[Adult asthma exacerbation: emergency room management]. / Exacerbation asthmatique chez l'adulte : prise en charge aux urgences.

Asthmatic exacerbations (AEs) are a frequent reason for emergency department visits. Management should be guided by the severity of the attack but should also focus on patient education and prevention of future exacerbations. This article summarizes current recommendations for the management of both simple and life-threatening AE. When the clinical evolution is favorable, and the patient no longer presents any criteria of severity or risk factors for decompensation, a return home can be considered, with appropriate treatment and the organization of outpatient follow-up. However, if the patient's prognosis is likely to be engaged, transfer to an intensive care unit should not be delayed, to ensure optimal care.

L'exacerbation asthmatique (EA) est un motif fréquent de consultation aux urgences. Sa prise en charge doit être guidée selon la sévérité de la crise mais doit également être axée sur l'éducation du patient et la prévention des récidives. Cet article résume les recommandations actuelles de prise en charge d'une EA autant pour les formes simples que sévères, engageant le pronostic vital. Lorsque l'évolution sous traitement est favorable et que le patient ne présente plus de critère de sévérité ou de facteur de risque de décompensation, un retour à domicile est envisageable avec un traitement adapté et l'organisation d'un suivi ambulatoire. Toutefois, lorsque le pronostic vital est susceptible d'être engagé, le transfert dans une unité de soins intensifs ne doit pas être retardé afin d'assurer une prise en charge optimale.

Long-Term Noninvasive Ventilation in Chronic Obstructive Pulmonary Disease: Association between Clinical Phenotypes and Survival.

BACKGROUND: Long-term noninvasive ventilation (LTNIV) is widely used in patients with chronic hypercapnic respiratory failure (CHRF) related to COPD. Prognosis of these patients is however poor and heterogenous. RESEARCH QUESTION: In COPD patients under LTNIV for CHRF, is it possible to identify specific phenotypes which are predictive of probability of pursuing NIV and survival? STUDY DESIGN AND METHODS: A latent class analysis was performed in a COPD population under LTNIV included in a comprehensive database of patients in the Geneva Lake area, to determine clinically relevant phenotypes. The observation period of this subgroup of COPD was extended to allow assessment of survival and/or pursuit of NIV for at least 2 years after inclusion. A logistic regression was conducted to generate an equation accurately attributing an individual patient to a defined phenotype. The identified phenotypes were compared on a series of relevant variables, as well as for probability of pursuing NIV or survival. A competitive risk analysis allowed to distinguish death from other causes of cessation of NIV. RESULTS: Two phenotypes were identified: a "respiratory COPD" profile with very severe airway obstruction, a low or normal body mass index, and a low prevalence of comorbidities and a "systemic COPD" profile of obese COPDs with moderate airway obstruction and a high rate of cardiovascular and metabolic comorbidities. The logistic regression correctly classified 95.7% of patients studied. Probability of pursuing NIV and survival were significantly related to these phenotypes, with a poorer prognosis for "respiratory COPD." Probability of death 5 years after implementing NIV was 22.3% (95% CI: 15.4-32.2) for "systemic COPD" versus 47.2% (37.4-59.6) for "respiratory COPD" (p = 0.001). CONCLUSION: The two distinct phenotypes of COPD under LTNIV for CHRF identified appear to be strongly related to prognosis and require further validation in other cohort studies.

Unenhanced computed tomography (CT) utility for triage at the emergency department during COVID-19 pandemic.

BACKGROUND: Unenhanced chest computed tomography (CT) can assist in the diagnosis and classification of coronavirus disease 2019 (COVID-19), complementing to the reverse-transcription polymerase chain reaction (RT-PCR) tests; the performance of which has yet to be validated in emergency department (ED) setting. The study sought to evaluate the diagnostic performance of chest CT in the diagnosis and management of COVID-19 in ED. METHODS: This retrospective single-center study included 155 patients in ED who underwent both RT-PCR and chest CT for suspected COVID-19 from March 1st to April 1st, 2020. The clinical information, CT images and laboratory reports were reviewed and the performance of CT was assessed, using the RT-PCR as standard reference. Moreover, an adjudication committee retrospectively rated the probability of COVID-19 before and after the CT calculating the net reclassification improvement (NRI). Their final diagnosis was considered as reference. The proportion of patients with negative RT-PCR test that was directed to the referent hospital based on positive CT findings was also assessed. RESULTS: Among 155 patients, 42% had positive RT-PCR results, and 46% had positive CT findings. Chest CT showed a sensitivity of 84.6%, a specificity of 80.0% and a diagnostic accuracy of 81.9% in suggesting COVID-19 with RT-PCR as reference. Concurrently, corresponding values of 89.4%, 84.3% and 86.5% were retrieved with the adjudication committee diagnosis as reference. For the subgroup of patients with age > 65, specificity and sensitivity were 50% and 80.8%, respectively. In patients with negative RT-PCR results, 20% (18/90) had positive chest CT finding and 22% (4/18) of those were eventually considered as COVID-19 positive according to the adjudication committee. After CT, the estimated probability of COVID-19 changed in 10/104 (11%) patients with available data: 4 (4%) were downgraded, 6 (6%) upgraded. The NRI was 1.92% (NRI event -2.08% + NRI non-event 5.36%). No patient with negative RT-PCR but positive CT was eventually directed to hospital. CONCLUSION: Chest CT showed promising sensitivity for diagnosing COVID-19 across all patients' subgroups. However, CT did not modify the estimated probability of COVID-19 infection in a substantial proportion of patients and its utility as an emergency department triage tool warrants further analyses.

