[Acute exacerbations of COPD admitted to hospital: predictive factors of 3 year mortality]. / Exacerbations aiguës de BPCO hospitalisées: facteurs prédictifs de mortalité à trois ans.

INTRODUCTION: COPD is a disease whose gravity is underestimated by doctors and patients. The development of acute exacerbations (AE) accelerates the progression of the disease and leads to increased financial costs, notably on account of hospitalisation. MATERIALS AND METHODS: An observational prospective study will be undertaken based on a cohort of consecutive patients hospitalised in departments of respiratory medicine in general hospitals. The main objective is to study the factors predictive of mortality at 3 years after one admission for AE. The secondary objectives are to describe the characteristics of the AE on arrival and 3 months after discharge from hospital. A register will be set up and a questionnaire will be completed for each patient, consisting of items concerning COPD, the AE and the condition of the patient and his treatments 3 months after discharge. The level of mortality at 3 years and the predictive factors will be calculated from the data in the register. EXPECTED RESULTS: Identification the characteristics of the AE and determination of a predictive score for mortality should allow optimisation of the management of patients suffering from COPD.

Phosphatidylinositol promotes cholesterol transport in vivo.

To examine the role that lipoprotein charge plays in cholesterol metabolism in vivo, we characterized the effects of an intravenous injection of 40 micromol of an uncharged phospholipid (phosphatidylcholine, PC) or an anionic phospholipid (phosphatidylinositol, PI) into fasted rabbits. PC injection had a negligible effect on lipoprotein charge and composition, similar to that observed in a saline-injected animal. In contrast, PI injection caused a significant increase in the net negative surface charge of all lipoproteins after only 10 min, followed by a gradual return to normal by 24 h. Lipoprotein compositional analysis showed that PI caused a significant increase of cholesteryl ester (CE) and cholesterol (FC) in the VLDL pool by 3 h, with no changes in VLDL-triglyceride content. While the bulk of the plasma CE was located in the HDL pool in the PC-injected animals, in the PI animals, VLDL became the major CE storage compartment. No major changes in the levels or composition of HDL or LDL were evident over the 24-h turnover period. Co-injection of [(3)H]FC revealed a 30-fold greater rate of clearance of the labeled cholesterol from the PI-injected rabbit plasma. In addition, the rate of cholesterol esterification by lecithin:cholesterol acyltransferase was almost completely inhibited in the PI animals. In summary, a bolus injection of PI into rabbits appears to enhance the mobilization of cellular sterol and promote a rapid clearance of both FC and CE from the plasma compartment. The data show that lipoprotein charge can affect cholesterol transport and that this process can be selectively manipulated.

[Hypersomnia. Sleep apnea syndrome and somnolence]. / Les hypersomnies. Syndrome des apnées du sommeil et somnolence.

A RECENTLY DEFINED SYNDROME: Sleep apnea syndrome is defined as 5 episodes of apnea or 10 episodes of hyopnea per hour of sleep; the cardinal symptom is excessive diurnal somnolence. Two factors could explain sleep apnea syndrome: hypoxemia and fragmented sleep. ROLE OF HYPOXEMIA: Early studies focused on hypoxemia, but few took into account the effect of subjective complaints of somnolence. Further investigations based on objective measurements introduced a certain degree of complexity distinguishing between sleepiness and the capacity for voluntary vigilance. FRAGMENTARY SLEEP: More recent work has demonstrated the important role played by perturbed sleep rhythm and particularly the effect of short repeated periods of vigilance fragmenting sleep. It has been suggested that finer fragmentation exists but non-documented on electroencephalograms. SIMPLE AND EFFECTIVE TREATMENT: The relative contribution of hypoxemia and fragmented sleeping patterns is still a topic of debate, but the clinical strategy is simple and based on the results of a therapeutic test with continuous positive pressure ventilation. There is an improvement both in hypoxemia and sleep pattern which resolves the problem of excessive diurnal somnolence in most cases.

Treatment of respiratory failure using minitracheotomy and intratracheal oxygenation in selected patients with chronic lung disease.

