Volume Status Assessment by Lung Ultrasound in End-Stage Kidney Disease: A Systematic Review.

Purpose of review: Lung ultrasound is a noninvasive bedside technique that can accurately assess pulmonary congestion by evaluating extravascular lung water. This technique is expanding and is easily available. Our primary outcome was to compare the efficacy of volume status assessment by lung ultrasound with clinical evaluation, echocardiography, bioimpedance, or biomarkers. The secondary outcomes were all-cause mortality and cardiovascular events. Sources of information: We conducted a MEDLINE literature search for observational and randomized studies with lung ultrasound in patients on maintenance dialysis. Methods: From a total of 2363 articles, we included 28 studies (25 observational and 3 randomized). The correlation coefficients were pooled for each variable of interest using the generic inverse variance method with a random effects model. Among the clinical parameters, New York Heart Association Functional Classification of Heart Failure status and lung auscultation showed the highest correlation with the number of B-lines on ultrasound, with a pooled r correlation coefficient of .57 and .36, respectively. Among echocardiographic parameters, left ventricular ejection fraction and inferior vena cava index had the strongest correlation with the number of B-lines, with a pooled r coefficient of .35 and .31, respectively. Three randomized studies compared a lung ultrasound-guided approach with standard of care on hard clinical endpoints. Although patients in the lung ultrasound group achieved better decongestion and blood pressure control, there was no difference between the 2 management strategies with respect to death from any cause or major adverse cardiovascular events. Key findings: Lung ultrasound may be considered for the identification of patients with subclinical volume overload. Trials did not show differences in clinically important outcomes. The number of studies was small and many were of suboptimal quality. Limitations: The included studies were heterogeneous and of relatively limited quality.

Motif de la revue: L'échographie pulmonaire est une technique non-invasive réalisée au chevet du patient qui permet d'évaluer avec précision la congestion pulmonaire en mesurant l'eau pulmonaire extravasculaire. Cette technique facilement accessible est de plus en plus utilisée. Notre principal critère de jugement était de comparer l'efficacité de l'évaluation de la volémie par échographie pulmonaire avec l'évaluation clinique, l'échocardiographie, la bio-impédance ou les biomarqueurs. Les critères d'évaluation secondaires étaient la mortalité toutes causes confondues et les événements cardiovasculaires. Sources: Nous avons recherché sur MEDLINE les études observationnelles et les essais randomisés où une échographie pulmonaire avait été réalisée chez des patients sous dialyse d'entretien. Méthodologie: Sur un total de 2 363 articles, nous avons retenu 28 études (25 observationnelles et 3 randomisées). Les coefficients de corrélation ont été regroupés pour chaque variable d'intérêt en utilisant la méthode générique de variance inverse avec un modèle à effets aléatoires. Les paramètres cliniques qui avaient montré les corrélations les plus élevées avec le nombre de lignes B à l'échographie étaient le statut de l'insuffisance cardiaque selon la classification de la New York Heart Association et l'auscultation pulmonaire, avec des coefficients de corrélation r regroupés respectifs de 0,57 et de 0,36. Les paramètres de l'échocardiographie qui avaient montré les plus fortes corrélations avec le nombre de lignes B étaient la fraction d'éjection du ventricule gauche et l'indice de la veine cave inférieure, avec des coefficients r regroupés respectifs de 0,35 et de 0,31. Trois essais randomisés avaient comparé une approche guidée par échographie pulmonaire aux normes de soins selon des critères cliniques stricts. Bien que les patients du groupe avec échographie pulmonaire aient montré une décongestion plus efficace et un meilleur contrôle de la pression artérielle, aucune différence n'a été observée entre les deux stratégies de prise en charge en ce qui concerne les décès de toutes causes confondues ou les événements cardiovasculaires indésirables majeurs. Principales observations: L'échographie pulmonaire pourrait être envisagée pour identifier les patients qui présentent une surcharge volumique subclinique. Les essais inclus n'ont pas montré de différences dans les résultats cliniquement pertinents. Le nombre d'études incluses était faible et plusieurs étaient de qualité sous-optimale. Limites: Les études incluses étaient hétérogènes et de qualité relativement limitée.

[Home oxygen therapy]. / Oxygénothérapie à domicile.

