Thoracic ultrasound accuracy for the investigation of initial neonatal respiratory distress.

Thoracic ultrasound (TUS) is increasingly studied in neonatal respiratory distress but chest x-ray (CXR) remains the first-line exam. We aimed to evaluate its diagnostic performance for the investigation of unselected causes of neonatal respiratory distress in daily practice. We conducted a descriptive, prospective, and single-center diagnostic accuracy study in a tertiary hospital, including term and preterm newborns who needed a CXR because of respiratory conditions occurring at birth or during the first 24h of life. TUS was compared to the reference diagnosis, which was the association between the CXR results, the clinical initial context, and the patient's outcome. Fifty-two newborns were included and 104 hemi-thorax ultrasounds were analyzed. Sensitivity, specificity, positive and negative predictive values (PPV, NPV), diagnosis accuracy, as well as the positive and negative likelihood ratio of TUSs were 100% for respiratory distress syndrome (RDS), transient tachypnea of newborn (TTN), pneumomediastinum, meconium aspiration syndrome, and absence of pulmonary disease. TUS also showed 100% sensitivity and NPV for pneumothorax, but specificity was 97% and PPV was 50%. Kappa concordance between TUS and either CXR alone or the radiological/clinical gold standard was 0.79 and 0.95, respectively. CONCLUSION: TUS at the newborn's bedside is efficient for investigating the main neonatal respiratory diseases, especially for the confirmation of RDS or TTN and for the exclusion of differential diagnosis or complications.

[Cerebral hemorrhage in a mechanically ventilated asthmatic child: multifactorial mechanisms]. / Hémorragie cérébrale chez un enfant asthmatique ventilé : mécanismes multifactoriels.

We report the case of a 7-year-old boy with acute status asthmaticus requiring mechanic ventilation in the pediatric intensive care unit. He developed a brain hemorrhage during the course of his illness. We discuss the mechanisms that may have precipitated this neurological complication.

[Management of newborns with meconium-stained amniotic fluid: prospective evaluation of practice]. / Prise en charge des nouveau-nés naissant dans un liquide méconial: évaluation prospective des pratiques.

OBJECTIVE: Regional guideline for immediate tracheal suctioning (ITS) in vigorous and non-vigorous infants born through meconium-stained amniotic fluid (MSAF) has been established in 2003. The objective of this study was to evaluate guideline application. STUDY DESIGN: Prospective cohort. PATIENTS AND METHODS: The first part of the study was a short survey about ITS practices in maternity hospitals then, management and early evolution of babies born through particulate MSAF was evaluated by questionnaire. RESULTS: Among 6761 neonates, 199 (3%) were born with MSAF. Early clinical evaluation showed 52 (26%) non-vigorous neonates; 22 of them (42%) have had an ITS. One hundred and forty-seven neonates were vigorous (74%); 27 of them (18%) have had an ITS. Implementation of recommendations in non-vigorous babies was better in maternities of level III, while they were lower in maternities of level IIA for vigorous babies. Among 52 non-vigorous children, eight had a meconium aspiration syndrome (MAS), including five who had an ITS. One MAS occurred in vigorous babies but infection could not be excluded. CONCLUSION: Recommendations for ITS were implemented in 70% of cases but only in 42% of cases in non-vigorous babies. We have to improve formation and circulation of new recommendations.

[Congenital tuberculosis in preterm neonate: a case report]. / Tuberculose congénitale chez le nouveau-né prématuré : à propos d'un cas.

Congenital tuberculosis is a rare but severe disease. Diagnosis is often delayed, especially in preterm neonates. We report a premature infant born after 27 weeks of gestation and in vitro fertilization. Tuberculosis was suspected after 112 days of life in view of sepsis, respiratory distress, and the discovery of maternal tuberculosis. Mycobacterium tuberculosis was isolated in endotracheal aspirates, gastric aspirates, and stools. The infant initially received four antitubercular antibiotics over 3 months, then two antibiotics over 9 months. A wide screening for a possible nosocomial transmission from this index case was set up. At the chronological age of 2 years, the baby is healthy without after-effects and no secondary cases were diagnosed. This article recalls the difficulty diagnosing congenital tuberculosis, particularly in preterm neonates. It also underlines the need to raise and eliminate the diagnosis of tuberculosis in an infertile woman.

