A Multicenter Randomized Trial Assessing the Efficacy of Helium/Oxygen in Severe Exacerbations of Chronic Obstructive Pulmonary Disease.

RATIONALE: During noninvasive ventilation (NIV) for chronic obstructive pulmonary disease (COPD) exacerbations, helium/oxygen (heliox) reduces the work of breathing and hypercapnia more than air/O2, but its impact on clinical outcomes remains unknown. OBJECTIVES: To determine whether continuous administration of heliox for 72 hours, during and in-between NIV sessions, was superior to air/O2 in reducing NIV failure (25-15%) in severe hypercapnic COPD exacerbations. METHODS: This was a prospective, randomized, open-label trial in 16 intensive care units (ICUs) and 6 countries. Inclusion criteria were COPD exacerbations with PaCO2 ≥ 45 mm Hg, pH ≤ 7.35, and at least one of the following: respiratory rate ≥ 25/min, PaO2 ≤ 50 mm Hg, and oxygen saturation (arterial [SaO2] or measured by pulse oximetry [SpO2]) ≤ 90%. A 6-month follow-up was performed. MEASUREMENTS AND MAIN RESULTS: The primary endpoint was NIV failure (intubation or death without intubation in the ICU). The secondary endpoints were physiological parameters, duration of ventilation, duration of ICU and hospital stay, 6-month recurrence, and rehospitalization rates. The trial was stopped prematurely (445 randomized patients) because of a low global failure rate (NIV failure: air/O2 14.5% [n = 32]; heliox 14.7% [n = 33]; P = 0.97, and time to NIV failure: heliox group 93 hours [n = 33], air/O2 group 52 hours [n = 32]; P = 0.12). Respiratory rate, pH, PaCO2, and encephalopathy score improved significantly faster with heliox. ICU stay was comparable between the groups. In patients intubated after NIV failed, patients on heliox had a shorter ventilation duration (7.4 ± 7.6 d vs. 13.6 ± 12.6 d; P = 0.02) and a shorter ICU stay (15.8 ± 10.9 d vs. 26.7 ± 21.0 d; P = 0.01). No difference was observed in ICU and 6-month mortality. CONCLUSIONS: Heliox improves respiratory acidosis, encephalopathy, and the respiratory rate more quickly than air/O2 but does not prevent NIV failure. Overall, the rate of NIV failure was low. Clinical trial registered with www.clinicaltrials.gov (NCT 01155310).

Family cluster of Middle East respiratory syndrome coronavirus infections, Tunisia, 2013.

In 2013 in Tunisia, 3 persons in 1 family were infected with Middle East respiratory syndrome coronavirus (MERS-CoV). The index case-patient's respiratory tract samples were negative for MERS-CoV by reverse transcription PCR, but diagnosis was retrospectively confirmed by PCR of serum. Sequences clustered with those from Saudi Arabia and United Arab Emirates.

Prednisone in COPD exacerbation requiring ventilatory support: an open-label randomised evaluation.

Recommendation of the use of systemic steroids in chronic obstructive disease (COPD) exacerbation rely on trials that excluded patients requiring ventilatory support. In an open-label, randomised evaluation of oral prednisone administration, 217 patients with acute COPD exacerbation requiring ventilatory support were randomised (with stratification on the type of ventilation) to usual care (n=106) or to receive a daily dose of prednisone (1 mg·kg(-1)) for up to 10 days (n=111). There was no difference regarding the primary end-point, intensive care unit mortality, which was 17 (15.3%) deaths versus 15 (14%) deaths in the steroid-treated and control groups, respectively (relative risk 1.08, 95% CI 0.6-2.05). Analysis according to ventilation modalities showed similar mortality rates. Noninvasive ventilation failed in 15.7% and 12.7% (relative risk 1.25, 95% CI 0.56-2.8; p=0.59), respectively. Both study groups had similar median mechanical ventilation duration and intensive care unit length of stay, which were 6 (interquartile range 6-12) days versus 6 (3.8-12) days and 9 (6-14) days versus 8 (6-14) days, respectively. Hyperglycaemic episodes requiring initiation or alteration of current insulin doses occurred in 55 (49.5%) patients versus 35 (33%) patients in the prednisone and control groups, respectively (relative risk 1.5, 95% CI 1.08-2.08; p=0.015). Prednisone did not improve intensive care unit mortality or patient-centred outcomes in the selected subgroup of COPD patients with severe exacerbation but significantly increased the risk of hyperglycaemia.

