[Treatment of severe acute asthma in adults]. / Traitement des asthmes aigus graves de l'adulte.

Although abnormal blood gases are unusual in status asthmaticus, hypercapnia indicates a considerable increase in bronchial resistance. The authors report their experience of 106 personal cases of acute severe asthma. Emergency management of acute respiratory failure consisted in symptomatic therapy (low rate oxygen or mechanical ventilation after nasal intubation). Corticosteroids, rehydration, antibiotics and beta-2 adrenergic agents were associated. Mechanical ventilation was necessary in patients who developed alterations of consciousness or PaCO2 above 60 mm Hg (8 kPa). In respirator-patients, sedative drugs were needed. Terbutaline and salbutamol were occasionally beneficial but epinephrine remains the drug of choice. In our series of 106 cases (79 with hypercapnia) the overall mortality was 3.8 p. 100. Of the 33 cases who underwent mechanical ventilation, there were 4 deaths (12 p. 100). A review of the literature showed a much higher mortality in other series.

[Changes in the electrocardiogram in status asthmaticus]. / Les modifications de l'électrocardiogramme dans l'état de mal asthmatique.

The aim of this study, based on the electrocardiographic analysis of 42 patients in status asthmaticus, is to define the basic criteria which may be used as a basis for electrocardiographic differential diagnosis. The following ECG changes were observed: the pulmonary "p" wave is common, sometimes with exaggerated amplitude in peripheral leads, however, in the precordial leads, the voltage of the "p" wave is reduced; most cases have a vertical heart with clockwise rotation and mild right axis deviation, S1 Q2 Q3 and the transitional zone displaced to the left. Ten cases also had a S1 S2 S3 appearance and three cases showed Q1 Q2 Q3, simulating myocardial infarction; there is poor progression of the R wave in the precordial leads and marked persistence of the S wave in the left precordial leads. In some cases, a QS complex dominates the right precordial leads. A variation in the amplitude of the QRS with the respiratory rhythm is often seen in V1 and V2; ventricular repolarization shows a lowered J point with an upward oblique ST segment in the peripheral leads. However, in the precordial leads, the repolarization is normal except for three cases which presented a frank hypokalaemia. The mechanism of these electrocardiographic changes appears to depend on the vertical position of the heart caused by over expansion of the lungs and pulmonary arterial hypertension. The elements of the electrocardiographic differential diagnosis with myocardial infarction and pulmonary embolism are discussed.

[Surgically treated chronic aortic valve insufficiency. Long term results. Surgical indications]. / L'insuffisance aortique chronique opérée. Le devenir à long terme - Les indications opératoires.

The timing of surgery in chronic aortic regurgitation depends to a large extent on the operative results that may be expected in this type of valve disease. In 88 cases of chronic aortic regurgitation submitted to surgery there were 6 operative deaths (6.8%). Five years after operation the actuarial survival was 58% for the whole of the group and 68% for cases of rheumatic aortic regurgitation. Analysis of the causes of failures, late deaths, persistence or recurrence of severe impairment of activity, and of serious disturbances of ventricular rhythm, showed that the most important cause was myocardial dysfunction, which was responsible for two thirds of the bad results. Analysis of the late prognosis as a function of the various pre-operative parameters revealed the bad influence of cardiomegaly as measured by radiological examination (cardio-thoracic ratio and cineangiography) and of disturbances in left ventricular function. The actuarial survival curves showed very significant differences according to whether the cardiothoracic ratio was greater or smaller than 58%, and according to the amount of heart failure pre-operatively. Similarly, an end-diastolic volume index of 240 ml/m2 and an ejection fraction less than. 40 seemed to be serious findings. These facts, taken in conjunction with the natural history of this valve lesion, suggest that the indications for surgery should not only be symptomatic aortic regurgitation but also well tolerated regurgitation in which cardiomegaly, end-diastolic volume and/or the ejection fraction have reached a certain level.