Long-Term Non-invasive Ventilation: Do Patients Aged Over 75 Years Differ From Younger Adults?

Background: Noninvasive ventilation (NIV) is accepted as standard of care for chronic hypercapnic respiratory failure (CHRF) and is being increasingly implemented in older subjects. However, little is known regarding the use of NIV on a long-term basis in the very old. The outcomes of this study were: 1/to report the proportion of patients ≥ 75 years old (elderly) among a large group of long-term NIV users and its trend since 2000; 2/to compare this population to a younger population (<75 years old) under long-term NIV in terms of diagnoses, comorbidities, anthropometric data, technical aspects, adherence to and efficiency of NIV. Methods: In a cross-sectional analysis of a multicenter cohort study on patients with CHRF under NIV, diagnoses, comorbidities, technical aspects, adherence to and efficiency of NIV were compared between patients ≥ 75 and <75 years old (chi-square or Welch Student tests). Results: Of a total of 489 patients under NIV, 151 patients (31%) were ≥ 75 years of age. Comorbidities such as systemic hypertension (86 vs. 60%, p < 0.001), chronic heart failure (30 vs. 18%, p = 0.005), and pulmonary hypertension (25 vs. 14%, p = 0.005) were more frequent in older subjects. In the older group, there was a trend for a higher prevalence of chronic obstructive pulmonary disease (COPD) (46 vs. 36%, p = 0.151) and a lower prevalence of neuromuscular diseases (NMD) (19 vs. 11%, p = 0.151), although not significant. Adherence to and efficacy of NIV were similar in both groups (daily use of ventilator: 437 vs. 419 min, p = 0.76; PaCO2: 5.8 vs. 5.9 kPa, p = 0.968). Unintentional leaks were slightly higher in the older group (1.8 vs. 0.6 L/min, p = 0.018). Conclusions: In this cross-sectional study, one third of the population under NIV was ≥ 75 years old. Markers of efficacy of NIV, and adherence to treatment were similar when compared to younger subjects, confirming the feasibility of long-term NIV in the very old. Health-related quality of life was not assessed in this study and further research is needed to address this issue.

Adaptive Servo-Ventilation: A Comprehensive Descriptive Study in the Geneva Lake Area.

Background: Use of adaptive servo-ventilation (ASV) has been questioned in patients with central sleep apnea (CSA) and chronic heart failure (CHF). This study aims to detail the present use of ASV in clinical practice. Methods: Descriptive, cross-sectional, multicentric study of patients undergoing long term (≥3 months) ASV in the Cantons of Geneva or Vaud (1,288,378 inhabitants) followed by public or private hospitals, private practitioners and/or home care providers. Results: Patients included (458) were mostly male (392; 85.6%), overweight [BMI (median, IQR): 29 kg/m2 (26; 33)], comorbid, with a median age of 71 years (59-77); 84% had been treated by CPAP before starting ASV. Indications for ASV were: emergent sleep apnea (ESA; 337; 73.6%), central sleep apnea (CSA; 108; 23.6%), obstructive sleep apnea (7; 1.5%), and overlap syndrome (6; 1.3%). Origin of CSA was cardiac (n = 30), neurological (n = 26), idiopathic (n = 28), or drug-related (n = 22). Among CSA cases, 60 (56%) patients had an echocardiography within the preceding 12 months; median left ventricular ejection fraction (LVEF) was 62.5% (54-65); 11 (18%) had a LVEF ≤45%. Average daily use of ASV was [mean (SD)] 368 (140) min; 13% used their device <3:30 h. Based on ventilator software, apnea-hypopnea index was normalized in 94% of subjects with data available (94% of 428). Conclusions: Use of ASV has evolved from its original indication (CSA in CHF) to a heterogeneous predominantly male, aged, comorbid, and overweight population with mainly ESA or CSA. CSA in CHF represented only 6.5% of this population. Compliance and correction of respiratory events were satisfactory. Clinical Trial Registration: www.ClinicalTrials.gov, identifier: NCT04054570.

