Daily multidisciplinary COVID-19 meeting: Experiences from a French university hospital.

OBJECTIVES: In March 2020, the World Health Organization declared the coronavirus disease 2019 (COVID-19) a pandemic. In absence of official recommendations, implementing daily multidisciplinary team (MDT) COVID-19 meetings was urgently needed. Our aim was to describe our initial institutional standard operating procedures for implementing these meetings, and their impact on daily practice. METHODS: All consecutive patients who were hospitalized in our institution due to COVID 19, from March 31 to April 15, 2020, were included. Criteria to be presented at MDT meetings were defined as a proven COVID-19 by PCR or strongly suspected on CT scan, requiring hospitalization and treatment not included in the standard of care. Three investigators identified the patients who met the predefined criteria and compared the treatment and outcomes of patients with predefined criteria that were presented during MDT meeting with those not presented during MDT meeting. COVID-19 MDT meeting implementation and adhesion were also assessed by a hospital medical staff survey. RESULTS: In all, 318 patients with confirmed or suspected COVID-19 were examined in our hospital. Of these, 230 (87%) were hospitalized in a COVID-19 unit, 91 (40%) of whom met predefined MDT meeting criteria. Fifty (55%) patients were presented at a MDT meeting versus 41 (45%) were not. Complementary exploration and inclusion in the CorImmuno cohort were higher in MDT meeting group (respectively 35 vs. 15%, P=0.03 and 80 versus 49%, P=0.0007). Prescription of hydrocortisone hemisuccinate was higher in group of patients not presented during MDT meeting (24 vs. 51%, P=0.007). Almost half of the patients fulfilling the inclusion criteria were not presented at MDT meeting, which can be partly explained by technical software issues. CONCLUSIONS: Multidisciplinary COVID-19 meetings helped implementing a single standard of care, avoided using treatments that were untested or currently being tested, and facilitated the inclusion of patients in prospective cohorts and therapeutic trials.

Diffuse alveolar haemorrhage: factors associated with in-hospital and long-term mortality.

Diffuse alveolar haemorrhage (DAH) is a feature of several immune and nonimmune disorders. Reported prognosis is poor, with in-hospital mortality ranging from 20% to 100%. Early identification of prognostic factors may be useful in the initiation of appropriate treatment. We retrospectively analysed the charts of all patients referred to a university hospital for DAH between 1980 and 2008. Variables associated with in-hospital and long-term mortality were determined using a logistic regression model and the Kaplan-Meier method, respectively. Immunosuppressed patients were excluded. Overall, 97 patients were included in the study. In-hospital mortality was 24.7%. Factors associated with in-hospital mortality were shock (OR 77.5, 95% CI 8.9-677.2), glomerular filtration rate <60 mL x min(-1) (OR 11.2, 95% CI 1.8-68.4) and plasmatic lactate dehydrogenase level more than twice the normal value (OR 12.1, 95% CI 1.7-84.3). Mortality among discharged patients was 16.4% with a median follow-up duration of 34 months. Factors associated with increased long-term mortality in univariate analysis were age over 60 yrs (p = 0.026), cardiovascular comorbidity (p = 0.027) and end-stage renal failure with dependence on haemodialysis (p = 0.026). Patients with immune and nonimmune DAH had similar outcomes. Early outcome depended on nonpulmonary organ failures. Conversely, late outcome was related to age, cardiac comorbidities and the need for haemodialysis.

[Normal and abnormal systemic pulmonary circulation: CT imaging features]. / Vascularisation systémique normale et pathologique du poumon: sémiologie tomodensitométrique.

In most cases, treatment of life-threatening hemoptysis requires systemic arterial embolization, bronchial or not. Knowledge of the normal and pathological features of this systemic arterial network as depicted on multidetector row CTA, is an essential key because this examination has become the main imaging study prior to any interventional procedure. This article will review the indications for chest CTA, technical considerations and protocol in the evaluation of the systemic pulmonary circulation, as well as the imaging features of this circulation with emphasis on the normal and pathological imaging features to better correlate with the clinical presentation.

