[Practical aspects of the management of patients treated by continuous positive airway pressure]. / Le suivi pratique des patients sous pression positive continue.

The therapeutic follow-up is a decisive factor of the success of a long course treatment by continuous positive airway pressure (CPAP). The effectiveness of this treatment on both symptoms and complications must be regularly verified. Polysomnography with CPAP could be necessary in order to check out the efficacy of this treatment and/or to find an associated diagnosis when symptoms persist, particularly a diurnal drowsiness, which is the main therapeutic target in obstructive sleep apnea syndrome (OSAS). The secondary effects that are likely to compromise the compliance of CPAP treatment must be resolved, particularly the nasal intolerance, which are enhanced by mask leakages and often corrected by using heated humidity with CPAP delivery systems. The efficacy of CPAP on both diurnal drowsiness and hypertension is related to the compliance of this treatment which must be regularly verified, at the same time that the clinical evaluation. The data obtained from the device's memory give information concerning the number of hours day to day, in which the CPAP device was running at the prescribed pressure. The first months with CPAP are decisive to avoid a failure of the treatment at long term. This period must be closely monitored by both the physician and the home care provider. Patients should use the CPAP at least 3-4 h by night and all possible means should be used to obtain a maximal compliance. Therapeutic educational programs could help to reach this goal.

[Central apnea developing during treatment with a mandibular advancement device]. / Apnées centrales induites sous traitement par orthèse d'avancée mandibulaire.

INTRODUCTION: Mandibular advancement (MA) has emerged over the last decade as an alternative solution to nasal continuous airway pressure (nCPAP) for the treatment of obstructive sleep apnea syndrome (OSAS). OBSERVATION: We report the case of a patient with history of chronic atrial fibrillation and moderate supine-dependent OSAS in whom central sleep apneas developed during treatment by a bi-bloc MA device. Central apneas increased with the level of MA and preferentially occurred in the supine position. We hypothesized that mouth opening under excessive mandibular advancement in supine position may have led to pharyngeal narrowing at the base of the tongue and potentially unstable ventilation. Sleep fragmentation that enhanced during progressive MA may also have compromised ventilatory control stability in our patient. Finally, chronic atrial fibrillation may have predisposed to central sleep apneas. CONCLUSION: Our case report highlights the importance of follow-up nocturnal recordings during progressive MA.

[Thrombocytopenia due to heparin therapy. Use of danaparoid (Orgaran), 13 monocentric cases under authorization of temporary prescription (ATU)]. / Thrombopenies sous héparinothérapie. Utilisation du danaparoïde (Orgaran), trieze cas monocentriques sous le régime de l'ATU.

Since September 1994, danaparoid (Orgaran), a heparinoid, has been used in our centre to treat patients with thrombocytopenia occurring during heparin therapy and who need continuing antithrombotic therapy. We carried out a retrospective study using clinical and biological data on the first 13 consecutive patients treated with danaparoid (for 1 to 18 consecutive days). The platelet count returned to normal for ten patients, but one patient died having contracted a severe sepsis and bleeding occurred in one patient with acute renal failure. In the three other cases, the diagnosis of heparin induced thrombocytopenia (HIT) was in retrospect unlikely and the death of these patients was related to severe underlying diseases which were held responsible for thrombocytopenia. We confirm that danaparoid appears to be an effective, well-tolerated substitute for heparin in HIT patients. The French regulation Temporary Authorization for Prescribing Medicines allowed the prompt use of this as yet unmarketed drug and collection of reliable and pertinent data.