Bacillus licheniformis septicemia in a very-low-birth-weight neonate: a case report.

Nosocomial infections in neonatal intensive care units are a preoccupying issue. Bacillus sp. can be pathogenic in immuno-compromised hosts, including premature infants. Central catheters and mechanical ventilation are potential sources of infection. We report for the first time a case of Bacillus licheniformis bacteremia in a premature infant. Recovery necessitated treatment with vancomycin and cefotaxime in combination with removal of the central catheter.

[Transcutaneous bilirubin measurement in preterm infants]. / Estimation de la bilirubinémie par méthode transcutanée chez le nouveau-né prématuré.

UNLABELLED: Transcutaneous bilirubinometry is an effective screening tool for neonatal jaundice in full-term babies. But its accuracy is not shown yet in preterm infants. METHODOLOGY: We carried out a prospective study in a neonatal intensive care unit. The study included 47 preterm infants. From birth, a transcutaneous bilirubin measurement (BTc) using the BiliCheck was made on the forehead of each newborn every 8 h. Blood sampling for determination of total serum bilirubin (BS) was combined with BTc: 1) if value of BTc was higher than limits values for phototherapy; 2) on the second day of life and 3) 4 hours after cessation of phototherapy. RESULTS: Mean gestational age was 30 week and mean birth weight was 1419 g. We studied 151 pairs of BTc and BS. Mean values obtained by BTc and BS were respectively 160.6+/-50 mumol/L and 190.6+/-61.4 mumol/L. A significant correlation between BTc and BS was found. But the limits of agreement were very wide. The negative predictive value (NPV) of BTc was above 90% in each group of gestational age. DISCUSSION: The need for phototherapy cannot be determined by BTc in preterm infants. But the BTc is reliable when its value is under the limits for phototherapy. CONCLUSION: With a very high incidence of neonatal jaundice (87%) in our cohort, a value of BTc under the limits for phototherapy has a good NPV in preterm infants.

[A case of type A botulism]. / Un cas de botulisme de type A.

The neurotoxin produced by Clostridium botulinum, is responsible for botulism. The clinical signs are digestive disorders, pupillar alterations, and peripheral muscular weakness. The failure of thoracic muscles is responsible for the severity of botulism. We describe a case of a 74 year old woman who presented a severe form of botulism, requiring a prolonged intensive care unit stay.

Congenital laryngeal cyst: benefits of prenatal diagnosis and multidisciplinary perinatal management.

Congenital laryngeal cysts are rare and can cause upper airway obstruction if they are misdiagnosed. We describe a case of large vallecular cyst diagnosed at 33 weeks of gestation. The purpose of an early diagnosis is to establish a careful perinatal management. If the airway is compromised, a multidisciplinary medical team is necessary to perform emergency immediate tracheostomy. Elective delivery should be always carried out in a tertiary referral center.

The combination of a heat and moisture exchanger and a Booster: a clinical and bacteriological evaluation over 96 h.

OBJECTIVE: To determine whether the combination with a new device (Booster ) for active humidification improves the efficacy of a hydrophobic heat and moisture exchanger (HME). DESIGN AND SETTING: Prospective, interventional study in the ICU of a university hospital. PATIENTS: Consecutive patients requiring controlled mechanical ventilation INTERVENTIONS: Patients were ventilated with a HME, and a Booster was added for 96 h to the ventilatory circuit. MEASUREMENTS AND RESULTS: During the inspiration phase the following factors were measured: peak and mean airway pressures, maximal (beginning of inspiration), minimal (end of inspiration), and mean values of temperature of inspired gases, and relative and absolute humidity of inspired gases. Microbiological samples were obtained from the Booster, the ventilator side of the HME, and the tracheal secretions on days 1 and 4. Minimal and mean temperatures were increased as soon as the Booster was used and this increase was maintained for 96 h until the Booster was withdrawn. Then the temperature returned to baseline values. Absolute humidity values followed the same course. There was also some indirect evidence of very little, if any, changes in the HME resistance. The ventilatory side of the HMEs remained sterile in each patient, and the Booster was colonized by the same bacteria as those in the tracheal secretions. CONCLUSIONS: Adding the Booster to a hydrophobic HME improved the heat and water preservation of ventilatory gas.