[Oxygen toxicity in acute care settings]. / Toxicité de l'oxygène dans les soins aigus.

Oxygen therapy is widespread in acute care settings as adequate oxygen supplementation is essential in case of hypoxemia. Excessive oxygen supplementation has several unrecognized deleterious effects. This article reviews the deleterious effects of hyperoxemia and sums up the actual recommendations for safe oxygen supplementation.

L'administration libérale d'oxygène dans les soins aigus est fréquente, mais n'est pas anodine. En cas d'hypoxémie, elle est bien sûr indispensable, mais son utilisation abusive peut résulter en une hyperoxie, avec de nombreux effets secondaires. Cet article résume les principes de l'oxygénothérapie ainsi que les effets néfastes provoqués par l'hyperoxie qui sont souvent méconnus.

[Long-term non-invasive ventilation in chronic obstructive pulmonary disease patients]. / Utilisation de la ventilation non invasive au long cours lors de BPCO.

Non-invasive ventilation (NIV) is recognized as first line therapy in acute hypercapnic respiratory failure and chronic alveolar hypoventilation caused by several diseases (restrictive thoracic disorders, neuromuscular disease and obesity-hypoventilation syndrome). In Switzerland and other European countries, long-term NIV has also been applied in hypercapnic patients with chronic obstructive pulmonary disease (COPD). However, only recently has conclusive evidence showing benefits of long-term NIV become available. Long-term NIV in COPD has now shown its efficacy in many studies. However, despite these findings, indications, ventilatory settings and monitoring remain poorly known and topic of debate.

La ventilation non invasive (VNI) est reconnue comme traitement de référence des décompensations respiratoires hypercapniques aiguës, ainsi que dans le traitement de nombreuses affections chroniques ayant pour conséquence une hypoventilation alvéolaire (pathologies restrictives thoraciques, maladies neuromusculaires, syndrome obésité hypoventilation). Elle est également utilisée depuis plusieurs années en Europe occidentale, et notamment en Suisse, en cas d'hypercapnie chronique chez le patient BPCO et ce malgré l'absence de validation scientifique solide jusqu'en 2014. L'utilisation de la VNI au long cours lors de BPCO a récemment fait la preuve de son efficacité dans un cadre épidémiologique bien défini ; néanmoins son indication, sa mise en place, ses réglages et son suivi sont autant d'aspects encore peu connus et débattus.

[Diagnosis, management and treatment of chylothorax]. / Diagnostic, prise en charge et traitement du chylothorax.

Chylothorax is characterized by a milky pleural effusion that results from the injury to the thoracic duct, causing leakage of chyle into the pleural space. Its diagnosis relies primarily, on the determination of triglycerides and/or the identification of chylomicrons in the pleural fluid. The most common causes are traumatic, mainly after surgery. Among non-traumatic causes, tumors are the most frequent (like lymphomas). Conservative treatment is based on pleural drainage with a low fat diet and appropriate etiological approach. In case of failure, occlusion of the thoracic lymph duct should be considered, either by a surgical approach or interventional radiology.

[Bone tuberculosis: when consider this diagnosis?]. / Tuberculose osseuse: quand faut-il y penser?

The most common presentation of bone tuberculosis (TB) is called spondylodiscitis, or "Pott's disease", which is a difficult diagnosis due to its low prevalence in Switzerland. It should be considered in patients with persistent back pain, who are at high risk, such as migrant population and immunocompromised patients. Diagnosis is based on imaging and the detection of M. tuberculosis in biopsy of affected vertebra orparaspinal abscess, or even if active tuberculosis is proven in any other site. It's essential to initiate appropriate treatment as quickly as possible in order to avoid neurological complications and spinal deformity and to identify cases that will require a surgical therapy.

[Postoperative pulmonary complications: how to anticipate and prevent the risk?]. / Complications pulmonaires postopératoires: comment anticiper et prévenir le risque?

Although less studied than cardiac complications, postoperative pulmonary complications are frequent and serious after major surgery. A close team working between primary care physician, surgeon, anesthesiologist, lung and heart physicians is essential to prevent and reduce postoperative pulmonary complications. Preoperative evaluation focused on clinical data and choice of surgical and anaesthetic adapted techniques are the key elements for a better control of these risks. Postoperative lung expansion techniques can minimize rate and severity of respiratory complications.