[Nonrespiratory sleep disorders in obese and diabetic patients]. / Troubles non respiratoires du sommeil chez le patient obèse et chez le patient diabétique de type II.

Pneumologists frequently see obese and diabetic patients because of the high prevalence of these pathologies associated with sleep apneas. Nevertheless, the search for a sleep apnea syndrome is sometimes negative and the pneumologist is faced with unexplained complaints of sleepiness and sleep disorders. Pneumologists have to be familiar with and explore other nonrespiratory disorders in order to improve patient care. Inflammatory mechanisms have been suspected in several recent studies on daytime sleepiness. Sleep duration, obesity and diabetes are supposed to be linked because of hormonal modifications induced by sleep deprivation. Moreover, a relationship between diabetes and restless legs syndrome is not excluded.

Efficacy and compliance of mandibular repositioning device in obstructive sleep apnea syndrome under a patient-driven protocol of care.

OBJECTIVE: To assess the efficacy and compliance of a traction-based mandibular repositioning device (MRD) for treatment of moderate to severe obstructive sleep apnea syndrome (OSAS) under a patient-driven protocol in a routine outpatient care setting. METHODS: Forty patients, 10 severe and 30 moderate OSAS sufferers (apnea-hypopnea index [AHI] >30 and between 15 and 30, respectively), were enrolled by four sleep centers. Nocturnal polygraphy, quality of life, and quality of sleep questionnaires were used to measure the effect of treatment after 45 days. RESULTS: Thirty-five patients completed the study. Frequency of respiratory events, daytime sleepiness, snoring, patient assessment of sleep quality, specific short-form multipurpose health survey (SF-36) and the Pittsburgh Sleep Quality Index (PSQI) improved significantly with the MRD. Sixty percent of patients were "responders" (>50% decrease in AHI); 46% of patients were "full responders" (>50% decrease and AHI <10). Observance of treatment was high; 80% of patients wore the MRD every night. Side effects and patient complaints were minor and transitory. No serious side effects or cases of pathology aggravation were reported. CONCLUSION: Efficacy on respiratory and somnolence parameters of this innovative traction-based MRD was validated under a simple protocol of care with response rates similar to those published in the literature. This study shows consistent significant improvement by the MRD in quality of life and quality of sleep parameters across several tests. Treatment with the MRD under a simple, patient-driven protocol of care with control of efficacy by nocturnal polygraphy is appropriate in routine outpatient practice for moderate OSAS patients.

Structural and functional arterial properties in patients with obstructive sleep apnoea syndrome and cardiovascular comorbidities.

The increased severity of obstructive sleep apnoea syndrome (OSAS) is associated with a parallel increase in the incidence of cardiovascular events. Whether the increased severity of OSAS is in fact associated with impaired arterial properties has never been thoroughly studied. In patients with OSAS who carry a high burden of cardiovascular risk factors, we investigated whether the severity of OSAS is associated with deterioration in the arterial properties, independent of classical cardiovascular risk factors. In 74 consecutive patients with OSAS, we non-invasively assessed, by means of tonometry and high-resolution ultrasound: carotid intima-media thickness (IMT), carotid diameter and plaques, carotid-femoral pulse wave velocity (PWV), central augmentation index (AI) and central blood pressures. The respiratory disturbance index was an independent predictor of IMT and PWV but not of carotid plaques, carotid diameter, AI or central blood pressures. Several parameters of nocturnal hypoxaemia were independently correlated with carotid IMT and PWV. In conclusion, arterial stiffening and thickening are modulated by the severity of OSAS, independently from age and cardiovascular risk factors.

Cardiac arrhythmias during the combined use of intravenous aminophylline and terbutaline in status asthmaticus.

