Associations of Awake Prone Positioning-Induced Changes in Physiology with Intubation: An International Prospective Observational Study in Patients with Acute Hypoxemic Respiratory Failure Related to COVID-19.

INTRODUCTION: Awake prone positioning has the potential to improve oxygenation and decrease respiratory rate, potentially reducing the need for intubation in patients with acute hypoxemic respiratory failure. We investigated awake prone positioning-induced changes in oxygenation and respiratory rate, and the prognostic capacity for intubation in patients with COVID-19 pneumonia. METHODS: International multicenter prospective observation study in critically ill adult patients with COVID-19 receiving supplemental oxygen. We collected data on oxygenation and respiratory rate at baseline, and at 1 h after being placed in prone positioning. The combined primary outcome was oxygenation and respiratory rate at 1 h. The secondary endpoint was treatment failure, defined as need for intubation within 24 h of start of awake prone positioning. RESULTS: Between March 27th and November 2020, 101 patients were enrolled of which 99 were fully analyzable. Awake prone positioning lasted mean of 3 [2-4] h. In 77 patients (77.7%), awake prone positioning improved oxygenation, and in 37 patients (54.4%) it decreased respiratory rate. Twenty-nine patients (29.3%) were intubated within 24 h. An increase in SpO2/FiO2 of < 10 (OR 5.1, 95% CI 1.4-18.5, P = 0.01), a failure to increase PaO2/FiO2 to > 116 mmHg (OR 3.6, 95% CI 1.2-10.8, P = 0.02), and a decrease in respiratory rate of < 2 breaths/min (OR 3.6, 95% CI 1.3-9.5, P = 0.01) were independent variables associated with need for intubation. The AUC-ROC curve for intubation using a multivariable model was 0.73 (95% CI 0.62-0.84). CONCLUSIONS: Awake prone positioning improves oxygenation in the majority of patients, and decreases respiratory rate in more than half of patients with acute hypoxemic respiratory failure caused by COVID-19. One in three patients need intubation within 24 h. Awake prone position-induced changes in oxygenation and respiratory rate have prognostic capacity for intubation within 24 h.

[Platypnea-orthodeoxia syndrome]. / Syndrome de platypnée-orthodéoxie.

Platypnea-orthodeoxia syndrome (POS) is a rare clinical syndrome characterized by dyspnea (platypnea) and arterial desaturation (orthodeoxia) upon changing from a lying to a standing or sitting position. The underlying physiopathological mechanisms involved are complex. Hypoxemia is attributed to the mixing of deoxygenated venous blood with arterial blood through a shunt, which can be intracardiac, or extracardiac. Patent foramen ovale is the main cause of intracardiac shunting. The transthoracic bubble contrast echocardiogram with intravenous agited saline is the most important test in the diagnosis process. Management is specific to the underlying etiology.

Le syndrome de platypnée-orthodéoxie (SPO) est une entité clinique rare associant une dyspnée (platypnée) ou une désaturation artérielle (orthodéoxie) au passage de la position couchée à la position debout ou assise. Les mécanismes physiopathologiques impliqués sont complexes. L'hypoxémie est attribuée au mélange du sang veineux désoxygéné au sang artériel par un shunt, dont l'étiologie peut être intracardiaque ou extracardiaque. Le foramen ovale perméable est la principale cause de shunt intracardiaque. L'échocardiographie avec test aux microbulles est un examen cardinal dans la démarche diagnostique. La prise en charge est spécifique à l'étiologie sous-jacente.

Outcomes with revascularization and medical therapy in patients with coronary disease and chronic kidney disease: A meta-analysis.