A 2-year multicenter, observational, prospective, cohort study on extracorporeal CO2 removal in a large metropolis area.

BACKGROUND: Extracorporeal carbon dioxide removal (ECCO2R) is a promising technique for the management of acute respiratory failure, but with a limited level of evidence to support its use outside clinical trials and/or data collection initiatives. We report a collaborative initiative in a large metropolis. METHODS: To assess on a structural basis the rate of utilization as well as efficacy and safety parameters of 2 ECCO2R devices in 10 intensive care units (ICU) during a 2-year period. RESULTS: Seventy patients were recruited in 10 voluntary and specifically trained centers. The median utilization rate was 0.19 patient/month/center (min 0.04; max 1.20). ECCO2R was started under invasive mechanical ventilation (IMV) in 59 patients and non-invasive ventilation in 11 patients. The Hemolung Respiratory Assist System (Alung) was used in 53 patients and the iLA Activve iLA kit (Xenios Novalung) in 17 patients. Main indications were ultraprotective ventilation for ARDS patients (n = 24), shortening the duration of IMV in COPD patients (n = 21), preventing intubation in COPD patients (n = 9), and controlling hypercapnia and dynamic hyperinflation in mechanically ventilated patients with severe acute asthma (n = 6). A reduction in median V T was observed in ARDS patients from 5.9 to 4.1 ml/kg (p <0.001). A reduction in PaCO2 values was observed in AE-COPD patients from 67.5 to 51 mmHg (p< 0.001). Median duration of ECCO2R was 5 days (IQR 3-8). Reasons for ECCO2R discontinuation were improvement (n = 33), ECCO2R-related complications (n = 18), limitation of life-sustaining therapies or measures decision (n = 10), and death (n = 9). Main adverse events were hemolysis (n = 21), bleeding (n = 17), and lung membrane clotting (n = 11), with different profiles between the devices. Thirty-five deaths occurred during the ICU stay, 3 of which being ECCO2R-related. CONCLUSIONS: Based on a registry, we report a low rate of ECCO2R device utilization, mainly in severe COPD and ARDS patients. Physiological efficacy was confirmed in these two populations. We confirmed safety concerns such as hemolysis, bleeding, and thrombosis, with different profiles between the devices. Such results could help to design future studies aiming to enhance safety, to demonstrate a still-lacking strong clinical benefit of ECCO2R, and to guide the choice between different devices. TRIAL REGISTRATION: ClinicalTrials.gov: Identifier: NCT02965079 retrospectively registered https://clinicaltrials.gov/ct2/show/NCT02965079.

[Risks associated with the use of non-steroidal anti-inflammatory drugs during pneumonia]. / Risques associés à la prise d'anti-inflammatoires non stéroïdiens au cours de la pneumonie.

INTRODUCTION: Outpatient treatment of community-acquired pneumonia (CAP) patients with non-steroidal anti-inflammatory drugs (NSAIDs) is frequent, although this is not based on clinical recommendations and there is no scientific evidence supporting better symptom relief in comparison to acetaminophen. STATE OF THE ART: Experimental data suggest that NSAIDs alter the intrinsic functions of neutrophils, limit their locoregional recruitment, alter bacterial clearance and delay the resolution of inflammatory processes during acute bacterial pulmonary challenge. In hospitalized children and adults with CAP, observational data suggest a strong and independent association between the outpatient exposure to NSAIDs and the occurrence of pleuropulmonary complications (pleural empyema, excavation, and abscess). In the only study taking into account possible protopathic bias, the association still persists. Other markers of morbidity have been described, including delay in hospital management, prolonged antibiotic therapy, and higher transfer rate to an intensive care unit. PERSPECTIVES: Data describing the role of self-medication and the biological mechanisms involved are needed. CONCLUSIONS: Intake of NSAIDs during outpatient treatment of CAP is probably the second modifiable factor of morbidity after inadequate antibiotic therapy. In light of existing data in children and adults, health authorities should urgently reassess the risk-benefit ratio of NSAIDS in CAP.