Only severe hypoxemia at rest in COPD patients has strong recommendations for long-term oxygen therapy. It is accepted that oxygen should be prescribed if PaO2 is ≤ 7,3 kPa (55 mmHg), or if PaO2 is ≤ 8 kPa (60 mmHg) in the presence of signs of pulmonary hypertension or a hematocrit ≥ 55 %. In Switzerland, prescription is governed by the LiMA (Liste des moyens et appareils) and the patient can obtain supplies from a health care provider or directly from the provider. The most suitable device taking patient's oxygen needs and mobility into account must be chosen. O2 prescription entails risks for the patient that must be known to the prescriber. This article presents the different aspects of long-term home oxygen therapy.

Seule l'hypoxémie sévère au repos chez le patient BPCO possède de solides recommandations pour la prescription d'oxygène au long cours. L'hypoxémie sévère est définie par une pression partielle en oxygène dans le sang artériel (PaO2) ≤ 7,3 kPa (55 mmHg) ou une PaO2 ≤ à 8 kPa (60 mmHg) en présence de signes d'hypertension pulmonaire ou d'un taux d'hématocrite ≥ 55 %. En Suisse, sa prescription est régie par la liste des moyens et appareils (LiMA) et le patient peut s'approvisionner auprès d'un prestataire de soins ou directement auprès du fournisseur. Le dispositif le mieux adapté à chaque patient tenant compte de son besoin en oxygène et de sa mobilité doit être choisi. Sa prescription entraîne des risques pour le patient, qui doivent être connus du prescripteur. Cet article expose les différents aspects de l'oxygénothérapie au long cours à domicile.

[POCUS : diagnosis of pneumonia by lung ultrasonography]. / POCUS : diagnostiquer la pneumonie par l'échographie pleuropulmonaire.

Point-Of-Care Ultrasonography (POCUS) has emerged to support the diagnosis process and management strategies. Its use for the diagnosis of pneumonia has been shown to be reliable and effective over the past decade. Various ultrasonography patterns exist, none of which are pathognomonic for pneumonia. Therefore, POCUS findings must be interpreted in association with the clinical setting. POCUS enables early identification of complications such as parapneumonic effusion and pulmonary abscess. It also provides guidance for invasive procedure such as thoracocentesis and pleural drainage. The forthcoming results of the Swiss OCTOPLUS study will provide data on the clinical and economic impact of a diagnostic strategy based on targeted lung ultrasonography.

L'échographie ciblée, aussi connue sous le terme de Point-Of-Care Ultrasonography (POCUS), a émergé comme outil essentiel dans la démarche diagnostique et la stratégie de prise en charge des patients. Son utilisation pour le diagnostic de la pneumonie a été démontrée comme fiable et performante depuis plus d'une décennie. Plusieurs profils échographiques existent mais aucun n'est pathognomonique de la pneumonie. L'examen échographique est ainsi indissociable du contexte clinique. Le POCUS permet en outre la recherche précoce de complications (épanchement parapneumonique et abcès pulmonaire) et le guidage des gestes invasifs (thoracocentèse et drainage thoracique). Les résultats à venir de l'étude suisse OCTOPLUS permettront d'en savoir plus sur l'impact clinique et économique d'une stratégie diagnostique basée sur l'échographie pleuropulmonaire.

Awake prone positioning in acute hypoxaemic respiratory failure: An international expert guidance.

BACKGROUND: Awake prone positioning (APP) of non-intubated patients with acute hypoxaemic respiratory failure (AHRF) has been inconsistently adopted into routine care of patients with COVID-19, likely due to apparent conflicting evidence from recent trials. This short guideline aims to provide evidence-based recommendations for the use of APP in various clinical scenarios. METHODS: An international multidisciplinary panel, assembled for their expertise and representativeness, and supported by a methodologist, performed a systematic literature search, summarized the available evidence derived from randomized clinical trials, and developed recommendations using GRADE (Grading of Recommendations, Assessment, Development, and Evaluation) methodology. RESULTS: The panel strongly recommends that APP rather than standard supine care be used in patients with COVID-19 receiving advanced respiratory support (high-flow nasal cannula, continuous positive airway pressure or non-invasive ventilation). Due to lack of evidence from randomized controlled trials, the panel provides no recommendation on the use of APP in patients with COVID-19 supported with conventional oxygen therapy, nor in patients with AHRF due to causes other than COVID-19. CONCLUSION: APP should be routinely implemented in patients with COVID-19 receiving advanced respiratory support.

Awake prone positioning in acute hypoxaemic respiratory failure.