BACKGROUND AND AIMS: Chronic kidney disease (CKD) confers a high risk for poor cardiovascular outcomes. We conducted a systematic review and meta-analysis to estimate the effects of revascularization as the initial management strategy compared with medical therapy among patients with CKD and coronary artery disease. METHODS: A Medline/PubMed literature research was conducted to identify randomized studies comparing early coronary revascularization with optimal medical therapy or medical therapy alone in patients with CKD (estimated glomerular filtration rate <60 mL/min/1.73 m2 or maintenance dialysis). The primary outcome was myocardial infarction. The secondary outcomes were all-cause mortality or progression to kidney failure. The risk ratio (RR) was estimated using a random-effects model. RESULTS: Eleven randomized trials were included (3422 patients). Revascularization was associated with lower incidence of myocardial infarction compared with medical therapy in patients with CKD: RR 0.71 (95% confidence interval [CI] 0.54-0.94; p=0.02). This result was mainly driven from a significantly lower incidence of myocardial infarction with early revascularization among patients with stable coronary artery disease: RR 0.59; 95% CI 0.37-0.93. A similar incidence of all-cause mortality was observed with both treatment strategies: RR 0.88 (95% CI 0.72-1.08; p=0.22). A trend towards lower incidence of all-cause mortality was observed with revascularization in the subgroup of patients presenting with NSTE-ACS: RR 0.73 (95% CI 0.51-1.04; p=0.08) but not among patients with stable coronary disease. There was no difference in progression to kidney failure between the two strategies. CONCLUSIONS: Coronary revascularization may be superior to medical therapy among patients with CKD and coronary disease.

Eight versus 28-point lung ultrasonography in moderate acute heart failure: a prospective comparative study.

Lung ultrasonography (LUS) is an accurate method of estimating lung congestion but there is ongoing debate on the optimal number of scanning points. The aim of the present study was to compare the reproducibility (i.e. interobserver agreement) and the feasibility (i.e. time consumption) of the two most practiced protocols in patients hospitalized for acute heart failure (AHF). This prospective trial compared 8- and 28-point LUS protocols. Both were performed by an expert-novice pair of sonographers at admission and after 4 to 6 days on patients admitted for AHF. A structured bio-clinical evaluation was simultaneously carried out by the treating physician. The primary outcome was expert-novice interobserver agreement estimated by kappa statistics. Secondary outcomes included time spent on image acquisition and interpretation. During the study period, 43 patients underwent a total of 319 LUS exams. Expert-novice interobserver agreement was moderate at admission and substantial at follow-up for 8-point protocol (weighted kappa of 0.54 and 0.62, respectively) with no significant difference for 28-point protocol (weighted kappa of 0.51 and 0.41; P value for comparison 0.74 at admission and 0.13 at follow-up). The 8-point protocol required significantly less time for image acquisition at admission (mean time difference - 3.6 min for experts, - 5.1 min for novices) and interpretation (- 6.0 min for experts and - 6.3 min for novices; P value < 0.001 for all time comparisons). Similar differences were observed at follow-up. In conclusion, an 8-point LUS protocol was shown to be timesaving with similar reproducibility when compared with a 28-point protocol. It should be preferred for evaluating lung congestion in AHF inpatients.

Early Measurement of ROX Index in Intermediary Care Unit Is Associated with Mortality in Intubated COVID-19 Patients: A Retrospective Study.

COVID-19 patients often present with rapidly progressing acute hypoxemic respiratory failure, requiring orotracheal intubation with different prognostic issues. However, ICU specialists lack predictive tools to stratify these patients. We conducted a single-center cross-sectional retrospective study to evaluate if the ROX index, measured under non-invasive oxygenation support, can predict ICU mortality in a COVID-19 intubated patient cohort. This study took place in the division of intensive care at the Geneva University Hospitals (Geneva, Switzerland). We included all consecutive adult patients treated by non-invasive oxygenation support and requiring intubation for acute respiratory failure due to COVID-19 between 9 September 2020 and 30 March 2021, corresponding to the second local surge of COVID-19 cases. Baseline demographic data, comorbidities, median ROX between H0 and H8, and clinical outcomes were collected. Overall, 82 patients were intubated after failing a non-invasive oxygenation procedure. Women represented 25.6% of the whole cohort. Median age and median BMI were 70 (60-75) years and 28 (25-33), respectively. Before intubation, the median ROX between H0 and H8 was 6.3 (5.0-8.2). In a multivariate analysis, the median ROX H0-H8 was associated with ICU mortality as a protective factor with an odds ratio (95% CI) = 0.77 (0.60-0.99); p < 0.05. In intubated COVID-19 patients treated initially by non-invasive oxygenation support for acute respiratory failure, the median ROX H0-H8 could be an interesting predictive factor associated with ICU mortality.