Critical care ultrasound among Tunisian intensive care residents: A Cross-sectional Survey.

INTRODUCTION: Critical Care ultrasound (CCUS) is more and more used in Tunisian critical care units. An objective assessment of this training has not yet been performed. AIM: To assess the theoretical and practical knowledge about CCUS among Intensive Care Unit (ICU) residents. METHODS: This is a cross-sectional study conducted during the period from January to June 2021. Data were collected using a French language questionnaire distributed on the day of the selection of the residents' posts for the next training period (at the end of June 2021). RESULTS: Out of 75 residents, 37 accepted to answer to the survey (Participation rate =49 %). The majority were female (66.4%). The mean age was 29±12.36 years. Only 5.4% of participants (n=2) had previously received training concerning echocardiography and only 8.1% of the participants have received dedicated training for lung ultrasound (LU). Among the participants, 80.1% of residents (n=30) had never performed a transthoracic echocardiography (TTE). Competence in performing echocardiography was self-assessed quite good and bad by 5.4% and 43.2% of responders respectively. Most of the residents (86%) did not insert before ultrasound-guided central venous catheters. Views known by the participants using TTE were mainly parasternal long axis section (56.8%) and apical 4/5 chambers section (52.8%). All participants (100%) thought that teaching CCU is a necessary part of the training of intensivists. CONCLUSION: Our study highlighted the lack of training of Tunisian ICU residents regarding CCUS learning. Therefore, it is crucial to integrate such learning and training into their training programs.

Simulation-based echocardiography learning contribution on training of medical residents.

INTRODUCTION: Echocardiography is a pivotal exam in critically ill patients, a specific training is crucial. Medical residents often lack echocardiography practice. AIM: This study aims to evaluate the impact of simulation-based training on medical residents' echocardiography mastery. METHODS: This interventional study was conducted among medical residents at the Simulation Center of the Faculty of Medicine in Monastir (CeSim) in January 2022. The intervention consisted of a theoretical training and a simulator-based practical training concerning echocardiography. Residents underwent evaluation before and after training through a "Pre-Test" and a "Post-Test," respectively, using a French-language questionnaire. Participation was entirely voluntary. RESULTS: A total of 28 medical residents participated in our study, with the majority being female (57.1%). The median age was 29 years (interquartile range: 28-31.75). Following training, the proportion of participants who reported having the necessary skills for echocardiography interpretation significantly increased (p<0.05). Respondents demonstrated significant improvements in their scores on theoretical tests and practical skills assessments. Concerning echocardiographic views, the percentage of participants who correctly identified the title of the parasternal small axis section increased from 53.6% before training to 100% after training (p <10-3). Significant enhancements were observed in all parameters evaluating the practice of echocardiographic sections by respondents on a mannequin after training, encompassing time to obtain the view, view quality, image quality, visualization of structures, interpretability, and image stability (p<10-3). There was a significant improvement in average response rates for echocardiographic clinical syndroms among medical residents before and after training. All participants emphasized the indispensability of ultrasound education in the training of physicians specializing in managing cardiopulmonary emergencies. CONCLUSIONS: This study reports the beneficial role of simulation-based training in enhancing the mastery of medical residents in echocardiography. Incorporating such training methods into their learning curricula is advisable.

N-terminal proB-type natriuretic peptide levels aid the diagnosis of left ventricular dysfunction in patients with severe acute exacerbations of chronic obstructive pulmonary disease and renal dysfunction.