Awake prone positioning (APP) of patients with acute hypoxaemic respiratory failure gained considerable attention during the early phases of the coronavirus disease 2019 (COVID-19) pandemic. Prior to the pandemic, reports of APP were limited to case series in patients with influenza and in immunocompromised patients, with encouraging results in terms of tolerance and oxygenation improvement. Prone positioning of awake patients with acute hypoxaemic respiratory failure appears to result in many of the same physiological changes improving oxygenation seen in invasively ventilated patients with moderate-severe acute respiratory distress syndrome. A number of randomised controlled studies published on patients with varying severity of COVID-19 have reported apparently contrasting outcomes. However, there is consistent evidence that more hypoxaemic patients requiring advanced respiratory support, who are managed in higher care environments and who can be prone for several hours, benefit most from APP use. We review the physiological basis by which prone positioning results in changes in lung mechanics and gas exchange and summarise the latest evidence base for APP primarily in COVID-19. We examine the key factors that influence the success of APP, the optimal target populations for APP and the key unknowns that will shape future research.

High-flow nasal oxygen in acute hypoxemic respiratory failure: A narrative review of the evidence before and after the COVID-19 pandemic.

High-flow nasal oxygen (HFNO) is a type of non-invasive advanced respiratory support that allows the delivery of high-flow and humidified air through a nasal cannula. It can deliver a higher inspired oxygen fraction than conventional oxygen therapy (COT), improves secretion clearance, has a small positive end-expiratory pressure, and exhibits a washout effect on the upper air space that diminishes dead space ventilation. HFNO has been shown to reduce the work of breathing in acute hypoxemic respiratory failure (AHRF) and has become an interesting option for non-invasive respiratory support. Evidence published before the COVID-19 pandemic suggested a possible reduction of the need for invasive mechanical ventilation compared to COT. The COVID-19 pandemic has resulted in a substantial increase in AHRF worldwide, overwhelming both acute and intensive care unit capacity in most countries. This triggered new trials, adding to the body of evidence on HFNO in AHRF and its possible benefits compared to COT or non-invasive ventilation. We have summarized and discussed this recent evidence to inform the best supportive strategy in AHRF both related and unrelated to COVID-19.

ERS International Congress 2021: highlights from the Respiratory Intensive Care Assembly.

Early Career Members of Assembly 2 (Respiratory Intensive Care) attended the European Respiratory Society International Congress through a virtual platform in 2021. Sessions of interest to our assembly members included symposia on the implications of acute respiratory distress syndrome phenotyping on diagnosis and treatment, safe applications of noninvasive ventilation in hypoxaemic respiratory failure, and new developments in mechanical ventilation and weaning, and a guidelines session on applying high-flow therapy in acute respiratory failure. These sessions are summarised in this article.

Awake prone positioning for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure: a systematic review and meta-analysis.

BACKGROUND: Awake prone positioning has been broadly utilised for non-intubated patients with COVID-19-related acute hypoxaemic respiratory failure, but the results from published randomised controlled trials (RCTs) in the past year are contradictory. We aimed to systematically synthesise the outcomes associated with awake prone positioning, and evaluate these outcomes in relevant subpopulations. METHODS: In this systematic review and meta-analysis, two independent groups of researchers searched MEDLINE, Embase, PubMed, Web of Science, Scopus, MedRxiv, BioRxiv, and ClinicalTrials.gov for RCTs and observational studies (with a control group) of awake prone positioning in patients with COVID-19-related acute hypoxaemic respiratory failure published in English from Jan 1, 2020, to Nov 8, 2021. We excluded trials that included patients intubated before or at enrolment, paediatric patients (ie, younger than 18 years), or trials that did not include the supine position in the control group. The same two independent groups screened studies, extracted the summary data from published reports, and assessed the risk of bias. We used a random-effects meta-analysis to pool individual studies. We used the Grading of Recommendations Assessment, Development, and Evaluation approach to assess the certainty and quality of the evidence. The primary outcome was the reported cumulative intubation risk across RCTs, and effect estimates were calculated as risk ratios (RR;95% CI). The analysis was primarily conducted on RCTs, and observational studies were used for sensitivity analyses. No serious adverse events associated with awake prone positioning were reported. The study protocol was prospectively registered with PROSPERO, CRD42021271285. FINDINGS: A total of 1243 studies were identified, we assessed 138 full-text articles and received the aggregated results of three unpublished RCTs; therefore, after exclusions, 29 studies were included in the study. Ten were RCTs (1985 patients) and 19 were observational studies (2669 patients). In ten RCTs, awake prone positioning compared with the supine position significantly reduced the need for intubation in the overall population (RR 0·84 [95% CI 0·72-0·97]). A reduced need for intubation was shown among patients who received advanced respiratory support (ie, high-flow nasal cannula or non-invasive ventilation) at enrolment (RR 0·83 [0·71-0·97]) and in intensive care unit (ICU) settings (RR 0·83 [0·71-0·97]) but not in patients receiving conventional oxygen therapy (RR 0·87 [0·45-1·69]) or in non-ICU settings (RR 0·88 [0·44-1·76]). No obvious risk of bias and publication bias was found among the included RCTs for the primary outcome. INTERPRETATION: In patients with COVID-19-related acute hypoxaemic respiratory failure, awake prone positioning reduced the need for intubation, particularly among those requiring advanced respiratory support and those in ICU settings. Awake prone positioning should be used in patients who have acute hypoxaemic respiratory failure due to COVID-19 and require advanced respiratory support or are treated in the ICU. FUNDING: OpenAI, Rice Foundation, National Institute for Health Research, and Oxford Biomedical Research Centre.