OBJECTIVE: To evaluate the efficacy of minitracheotomy (MT) insertion for intratracheal oxygen insufflation (ITO2) on arterial blood gases and survival in patients with respiratory failure from chronic lung disease. DESIGN: Open, prospective clinical study. SETTING: A 12-bed medical intensive care unit in a non-university hospital. PATIENTS: 20 patients (14 males and 6 females, mean age 74.8 +/- 2.6 years), admitted for respiratory failure and denied mechanical ventilation. INTERVENTION: Percutaneous insertion of an MT for ITO2. Arterial blood gases were drawn just prior to, then 3, 24, 48 h and 1 week after MT insertion. Data are evaluated with a two-way analysis of variance for distribution-free data (Friedman's rank sums test). MEASUREMENTS AND RESULTS: Three hours after starting ITO2, the partial pressure of oxygen in arterial blood (PaO2) and the arterial oxygen saturation (SaO2) both increased from 51.7 +/- 2.8 to 85.4 +/- 5.6 mmHg and from 79.7 +/- 3.1 to 93.7 +/- 0.9%, respectively (p < 0.001 for both), along with a slight worsening in the partial pressure of carbon dioxide in arterial blood (PaCO2), from 59.6 +/- 2.5 to 63.5 +/- 3.0 mmHg (p < 0.05). At 1 week, improvements in PaO2 and SaO2 were maintained in all patients, while PaCO2 decreased in 14 patients (mean decrease 8.3 mmHg) and increased in the remaining patients (mean 12.5 mmHg), when compared to pre-ITO2 values. Seven patients died during follow-up, leading to a success rate of 65%. Eight and 4 patients were discharged home and to a nursing home, respectively, 9 still receiving ITO2 via MT as chronic oxygen therapy. CONCLUSION: Our results suggest that MT insertion for ITO2 may be a therapeutic option in selected patients with respiratory failure from CLD.

[Results of an educational program on the autonomy of patients tracheotomized for chronic respiratory insufficiency]. / Résultats d'un programme d'éducation à l'autonomie des insuffisants respiratoires chroniques trachéotomisés.

In 1984 an educational programme was drawn up for patients with chronic respiratory failure and tracheotomies (IRCT) aimed at their obtaining independence and self-sufficiency. A prospective evaluation was made in parallel with the diary cards of the nurses (SI) measuring the level of dependence of care, defined by 15 characteristics and based on objective and analysable data. After excluding those patients who are already independent (22), decreased or transferred on account of decompensation (23) or removal of the tracheostomy tube (27), 92 patients (46 obstructive and 46 restrictive) coming from 31 centres of respiratory care or intensive care were studied between January 1985 and December 1986: 17 patients were bed-ridden and non-educable and were used as control subjects (T), and 75 patients entered the educational programme. For the results 3 different categories were defined: 1. Success (S): complete self-sufficiency for all care and the maintenance of the equipment, 2. A partial result (RP) with complete independence of the patient but only with stimulation where the patients aspirate by themselves but do not change the tubing and/or do not maintain the equipment, 3. Failure (E): no autonomy. Success was obtained in 43 cases (57%), a partial success in 20 cases (27%) and failure in 12 cases (16%). At entry as well as at the end the T group had significantly lower SI scores than the S, RP and E groups (P less than 0.001 to less than 0.01). The S, RP and E did not differ between each other nor by duration of stay, nor by the PaO2, nor PaCO2.(ABSTRACT TRUNCATED AT 250 WORDS)

[Complications of tracheotomy]. / Complications de la trachéotomie.

The complications of tracheotomy are reviewed and divided into two categories: early and late complications depending on whether the cannula has been removed or remains in situ. In the acute period, severe haemorrhages (0.3 to 2%) and oesophagotracheal fistulae (0.5 to 2%) result from a conflict between cannula and trachea during prolonged intensive care. Cardiac arrhythmia is frequent during aspiration (35%) but rarely lethal. Various technical problems related to the tracheotomy material are common (4 to 6%) and often very serious. Air leakage is represented mainly by severe pneumothorax (1 to 5%) under artificial ventilation. Tracheotomy wound infections (0.5 to 3.5%) may facilitate pulmonary superinfections (15 to 30%) which have a 5 to 8.5% mortality rate. In the acute phase, the overall mortality rate due to the tracheotomy itself is 1.7% (40 deaths in the 2,692 tracheotomies reviewed). The main post-decannulation complication is tracheal stenosis. The incidence of severe stenosis (more than two-thirds of the tracheal diameter) varies from 8 to 12%. Stenosis is difficult to diagnose unless endoscopic examination is routinely performed. The classical treatment is surgical, but laser is helpful in this as in granulomas. In patients with in-dwelling cannula, granulomas may be responsible for pain, obstruction and bleeding which can be avoided by using an adequate equipment. Chronic invasion of the bronchi by Gram-negative organisms is almost constant and results in episodes of superinfection. Finally, patients with a permanent cannula often have psychological and social problems influencing their quality of life.