[Neonatal consequences of preterm premature rupture of membrane (PPROM) at 24-34 WG: 118 singleton pregnancies]. / Conséquences néonatales de la rupture prématurée des membranes entre 24 et 34 semaines d'aménorrhée: à propos de 118 grossesses uniques.

OBJECTIVES: To evaluate the outcome of preterm infants born after preterm premature rupture of membranes (PPROM) between 24 and 34 weeks gestation (WG). METHODS: One hundred and eighteen consecutive singleton infants were included in a prospective unicenter study during 3 years. A PPROM management had been instituted by the local obstetrician's board committee. In case of suspected chorioamniotitis defined by maternal or fetal criteria or in case of fetal heart rate abnormalities, a fetal extraction was decided. Diagnosis of chorioamnionitis was confirmed regarding the results of placenta culture and/or histology. Neonatal sepsis was defined by positive blood placenta culture or by the association of 2 positive bacterial cultures with a CRP>15 mg/l. RESULTS: The mean gestational age was 29.8 WG (24-34 SA) for PPROM and 30.4 WG for delivery. Mean latency period between PPROM and delivery was 119 hours +/- 208. The incidence of choriamnionitis was 31%. The overall incidence of neonatal sepsis was 15%. Neonatal mortality was 11.7%. Bronchopulmonary dysplasia occured in 8.4% of the liveborn cases and cranial ultrasound abnormalities (HIV III-IV, kystic LPV) in 11.7% of overall cases. Cerebral lesions were positively correlated with hypotension and negatively correlated with GA. Cerebral lesions seemed to occur more frequently in case of chorioamnionitis but it is not significant. CONCLUSION: In this study, in case of PPROM between 24-34 SA, gestational age and hypotension are correlated with neurologic injury.

Measurement of tracheal temperature is not a reliable index of total respiratory heat loss in mechanically ventilated patients.

BACKGROUND: Minimizing total respiratory heat loss is an important goal during mechanical ventilation. The aim of the present study was to evaluate whether changes in tracheal temperature (a clinical parameter that is easy to measure) are reliable indices of total respiratory heat loss in mechanically ventilated patients. METHOD: Total respiratory heat loss was measured, with three different methods of inspired gas conditioning, in 10 sedated patients. The study was randomized and of a crossover design. Each patient was ventilated for three consecutive 24-h periods with a heated humidifier (HH), a hydrophobic heat-moisture exchanger (HME) and a hygroscopic HME. Total respiratory heat loss and tracheal temperature were simultaneously obtained in each patient. Measurements were obtained during each 24-h study period after 45 min, and 6 and 24 h. RESULTS: Total respiratory heat loss varied from 51 to 52 cal/min with the HH, from 100 to 108 cal/min with the hydrophobic HME, and from 92 to 102 cal/min with the hygroscopic HME (P < 0.01). Simultaneous measurements of maximal tracheal temperatures revealed no significant differences between the HH (35.7-35.9 degrees C) and either HME (hydrophobic 35.3-35.4 degrees C, hygroscopic 36.2-36.3 degrees C). CONCLUSION: In intensive care unit (ICU) mechanically ventilated patients, total respiratory heat loss was twice as much with either hydrophobic or hydroscopic HME than with the HH. This suggests that a much greater amount of heat was extracted from the respiratory tract by the HMEs than by the HH. Tracheal temperature, although simple to measure in ICU patients, does not appear to be a reliable estimate of total respiratory heat loss.

Changing heat and moisture exchangers after 96 hours rather than after 24 hours: a clinical and microbiological evaluation.