Prone position in COVID 19-associated acute respiratory failure.

PURPOSE OF REVIEW: Prone position has been widely used in the COVID-19 pandemic, with an extension of its use in patients with spontaneous breathing ('awake prone'). We herein propose a review of the current literature on prone position in mechanical ventilation and while spontaneous breathing in patients with COVID-19 pneumonia or COVID-19 ARDS. RECENT FINDINGS: A literature search retrieved 70 studies separating whether patient was intubated (24 studies) or nonintubated (46 studies). The outcomes analyzed were intubation rate, mortality and respiratory response to prone. In nonintubated patient receiving prone position, the main finding was mortality reduction in ICU and outside ICU setting. SUMMARY: The final results of the several randomized control trials completed or ongoing are needed to confirm the trend of these results. In intubated patients, observational studies showed that responders to prone in terms of oxygenation had a better survival than nonresponders.

Implementing Lung Ultrasound in the Outpatient Management of COVID-19 Pneumonia: A Pilot Study to Update Local Guidelines.

Background: Lung ultrasound (LUS) has a good performance with a high sensitivity and specificity for the diagnosis of pneumonia compared with chest X-ray, and it has been extensively used to assess patients during the COVID-19 pandemic. This study aims to evaluate the potential advantages of the regular use of LUS for the assessment of the severity and prognosis of COVID-19 pneumonia and to propose an adapted protocol with its inclusion in current local validated and published guidelines. Methods: This is a single-center prospective study conducted during the first (April-May 2020) and second (October 2020-January 2021) waves of the SARS-CoV2 pandemic in Switzerland. All adult patients presenting to dedicated test centers with a suspicion of mild-to-moderate COVID-19 pneumonia and not requiring hospitalization at the time of diagnosis were included. Patients with confirmed COVID-19 pneumonia were referred to an ambulatory follow-up unit at our institution for reassessment, with the inclusion of the use of LUS in a random selection. Descriptive statistics were calculated for demographics using percentages, means, and standard deviations according to the distribution of variables. Results: Eighty-eight ambulatory patients with a confirmed COVID-19 pneumonia were included (men = 57 [59%]; mean age, 52.1 ± 13.5 years). Among these, 19 (21%) were hospitalized and none died. Twenty-five lung assessments by ultrasound were performed during the follow-up consultation. All were consistent with the clinical examination and confirmed the clinician's opinion. Conclusion: The use of a standardized pleuro-pulmonary ultrasound protocol for ambulatory patients with COVID-19 could help to reduce the use of chest X-rays and improve overall management at the time of referral and eventual follow-up. However, a specific study including LUS in a systematic approach should be performed to evaluate the outcome of patients according to findings.

[Diaphragmatic assessment by ultrasonography]. / Évaluation diaphragmatique par échographie.

Ultrasound of the diaphragm is an emerging technique that is performed at the bedside and allows assessment of diaphragm function in a variety of settings. Ultrasound is widely available, can be repeated if necessary, and is non-irradiating. First developed in intensive care, mainly for weaning from mechanical ventilation, its use is now extending to pulmonology. Different measurements are described such as diaphragmatic excursion, diaphragmatic thickness and diaphragmatic thickening fraction. The latter helps to diagnose dysfunction and is correlated with pulmonary hyperinflation. The main use in pulmonology is for the respiratory evaluation of patients with neuromuscular diseases, for the search of isolated diaphragmatic impairment and for patients with COPD. Numerous studies are in progress to better determine the role of diaphragmatic ultrasound.

