Effect of plasma exchange in acute respiratory failure due to Anti-neutrophil cytoplasmic antibody-associated vasculitis.

BACKGROUND: Acute respiratory failure related to diffuse alveolar hemorrhage (DAH) is a typical presentation of small-vessel vasculitis that requires prompt multidisciplinary management. The primary treatment is based on immunosuppressive drugs, whereas urgent plasma exchange has been proposed in case of life-threatening complications. We addressed the course of respiratory failure in 12 patients with ANCA-associated vasculitis-related DAH. PATIENTS AND METHODS: Observational retrospective case series performed in the medical ICU of a tertiary hospital in Paris, France. Consecutive patients with ANCA-associated DAH admitted to our ICU for acute respiratory failure and treated by plasmapheresis were included in the analysis. We evaluated the SpO2/FiO2 ratio and assessed the mechanical ventilation mode hourly for 7 days. RESULTS: Twelve patients were included. Five of them required invasive mechanical ventilation. All patients were treated by plasma exchange in addition to a combination of glucocorticoids and immunosuppressive agents. Oxygenation improved over the first 7 days following initiation of plasma exchange, as shown by a dramatic increase in the median SpO2/FiO2 ratio from 183 [interquartile 137-321] to 353 [239-432] (p = 0.003), along with a decrease in the level of ventilatory support. All but one patient survived. CONCLUSIONS: A multimodal induction regimen combining immunosuppressants and plasma exchange may rapidly reverse the respiratory dysfunction in ANCA-associated vasculitis-related DAH.

"It Was the Only Thing I Could Hold Onto, But ": Receiving a Letter of Condolence After Loss of a Loved One in the ICU: A Qualitative Study of Bereaved Relatives' Experience.

OBJECTIVES: Family members of patients who die in the ICU often remain with unanswered questions and suffer from lack of closure. A letter of condolence may help bereaved relatives, but little is known about their experience of receiving such a letter. The objective of the study was to understand bereaved family members' experience of receiving a letter of condolence. DESIGN: Qualitative study using interviews with bereaved family members who received a letter of condolence and letters written by these family members to the ICU team. This study was designed to provide insight into the results of a larger randomized, controlled, multicenter study. SETTING: Twenty-two ICUs in France. SUBJECTS: Family members who lost a loved one in the ICU and who received a letter of condolence. MEASUREMENTS AND MAIN RESULTS: Thematic analysis was used and was based on 52 interviews and 26 letters. Six themes emerged: 1) a feeling of support, 2) humanization of the medical system, 3) an opportunity for reflection, 4) an opportunity to describe their loved one, 5) continuity and closure, and 6) doubts and ambivalence. Possible difficulties emerged, notably the re-experience of the trauma, highlighting the absence of further support. CONCLUSIONS: This study describes the benefits of receiving a letter of condolence; mainly, it humanizes the medical institution (feeling of support, confirmation of the role played by the relative, supplemental information). However, this study also shows a common ambivalence about the letter of condolence's benefit. Healthcare workers must strive to adapt bereavement follow-up to each individual situation.

Effect of a condolence letter on grief symptoms among relatives of patients who died in the ICU: a randomized clinical trial.

PURPOSE: Family members of patients who die in the intensive care unit (ICU) may experience symptoms of stress, anxiety, depression, posttraumatic stress disorder (PTSD), and/or prolonged grief. We evaluated whether grief symptoms were alleviated if the physician and the nurse in charge at the time of death sent the closest relative a handwritten condolence letter. METHODS: Multicenter randomized trial conducted among 242 relatives of patients who died at 22 ICUs in France between December 2014 and October 2015. Relatives were randomly assigned to receiving (n = 123) or not receiving (n = 119) a condolence letter. The primary endpoint was the Hospital Anxiety and Depression Score (HADS) at 1 month. Secondary endpoints included HADS, complicated grief (ICG), and PTSD-related symptoms (IES-R) at 6 months. Observers were blinded to group allocation. RESULTS: At 1 month, 208 (85.9%) relatives completed the HADS; median score was 16 [IQR, 10-22] with and 14 [8-21.5] without the letter (P = 0.36). Although scores were higher in the intervention group, there were no significant differences regarding the HADS-depression subscale (8 [4-12] vs. 6 [2-12], mean difference 1.1 [-0.5 to 2.6]; P = 0.09) and prevalence of depression symptoms (56.0 vs. 42.4%, RR 0.76 [0.57-1.00]; P = 0.05). At 6 months, 190 (78.5%) relatives were interviewed. The intervention significantly increased the HADS (13 [7-19] vs. 10 [4-17.5], P = 0.04), HADS-depression subscale (6 [2-10] vs. 3 [1-9], P = 0.02), prevalence of depression symptoms (36.6 vs. 24.7%, P = 0.05) and PTSD-related symptoms (52.4 vs. 37.1%, P = 0.03). CONCLUSIONS: In relatives of patients who died in the ICU, a condolence letter failed to alleviate grief symptoms and may have worsened depression and PTSD-related symptoms. Trial registration Clinicaltrials.gov Identifier: NCT02325297.

Evaluation of the Double-Lumen Tube Vivasight-DL (DLT-ETView): A Prospective Single-Center Study.

OBJECTIVES: VivaSight-DL (DLT-ETView) is a single-use double-lumen tube (DLT) with an integrated camera visualizing the carina continuously, which could reduce the need for a routine fiberoptic bronchoscopy. The objective of this study was to evaluate its rate of correct positioning. DESIGN: A prospective, observational study. SETTING: A university hospital. PARTICIPANTS: 170 patients undergoing a thoracic surgical procedure. INTERVENTIONS: Selective left bronchus intubation. MEASUREMENTS AND MAIN RESULTS: The main outcome measure was a double criteria assessed by fiberoptic bronchoscopy: the bronchial cuff in the left main bronchus and end of the bronchial lumen upstream of the lobar bifurcation. Between September 2013 and April 2014, 84 patients of the planned 170 were included. Seven patients were excluded: 3 for failed intubation, 3 for protocol violation, and 1 because the DLT melted before insertion. The study was terminated after this event. Seventy-six patients (99%) had correct positioning, with a median margin of safety of 20 mm (interquartile range: 15-27) in the surgical position. In 40 patients (53%), malpositioning required mobilization of the tube at least once intraoperatively. CONCLUSIONS: The tube was well positioned in almost all patients. Continuous visualization of the carina is a major improvement for patient care as intraoperative displacement can be diagnosed immediately and corrected. However, an incident induced premature ending of the study.