OBJECTIVE: The aim of this study was to determine whether changing heat and moisture exchangers (HMEs) every 96 hrs rather than 24 hrs would affect their efficacy to preserve the heat and moisture of inspiratory gases. The impact of a prolonged use of the HME on its microbial colonization was also assessed. DESIGN: Prospective cohort observational study. SETTING: Intensive care unit of a university hospital. PATIENTS: Thirteen consecutive patients with no previous history of respiratory disease requiring controlled mechanical ventilation with an HME for >4 days were evaluated. INTERVENTIONS: The same HME was used for 96 hrs in each patient. MEASUREMENTS AND MAIN RESULTS: In each patient, during the inspiration phase, the following measurements were performed: peak and mean airway pressures, mean values of temperature, and relative and absolute humidity of inspired gases. In each patient, measurements were performed after 1 hr of HME use and then daily up to the fourth day. On days 1 and 4, microbiological samples were obtained from the patients' bronchial secretions and the ventilator side of the HME. After 96 hrs of ventilation with the same HME, tracheal tube occlusion was never observed. Using the same HME for 96 hrs rather than 24 hrs did not affect its technical performances: temperature at 24 hrs: 32.2 +/- 1.5 degrees C (90.0 +/- 34.7 degrees F), at 96 hrs: 32.1 +/- 1.6 degrees C (89.8 +/- 34.9 degrees F); relative humidity at 24 hrs: 97.9 +/- 2%, at 96 hrs: 98.1 +/- 1.7%; absolute humidity at 24 hrs: 33.1 +/- 2.4 mg H2O/L, at 96 hrs: 33.0 +/- 2.5 mg H2O/L. This analysis was based on a total of 312 measurements performed on the 13 patients. Peak and mean airway pressures did not change during the 96-hr study period, with identical tidal and minute volumes in the study patients. On day 1, ten patients had a positive culture of their tracheal secretions at a colony count of > or = 10(3) colony forming units/mL. After 96 hrs of use with the same HME, only seven patients had a positive culture of their tracheal secretions. Cultures from the ventilator sides of the HMEs were all sterile (13/13) after 96 hrs of use. CONCLUSIONS: In patients free from previous chronic respiratory disorder and ventilated for neurologic reasons, changing the HME after 96 hrs rather than 24 hrs did not affect its technical performance in terms of heat and water preservation of ventilatory gases. There is also some indirect evidence of very little, if any, changes in the HME resistance. No bacterial colonization of the ventilator sides of the HMEs was observed after 96 hrs of use. However, other large clinical trials should be undertaken to confirm the safety of extending the time between HME changes.

Do the components of heat and moisture exchanger filters affect their humidifying efficacy and the incidence of nosocomial pneumonia?

OBJECTIVES: To compare the efficiency of two heat and moisture exchange filters (HMEFs) of different compositions of the humidifying capacity and the rate of bronchial colonization and ventilator-associated pneumonia in patients in the intensive care unit (ICU). DESIGN: Prospective, randomized study. SETTING: ICU of a university hospital. PATIENTS: All patients who required mechanical ventilation for 24 hrs or more during the study period. INTERVENTIONS: At admission to the ICU, patients were randomly assigned to one of two groups. In one group, the patients were ventilated with Humid-Vent Filter Light HMEF. The condensation surface was made of paper impregnated with CaCl2. The filter membrane was made of polypropylene. In the other group, the patients were ventilated with the Clear ThermAl HMEF (Intersurgical, France). The condensation surface was made of plastic foam impregnated with AlCl2. The filter membrane was made of two polymer fibers (modacrylic and polypropylene). In both groups, HMEFs were changed daily. MEASUREMENTS AND MAIN RESULTS: Seventy-seven patients were ventilated for 19+/-7 days with the Humid-Vent Filter Light HMEF and 63 patients for 17+/-6 days with the Clear ThermAl HMEF. Patients ventilated with the Humid-Vent Filter Light underwent 8.7+/-3.7 tracheal aspirations and 1.2+/-2.0 instillations per day and those with the Clear ThermAl, 8.2+/-3.9 and 1.5+/-2.4 per day, respectively (NS). The abundance of tracheal secretions and the presence of blood and viscosity, as evaluated by semiquantitative scales, were similar in both groups. One episode of tracheal tube occlusion was observed with the Humid-Vent Filter Light HMEF and none with the other HMEF (NS). Tracheal colonization was observed at a rate of 91% with the Humid-Vent Filter Light and 97% with the Clear ThermAl (NS). The rate of ventilator-associated pneumonia was similar in both groups (35%). Bacteria responsible for tracheal colonization and pneumonia were similar in both groups. CONCLUSIONS: Despite differences in their components, the two HMEFs that were tested achieved similar performances in terms of humidification and heating of inspired gases. Only one episode of endotracheal tube occlusion was detected, and very few patients (three in each group) had to be switched to an active heated humidifier. No difference was observed either in the rate of tracheal colonization or of ventilator-associated pneumonia. These data show that the Humid-Vent Filter Light and the Clear ThermAl HMEFs are suited for use with ICU patients.