BACKGROUND AND OBJECTIVE: The aim of this study was to assess the performance of N-terminal proB-type natriuretic peptide (NT-proBNP) levels for the diagnosis of left ventricular dysfunction in patients with severe acute exacerbations of chronic obstructive pulmonary disease (COPD) and renal dysfunction. METHODS: NT-proBNP levels at admission were measured in consecutive patients admitted to two participating intensive care units with acute exacerbations of COPD. Left ventricular dysfunction was assessed on the basis of clinical and echocardiographic criteria. The performance of NT-proBNP levels was evaluated in patients with or without renal dysfunction. RESULTS: Among the 120 patients included in the study, 70 had impaired renal function, defined as a glomerular filtration rate of <90 mL/min/1.73 m(2). NT-proBNP levels were inversely correlated with glomerular filtration rate (Spearman's correlation coefficient = -0.457, P < 0.001). Overall, left ventricular dysfunction was diagnosed in 58 patients (48.3%). Median NT-proBNP levels were significantly higher in these patients, irrespective of whether their renal function was normal (3313 (interquartile range (IQR) 4603) vs 337 (IQR 695) pg/mL, P < 0.001) or impaired (5692 (IQR 10714) vs 887 (IQR 1165) pg/mL, P < 0.001). The areas under the receiver operating characteristic curves were 0.87 and 0.78, respectively. The threshold NT-proBNP value with the highest diagnostic accuracy was greater in the setting of renal dysfunction (2000 pg/mL; sensitivity 71%, specificity 82%, compared with 1000 pg/mL in patients with normal renal function; sensitivity 94%, specificity 82%). Multivariate analysis showed that left ventricular dysfunction and glomerular filtration rate were independently associated with elevated NT-proBNP levels. CONCLUSIONS: NT-proBNP remains an accurate biomarker for the diagnosis of left ventricular dysfunction associated with acute exacerbations of COPD. Threshold values of NT-proBNP were higher in patients with impaired renal function than in those with normal renal function.

An updated study-level meta-analysis of randomised controlled trials on proning in ARDS and acute lung injury.

INTRODUCTION: In patients with acute lung injury (ALI) and/or acute respiratory distress syndrome (ARDS), recent randomised controlled trials (RCTs) showed a consistent trend of mortality reduction with prone ventilation. We updated a meta-analysis on this topic. METHODS: RCTs that compared ventilation of adult patients with ALI/ARDS in prone versus supine position were included in this study-level meta-analysis. Analysis was made by a random-effects model. The effect size on intensive care unit (ICU) mortality was computed in the overall included studies and in two subgroups of studies: those that included all ALI or hypoxemic patients, and those that restricted inclusion to only ARDS patients. A relationship between studies' effect size and daily prone duration was sought with meta-regression. We also computed the effects of prone positioning on major adverse airway complications. RESULTS: Seven RCTs (including 1,675 adult patients, of whom 862 were ventilated in the prone position) were included. The four most recent trials included only ARDS patients, and also applied the longest proning durations and used lung-protective ventilation. The effects of prone positioning differed according to the type of study. Overall, prone ventilation did not reduce ICU mortality (odds ratio = 0.91, 95% confidence interval = 0.75 to 1.2; P = 0.39), but it significantly reduced the ICU mortality in the four recent studies that enrolled only patients with ARDS (odds ratio = 0.71; 95% confidence interval = 0.5 to 0.99; P = 0.048; number needed to treat = 11). Meta-regression on all studies disclosed only a trend to explain effect variation by prone duration (P = 0.06). Prone positioning was not associated with a statistical increase in major airway complications. CONCLUSIONS: Long duration of ventilation in prone position significantly reduces ICU mortality when only ARDS patients are considered.

Meta-analysis of controlled studies on immunotherapy in severe scorpion envenomation.

