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1.
BMJ Open Respir Res ; 8(1)2021 12.
Artigo em Inglês | MEDLINE | ID: mdl-34893522

RESUMO

BACKGROUND: The gold-standard treatment for acute exacerbation of chronic obstructive pulmonary disease (ae-COPD) is non-invasive ventilation (NIV). However, NIV failures may be observed, and invasive mechanical ventilation (IMV) is required. Extracorporeal CO2 removal (ECCO2R) devices can be an alternative to intubation. The aim of the study was to assess ECCO2R effectiveness and safety. METHODS: Patients with consecutive ae-COPD who experienced NIV failure were retrospectively assessed over two periods of time: before and after ECCO2R device implementation in our ICU in 2015 (Xenios AG). RESULTS: Both groups (ECCO2R: n=26, control group: n=25) were comparable at baseline, except for BMI, which was significantly higher in the ECCO2R group (30 kg/m² vs 25 kg/m²). pH and PaCO2 significantly improved in both groups. The mean time on ECCO2R was 5.4 days versus 27 days for IMV in the control group. Four patients required IMV in the ECCO2R group, of whom three received IMV after ECCO2R weaning. Seven major bleeding events were observed with ECCO2R, but only three led to premature discontinuation of ECCO2R. Eight cases of ventilator-associated pneumonia were observed in the control group. Mean time spent in the ICU and mean hospital stay in the ECCO2R and control groups were, respectively, 18 vs 30 days, 29 vs 49 days, and the 90-day mortality rates were 15% vs 28%. CONCLUSIONS: ECCO2R was associated with significant improvement of pH and PaCO2 in patients with ae-COPD failing NIV therapy. It also led to avoiding intubation in 85% of cases, with low complication rates. TRIAL REGISTRATION NUMBER: ClinicalTrials.gov, NCT04882410. Date of registration 12 May 2021, retrospectively registered.https://www.clinicaltrials.gov/ct2/show/NCT04882410.


Assuntos
Ventilação não Invasiva , Doença Pulmonar Obstrutiva Crônica , Dióxido de Carbono , Humanos , Tempo de Internação , Doença Pulmonar Obstrutiva Crônica/terapia , Respiração Artificial
2.
Lancet ; 374(9702): 1687-93, 2009 Nov 14.
Artigo em Inglês | MEDLINE | ID: mdl-19896184

RESUMO

BACKGROUND: Present guidelines recommend routine daily chest radiographs for mechanically ventilated patients in intensive care units. However, some units use an on-demand strategy, in which chest radiographs are done only if warranted by the patient's clinical status. By comparison between routine and on-demand strategies, we aimed to establish which strategy was more efficient and effective for optimum patient care. METHODS: In a cluster-randomised, open-label crossover study, we randomly assigned 21 intensive care units at 18 hospitals in France to use a routine or an on-demand strategy for prescription of chest radiographs during the first of two treatment periods. Units used the alternative strategy in the second period. Each treatment period lasted for the time taken for enrolment and study of 20 consecutive patients per intensive care unit; patients were monitored until discharge from the unit or for up to 30 days' mechanical ventilation, whichever was first. Units enrolled 967 patients, but 118 were excluded because they had been receiving mechanical ventilation for less than 2 days. The primary outcome measure was the mean number of chest radiographs per patient-day of mechanical ventilation. Analysis was by intention to treat. This study is registered with ClinicalTrials.gov, number NCT00893672. FINDINGS: 11 intensive care units were randomly allocated to use a routine strategy to order chest radiographs in the first treatment period, and 10 units to use an on-demand strategy. Overall, 424 patients had 4607 routine chest radiographs (mean per patient-day of mechanical ventilation 1.09, 95% CI 1.05-1.14), and 425 had 3148 on-demand chest radiographs (mean 0.75, 0.67-0.83), which corresponded to a reduction of 32% (95% CI 25-38) with the on-demand strategy (p<0.0001). INTERPRETATION: Our results strongly support adoption of an on-demand strategy in preference to a routine strategy to decrease use of chest radiographs in mechanically ventilated patients without a reduction in patients' quality of care or safety. FUNDING: Assistance Publique-Hôpitaux de Paris (Direction Régionale de la Recherche Clinique Ile de France).


