[Acidosis in severe acute asthma]. / Les acidoses au cours des asthmes aigus graves.

On admission to intensive care units, the acid-base profile in acute severe asthma appears to be more diverse than previously. Especially a mixed or less frequently metabolic acidosis is eventually observed, which is not always caused by elevated lactate. On the other hand, hyperlactatemia is actually rather common, not necessarily accompanied by acidosis. This finding is as a rule related to massive doses of beta 2 adrenergic agents given parenterally: subsequent elevated lactate is in no way a marker of cellular hypoxia and has no pejorative meaning in this event. Hypercapnia with severe respiratory acidosis implies less and less mechanical ventilation; however, when mandatory, it has to be carried out using permissive hypercapnia, giving more favorable outcome while lowering side-effects.

[Recent data on the physiopathology of septic shock]. / Données récentes sur la physiopathologie du choc septique.

This review is going on to emphasize recent advances of the pathophysiology of septic shock (SS) which goes-between the systemic inflammatory response syndrome (SIRS) and the multisystem organ failure (MOF). By several recent studies, our knowledge of the cellular and molecular pathophysiology of the SS has dramatically increased. Bacterial products, immunocompetent cells, soluble mediators, and cell-cell interactions between blood cells and endothelium have been reviewed. The metabolic disorders following SS can also be observed during SIRS. Still further, these abnormalities do not accurately predict prognosis, except some of them. A wealth of pre-clinical data suggests the efficacy and potentially useful therapeutic strategies like specific immunotherapy (anti-endotoxin, antimediators). Discrepancies between animals models and unexpected and disappointing clinical trial results during SS are discussed. Blocking simultaneously the hole metabolic patterns of SS which is a complex, multisystem, and multifactorial pathologic process seems to be a utopian situation. Furthermore SS occuring more frequently as a complication of nosocomial infection, the high cost of such a novel therapeutic strategy has to be taken into account.

[Spontaneous and iatrogenic pneumothorax in the adult. 217 personal cases]. / Pneumothorax spontanés et iatrogènes chez l'adulte. A propos de 217 cas personnels.

This study is dedicated to the epidemiology of pneumothoraces (217 cases) during the last 8 years in an Intensive Care Department where most patients were admitted for respiratory diseases. Cases resulting from road-injury or surgery were excluded. Spontaneous pneumothoraces accounted for 61.8% of the cases. Among them, the most current etiology was idiopathic pneumothorax owing to small subpleural blebs, rarely leading to tension pneumothorax or hemapneumothorax. Other causes were pulmonary emphysema, more often than chronic obstructive pulmonary disease or acute asthma, active pulmonary tuberculosis, and acute pneumonia (especially AIDS-related Pneumocystis Carinii pneumonia). Among the iatrogenic pneumothoraces (38.2%), three sources accounted for 79 out of the 83 cases observed: drainage of pleural effusions, subclavian vein catheterization, mechanical ventilation of patients suffering from refractory hypoxemia or evincing very high bronchial resistances, therefore requiring special ventilatory techniques, such as positive end-expiratory pressure. Whereas pneumothoraces induced by pleural or venous access were not by themselves detrimental, the course of pneumothorax associated with ventilatory support was as a rule unfavourable, death being due to the pneumothorax per se in about fifty per cent of the cases. Various techniques, unequally efficient, were suggested to avoid or control this ominous side-effect of mechanical ventilation, which remains a serious problem.

[Metabolic alkalosis]. / Alcaloses métaboliques.

Metabolic alkalosis (MA) only occurs after bicarbonate administration if given quickly and massively, or in the presence of renal failure. Most cases of MA are caused by a loss of hydrogen ions. This paper reviews the common causes (gastric aspiration, chronic diuretic therapy) and updates the list of drugs which may lead to this complication. Rare causes (such as hyper mineralo-corticoid secretion) should be suspected in patients with MA unresponsive to usual doses of potassium chloride. Hydrochloric acid infusions are reserved for very special cases.

[Hemodynamic effects of enoximone and comparison with dobutamine in patients with chronic respiratory insufficiency and pulmonary arterial hypertension]. / Effets hémodynamiques de l'énoximone et comparaison avec la dobutamine chez l'insuffisant respiratoire chronique avec HTAP.