La diffusion de l'accès à l'échographie a permis le développement de cette technique en pneumologie avec, plus récemment, l'évaluation du diaphragme. Plusieurs mesures sont décrites comme l'excursion, l'épaisseur et la fraction d'épaississement du diaphragme. Cela permet d'identifier la présence d'une dysfonction diaphragmatique, d'estimer l'activité et la capacité de réserve diaphragmatique. Cet outil non invasif, non irradiant et dynamique s'intègre de plus en plus à la prise en charge du patient. Des études ont permis de montrer l'existence d'une bonne corrélation entre l'échographie et les épreuves fonctionnelles respiratoires. D'autres sont en cours pour déterminer plus précisément l'impact de l'échographie diaphragmatique dans différentes prises en charge.

Self-proning in COVID-19 patients on low-flow oxygen therapy: a cluster randomised controlled trial.

RATIONALE AND OBJECTIVES: Prone positioning as a complement to oxygen therapy to treat hypoxaemia in coronavirus disease 2019 (COVID-19) pneumonia in spontaneously breathing patients has been widely adopted, despite a lack of evidence for its benefit. We tested the hypothesis that a simple incentive to self-prone for a maximum of 12 h per day would decrease oxygen needs in patients admitted to the ward for COVID-19 pneumonia on low-flow oxygen therapy. METHODS: 27 patients with confirmed COVID-19 pneumonia admitted to Geneva University Hospitals were included in the study. 10 patients were randomised to self-prone positioning and 17 to usual care. MEASUREMENTS AND MAIN RESULTS: Oxygen needs assessed by oxygen flow on nasal cannula at inclusion were similar between groups. 24 h after starting the intervention, the median (interquartile range (IQR)) oxygen flow was 1.0 (0.1-2.9) L·min-1 in the prone position group and 2.0 (0.5-3.0) L·min-1 in the control group (p=0.507). Median (IQR) oxygen saturation/fraction of inspired oxygen ratio was 390 (300-432) in the prone position group and 336 (294-422) in the control group (p=0.633). One patient from the intervention group who did not self-prone was transferred to the high-dependency unit. Self-prone positioning was easy to implement. The intervention was well tolerated and only mild side-effects were reported. CONCLUSIONS: Self-prone positioning in patients with COVID-19 pneumonia requiring low-flow oxygen therapy resulted in a clinically meaningful reduction of oxygen flow, but without reaching statistical significance.

Ultrasound-Derived Diaphragm Contractile Reserve as a Marker of Clinical Status in Patients With Cystic Fibrosis.

Introduction: In patients with cystic fibrosis (CF), the monitoring of respiratory muscle activity using electromyography can provide information on the demand-to-capacity ratio of the respiratory system and act as a clinical marker of disease activity, but this technique is not adapted to routine clinical care. Ultrasonography of the diaphragm could provide an alternative, simpler and more widely available alternative allowing the real-time assessment of the diaphragm contractile reserve (DCR), but its relationship with recognized markers of disease severity and clinical outcomes are currently unknown. Methods: Stable patients with CF were prospectively recruited. Diaphragm ultrasound was performed and compared to forced expiratory volume in 1 s (FEV1), residual volume (RV), handgrip strength, fat-free mass index (FFMI), serum vitamin levels, dyspnea levels and rate of acute exacerbation (AE). Diaphragm activity was reported as DCR (the ratio of tidal-to-maximal thickening fractions, representing the remaining diaphragm contractility available after tidal inspiration) and TFmax (representing maximal diaphragm contractile strength). Inter-observer reliability of the measurement of DCR was evaluated using intra-class correlation analysis. Results: 110 patients were included [61 males, median (interquartile range), age 31 (27-38) years, FEV1 66 (46-82)% predicted]. DCR was significantly correlated to FEV1 (rho = 0.46, p < 0.001), RV (rho = -0.46, p < 0.001), FFMI (rho = 0.41, p < 0.001), and handgrip strength (rho = 0.22, p = 0.02), but TFmax was not. In a multiple linear regression analysis, both RV and FFMI were independent predictors of DCR. DCR, but not TFmax, was statistically lower in patients with > 2 exacerbations/year (56 ± 25 vs. 71 ± 17%, p = 0.001) and significantly lower with higher dyspnea levels. A ROC analysis showed that DCR performed better than FEV1 (mean difference in AUROC 0.09, p = 0.04), RV (mean difference in AUROC 0.11, p = 0.03), and TFmax at identifying patients with an mMRC score > 2. Inter-observer reliability of DCR was high (ICC = 0.89, 95% CI 0.84-0.92, p < 0.001). Conclusion: In patients with CF, DCR is a reliable and non-invasive marker of disease severity that is related to respiratory and extra-pulmonary manifestations of the disease and to clinical outcomes. Future studies investigating the use of DCR as a longitudinal marker of disease progression, response to interventions or target for therapy would further validate its translation into clinical practice.