BACKGROUND: Despite conflicting evidence, specific serotherapy is recommended for scorpion envenomation. METHODS: A meta-analysis of prospective or observational controlled studies, comparing intravenous scorpion antivenin (SAV) with control, was performed. Binary outcomes are reported as risk difference for clinical improvement and mortality rates. Analysis was performed both for the whole number of included studies and for two subgroups (set up according to the geographic origin of scorpions). RESULTS: Nine studies (four randomised controlled trials (RCTs), five observational) enrolling 687 patients were identified. Six dealt with Old World scorpions and three originated from Arizona. Overall, the rate of clinical improvement was similar in SAV treated and untreated patients (risk difference=0.22, 95% CI -0.35 to 0.79; p=0.45 for effect). Subgroup analysis showed favourable effects of SAV in the Arizona scorpion envenomation (risk difference=0.53; 95% CI 0.16 to 0.91; p<0.001), and non-significant unfavourable effects in Old World scorpion envenomation (risk difference=-0.05; 95% CI -0.28 to 0.18; p=0.65; p=0.003 for z-value, indicating a true heterogeneity of treatment effects). In Old World scorpion envenomation, there was no statistical difference in the risk of death in SAV treated and untreated scorpion envenomated patients (risk difference=0.007, 95% CI -0.02 to 0.03; p=0.6 for effect). Overall, administration of scorpion antivenin was associated with a reduction by 13 h in the mean time of symptom resolution (95% CI -17 to -9; p<0.0001). Serious adverse events were reported at a rate of 1-2% while minor adverse events occurred in up to 40% of patients. CONCLUSIONS: SAV should not be administered in Old World scorpion envenomation until its efficacy is established by an appropriately designed RCT. In the Arizona scorpion sting, SAV hastens the recovery process.

Scorpion envenomation: state of the art.

Scorpion envenomation is common in the tropical and subtropical regions. It poses a major public health problem with some patients having serious clinical manifestations and severe complications including death. Old World and New World scorpions are usually contrasted because of differences in venom composition, clinical presentation and severity, and, accordingly, different therapeutic approaches. The majority of scorpion stings are either dry or result in low amounts of injected venom, thus explaining why up to 95% of scorpion stings ensue only in local signs. For a clinical envenomation to occur, it has been suggested that the interaction between the quantity of venom introduced in the body of the prey and the distribution volume should ensue in a critical threshold of scorpion toxin plasma concentration. In this case, there is a massive release of neurohormonal mediators (mainly catecholamine), with systemic vasoconstrictor effects eliciting a sharp increase in systemic arterial pressure and LV-filling pressure and decreased cardiac output. This early phase of cardiac dysfunction, also called "vascular phase", is followed by a severe cardiomyopathy, a form of Takotsubo cardiomyopathy, involving both ventricles and reversible in days to weeks. The more comprehensive understanding of the disease pathophysiology has allowed for a well-codified symptomatic treatment, thus contributing to a substantial reduction in the death toll of scorpion envenomation over the past few decades. The standard intensive-care treatment (when available) overcomes envenomation's consequences such as acute pulmonary edema and cardiogenic shock. Even though it continues to inspire many evaluative studies, immunotherapy seems less attractive because of the major role held by mediators in the pathogenesis of envenomation, and unfavorable pharmacokinetic properties to existing sera compared to venom. Meta-analyses of controlled trials of immunotherapy in severe scorpion envenomation reached similar conclusions: there is an acceptable level of evidence in favor of the use of scorpion antivenom (Fab'2) against Centruroides sp. in USA/Mexico, while there is still a need for a higher level of evidence for immunotherapy in the Old World envenomation.

How to ventilate obstructive and asthmatic patients.

Exacerbations are part of the natural history of chronic obstructive pulmonary disease and asthma. Severe exacerbations can cause acute respiratory failure, which may ultimately require mechanical ventilation. This review summarizes practical ventilator strategies for the management of patients with obstructive airway disease. Such strategies include non-invasive mechanical ventilation to prevent intubation, invasive mechanical ventilation, from the time of intubation to weaning, and strategies intended to prevent post-extubation acute respiratory failure. The role of tracheostomy, the long-term prognosis, and potential future adjunctive strategies are also discussed. Finally, the physiological background that underlies these strategies is detailed.

The role for high flow nasal cannula as a respiratory support strategy in adults: a clinical practice guideline.