[Role of point-of-care ultrasonography in the management of heart failure]. / Rôle de l'échographie ciblée dans la prise en charge de l'insuffisance cardiaque.

Heart failure is a common disease and one of the main reasons of hospital admission. It is a rich research field, marked by regular novelties in the management of heart failure. In the last decades point-of-care ultrasonography has been more prominent in internal medicine, particularly for the management of heart failure. A structured training is required to acquire core competencies. In heart failure, this bedside tool includes focused lung, cardiac and vascular ultrasonography. The combination of these modalities raises diagnostic accuracy, reduce time to diagnosis in dyspneic patients and plays a role in adaptation of decongestive therapy.

L'insuffisance cardiaque est une pathologie fréquente et l'un des principaux motifs d'admission à l'hôpital. La recherche clinique, riche dans ce domaine, marque régulièrement le paysage médical de nouveautés dans sa prise en charge. L'échographie ciblée s'est développée de manière importante ces dernières années en médecine interne, en particulier pour la prise en charge de l'insuffisance cardiaque. L'apprentissage de celle-ci nécessite une formation structurée pour l'acquisition des compétences de base, permettant l'exploration ciblée du cœur, des vaisseaux et de l'appareil pleuropulmonaire au lit du patient. La combinaison de ces modalités améliore la précision diagnostique, diminue le délai diagnostique lors de dyspnée, et joue un rôle dans l'adaptation du traitement décongestif.

[Internal medicine in 2020]. / 2020 en revue par les internistes hospitaliers.

2020: annus horribilis for hospital medicine? The past year, notable because of the current pandemic, has had a profound impact on multiple aspects of medical practice. Just as all medical staff and the general population, hospital internists were put under immense strain in 2020. This year has more than ever reinforced our belief in the importance of keeping a critical and scientific eye on the mass of new studies and data produced every year. The internists of the HUG propose a critical review of selected recent publications that may influence our daily management of patients.

2020 : annus horribilis pour la médecine hospitalière ? L'année écoulée, marquée par la pandémie en cours, a eu un impact majeur sur de multiples aspects de notre pratique. Comme l'ensemble du monde médico-soignant et de la population, les internistes hospitaliers ont été mis à rude épreuve en 2020. Cette année a plus que jamais renforcé notre conviction de l'importance de porter un regard scientifique sur la masse de nouveautés qui surviennent chaque année. Les internistes hospitaliers des HUG vous proposent de partager leur vision critique de publications scientifiques récentes utiles pour notre pratique quotidienne.

[Ethics and the decision of cardiopulmonary resuscitation]. / Ne pas réanimer ou laisser mourir naturellement? Enjeux éthiques.

Following the guidelines of the Swiss Academy of Medical Science, most Swiss hospitals have implemented advanced directives that define what should be undertaken in case of cardiorespiratory arrest for every patient. This remains difficult to apply for physicians and difficult to understand for patients. From a medical perspective, some confusion occurs around medical directives. Difficulties include subjective misinterpretation of patient's quality of life, as well as decision making bias. In addition, patients overestimate the cardiopulmonary reanimation success rate, modify their choices with time and health status, and might lack their individual ability of discernment. Patient's autonomy must always be encouraged as long as it stays within the limits of medical indications.

Conformément aux recommandations de l'Académie suisse des sciences médicales (ASSM), la majorité des hôpitaux suisses ont mis en place une obligation de directives anticipées déterminant l'attitude à adopter en cas d'arrêt cardiorespiratoire pour chaque patient. En pratique, cela est souvent difficile à appliquer pour les médecins et à comprendre par les patients. Du point de vue médical, on observe notamment des problèmes de compréhension des attitudes, des interprétations subjectives erronées du pronostic de vie et de la qualité de vie, ainsi que des biais décisionnels. Le patient quant à lui surestime le taux de succès de la réanimation cardiopulmonaire, fait des choix inconstants, et n'a pas toujours sa capacité de discernement au moment de se prononcer. L'autonomie du patient doit être encouragée, toutefois dans les limites de l'éventail de propositions thérapeutiques jugées médicalement indiquées.