[Purulent pleurisy and empyema. With the exception of pleural tuberculosis]. / Pleurésies purulentes et empyèmes. A l'exception des pleurésies tuberculeuses.

CLINICAL SETTING: Purulent collections in the pleural cavity usually occur as complications of pneumonia in immunodeficient or socially underprivileged patients. PUNCTURE ASPIRATION: The key to diagnosis, pleural aspiration is indicated in case of sufficiently abundant collections, especially in patients with fever. Exploratory puncture is a therapeutic emergency, allowing optimal antibiotic therapy when a causal germ is isolated and drainage of the purulent collection. If there is the slightest doubt, imaging techniques should be used to guide the puncture. DRAINAGE: Drainage is essential and is indicated whenever the aspiration fluid is purulent, contains, germs or the chemistry suggests major bacterial colonisation (acid pH, low glucose, high lactic acid dehydrogenase). Local injections of fibrinolytic agents improve drainage. PROGNOSIS: Complete recovery without sequellae is usually achieved. Physical therapy, provided early and for a prolonged period, helps improve the prognosis. Early care reduces the risk of recurrence of this potentially severe condition.

[Acute drug poisoning in suicidal elderly patients 70 years' old and over. 92 cases in a medical ICU]. / Les intoxications aiguës volontaires des personnes âgées de 70 ans et plus. Quatre-vingt douze cas observés en unité lourde de Réanimation.

Self-inflicted acute drug overdose in suicidal elderly patients appears to be a growing challenge to public health. To the best of our knowledge, little has been published on this topic. Thus we undertook a retrospective study, from January 1969 to October 1989, in a medical ICU. Ninety-two suicidal, elderly patients (54 women, 38 men) with a mean age of 77 years were included. The mean length of the hospital stay was 7 days (range: 1-45 days). Seventy-six percent of them were intubated and subjected to mechanical ventilation for a mean duration of 3 days. Overdosing on one drug occurred in 46 cases (50%). Toxicological analyses implicated the following medications: benzodiazepines, 50 cases; meprobamate, 26 cases; barbiturates, 24 cases; tricyclic anti-depressants, 17 cases; trichloroethylene, 1 case; insulin, 1 case. Psychiatric history, recorded for 47 patients, revealed previous suicide attempts by 20 of them. Complications were reported in 40 cases (43.5%): respiratory complications, 25 cases; shock, 13 cases; postanoxic coma, 2 cases. The incidence of mortality (13 cases) was 14%. Thirty-three patients were transferred to psychiatric units after release from ICU. During the same period, our ICU admitted 2,762 patients for acute drug poisoning and observed a 1% mortality rate. Thus, morbidity and mortality are higher in the elderly than in younger patients.

Expiratory flow limitation in COPD patients after single lung transplantation.

Expiratory flow limitation and dyspnea during resting breathing are common in patients with severe chronic obstructive pulmonary disease (COPD). Although single lung transplantation (SLT) is used to treat end-stage COPD, its effects on flow limitation and dyspnea are not well established. We assessed expiratory flow-limitation and dyspnea in 13 COPD patients after SLT at rest in the sitting and supine positions by applying negative pressure at the mouth during tidal expiration (negative expiratory pressure [NEP] technique). If NEP increases flow throughout the control tidal volume (VT), flow limitation is absent (not flow limited [NEL]). If NEP does not increase flow during part of the control VT, flow limitation is present. After SLT, lung function improved in all but one patient. Twelve patients were NFL during resting breathing in both positions studied. The patient whose lung function did not improve after SLT was flow-limited (FL) both when seated and supine. This patient also exhibited moderately severe chronic dyspnea (Medical Research Council [MRC] score = 3). In the nine other patients in whom dyspnea was assessed, it was slight (MRC score = 1). In conclusion, after SLT for end-stage COPD, expiratory flow limitation at rest is uncommon in both the seated and supine positions. This is consistent with the finding that after SLT the degree of chronic dyspnea is generally slight.

Expiratory flow limitation in stable asthmatic patients during resting breathing.

Application of negative pressure at the mouth during tidal expiration (NEP) provides a simple, rapid, noninvasive method for detecting expiratory flow limitation during spontaneous breathing. Patients in whom NEP elicits an increase in flow throughout expiration are not flow-limited (FL). In contrast, patients in whom application of NEP does not elicit an increase in flow during most or part of tidal expiration are considered FL. We have used the NEP technique to assess the prevalence of expiratory flow limitation during resting breathing in sable asthmatic patients in both the seated and supine positions. In patients in the sitting position, we have also assessed flow limitation with the conventional method, based on comparison of tidal and maximal expiratory flow-volume (MEFV) curves. We studied 13 patients (FEV1 range: 48 to 94% predicted) with both the NEP and conventional techniques. According to the NEP technique, none of the patients was FL in the seated and only two were FL in the supine position. By contrast, on the basis of the conventional method, six of the patients would have been classified as FL in the sitting position. We conclude that: (1) most stable asthmatic patients do not exhibit tidal expiratory flow limitation during resting breathing; and (2) the conventional method for assessing flow limitation may lead to erroneous conclusions.