Assuntos
Cuidados Críticos/estatística & dados numéricos , Seleção de Pacientes , Padrões de Prática Médica/estatística & dados numéricos , Prescrições/estatística & dados numéricos , Radiografia Torácica/estatística & dados numéricos , Respiração Artificial , Análise por Conglomerados , Estudos Cross-Over , Prática Clínica Baseada em Evidências , Feminino , França/epidemiologia , Mortalidade Hospitalar , Humanos , Tempo de Internação/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Avaliação de Resultados em Cuidados de Saúde , Guias de Prática Clínica como Assunto , Estudos Prospectivos , Respiração Artificial/efeitos adversos , Respiração Artificial/estatística & dados numéricos , Estatísticas não Paramétricas , Procedimentos Desnecessários/estatística & dados numéricos
3.
PLoS One ; 15(10): e0240645, 2020.
Artigo em Inglês | MEDLINE | ID: mdl-33052968

RESUMO

INTRODUCTION: Because of the COVID-19 pandemic, intensive care units (ICU) can be overwhelmed by the number of hypoxemic patients. MATERIAL AND METHODS: This single centre retrospective observational cohort study took place in a French hospital where the number of patients exceeded the ICU capacity despite an increase from 18 to 32 beds. Because of this, 59 (37%) of the 159 patients requiring ICU care were referred to other hospitals. From 27th March to 23rd April, consecutive patients who had respiratory failure or were unable to maintain an SpO2 > 90%, despite receiving 10-15 l/min of oxygen with a non-rebreather mask, were treated by continuous positive airway pressure (CPAP) unless the ICU physician judged that immediate intubation was indicated. We describe the characteristics, clinical course, and outcomes of these patients. The main outcome under study was CPAP discontinuation. RESULTS: CPAP was initiated in 49 patients and performed out of ICU in 41 (84%). Median age was 65 years (IQR = 54-71) and 36 (73%) were men. Median respiratory rate before CPAP was 36 (30-40) and median SpO2 was 92% (90-95) under 10 to 15 L/min oxygen flow. Median duration of CPAP was 3 days (IQR = 1-5). Reasons for discontinuation of CPAP were: intubation in 25 (51%), improvement in 16 (33%), poor tolerance in 6 (12%) and death in 2 (4%) patients. A decision not to intubate had been taken for 8 patients, including the 2 who died while on CPAP. Two patients underwent less than one hour CPAP for poor tolerance. In the end, 15 (38%) out of 39 evaluable patients recovered with only CPAP whereas 24 (62%) were intubated. CONCLUSIONS: CPAP is feasible in a non-ICU environment in the context of massive influx of patients. In our cohort up to 1/3 of the patients presenting with acute respiratory failure recovered without intubation.


Assuntos
Pressão Positiva Contínua nas Vias Aéreas/métodos , Infecções por Coronavirus/terapia , Pneumonia Viral/terapia , Idoso , COVID-19 , Pressão Positiva Contínua nas Vias Aéreas/economia , Pressão Positiva Contínua nas Vias Aéreas/instrumentação , Infecções por Coronavirus/economia , Infecções por Coronavirus/epidemiologia , Custos e Análise de Custo , Feminino , França , Número de Leitos em Hospital/estatística & dados numéricos , Humanos , Unidades de Terapia Intensiva/estatística & dados numéricos , Masculino , Pessoa de Meia-Idade , Pandemias/economia , Admissão do Paciente/estatística & dados numéricos , Pneumonia Viral/economia , Pneumonia Viral/epidemiologia
4.
Arch Dis Child ; 104(7): 629-635, 2019 07.
Artigo em Inglês | MEDLINE | ID: mdl-30127061

RESUMO

BACKGROUND: Diagnosis of intrathoracic tuberculosis (ITB) is limited in children partly by their difficulty to produce sputum specimen. OBJECTIVE: To systematically review the detection yields of mycobacterial culture and Xpert MTB/RIF from induced sputum (IS), nasopharyngeal aspirate (NPA) and gastric aspirate (GA) in children with presumptive ITB. DESIGN: Pubmed, Embase and Biosis databases and grey literature were searched. Randomised controlled trials, cohort, cross-sectional or case control studies using IS, GA and NPA for diagnosis of ITB published between January 1990 and January 2018 were included. Data were extracted on study design, case definition of presumptive ITB, sample collection methods, outcome measures and results. RESULTS: 30 studies were selected, including 11 554 children. Detection yields for culture ranged between 1% and 30% for IS, 1% and 45% for GA and 4% and 24% for NPA. For Xpert MTB/RIF, it was between 2% and 17% for IS, 5% and 51% for GA and 3% and 8% for NPA. There was a tendency of better yields with IS when the pretest probability of ITB was low to moderate and with GA when it was high. Sampling a second specimen contributed for 6%-33% of the cumulative yield and combination of different methods significantly increase the detection yields. CONCLUSIONS: Despite the important study heterogeneity, any of the specimen collection methods offers good potential to confirm childhood ITB. However, their operational challenges were poorly evaluated. In the absence of a sensitive non-sputum based test, only a minority of children with ITB can be confirmed.