The aim of this study was to assess the effects of enoximone on the right ventricle and pulmonary hypertension in 10 patients (53 to 84 years) with chronic obstructive airway disease resulting in acute or chronic respiratory failure requiring mechanical ventilation in 9 cases. These effects were compared with those of dobutamine. All patients were in sinus rhythm and 6 had signs of right ventricular failure. Haemodynamic and 2D echocardiographic (study of left and right ventricular function) measurements were made under basal conditions (TB1), with 10 micrograms/kg/mn of dobutamine (TDob), again under basal conditions (TB2) three hours after the end of the dobutamine infusion, and then 30 minutes after an intravenous bolus (1 mg/kg) of enoximone (TE1) relayed by an infusion of 10 micrograms/kg/mn at 3 hours (TE2) and at 12 hours (TE3). The results (x +/- SD) were studied by a 2 factor variance analysis and compared by Student's test with Dunnett's correction. Cardiac index increased similarly by about 45% with enoximone (2.8 +/- 0.8 vs 4.1 +/- 1 l/min/m2; p less than 0.001 at TE2) and dobutamine, although the heart rate did not change significantly. Systemic arterial resistance fell significantly with enoximone (31.3 +/- 11 vs 21.3 +/- 6.8 IU; p less than 0.05 at TE2) but mean arterial pressures were unchanged; mean pulmonary artery pressures decreased from TE1 to TE3 (27.6 +/- 6.9 vs 22.6 +/- 6.3 mmHg; p less than 0.05 at TE2) mainly because pulmonary artery diastolic pressures decreased from TE1 to TE3 (20.1 +/- 4 vs 11.1 +/- 5.2 mmHg; p less than 0.05 at TE3).(ABSTRACT TRUNCATED AT 250 WORDS)

[Current humoral profile in acute severe asthma]. / Profil humoral actuel des asthmes aigus graves.

This study examined the relationships between acid-base disorders, hypoxemia, electrolyte imbalances, plasma adrenaline (Ad) and noradrenaline (NAd) in 94 patients with acute severe asthma. Criteria of inclusion were [PaO2 + PaCO2/.8] less than 140 mmHg when breathing air (FiO2 = 21%) and/or PaCO2 greater than or equal to 45 mmHg. PaCO2 was closely related to H+ in those patients with hypercapnia: H+ nmol/l = 0.88 PaCO2 + 4 (r 0.91 ; n = 61; p less than 0.001). However, among the 62 acidotic cases (pH less than or equal to 7.36), 24 were classified as respiratory, 22 as mixed and 16 as metabolic. A loose though highly significant relationship was found between PaO2 and PaCO2 (when breathing air). Blood lactate, which was 3.61 +/- 1.9 mmol/l (+/- SD), was not correlated with anion gap or H+, but was loosely related to PaO2 and kalemia. Ad (1.53 +/- 1.17 nmol/l) and NAd (5.85 +/- 3.44 nmol/l), measured at the time of admission in 27 patients (FIO2 = 21%), varied significantly from those of a control group (p less than 0.01). NAd was correlated with H+, lactate and especially PaCO2, whereas no correlation could be established for Ad with these factors or NAd values. On the average, kalemia, phosphatemia and calcemia were lowered. In conclusion, mixed and metabolic acidosis were more common in this study than in a previous personal series and were not necessarily associated with an increase in blood lactate. Drugs taken prior to hospitalization must be considered in the pathophysiology of hyperlactatemia, which appears to be one among several factors linked to NAd levels.

[Treatment of severe acute asthma in adults]. / Traitement des asthmes aigus graves de l'adulte.

Although abnormal blood gases are unusual in status asthmaticus, hypercapnia indicates a considerable increase in bronchial resistance. The authors report their experience of 106 personal cases of acute severe asthma. Emergency management of acute respiratory failure consisted in symptomatic therapy (low rate oxygen or mechanical ventilation after nasal intubation). Corticosteroids, rehydration, antibiotics and beta-2 adrenergic agents were associated. Mechanical ventilation was necessary in patients who developed alterations of consciousness or PaCO2 above 60 mm Hg (8 kPa). In respirator-patients, sedative drugs were needed. Terbutaline and salbutamol were occasionally beneficial but epinephrine remains the drug of choice. In our series of 106 cases (79 with hypercapnia) the overall mortality was 3.8 p. 100. Of the 33 cases who underwent mechanical ventilation, there were 4 deaths (12 p. 100). A review of the literature showed a much higher mortality in other series.

[Therapeutic importance and tolerance of coated 50 mg Vectarion tablets (almitrine bismesylate) at a dosage of 100 mg/day. Study of blood gas, clinical and biological results after a year of long-term treatment]. / Intérêt thérapeutique et acceptabilité du Vectarion 50 mg comprimés enrobés (bismésilate d'almitrine) à la dose de 100 mg/jour. Etude des résultats gazométriques, cliniques et biologiques en traitement prolongé pendant 1 an.

