Natural history of allergic sensitization in infants with early-onset atopic dermatitis: results from ORCA Study.

BACKGROUND: Early-onset atopic dermatitis (AD) is a particular phenotype that may convey a risk of developing multiple sensitizations to allergens but little is known about the pathway of sensitization. The aims of this study were to describe the natural history of sensitization to allergens for this phenotype and to identify the most predictive marker associated with the risk of developing sensitization to inhaled allergens in a well-selected cohort of infants with AD. METHODS: Infants with active AD were enrolled and prospectively explored for biological markers of atopy every year until the age of 6 yr. Allergic sensitization was defined as the presence of positive specific IgEs to allergens and multiple sensitizations as being sensitized to ≥2 allergens. Elevated blood eosinophilia was defined as an eosinophil blood count ≥470 eosinophils/mm(3) and elevated total IgE as a serum IgE level ≥45 kU/l. RESULTS: Two hundred and twenty-nine infants were included. Elevated blood eosinophilia was observed at baseline in 60 children (26.2%) and elevated total IgE in 85 (37.1%). When elevated at baseline, eosinophilia and IgE levels remained significantly higher during the follow-up period. Sensitization to food allergens decreased from 58% to 34%, whereas sensitization to inhaled allergens increased over time from 17% to 67%. Initial multiple sensitizations to food allergens were the most predictive factor for the risk of developing sensitization to inhaled allergens at 6 yr (OR 3.72 [1.68-8.30] p < 0.001). CONCLUSIONS: In the early-onset AD phenotype, multiple sensitization to food allergens conveys a higher risk of sensitization to inhaled allergens than single sensitization.

Intensive care unit admission in chronic obstructive pulmonary disease: patient information and the physician's decision-making process.

INTRODUCTION: ICU admission is required in more than 25% of patients with chronic obstructive pulmonary disease (COPD) at some time during the course of the disease. However, only limited information is available on how physicians communicate with COPD patients about ICU admission. METHODS: COPD patients and relatives from 19 French ICUs were interviewed at ICU discharge about their knowledge of COPD. French pulmonologists self-reported their practices for informing and discussing intensive care treatment preferences with COPD patients. Finally, pulmonologists and ICU physicians reported barriers and facilitators for transfer of COPD patients to the ICU and to propose invasive mechanical ventilation. RESULTS: Self-report questionnaires were filled in by 126 COPD patients and 102 relatives, and 173 pulmonologists and 135 ICU physicians were interviewed. For 41% (n = 39) of patients and 54% (n = 51) of relatives, ICU admission had never been expected prior to admission. One half of patients were not routinely informed by their pulmonologist about possible ICU admission at some time during the course of COPD. Moreover, treatment options (that is, non-invasive ventilation, intubation and mechanical ventilation or tracheotomy) were not explained to COPD patients during regular pulmonologist visits. Pulmonologists and ICU physician have different perceptions of the decision-making process pertaining to ICU admission and intubation. CONCLUSIONS: The information provided by pulmonologists to patients and families concerning the prognosis of COPD, the risks of ICU admission and specific care could be improved in order to deliver ICU care in accordance with the patient's personal values and preferences. Given the discrepancies in the decision-making process between pulmonologists and intensivists, a more collaborative approach should probably be discussed.

Neurally adjusted ventilatory assist improves patient-ventilator interaction during postextubation prophylactic noninvasive ventilation.

OBJECTIVES: To compare the respective impact of pressure support ventilation and naturally adjusted ventilatory assist, with and without a noninvasive mechanical ventilation algorithm, on patient-ventilator interaction. DESIGN: Prospective 2-month study. SETTING: Adult critical care unit in a tertiary university hospital. PATIENTS: Seventeen patients receiving a prophylactic postextubation noninvasive mechanical ventilation. INTERVENTIONS: Patients were randomly mechanically ventilated for 10 mins with: pressure support ventilation without a noninvasive mechanical ventilation algorithm (PSV-NIV-), pressure support ventilation with a noninvasive mechanical ventilation algorithm (PSV-NIV+), neurally adjusted ventilatory assist without a noninvasive mechanical ventilation algorithm (NAVA-NIV-), and neurally adjusted ventilatory assist with a noninvasive mechanical ventilation algorithm (NAVA-NIV+). MEASUREMENTS AND MAIN RESULTS: Breathing pattern descriptors, diaphragm electrical activity, leak volume, inspiratory trigger delay, inspiratory time in excess, and the five main asynchronies were quantified. Asynchrony index and asynchrony index influenced by leaks were computed. Peak inspiratory pressure and diaphragm electrical activity were similar for each of the four experimental conditions. For both pressure support ventilation and neurally adjusted ventilatory assist, the noninvasive mechanical ventilation algorithm significantly reduced the level of leakage (p < .01). Inspiratory trigger delay was not affected by the noninvasive mechanical ventilation algorithm but was shorter in neurally adjusted ventilatory assist than in pressure support ventilation (p < .01). Inspiratory time in excess was shorter in neurally adjusted ventilatory assist and PSV-NIV+ than in PSV-NIV- (p < .05). Asynchrony index was not affected by the noninvasive mechanical ventilation algorithm but was significantly lower in neurally adjusted ventilatory assist than in pressure support ventilation (p < .05). Asynchrony index influenced by leaks was insignificant with neurally adjusted ventilatory assist and significantly lower than in pressure support ventilation (p < .05). There was more double triggering with neurally adjusted ventilatory assist. CONCLUSIONS: Both neurally adjusted ventilatory assist and a noninvasive mechanical ventilation algorithm improve patient-ventilator synchrony in different manners. NAVA-NIV+ offers the best compromise between a good patient-ventilator synchrony and a low level of leaks. Clinical studies are required to assess the potential clinical benefit of neurally adjusted ventilatory assist in patients receiving noninvasive mechanical ventilation. TRIAL REGISTRATION: Clinicaltrials.gov Identifier NCT01280760.