Changing a hydrophobic heat and moisture exchanger after 48 hours rather than 24 hours: a clinical and microbiological evaluation.

OBJECTIVE: Complications following ventilation with dry and cold gases may be prevented by the use of artificial noses or heat and moisture exchangers, which are a solution to both the problems of humidification and heat preservation. The aim of the present study was to determine whether changing hydrophobic heat and moisture exchangers (HMEs) every 48 h rather than 24 h would affect their efficacy to preserve the heat and moisture of inspiratory gases. The impact of a prolonged use of the HME on its microbial colonization was also assessed. DESIGN: Prospective observational study. SETTING: ICU of a university hospital. PATIENTS: Twelve patients requiring controlled mechanical ventilation for more than 2 days were evaluated. INTERVENTIONS: The patients were ventilated with a heat and moisture exchanger (HME) (Maxipleat Filter, Europe Medical, France). The hydrophobic HME was placed between the Y-piece and the connecting tube and changed after 48 h of continuous use. Temperature (degree C), relative humidity (%) and absolute humidity (mgH2O/l) were obtained using the capacitive sensor principle. Bacterial colonization (tracheal secretions and ventilator side of the HME) were obtained on days 1 and 2. MEASUREMENTS AND RESULTS: After 48 h of ventilation with the same HME, tracheal tube occlusion was never observed. Using the same hydrophobic HME for 48 h rather than 24 h did not affect its technical performance: temperature at 24 h: 32.5 +/- 1.3 degrees C, at 48 h: 32.7 +/- 1.8 degrees C; relative humidity (RH) at 24 h: 99.0 +/- 1.4%, at 48 h: 99.0 +/- 1.4%; absolute humidity (AH) at 24 h: 34.0 +/- 2.4 mgH2O/l, at 48 h: 34.4 +/- 3.5 mgH2O/l. Peak and mean airway pressures did not change over the 48-h study period, with identical tidal and minute volumes in the study patients. Total respiratory heat losses were not modified during the 48-h study period (at 24 h: 152 +/- 47 cal/min, at 48 h: 149 +/- 65 cal/min). Evaporative and convective heat losses were not modified either. On day 1, eight patients had positive cultures of their tracheal secretions at a colony count of 10(3) or higher cfu/ml. After 48 h of use of the same HME, only six patients had a positive culture of their tracheal secretions. Cultures from the ventilator sides of the HMEs were all sterile (12/12) after 48 h of use. CONCLUSIONS: Changing the hydrophobic HME after 48 h rather than 24 h did not affect its technical performance in terms of heat and water preservation of ventilatory gases. There is also some indirect evidence of very little, if any, change in HME resistance. No bacterial colonization of the ventilator sides of the HMEs was observed after 48 h of use. However, other large clinical trials should be undertaken to confirm the safety of extending the time between HME changes.

Comparing two heat and moisture exchangers, one hydrophobic and one hygroscopic, on humidifying efficacy and the rate of nosocomial pneumonia.