The purpose of this study was to evaluate prospectively the occurrence of cardiac arrhythmias during the combined therapy with intravenous aminophylline and terbutaline in 29 consecutive patients with status asthmaticus. The 24-hour Holter recordings were performed during continuous intravenous infusions of aminophylline (0.56 +/- 0.20 mg/kg/h) and terbutaline (0.034 +/- 0.014 microgram/kg/min). Serum theophylline concentration was 12.1 +/- 3.8 micrograms/ml and never reached the toxic level (greater than 20 micrograms/ml). Premature ventricular contractions (PVCs) were absent in 35 percent of patients and 48 percent had rare unifocal PVCs (less than 10/h). Only 17 percent of patients (five of 29) exhibited severe ventricular arrhythmias: PVCs greater than 10/h (n = 3), multifocal PVCs (n = 1); and a short run of ventricular tachycardia (n = 1). Serious supraventricular arrhythmias occurred in only 7 percent of patients (two of 29) who developed sustained runs of atrial tachycardia. These arrhythmias were always clinically well tolerated and spontaneously resolved without any antiarrhythmic treatment. We conclude that severe arrhythmias are rarely observed during combined therapy with aminophylline and terbutaline in status asthmaticus.

Noninvasive estimation of systolic pulmonary artery pressure using Doppler echocardiography in patients with chronic obstructive pulmonary disease.

In patients with acquired or congenital heart diseases, the systolic pulmonary artery pressure (PAPs) can be predicted using continuous-wave Doppler ultrasound (CWD) measurement of the peak velocity of a tricuspid regurgitation (TR) jet. The aim of this study was to determine whether CWD could be used to accurately estimate PAP in patients with chronic obstructive pulmonary disease (COPD). In 41 patients with stable COPD, we prospectively performed CWD and right heart catheterization. The mean value of PAPs for the entire group was 38.5 +/- 14.9 mm Hg. Pulmonary arterial hypertension (PAPs greater than or equal to 35 mm Hg) occurred in 51 percent (21/41) of patients. Doppler estimation of PAP was impossible in 34 percent (14/41) because of poor signal quality (n = 3), absence of Doppler-detected TR (n = 8), and inadequate TR Doppler signal (n = 3). The PAP could be estimated in 66 percent (27/41) of patients. A statistically significant correlation was found between the Doppler-estimated PAP and the catheter-measured PAPs (r = 0.65; p less than 0.001; SEE = 9 mm Hg). Therefore, CWD appears to be useful for the noninvasive estimation of PAP in patients with COPD. However, this method is associated with two limitations: (1) the high percentage of patients in whom the PAP cannot be estimated by CWD, mainly because of the absence of Doppler-detected TR, and (2) the high value of the standard error of the estimate. The combination of CWD with other Doppler methods should increase the feasibility and accuracy of Doppler echography for the prediction of PAP in patients with COPD.

Nutritional status of patients with chronic obstructive pulmonary disease and acute respiratory failure.

The prevalence and features of malnutrition in COPD patients have been studied extensively in stable conditions but are poorly defined in the presence of acute respiratory failure (ARF). Nutritional status was prospectively assessed, on hospital admission, in 50 consecutive COPD patients presenting with ARF, 27 of them requiring mechanical ventilation (MV). Malnutrition, defined on a multiparameter nutritional index, was observed in 60 percent (30/50) of all patients, and in 39 percent (13/33) of those whose body weight was equal to or above 90 percent ideal body weight (IBW). Malnutrition was more frequent in those patients who required MV than in those who did not (74 percent vs 43 percent, p < 0.05). Subcutaneous fat stores were decreased (triceps skinfold thickness [TSF] < 80 percent pred) in 68 percent of patients, and markedly depleted (TSF < 60 percent pred) in 52 percent of them. The indices of lean body mass, ie, mid-arm muscle circumference (MAMC) and creatinine height index (CHI) were decreased in, respectively, 42 percent and 71 percent of patients, but MAMC was severely depressed (< 60 percent pred) in only 6 percent of them. A severe decrease of prealbumin (< 100 mg/L), retinol-binding-protein (< 20 mg/L), and albumin (< 20 g/L) serum concentrations was observed in, respectively, 22 percent, 28 percent, and 4 percent of patients. These results suggest that an assessment of nutritional status using a multiparameter approach should be systematically performed in COPD patients with ARF, especially in those requiring MV, as malnutrition may have deleterious effects on weaning off MV.

Influence of caloric intake on the respiratory mode during mandatory minute volume ventilation.