Assuntos
Mycobacterium tuberculosis/isolamento & purificação , Manejo de Espécimes/métodos , Escarro/microbiologia , Tuberculose Pulmonar/diagnóstico , Criança , Serviços de Saúde da Criança , Humanos , Tuberculose Pulmonar/microbiologia , Tuberculose Pulmonar/patologia
5.
Chest ; 133(5): 1107-12, 2008 May.
Artigo em Inglês | MEDLINE | ID: mdl-17989166

RESUMO

BACKGROUND: Strategies for ordering bedside chest radiographs (CXRs) have substantial logistic and financial consequences in the ICU. Many of the indications for CXRs in the ICU are controversial, such as the ordering of daily routine CXRs for intubated patients. The opinions of intensivists about ordering CXRs have not been reported. Comparing these opinions to established guidelines and identifying situations where opinions diverge in the absence of guidelines are of considerable interest. METHODS: We asked 190 intensivists from 34 ICUs in the area of Paris, France, to anonymously complete a 29-item questionnaire about their opinions regarding the ordering of CXRs; each item described a clinical scenario. Of the 29 scenarios, 10 dealt with the placement of medical devices, 8 with the presence of medical devices, and 11 with other clinical situations. The study was based on a Delphi process deployed over the Internet through an original software application. Three Delphi rounds were run between January and March 2006, using the same questionnaire. Detailed feedback for the answers given during the previous round was supplied to each intensivist solicited for updating his answers. RESULTS: Eighty-two intensivists from 32 ICUs completed the study. A consensus emerged that routine CXRs were necessary for eight scenarios and unnecessary for two scenarios. The study also shed light on items without a consensus. In particular, 75% of intensivists (58% on the first round) did not support obtaining daily routine CXRs in intubated patients. CONCLUSION: The study underlines situations in which intensivists do not support the guidelines and outlines recommendations likely to be followed in clinical practice.


Assuntos
Técnica Delphi , Unidades de Terapia Intensiva/estatística & dados numéricos , Internet , Radiografia Torácica/estatística & dados numéricos , Estado Terminal/terapia , Humanos , Paris , Respiração Artificial , Estudos Retrospectivos
7.
Circulation ; 111(23): 3105-11, 2005 Jun 14.
Artigo em Inglês | MEDLINE | ID: mdl-15939821

RESUMO

BACKGROUND: Characteristics of patients with idiopathic pulmonary arterial hypertension (IPAH) who benefit from long-term calcium channel blockers (CCB) are unknown. METHODS AND RESULTS: Acute pulmonary vasodilator testing with epoprostenol or nitric oxide was performed in 557 IPAH patients. Acute responders, defined by a fall in both mean pulmonary artery pressure (PAP) and pulmonary vascular resistance (PVR) >20%, received long-term oral CCB. Patients who benefit from long-term CCB were defined as those being in New York Heart Association (NYHA) functional class I or II after at least 1 year on CCB monotherapy. Among the 70 patients who displayed acute pulmonary vasoreactivity (12.6%; 95% CI, 9.8% to 15.3%) and received CCB therapy, only 38 showed long-term improvement (6.8%; 95% CI, 4.7% to 8.9%). Long-term CCB responders had less severe disease at baseline than patients who failed. During acute vasodilator testing, long-term CCB responders displayed a more pronounced fall in mean PAP (-39+/-11% versus -26+/-7%; P<0.0001), reaching an absolute value of mean PAP lower than that measured in patients who failed (33+/-8 versus 46+/-10 mm Hg; P<0.0001). After 7.0+/-4.1 years, all but 1 long-term CCB responders were alive in NYHA class I or II, with a sustained hemodynamic improvement. In the group of patients who failed on CCB, the 5-year survival rate was 48%. CONCLUSIONS: Long-term CCB responders represent <10% of IPAH patients evaluated in a pulmonary vascular referral center. During acute vasodilator testing, these patients showed significantly lower levels of both mean PAP and PVR, which reached near-normal values.