OBJECTIVE: Many heat and moisture exchangers with filter (HMEF) have been developed. In-house data from companies provide some information about their performances; unfortunately, to our knowledge, no comparative evaluation in clinical conditions has been undertaken of these newer products. The aim of this study was to compare the efficiency of two HMEFs, one hydrophobic and one hygroscopic, on humidifying capacity and the rate of bronchial colonization and ventilator-associated pneumonia in ICU patients. DESIGN: Prospective, randomized study. SETTING: ICU of a university hospital. PATIENTS: All patients who required mechanical ventilation for > or = 24 h during the study period. INTERVENTIONS: On admission to the ICU, patients were randomly assigned to one of two groups. In one group, the patients were ventilated with a hygroscopic device (Humid-Vent Filter Light HMEF; Gibeck; Upplands Vaesby, Sweden). The condensation surface was made of paper (Microwell) impregnated with CaCl2. The filter membrane was made of polypropylene. In the other group, the patients were ventilated with a hydrophobic device (Pall BB100 HMEF). The condensation surface was made of a hydrophobic resin with a hydrophylic layer. The filter membrane was made of ceramic fibers. In both groups, HMEFs were changed daily. MEASUREMENTS AND RESULTS: Both groups of patients were similar for the tested characteristics, including parameters of mechanical ventilation. Sixty-six patients were ventilated for 11.7+/-11 days with the Humid-Vent Filter Light HMEF and 70 patients for 12.2+/-12 days with the Pall BB 100. Patients ventilated with the Humid-Vent Filter Light underwent 6.0+/-3.0 tracheal aspirations and 1.7+/-2.0 instillations per day, and those with the Pall BB 100, 6.0+/-3.0 and 1.6+/-2.0 per day, respectively (not significant [NS]). Abundance of tracheal secretions, presence of blood, and viscosity, evaluated by semiquantitative scales, were similar in both groups. No difference in the rate of atelectasis was observed between the two groups (7.5% and 7.1%, NS). One episode of tracheal tube occlusion was observed with the Humid-Vent Filter Light HMEF, and one with the other HMEF (NS). One patient in each group (NS) was switched to an active heated humidifier because of very tenacious bronchial secretions despite repeated instillations. Tracheal colonization was observed at a rate of 67% with the Humid-Vent Filter Light and 58% with the Pall BB 100 (NS). A small, but NS difference was observed in the rate of ventilator-associated pneumonia: Humid-Vent Filter Light, 32% (27.1 per 1000 ventilator days); and Pall BB 100, 37% (30.4 per 1000 ventilator days). Bacteria responsible for tracheal colonization and pneumonia were similar in both groups. Three patients in each group died from their nosocomial pneumonia. CONCLUSION: Despite differences in their components, the two HMEFs tested achieved similar performances in terms of humidification and heating of inspired gases. Only one episode of endotracheal tube occlusion was detected and very few patients (one in each group) had to be switched to an active heated humidifier. No difference was observed either in the rate of tracheal colonization or of ventilator-associated pneumonia. These data show that the hygroscopic HME (Humid-Vent Filter Light) and the hydrophobic HME (Pall BB 100) are suited for use in ICU patients.

[Lethal portal venous gas after cardiopulmonary arrest]. / Aéroportie mortelle après un arrêt cardiorespiratoire.

We report the case of a 51-year-old patient admitted after a transient cardiorespiratory arrest. The abdominal CT scan revealed the presence of hepatic portal venous gas. At laparotomy, a diffuse mesenteric ischaemia was diagnosed. The patient died from multiple organ failure in the subsequent hours. Necrotic bowel is associated with hepatic portal venous gas in 50% of the cases and the current mortality rate is 85%. Gas originates either through intestinal transmucosal passage, either by intraportal bacterial gas production, or through both mechanisms.

Preservation of humidity and heat of respiratory gases in spontaneously breathing, tracheostomized patients.

BACKGROUND: Ventilation with endotracheal intubation bypasses the upper airway and the normal heat and moisture exchanging process of inspired gases. A continuous loss of moisture and heat occurs and predisposes patients to serious airway damage. We therefore prospectively studied one heated humidifier system, one cold humidifier system and one heat and moisture exchanger in spontaneously breathing, tracheostomized intensive care unit patients to determine the ability to preserve patients' heat and water. METHODS: Following a randomized order, 10 patients were spontaneously ventilated for 24-h periods with the Nam 35 humidifier (Europe Medical, France, a cold water humidifier), the heat and moisture exchange Trach-Vent (Gibeck, Sweden), and the Aerodyne humidifier (Kendall USA). In each patient, during the inspiration phase, the following measurements were performed: mean values of temperature and relative humidity of inspired gases. The absolute humidity was calculated. Values were obtained in each patients after 40 min and 24 h. RESULTS: The Trach-Vent filter and the Aerodyne humidifier had better humidification and thermic capacities than the Nam 35 humidifier (P < 0.001). With the Nam 35 humidifier, no patient had temperature of inspired gas > 29 degrees C. Concerning absolute humidity of inspired gases, the Nam 35 humidifier achieved a lower performance than the other two tested systems (P < 0.001). CONCLUSION: In spontaneously breathing, tracheostomized intensive care unit patients, the Trach-Vent heat and moisture exchanger and the Aerodyne heated system achieved satisfactorily preservation of heat and humidity of inspired gases.