[Management of severe hemoptysis: experience in a specialized center]. / Prise en charge des hémoptysies graves: expérience d'un centre spécialisé

Bronchiectasis, cancer and tuberculosis account for the majority of haemoptysis requiring intensive care unit admission. Bedside evaluation (volume and bronchoscopic active bleeding) is safe to screen patients for arteriography and bronchial artery embolisation (BAE). First-line interventional arteriography should be favour over surgery in patients with non traumatic life-threatening hemoptysis. Surgery must be reserved in cases of failure or recurrence of bleeding after BAE.

[Critical evaluation and predictive value of clinical presentation in out-patients with acute community-acquired pneumonia]. / 07--analyse critique et valeurs prédictives des signes de pneumonies aiguës communautaires en médecine ambulatoire.

Diagnostic probability of community-acquired pneumonia (CAP) depends on data related to age and clinical and radiological findings. The critical evaluation of data in the literature leads to the following conclusions: 1) the prevalence of CAP in a given population with acute respiratory disease is 5% in outpatients and 10% in an emergency care unit. This could be as low as 2% in young people and even higher than 40% in hospitalized elderly patients; 2) the collection of clinical data is linked to the way the patient is examined and to the expertise of the clinician. The absolute lack of "vital signs" has a good negative predictive value in CAP; presence of unilateral crackles has a good positive predictive value; 3) there is a wide range of X-ray abnormalities: localized alveolar opacities; interstitial opacities, limited of diffused. The greatest radiological difficulties are encountered in old people with disorders including chronic respiratory or cardiac opacities and as a consequence of the high prevalence of bronchopneumonia episodes at this age; 4) among patients with lower respiratory tract (LRT) infections, the blood levels of leukocytes, CRP and procalcitonine are higher in CAP patients, mainly when their disease has a bacterial origin. Since you have not a threshold value reliably demonstrated in large populations with LRT infections or acute respiratory disease, presence or absence of these parameters could only be taken as a slight hint for a CAP diagnosis.

[Intra-alveolar hemorrhage revealing pheochromocytoma]. / Hémorragie intra-alvéolaire révélatrice d'un phéochromocytome.

We report a case of pheochromocytoma revealed by alveolar hemorrhage in a 51-year-old woman. Pheochromocytomas are rare tumors deriving from the chromaffin tissue, and which clinical manifestations are highly variable, mostly unspecific, and very rarely concern the lung. Therefore, the diagnosis is often missed or delayed. However, without correct diagnosis and subsequently adapted treatment, the disease may be fatal. Thus, clinicians should be aware of the possible diagnosis of pheochromocytoma in patients presenting hemoptysis of an unknown origin.

[Acute forms of diffuse interstitial hypoxemic pneumonia in immunocompetent patients]. / Les formes aiguës des pneumopathies infiltrantes diffuses hypoxémiantes de l'immunocompétent.

The large majority of patients with acute respiratory failure present diffuse pulmonary opacities resulting from pulmonary embolism, intra-alveolar hemorrhage, or a classical cause of ARDS. In a small number of patients however, these opacities correspond to diffuse interstitial pneumonia. This should be suspected in light of the context, the time of formation, and the unusual respiratory and/or extrarespiratory signs. If there is a clinical doubt, thoracic scan and bronchoalveolar lavage should be performed together with infectious and immunology tests. Treatment depends on the cause and/or the type of lesion.

[Alveolar hemorrhage]. / Hémorragie intra-alvéolaire.

Alveolar hemorrhage occurs relatively rarely and is a therapeutic emergency because it can quickly lead to acute respiratory failure, which can be fatal. Hemoptysis associated with anemia and pulmonary infiltrates suggest the diagnosis of alveolar hemorrhage, but may be absent in one third of cases including patients in respiratory distress. The diagnosis of alveolar hemorrhage is based on the findings of a bronchoalveolar lavage. The causes are numerous. It is important to identify alveolar hemorrhage due to sepsis, then separate an autoimmune cause (vasculitis associated with antineutrophil cytoplasmic antibody, connective tissue disease and Goodpasture's syndrome) with the search for autoantibodies and biopsies from readily accessible organs, from a non-immune cause, performing echocardiography. Lung biopsy should be necessary only in exceptional cases. If the hemorrhage has an immune cause, treatment with steroids and cyclophosphamide may be started. The indications for treatment with rituximab are beginning to be established (forms that are not severe and refractory forms). The benefit of plasma exchange is unquestionable in Goodpasture's syndrome. In patients with an immune disease that can lead to an alveolar hemorrhage, removing any source of infection is the first priority.