ERS International Congress, Madrid, 2019: highlights from the Respiratory Intensive Care Assembly.

The Respiratory Intensive Care Assembly of the European Respiratory Society is delighted to present the highlights from the 2019 International Congress in Madrid, Spain. We have selected four sessions that discussed recent advances in a wide range of topics: from acute respiratory failure to cough augmentation in neuromuscular disorders and from extra-corporeal life support to difficult ventilator weaning. The subjects are summarised by early career members in close collaboration with the Assembly leadership. We aim to give the reader an update on the most important developments discussed at the conference. Each session is further summarised into a short list of take-home messages.

Modern diagnosis of chronic thromboembolic pulmonary hypertension.

Chronic thromboembolic pulmonary hypertension (CTEPH) should be suspected in patients presenting persistent dyspnea three months after a pulmonary embolism or in patients presenting with acute pulmonary embolism and suggestive images on the CT-scan. For these patients, a specific diagnostic work-up should be performed. First step consists of the ventilation/perfusion (V/Q) scan which is a good screening test due to its high sensitivity and high negative predictive value. Pulmonary angiography remains the gold standard approach for the confirmation of the diagnosis and pre-surgical evaluation of CTEPH. New emerging technologies such as Dual-Energy Computed Tomography angiography (DECT) and Computed Tomography angiography (CTA) are developing and broadly available. These non invasive methods provide diagnostic information similar to conventional pulmonary angiography and surgical operability information. They are to be considered as an alternative in the diagnostic approach of patients with CTEPH as presented in the ESC/ERS guidelines. Haemodynamic measurement whiles exercising during right heart catheterization may improve diagnostic sensitivity of CTEPH and could therefore be used as a diagnostic test in patient with normal haemodynamic at rest.

[The place of balloon pulmonary angioplasty in the management of chronic thromboembolic pulmonary hypertension]. / Place de l'angioplastie percutanée dans le traitement de l'hypertension pulmonaire postembolique.

Chronic thromboembolic pulmonary hypertension (CTEPH) is uncommon. Its diagnosis should not be delayed as its prognosis is poor if not treated. In most cases, an acute pulmonary embolism is found in the medical history of the patient. Once suspected, a specific work-up should be performed in a pulmonary hypertension (PH) center. The ventilation/perfusion scan has a central role in this workup but the emergence of non invasive imaging technologies provides morphological and functional information which take part in the therapeutic decision making, such as operability. Surgical endarterectomy remains the only curative treatment. In some specific patients, percutaneous transluminal pulmonary angioplasty (AAP) is performed. This developing technique is a safe and efficient treatment on a clinical and hemodynamic standpoint. The main complication after AAP is lung reperfusion edema.

L'hypertension pulmonaire postembolique (CTEPH) est une maladie rare. Son diagnostic ne doit pas être retardé, compte tenu de son mauvais pronostic en l'absence de prise en charge adaptée. Dans la plupart des cas, un épisode d'embolie pulmonaire est retrouvé dans l'histoire médicale du patient. Une fois suspectée, la CTEPH nécessite une approche multidisciplinaire tant pour la stratégie diagnostique que thérapeutique. Les nouvelles techniques d'imagerie permettent de définir précisément le traitement de choix, tenant compte des comorbidités et de la topographie des lésions. Le seul traitement curatif reste l'endartérectomie pulmonaire. L'angioplastie percutanée des artères pulmonaires, effectuée dans des centres experts, se profile comme une alternative en cours de validation et doit se discuter au cas par cas. Cette technique permet de traiter non seulement des patients jugés inopérables mais également les patients avec une hypertension pulmonaire résiduelle postendartérectomie. La complication la plus fréquente est l'œdème de reperfusion.