PURPOSE: High flow nasal cannula (HFNC) is a relatively recent respiratory support technique which delivers high flow, heated and humidified controlled concentration of oxygen via the nasal route. Recently, its use has increased for a variety of clinical indications. To guide clinical practice, we developed evidence-based recommendations regarding use of HFNC in various clinical settings. METHODS: We formed a guideline panel composed of clinicians, methodologists and experts in respiratory medicine. Using GRADE, the panel developed recommendations for four actionable questions. RESULTS: The guideline panel made a strong recommendation for HFNC in hypoxemic respiratory failure compared to conventional oxygen therapy (COT) (moderate certainty), a conditional recommendation for HFNC following extubation (moderate certainty), no recommendation regarding HFNC in the peri-intubation period (moderate certainty), and a conditional recommendation for postoperative HFNC in high risk and/or obese patients following cardiac or thoracic surgery (moderate certainty). CONCLUSIONS: This clinical practice guideline synthesizes current best-evidence into four recommendations for HFNC use in patients with hypoxemic respiratory failure, following extubation, in the peri-intubation period, and postoperatively for bedside clinicians.

The effect of prone positioning in acute respiratory distress syndrome or acute lung injury: a meta-analysis. Areas of uncertainty and recommendations for research.

OBJECTIVE: To compare the effects of ventilation in prone and in supine position in patients with acute lung injury/acute respiratory distress syndrome (ALI/ARDS). DESIGN: Meta-analysis of randomised controlled trials. DATA SOURCES: BioMedCentral, PubMed, CINAHL, and Embase (to November 2007), with additional information from authors. MEASUREMENTS AND RESULTS: From selected randomised controlled trials comparing positioning in ALI/ARDS we extracted data concerning study design, disease severity, clinical outcomes, and adverse events. Five trials including 1,372 patients met the inclusion criteria for mortality analysis; one trial was added to assess the effects on acquisition of ventilator-associated pneumonia (VAP). The included trials were significantly underpowered and enrolled patients with varying severity. Prone positioning duration and mechanical ventilation strategy were not standardised across studies. Using a fixed-effects model, we did not find a significant effect of prone positioning (proning) on mortality (odds ratio 0.97, 95% confidence interval 0.77-1.22). The PaO(2)/FiO(2) ratio increased significantly more with proning (weighted means difference 25 mmHg, p < 0.00001). Proning was associated with a non-significant 23% reduction in the odds of VAP (p=0.09), and with no increase in major adverse airway complications: OR 1.01, 95% CI 0.71-1.43. Length of intensive care unit stay was marginally and not significantly increased by proning. CONCLUSIONS: Prone position is not associated with a significant reduction in mortality from ALI/ARDS despite a significant increase in PaO(2)/FiO(2), is safe, and tends to decrease VAP. Published studies exhibit substantial clinical heterogeneity, suggesting that an adequately sized study optimising the duration of proning and ventilation strategy is warranted to enable definitive conclusions to be drawn.

Detection of acute heart failure in chronic obstructive pulmonary disease patients: role of B-type natriuretic peptide.

PURPOSE OF REVIEW: Unrecognized chronic heart failure is present in 21-30% of chronic obstructive pulmonary disease patients. It may be a precipitating factor for acute exacerbation of chronic obstructive pulmonary disease or may hinder weaning from mechanical ventilation. The aim of the review is to emphasize recent studies that validated measurements of plasma B-type natriuretic peptide in the diagnosis of heart dysfunction in chronic obstructive pulmonary disease patients. RECENT FINDINGS: Measurements of B-type natriuretic peptide or N-terminal pro-B-type natriuretic peptides are accurate in the diagnosis of left heart dysfunction in chronic obstructive pulmonary disease patients either in stable condition or during acute exacerbation of chronic obstructive pulmonary disease. Natriuretic peptide thresholds are elevated in comparison to cut-offs usually reported in patients without pulmonary disease. B-type natriuretic peptide dosage is also able to uncover new onset of left heart failure associated with weaning difficulties from mechanical ventilation in chronic obstructive pulmonary disease patients. SUMMARY: Recent evidence suggests that natriuretic peptide measurements are accurate in the diagnosis of coexisting left heart failure in chronic obstructive pulmonary disease patients, either in stable condition or during severe cardiopulmonary interactions occurring during acute exacerbation of chronic obstructive pulmonary disease, or evoking weaning difficulties related to left heart dysfunction.