Severe hemoptysis: From diagnosis to embolization.

Severe hemoptysis is life-threatening to patients because of the asphyxia it causes. The diagnosis and treatment are therefore urgent and chest imaging is essential. Multidetector CT-angiography provides an exhaustive non-invasive assessment which includes localization, mechanisms, causes and severity of the hemoptysis. It is an invaluable step in preparation for endovascular treatment which is the first line invasive therapy, particularly with bronchial arteriography embolization in the majority of cases (over 90%) and erosion or rupture of the pulmonary artery in less than 10% of cases. Hemoptysis control is achieved in 65 to 92% of cases depending on the cause.

Inhaled nitric oxide for acute chest syndrome in adult sickle cell patients: a randomized controlled study.

PURPOSE: Previous clinical trials suggested that inhaled nitric oxide (iNO) could have beneficial effects in sickle cell disease (SCD) patients with acute chest syndrome (ACS). METHODS: To determine whether iNO reduces treatment failure rate in adult patients with ACS, we conducted a prospective, double-blind, randomized, placebo-controlled clinical trial. iNO (80 ppm, N = 50) gas or inhaled nitrogen placebo (N = 50) was delivered for 3 days. The primary end point was the number of patients with treatment failure at day 3, defined as any one of the following: (1) death from any cause, (2) need for endotracheal intubation, (3) decrease of PaO2/FiO2 ≥ 15 mmHg between days 1 and 3, (4) augmented therapy defined as new transfusion or phlebotomy. RESULTS: The two groups did not differ in age, gender, genotype, or baseline characteristics and biological parameters. iNO was well tolerated, although a transient decrease in nitric oxide concentration was mandated in one patient. There was no significant difference in the primary end point between the iNO and placebo groups [23 (46 %) and 29 (58 %); odds ratio (OR), 0.8; 95 % CI, 0.54-1.16; p = 0.23]. A post hoc analysis of the 45 patients with hypoxemia showed that those in the iNO group were less likely to experience treatment failure at day 3 [7 (33.3 %) vs 18 (72 %); OR = 0.19; 95 % CI, 0.06-0.68; p = 0.009]. CONCLUSIONS: iNO did not reduce the rate of treatment failure in adult SCD patients with mild to moderate ACS. Future trials should target more severely ill ACS patients with hypoxemia. CLINICAL TRIAL REGISTRATION: NCT00748423.

Spontaneous hemomediastinum complicating steroid-induced mediastinal lipomatosis.

Spontaneous hemomediastinum is a rare event, occurring in association with bleeding disorders, intratumoral bleeding, or following an abrupt increase in intrathoracic pressure. We report the case of a patient with systemic lupus erythematosus, nephrotic syndrome, and renal failure, in whom mediastinal lipomatosis (ML) developed following increased corticosteroid therapy. Anticoagulant therapy likely precipitated a massive spontaneous hemomediastinum secondary to diffuse hemorrhage of mediastinal fat, which required emergency decompressive surgery. Steroid-induced ML is common and usually well tolerated, but clinicians should be aware of its potential risk of bleeding when associated with anticoagulant therapy. This case further emphasizes the bleeding complications of treatment with low-molecular-weight heparin in patients with renal failure.

Primary pulmonary hypertension associated with the use of fenfluramine derivatives.