Mandatory minute volume ventilation has been proposed as a method for weaning patients from ventilators. The purpose of this study was to delineate the influence of caloric intake on spontaneous ventilation in patients receiving mandatory minute volume ventilation. While the value of such ventilation remained unchanged, eight patients were studied at the following three different levels of daily caloric intake: (1) level A, mean of 223 kcal/sq m; (2) level B, mean of 1,380 kcal/sq m; and (3) level C, mean of 2,100 kcal/sq m. We performed gas exchange measurements and a 24-hour recording of ventilation with a monitoring system providing distinction between spontaneous and mechanical cycles. We found that the ventilatory mode was markedly dependent upon the nutritional intake; the percentage of spontaneous ventilation over 24 hours increased from 11 +/- 7 percent (+/- SE) during diet A to 50 +/- 9 percent during diet B and 79 +/- 8 percent during diet C. This increment paralleled the increase in production of carbon dioxide with caloric intake. We suggest therefore that the patient's ability to breathe spontaneously when receiving mandatory minute volume ventilation should be interpreted according to caloric intake.

Bioelectrical impedance analysis in estimating nutritional status and outcome of patients with chronic obstructive pulmonary disease and acute respiratory failure.

OBJECTIVE: To evaluate bioelectrical impedance analysis (BIA) in estimating the nutritional status and outcome of patients with chronic obstructive pulmonary disease (COPD) and acute respiratory failure (ARF) in comparison with measurements of anthropometric parameters and plasma levels of visceral proteins. DESIGN: Retrospective study. SETTING: A ten-bed intensive care unit (ICU) in a university teaching hospital. PATIENTS: 51 COPD patients with ARF in whom BIA data, anthropometric parameters, and measurements of visceral proteins were available. MEASUREMENTS AND RESULTS: BIA results in patients requiring mechanical ventilation (MV) vs. those who did not showed lower active cell mass (ACM; 37.5 +/- 6.5% vs. 42.4 +/- 7.2% body weight, P = 0.01) and a higher extra-/intracellular water volume ratio (ECW/ICW; 1.25 +/- 0.2 vs. 1.04 +/- 0.2, P = 0.0001), suggesting a more severe alteration in the nutritional status among those on MV. Anthropometric data showed the opposite results, since body weight, body mass index (BMI), triceps skinfold thickness (TSF), and fat mass were significantly higher in the invasively ventilated patients, whereas middle-arm muscle circumference (MAMC) did not differ between the two groups. The marked inflation of the extracellular compartment (ECW, ECW/ICW) that was well shown by BIA in the invasively ventilated patients presumably lead to inaccurate anthropometric results (overestimation of TSF and fat mass, and erroneous measure of MAMC). A higher death rate (38% vs. 0%, P = 0.01) was observed in the patients with ACM depletion (ACM < or = 40.6% body weight, n = 26) than in those without ACM depletion (n = 25). Low albumin level (< 30 g/l) was associated with increased mortality (33% vs. 7%, P = 0.04), but the differences in the other biological and anthropometric parameters (prealbumin and transferrin levels, body weight, BMI, TSF, MAMC, fat mass, and fat-free mass) were not associated with mortality. CONCLUSION: This study suggests that the decrease in BIA-derived ACM is a good indication of malnutrition and of poor outcome in COPD patients with ARF.

Hyperlactatemia during acute severe asthma.