Prevalence of anxiety and depressive symptoms among medical residents in Tunisia: a cross-sectional survey.

OBJECTIVE: To assess the prevalence of anxiety and depressive symptoms and the associated risk factors among Tunisian medical residents. DESIGN: Cross-sectional survey. SETTING: Faculty of Medicine, Tunis. PARTICIPANTS: All Tunisian medical residents brought together between 14 and 22 December 2015 to choose their next 6-month rotation. INTERVENTION: The items of the Hospital Anxiety and Depression (HAD) questionnaire were employed to capture the prevalence of anxiety and/or depression among the residents. The statistical relationships between anxiety and depression (HAD score) and sociodemographic and work-related data were explored by Poisson regression. RESULTS: 1700 out of 2200 (77%) medical residents (mean age: 28.5±2 years, female: 60.8%) answered the questionnaire. The mean working hours per week was 62±21 hours; 73% ensured a mean of 5.4±3 night shifts per month; and only 8% of them could benefit from a day of safety rest. Overall, 74.1% of the participating residents had either definite (43.6%) or probable (30.5%) anxiety, while 62% had definite (30.5%) or probable (31.5%) depression symptoms, with 20% having both definite anxiety and definite depression. The total HAD score was significantly associated with the resident's age (OR=1.014, 95% CI 1.006 to 1.023, p=0.001); female gender (OR=1.114, 95% CI 1.083 to 1.145, p<0.0001); and the heavy burden of work imposed on a weekly or monthly basis, as reflected by the number of night shifts per month (OR=1.048, 95% CI 1.016 to 1.082, p=0.03) and the number of hours worked per week (OR=1.008, 95% CI 1.005 to 1.011, p<0.0001). Compared with medical specialties, the generally accepted difficult specialties (surgical or medical-surgical) were associated with a higher HAD score (OR=1.459, 95% CI 1.172 to 1.816, p=0.001). CONCLUSION: Tunisian residents experience a rate of anxiety/depression substantially higher than that reported at the international level. This phenomenon is worrying as it has been associated with an increase in medical errors, work dissatisfaction and attrition. The means of improving the well-being of Tunisian medical residents are explored, emphasising those requiring immediate implementation.

Inverted Takotsubo syndrome in Androctonus australis scorpion envenomation.

CONTEXT: The nature of scorpion-related cardiomyopathy is still a matter of debate where specific toxin-induced cardiomyopathy, ischemic, or catecholaminergic cardiomyopathy is advocated as well. We report two cases of Takotsubo syndrome following envenomation by Androctonus australis, bringing new evidence for the fundamental role of catecholamines in the pathogenesis of this cardiomyopathy. Case 1: A woman aged 36 presented with pulmonary edema and shock following scorpion envenomation. Echocardiography-Doppler showed a LVEF at 30%. Cardiac magnetic resonance (CMR) imaging showed a basal ballooning of the left and right ventricles suggestive of an inverted biventricular Takotsubo syndrome. A second CMR performed after recovery was normal. Case 2: A woman aged 45 was admitted for pulmonary edema and shock consecutive to scorpion envenomation. Echocardiography showed a LVEF at 35%. CMR showed a basal ballooning. The patient was discharged four days following admission with a normal LV function on repeat echocardiography examination. CONCLUSIONS: Cardiomyopathy in these cases, following scorpion envenomation by Androctonus australis, fulfills the criteria of Takotsubo syndrome. These observations contribute to our understanding of the mechanism, prognosis, and treatment of scorpion-related cardiomyopathy.

A global perspective on vasoactive agents in shock.

PURPOSE: We set out to summarize the current knowledge on vasoactive drugs and their use in the management of shock to inform physicians' practices. METHODS: This is a narrative review by a multidisciplinary, multinational-from six continents-panel of experts including physicians, a pharmacist, trialists, and scientists. RESULTS AND CONCLUSIONS: Vasoactive drugs are an essential part of shock management. Catecholamines are the most commonly used vasoactive agents in the intensive care unit, and among them norepinephrine is the first-line therapy in most clinical conditions. Inotropes are indicated when myocardial function is depressed and dobutamine remains the first-line therapy. Vasoactive drugs have a narrow therapeutic spectrum and expose the patients to potentially lethal complications. Thus, these agents require precise therapeutic targets, close monitoring with titration to the minimal efficacious dose and should be weaned as promptly as possible. Moreover, the use of vasoactive drugs in shock requires an individualized approach. Vasopressin and possibly angiotensin II may be useful owing to their norepinephrine-sparing effects.

