8, de type spa t008, muni d’une cassette mec de type IV, producteur de LPV et ne possedant pas l’element genetique mobile ACME, signature moleculaire d’USA300. Conclusion Un nouveau clone de SARM communautaire emerge dans une zone geographique limitee, parmi des patients toxicomanes ou ayant des conditions de vie precaires. Son extension geographique est cependant difficile a preciser a partir des seules infections prises en charge en milieu hospitalier. Ses caracteristiques moleculaires le designent comme genetiquement proche d’USA300, clone virulent nord-americain dont il se rapproche egalement par la production de LPV mais dont il differe par l’absence de l’element mobile ACME.