Assuntos
Bloqueadores dos Canais de Cálcio/farmacologia , Hipertensão Pulmonar/tratamento farmacológico , Adulto , Bloqueadores dos Canais de Cálcio/uso terapêutico , Avaliação de Medicamentos , Epoprostenol , Feminino , Humanos , Hipertensão Pulmonar/etiologia , Hipertensão Pulmonar/mortalidade , Masculino , Pessoa de Meia-Idade , Óxido Nítrico , Artéria Pulmonar/fisiopatologia , Estudos Retrospectivos , Taxa de Sobrevida , Resultado do Tratamento , Vasodilatação/efeitos dos fármacos , Vasodilatadores
8.
Rev Pneumol Clin ; 61(3): 159-63, 2005 Jun.
Artigo em Francês | MEDLINE | ID: mdl-16142188

RESUMO

Chronic interstitial lung disease (ILD) groups a number of diseases with the common feature of radiological pulmonary infiltration, typical functional syndrome, and diffuse involvement of the deep pulmonary parenchyma identified histologically. Correlations between histological and radiological findings have enabled progress in both fields, leading to better interpretation of the radiological findings and optimizing the etiological diagnosis. Besides the signs themselves, their distribution in relation to the normal lung structures is highly contributive. Function tests can be used to quantify the impact on the respiratory system and assess the effect of treatment. Evidence-based criteria will progressively replace the consensual criteria enabling more effective evaluation of treatment in difficult pathological conditions such as idiopathic pulmonary fibrosis.


Assuntos
Doenças Pulmonares Intersticiais/fisiopatologia , Humanos , Doenças Pulmonares Intersticiais/etiologia
9.
Ann Intensive Care ; 1(1): 4, 2011 Mar 21.
Artigo em Inglês | MEDLINE | ID: mdl-21906323

RESUMO

Chest x-rays (CXRs) are the main imaging tool in intensive care units (ICUs). CXRs also are associated with concerns inherent to their use, considering both healthcare organization and patient perspectives. In recent years, several studies have focussed on the feasibility of lowering the number of bedside CXRs performed in the ICU. Such a decrease may result from two independent and complementary processes: a raw reduction of CXRs due to the elimination of unnecessary investigations, and replacement of the CXR by an alternative technique. The goal of this review is to outline emblematic examples corresponding to these two processes. The first part of the review concerns the accumulation of evidence-based data for abandoning daily routine CXRs in mechanically ventilated patients and adopting an on-demand prescription strategy. The second part of the review addresses the use of alternative techniques to CXRs. This part begins with the presentation of ultrasonography or capnography combined with epigastric auscultation for ensuring the correct position of enteral feeding tubes. Ultrasonography is then also presented as an alternative to CXR for diagnosing and monitoring pneumothoraces, as well as a valuable post-procedural technique after central venous catheter insertion. The combination of the emblematic examples presented in this review supports an integrated global approach for decreasing the number of CXRs ordered in the ICU.

10.
Ther Clin Risk Manag ; 4(6): 1375-9, 2008 Dec.
Artigo em Inglês | MEDLINE | ID: mdl-19337445

RESUMO

Three women were consecutively admitted to our medical intensive care unit for thyrotoxicosis after the ingestion of dietary pills accidentally containing high levels of thyroxin. These cases were observed during an outbreak in the Paris area. Despite similar blood levels of thyroid hormones, their clinical presentation and outcome were very different. One patient developed febrile confusion and died from malignant hyperthermia. The second one had progressive confusion requiring mechanical plasma exchange therapy and had a favorable outcome. The third one had very moderate symptoms. These exceptional observations raise several issues concerning diagnosis, physiopathology and treatment of thyrotoxicosis factitia.

11.
Hemoglobin ; 27(3): 139-47, 2003 Aug.
Artigo em Inglês | MEDLINE | ID: mdl-12908798

RESUMO

Dehydrated hereditary stomatocytosis (DHS) belongs to the heterogeneous class of hemolytic anemias with leaky red cell membranes. Splenectomy is a highly deleterious treatment, because it favors, with virtually no exception, the occurrence of thromboembolic disease. We describe here the extreme case of a patient with DHS and an associated sickle cell trait. Splenectomy was carried out due to a splenic infarction that occurred during an airplane journey. About 12 years later, the patient noticed an exertional dyspnea, which gradually worsened to such a degree that she became severely incapacitated within 5 years. Eventually, the patient developed a cor pulmonale associated with chronic thromboembolic pulmonary hypertension (CTEPH) and successfully underwent a heart-lung transplant operation. This case ranks as one of the most severe examples ever recorded of the effect that splenectomy may have in DHS patients. Nonetheless, it represents the first case to receive a heart-lung transplant.


Assuntos
Anemia Hemolítica Congênita/cirurgia , Transplante de Coração-Pulmão , Hipertensão Pulmonar/etiologia , Embolia Pulmonar/etiologia , Esplenectomia/efeitos adversos , Adulto , Anemia Hemolítica Congênita/complicações , Anemia Falciforme/complicações , Dispneia , Feminino , Humanos , Hipertensão Pulmonar/patologia , Hipertensão Pulmonar/cirurgia , Embolia Pulmonar/patologia , Embolia Pulmonar/cirurgia , Resultado do Tratamento
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