The objectives of this study, in which Almitrine bismesylate was administered for one year in chronic bronchitics with obstructive hypoxia, were to assess its clinical and gasometric efficacy and its clinical, laboratory, spirometric and electrocardiac acceptability. The blood gas results show a significant rise in PaO2 (p less than 0.001) rising by 5.5 mmHg after 6 months (T6) and by 6.0 mmHg after 12 months (T12) in comparison with the value at the study's onset. The PaCO2 fell by 3.3 mmHg at T6 and 2.7 mmHg at T12 (p less than 0.001). The dyspnoea of the patient, scored by the doctor on a scale of severity from 0 to 5 was situated on a mean of 3.3 points at the beginning of the study. It was significantly reduced by 0.8 points at T6 and by 0.9 points at T12 (p less than 0.001). The percentage of patients hospitalised during the course of the study fell significantly in comparison with the previous year, from 68% to 49% (p less than 0.001). The improvement in clinical status and in blood gases bore no relation to changes in respiratory function. The clinical acceptability of the product was good; few side effects were observed and the respiratory, digestive and neurological problems were often pre-existing. They only led to cessation of treatment in three cases. The electrocardiogram was unchanged. The laboratory investigations was unchanged, with the exception of a fall in red blood cells in relation to the correction of the hypoxaemia in polycythaemic patients.

Diffuse interstitial pneumonitis due to aspiration of gastric contents.

Two cases of interstitial pneumonitis are described which developed after the acute phase of aspiration pneumonitis. Open lung biopsy revealed an interstitial, granulomatous foreign body response induced by foodstuff aspiration. Steroid treatment was administered and both cases then showed a favourable course, with the pulmonary lesion healing within 12 days.

[Changes in the electrocardiogram in status asthmaticus]. / Les modifications de l'électrocardiogramme dans l'état de mal asthmatique.

The aim of this study, based on the electrocardiographic analysis of 42 patients in status asthmaticus, is to define the basic criteria which may be used as a basis for electrocardiographic differential diagnosis. The following ECG changes were observed: the pulmonary "p" wave is common, sometimes with exaggerated amplitude in peripheral leads, however, in the precordial leads, the voltage of the "p" wave is reduced; most cases have a vertical heart with clockwise rotation and mild right axis deviation, S1 Q2 Q3 and the transitional zone displaced to the left. Ten cases also had a S1 S2 S3 appearance and three cases showed Q1 Q2 Q3, simulating myocardial infarction; there is poor progression of the R wave in the precordial leads and marked persistence of the S wave in the left precordial leads. In some cases, a QS complex dominates the right precordial leads. A variation in the amplitude of the QRS with the respiratory rhythm is often seen in V1 and V2; ventricular repolarization shows a lowered J point with an upward oblique ST segment in the peripheral leads. However, in the precordial leads, the repolarization is normal except for three cases which presented a frank hypokalaemia. The mechanism of these electrocardiographic changes appears to depend on the vertical position of the heart caused by over expansion of the lungs and pulmonary arterial hypertension. The elements of the electrocardiographic differential diagnosis with myocardial infarction and pulmonary embolism are discussed.

[Fatal pneumopathy linked to subcutaneous injections of liquid silicone into soft tissue]. / Pneumopathie mortelle liée à l'injection sous-cutanée de silicone liquide dans les parties molles.

The case of a 23-year old transsexual male who developed a lethal lung disease 48 hr after a 1 l subcutaneous silicone fluid injection is reported. Histologic examination showed optically empty oil red O negative vacuoles in several specimens, and particularly in the lungs; refractile particles of silicium were also found. We identified the material as silicium, and evaluated its quantity in tissues by atomic absorption and spectrometric and toxicological analysis. Experimental studies and rare human accidents suggest that silicone fluid is transported by migrating phagocytes, thereby explaining lymph node, spleen, liver, adrenal and lung deposits. In our patient's report, we added gradual blood contamination to explain the progressive development of respiratory failure with the severity of the respiratory disorder linked to the massive dose injected. Massive silicone blood embolization could be excluded because of the interval between the injection and emergence of the first clinical signs.

Adult respiratory distress syndrome and silicone injection.

This report describes a case of adult respiratory distress syndrome (ARDS) after massive subcutaneous injections of silicone. The patient, a 23 year-old transsexual man, treated with mechanical ventilation, died on the 12th day of hospital, in septic shock and refractory hypoxemia. Autopsy findings revealed empty vacuoles surrounded by macrophages in various organs, especially in lung tissue. Toxicological analysis by emission by high frequency induced plasma showed silicone in the organs with histological lesions. The pathophysiology of this ARDS is considered.