Fenfluramine derivatives (Fds) are a well-established risk factor for primary pulmonary hypertension (PPH). We compared 62 Fd-PPH patients (61 women) evaluated in our center between 1986 and 1997 with 125 sex-matched PPH patients nonexposed to Fd referred during the same period (control PPH). In the Fd-PPH group, 33 patients (53%) used dexfenfluramine alone, 7 patients (11%) used fenfluramine alone, and 5 patients (8%) used both drugs. In 17 cases (27%), Fd use was associated with that of amphetamines. Most of the exposed patients used Fd for at least 3 months (81%). The interval between the onset of dyspnea and that of drug intake was 49+/-68 months (27 days to 23 years). At the time of diagnosis, Fd-PPH and control PPH were similar in terms of New York Heart Association functional class and symptoms. The two groups significantly differed only in terms of age (50+/-12 vs 40+/-14 years) and body mass index (28+/-6 vs 23+/-4). The two groups displayed similar severe baseline hemodynamics (total pulmonary vascular resistance: 32+/-12 vs 31+/-12 IU/m2), but the percentage of responders to acute vasodilator testing was higher in control PPH (27% vs 10%, p < 0.01). As a result, more patients were treated with oral vasodilators in the control PPH group (36% vs 16%, p < 0.01) and long-term epoprostenol infusion was more frequently used in the Fd-PPH group (52% vs 31%, p < 0.01). Overall survival was similar in the two groups with a 3-year survival rate of 50%.

Routine exploratory thoracentesis in ICU patients with pleural effusions: results of a French questionnaire study.

PURPOSE: The purpose of this study was to report the opinions of intensivists regarding pleural effusions in patients in the intensive care unit (ICU). MATERIALS AND METHODS: Questionnaires were sent to 1,032 intensivists, who were members of the French Society of Critical Care. RESULTS: Four hundred thirty-one questionnaires (41.7%) were returned. Overall, the respondents' estimated the incidence of pleural effusion in ICU patients to be 22.19 +/- 17%, whereas 37 +/- 27% considered that exploratory thoracentesis was likely to determine the cause of the effusion, and 17.36 +/- 16% considered that its results were likely to result in a change in their therapeutic attitude. Sixty-five (15%) physicians, chiefly pulmonologists, performed exploratory thoracentesis routinely (Group 1). Compared with those who did not perform routine thoracentesis (Group 2), they ascribed a higher proportion of pleural effusions to infection (31.3% vs. 13.5%) and were more likely to consider that exploratory thoracentesis had a diagnostic and therapeutic contribution (51.2% vs. 34% and 23% vs. 16%, respectively). In addition to the respiratory medicine subspecialty, the practice of routine exploratory thoracentesis was significantly related to seniority, to the frequency of the suspicion of an infectious cause in the physician's practice, and to his or her appreciation of the risks associated with exploratory thoracentesis. Physicians from Group 1 were also more likely to describe exploratory thoracentesis as a noninvasive procedure. CONCLUSIONS: The beliefs and attitudes of intensivists regarding pleural effusions and exploratory thoracentesis are divergent. This may be due to the lack of precise guidelines on the topic and prompt the design of further studies to establish precisely the epidemiology and causes of pleural effusions in ICU patients.

[Strategies for utilization of anticoagulants in pulmonary embolism]. / Stratégie d'utilisation des anticoagulants dans l'embolie pulmonaire.

Anticoagulant therapy significantly reduces the incidence of fatal recurrent thromboembolism and mortality. Today, initial anticoagulant therapy in acute pulmonary embolism mostly consists in the use of intravenous non fractioned heparin associated with simultaneous oral anticoagulation. Treatment with non fractioned heparin is continued until the INR is between 2 and 3 for 2 consecutive days. Long term therapy with antivitamin K should be continued for at least 3 months. It is recommended that patients with recurrent venous thromboembolism should be treated indefinitively. Long term anticoagulant therapy will be discussed individually in the presence of a persistent risk factor. Low molecular weight heparins have been evaluated in the initial treatment of patients with acute, hemodynamically stable pulmonary embolism and are as effective and safe as continuous intravenous non fractioned heparin. Low molecular weight heparins will probably replace non fractioned heparin in the initial treatment of acute hemodynamically stable pulmonary embolism, on a short term perspective.