OBJECTIVE: To evaluate arterial lactate levels during treatment of acute severe asthma (ASA) and the prognostic value of arterial hyperlactatemia in ASA. DESIGN: Prospective study. SETTING: A respiratory intensive care unit (ICU) of a university hospital. PATIENTS: 29 consecutive patients admitted to the ICU for ASA not intubated on admission and with a peak expiratory flow (PEF) < 150 l/min or an arterial carbondioxide tension (PaCO2) > 40 mm Hg. All patients received standardized treatment during the first 24 h including i.v. and nebulized salbutamol, i.v. theophylline, and dexamethasone. MEASUREMENTS AND RESULTS: Arterial lactate levels were serially measured by an enzymatic method during the first 24 h following admission. On admission, the mean arterial lactate level was 3.1 +/- 0.38 mmol/l (range 1.1-10.4); 17 patients (59%) had arterial hyperlactatemia with a lactate level > 2 mmol/l. No difference was found in lactate levels between patients with progressively worsening asthma and those with an acute onset of severe asthma. No correlation was found between arterial lactate levels on admission, on the one hand, and respiratory rate (RR), heart rate, PEF, pH, PaCO2, arterial oxygen tension, potassium, phosphorus, creatine kinase, or transaminase values on admission, on the other hand. All patients developed an important but transient increase in arterial lactate levels during treatment, with a peak at 7.72 +/- 0.46 mmol/l and a mean elevation of 4.62 +/- 0.45 mmol/l (range 0.4-12.1), from the initial admission value contrasting with a significant clinical improvement assessed by RR, PEF, and arterial blood gas parameters. CONCLUSION: This study suggests that, in ASA, arterial hyperlactatemia is frequently present on admission to the ICU. Delayed hyperlactatemia is a constant finding during treatment of ASA. Initial or delayed hyperlactatemia seems of no prognostic value because none of the patients required mechanical ventilation. The effects of therapy for acute asthma on lactate metabolism still need to be studied.

Seizures related to severe hypophosphataemia induced by mechanical ventilation.

A patient with chronic obstructive pulmonary disease and acute respiratory failure developed grand mal seizures in the hours following onset of mechanical ventilation. These seizures were associated with an acute increase in arterial pH and were related to the occurrence of acute severe hypophosphataemia associated with recovery from respiratory acidosis.

Bronchial hyperresponsiveness following acute severe asthma.

OBJECTIVE: To evaluate bronchial hyperresponsiveness (BHR) early after recovery from acute severe asthma (ASA). DESIGN: Prospective study including all patients admitted to the intensive care unit (ICU) for ASA over a 12-month period. SETTING: University teaching ICU and pneumonology department. PATIENTS: 41 consecutive patients admitted to the ICU for ASA. Results were compared with those of a control group with stable asthma and no history of ASA or steroid therapy, matched for sex and age. MEASUREMENT AND RESULTS: Of the 41 patients, 40 completed respiratory function tests 10 days after ICU admission, and the minimal dose of acetylcholine inducing a fall in forced expiratory volume in 1 s (FEV1) of 20% or more (PD AC) could be determined safely by a novel method in 26 patients with an FEV1 above 60% predicted. PD AC (micrograms) was found to be significantly lower in ASA than in control patients. Very severe BHR (PD AC < or = 100 micrograms) was found in 18 ASA patients, but not in the control patients; 5 ASA versus 12 control patients had marked BHR (100 > PD AC < or = 500 micrograms); and 3 ASA versus 14 control patients had moderate BHR (> 500 micrograms). A similar level of BHR was found in ASA patients with progressive or acute worsening. No correlation was found between PD AC and admission PaCO2 value, admission peak expiratory flow (PEF) value, delay in improvement of PEF, delay in PD AC determination, or prechallenge FEV1 value. CONCLUSION: BHR measurement is safe soon after an episode of ASA if done with caution. At this time, patients who are free of clinical symptoms and have no significant objective bronchial obstruction appear to have severe bronchial hyper-responsiveness.

Primary pneumococcal pericarditis complicated by acute constriction.

We report a case of a 31-year-old male with primary pneumococcal pericarditis. Severe acute constrictive pericarditis developed within a month of the onset of the illness in spite of adequate antibiotic therapy and pericardial drainage.

[Quantitative analysis of systolic function of the right ventricule by Doppler echocardiography]. / Analyse quantitative de la fonction systolique ventriculaire droite par échocardiographie Doppler.