Prediction of recurrent spontaneous pneumothorax: CT scan findings versus management features.

OBJECTIVE: To assess the association between primary spontaneous pneumothorax (PSP) recurrence and pulmonary CT scan findings, and other variables pertaining to clinical presentation and management. METHODS: Consecutive patients hospitalized for the first episode of PSP and treated by various strategies including chest tube or pleurocatheter drainage and, in persistent pneumothorax, by chemical or surgical pleurodesis. All patients had a pulmonary CT scan examination in the week following hospital discharge in order to calculate a score combining distribution, number and size of dystrophic pulmonary abnormalities. This score as well as other pertinent clinical and therapeutic parameters were compared between patients who ultimately experienced PSP recurrence and those who did not. RESULTS: Eighty patients (mean age: 27+/-7 yr) were admitted for PSP and had a chest drainage with either a drain or pleurocatheter. Chest drainage and hospitalization durations were 4.7+/-3.2 and 6.2+/-3.5 days, respectively. Sixteen patients required chemical pleurodesis. Dystrophic bullae were present in CT scans in 72.5% patients. After a mean follow up of 34+/-20 months, 15 out of the 80 patients (19%) had a PSP recurrence. Multivariate statistical analysis disclosed the use of pleurocatheter (OR=5; 95% CI: 1.4-20; P=0.02) and of chemical pleurodesis (OR=8; 95% CI: 1.5-47; P=0.015) as independent predictors of PSP recurrence. The severity of dystrophic lesions inferred from the dystrophic score was not statistically associated with the risk of recurrence. CONCLUSION: Dystrophic lesions are frequently present in PSP. They are not associated with an increased risk of recurrence.

Noninvasive ventilation with helium-oxygen mixture in hypercapnic COPD exacerbation: aggregate meta-analysis of randomized controlled trials.

When used as a driving gas during NIV in hypercapnic COPD exacerbation, a helium-oxygen (He/O2) mixture reduces the work of breathing and gas trapping. The potential for He/O2 to reduce the rate of NIV failure leading to intubation and invasive mechanical ventilation has been evaluated in several RCTs. The goal of this meta-analysis is to assess the effect of NIV driven by He/O2 compared to air/O2 on patient-centered outcomes in hypercapnic COPD exacerbation. Relevant RCTs were searched using standard procedures. The main endpoint was the rate of NIV failure. The effect size was computed by a fixed-effect model, and estimated as odds ratio (OR) with 95% confidence interval (CI). Additional endpoints were ICU mortality, NIV-related side effects, and the length and costs of ICU stay. Three RCTs fulfilled the selection criteria and enrolled a total of 772 patients (386 patients received He/O2 and 386 received air/O2). Pooled analysis showed no difference in the rate of NIV failure when using He/O2 mixture compared to air/O2: 17 vs 19.7%, respectively; OR 0.84, 95% CI 0.58-1.22; p = 0.36; I 2 for heterogeneity = 0%, and no publication bias. ICU mortality was also not different: OR 0.8, 95% CI 0.45-1.4; p = 0.43; I 2 = 5%. However, He/O2 was associated with less NIV-related adverse events (OR 0.56, 95% CI 0.4-0.8, p = 0.001), and a shorter length of ICU stay (difference in means = -1.07 day, 95% CI -2.14 to -0.004, p = 0.049). Total hospital costs entailed by hospital stay and NIV gas were not different: difference in means = -279$, 95% CI -2052-1493, p = 0.76. Compared to air/O2, He/O2 does not reduce the rate of NIV failure in hypercapnic COPD exacerbation. It is, however, associated with a lower incidence of NIV-related adverse events and a shortening of ICU length of stay with no increase in hospital costs.