The recording of the velocity of tricuspid valve regurgitation by continuous wave Doppler enables the calculation of the instantaneous systolic pressure gradient between the right ventricle and right atrium. As right atrial pressure is relatively constant, the rate of acceleration of the regurgitant jet reflects the quality of the rise in pressure in the right ventricle in early diastole, and therefore right ventricular contractility. The authors studied 3 Doppler parameters of the rate of velocity increase of the tricuspid regurgitation; the maximum rate of acceleration (dV/dt max), the maximum derivative of the pressure (dP/dt max) and the mean rate of increase in pressure (T). The interobserver variability of these indices is low (r greater than 0.96); reproducibility is good in patients with sinus rhythm but mediocre in atrial fibrillation. The comparison of the Doppler indices with the right ventricular isotopic fraction in 26 patients with tricuspid regurgitation showed a good correlation (dV/dt max, r = 0.79, p less than 0.0001; dP/dt max, r = 0.69, p less than 0.0001; T, r = 0.60, p = 0.0012). These results show that right ventricular systolic function can be evaluated by continuous wave cardiac Doppler by recording the spectral envelope of tricuspid regurgitation.

[Fatal hemoptysis during bronchial aspergillosis with multiple pulmonary artery aneurysms]. / Hémoptysie fatale au cours d'une aspergillose bronchique par anévrysmes artériels pulmonaires multiples.

Aspergillosis with fatal outcome are usually pulmonary invasive aspergillosis with or without dissemination, developed in patients with severe immunosuppression. We report a fatal case of bronchial necrotizing aspergillosis in a young woman with diabetes mellitus, who developed similar lesions to "Semi-invasive Aspergillosis", so-called "Chronic Necrotizing Pulmonary Aspergillosis". This aspergillosis was complicated by large pulmonary artery aneurysms requiring an hemostatic lobectomy. These aneurysms, secondary to the bronchial lesions, contrast with infectious aneurysms (so-called mycotic) secondary to septic embols. They differ from Rasmussen's aneurysms, due to tuberculosis, by their size, fusiform shape and extent. Lesions of vessels' walls and parietal fungal invasion in the vicinity of an endo-bronchial aspergilloma explain the vascular rupture. The multiplicity of these aneurysms, showed on C T Scan, is responsible for death by post-surgical recurrence of hemoptysis.

[Artificial nutrition in patients with chronic respiratory insufficiency undergoing surgery]. / Nutrition artificielle chez l'insuffisant respiratoire chronique opéré.

Denutrition is a common finding in patients with chronic respiratory failure (CRF). Preoperative denutrition increases the risk of nosocomial pneumonia and difficulties in weaning from mechanical ventilation. A preoperative nutritional support may have beneficial effects on respiratory muscles performance. However, prospective studies need to be carried out in patients with CRF to substantiate this hypothesis. Postoperative nutritional support is indicated if weaning from the ventilator is expected to require more than several days, in order to preserve the diaphragmatic function. Lipid-enriched nutrition may have a beneficial effect, when energy supply is high, as the resulting decrease in CO2 production may facilitate the weaning from the ventilator. A beneficial effect of branched-chain amino acid-enriched solutions has not been demonstrated in patients with CRF.

[The value of biological and clinical signs of pulmonary embolism]. / La valeur des signes cliniques et biologiques de l'embolie pulmonaire.

Pulmonary embolism (PE) is often underdiagnosed, mainly because it is not thought of. Its clinical signs are not highly specific and are encountered in a wide range of pulmonary diseases. Certain symptoms and signs, particularly when combined, are suggestive of PE: unexplained dyspnea, pleuretic pain with or without hemoptysis, tachypnea, etc. but they are not pathognomonic. Routine laboratory investigations such as arterial blood gas analysis, total blood cell count, serum LDH, etc. ... contribute poorly to making the diagnosis. D-dimers are fibrin degradation products. It has now been made possible to rule out PE in almost 20% of suspected cases, when plasma D-dimers levels are lower than 500 ng/ml, using the ELISA technique, with a very high sensitivity rate (98%). On the other hand, their specificity and positive predictive value are low (< 50%) and under no circumstances should their measurement be used to confirm the diagnosis of PE. This test is time-consuming, but new faster techniques seem to be promising.

[Spontaneous bilateral chylothorax revealing disseminated tuberculosis complicated by massive pulmonary embolism]. / Chylothorax spontané bilatéral révélateur d'une tuberculose disséminée, compliquée d'une embolie pulmonaire massive.

We report a case of bilateral chylothorax revealing diffuse tuberculosis. The clinical presentation was complicated by the apparition of a massive acute pulmonary embolism and an acute respiratory distress syndrome. Mycobacterium tuberculosis was isolated from the cultures of the bronchi aspiration of the bronchoscopic examination. With antituberculous chemotherapy, the course of the chylothorax was satisfactory.

[Pleural symphysis with tetracyclines for pneumothorax. The value of thoracic peridural analgesia]. / Symphyse pleurale aux tétracyclines pour pneumothorax. Intérêt de l'analgésie péridurale thoracique.

The aim of this study was to assess the value of peridural thoracic analgesia (ATP) to prevent pain observed during pleural symphysis with tetracycline (STP) for pneumothorax (PNO). 12 patients (age 27 +/- 6 years) having a spontaneous PNO benefited from 13 SPT (1 gm, tetracycline diluted in 60 cc of normal saline) under cover of an APT (at the D5-D6 level) with Fentanyl (0.1 mg) and Bupivacaine 0.5% adrenalin (1 mg/kg). The protocol was used on three successive days. Repeated determinations of blood bupivacaine levels were performed in 9 patients on the first day. No patient had an intolerable pain which required injection of parenteral morphine and/or an interruption of the protocol. For two patients (one of them having a right symphysis and then a left symphysis one month later) the treatment sessions to achieve a symphysis were totally painless. 10 patients experienced moderate pain, mainly on the first day, which was relieved by reinjection of peridural bupivacaine (25 mg) (n = 9) or by the parenteral injection of non morphine analgesia (n = 1). No patient had a respiratory depression, collapse or bradycardia. The blood bupivacaine levels were always significantly less than the toxic levels (1.6 mg). The results observed suggest that APT, (Fentanyl and Bupivacaine) is an effective method, non toxic and well tolerated for the prevention of intolerable pain which is seen in SPT for PNO.

[Theophylline overdoses on admission to a resuscitation unit]. / Les surdosages en théophylline à l'admission en réanimation.

The aim of this study is to assess in a prospective fashion the causes and the frequency of overdosage with Theophylline on admission to intensive care units, in patients on long term treatment with oral Theophylline and/or had previously received an intravenous injection (IV) of Aminophylline. In 72 patients [52 chronic airflow obstruction (or BPCO), 21 asthmatics] admitted for acute respiratory insufficiency (IRA) the blood level of Theophylline on admission to intensive care (T0) was determined systematically, and was in the toxic range (greater than 29 mg/l) in 17% of cases (12/72). In patients with T0 greater than 20 mg/l, repeat measurements of Theophylline clearance were carried out: 12 hours after admission by studying the fall in plasma levels (Cl1), then after 8 days (+/- 5) while perfusing IV Aminophylline at a constant flow (Cl2) and finally after changing over to slow release oral Theophylline 18 days (+/- 10) after admission (Cl3). Cl1 was less than 35 ml/kg/h in 9 patients (group I) and greater than 55 ml/kg/h in 3 patients (group II). All the patients in group I were on oral Theophylline in a dose which was not excessive (mean 10.6 +/- 3.3 mg/kg/24 h) and only one patient received an injection of IV Aminophylline. In group I, the clearance of Theophylline was very low initially (Cl1 = 18.6 +/- 9.6 ml/kg/h) and finally rose (Cl2 = 34.7 +/- 14 ml/kg/h p less than 0.02; and Cl3 = 46.9 +/- 24 ml/kg/h p less than 0.02).(ABSTRACT TRUNCATED AT 250 WORDS)

[Icterohemorrhagic leptospirosis with acute respiratory distress syndrome and pulmonary hemorrhage]. / Leptospirose ictérohémorragique avec syndrome de détresse respiratoire aiguë et hémorragie pulmonaire.

We report a case of the respiratory distress syndrome occurring in a patient with leptospirosis ictero-haemorrhagica (LIH). The respiratory failure was associated with pulmonary haemorrhage. There was a rapid favourable outcome after treatment with antibiotics and artificial ventilation. The diagnosis of LIH has been confirmed by serological examination. The mechanisms of the pulmonary disorder during the course of LIH were discussed.