Search

This study aimed to evaluate an objective measure of cough strength, the peak cough expiratory flow (PCEF), as a predictive criterion of success or failure of extubation.Patients under mechanical ventilation for more than 24 h who successfully passed the spontaneous breathing trial were included in the study. Just before extubation, PCEF was measured with an electronic flowmeter.A total of 130 patients were included. The median duration of mechanical ventilation before extubation was 8 days (4-17). Fourteen patients (10.8%) failed extubation. The sole factor significantly associated with extubation failure was the measure of PCEF. The patients who did not cough at order had a higher rate of extubation failure than those who did (P = 0.03). The mean PCEF of patients who failed extubation (36.3 +/- 15 l/min) was significantly lower than the one of patients who succeeded (63.6 +/- 32 l/min) (P0.001). The optimal cut-off value of PCEF was 35 l/min. Overall, an inability to cough at order or a PCEFor =35 l/min predicted extubation failure with a sensitivity of 79% and a specificity of 71%. The risk of extubation failure was 24% for the patients who did not cough at order or with a PCEFor =35 l/min and 3.5% for those with a PCEF35 l/min [RR = 6.9 (95% CI, 2-24); P = 0.002].This study confirmed the interest of measuring the PCEF to predict extubation outcome in patients having successfully passed the spontaneous breathing trial.

Resume Le depistage de la microalbumine (μAlb) est une analyse a forte valeur clinique pour le suivi des patients diabetiques ou suspects d’atteinte renale. Pour le clinicien, le resultat de cette recherche est determinante pour la conduite de la consultation, la decision therapeutique et la prise en charge du risque cardiovasculaire. La biologie delocalisee peut fournir une bonne reponse pour le depistage au plus pres du patient de l’atteinte renale debutante par l’utilisation d’un test semi-quantitatif simple rapide et fiable. Le seuil de positivite du Micral Test ® (MT) propose par la societe Roche est a 20 mg/L, identique a celui du dosage. Il a ete utilise simultanement par le personnel soignant et par les techniciens. Cinquante echantillons ont ete doses par la technique immunoturbidimetrique (IT) avec des valeurs de μAlb allant de 2,5 a 120 mg/L. La concordance du dosage de la μAlb avec le resultat du MT fait par les techniciens est de 94 % versus 64 % pour le test fait par les soignants dont 8 % de faux negatifs. Dans les mains des techniciens, le MT fournit des resultats bien correles avec le dosage IT de la μAlb ( r 2 = 0,907), mais sur une plage de mesure limitee de 0 a 100 mg. En revanche, les resultats obtenus par l’equipe soignante sont nettement moins favorables ( r 2 = 0,545). La mise en œuvre du MT, bien que simple, doit etre confiee a des personnes soigneusement formees pour en garantir la bonne utilisation. Ce test peut rendre service au cours des consultations de diabetologie et de nephrologie lorsque le patient est vu pour la toute premiere fois.

Objective: Comatose patients frequently exhibit pulmonary function worsening, especially in cases of pulmonary infection. It appears to have a deleterious effect on neurologic outcome. We therefore conducted a randomized trial to determine whether daily prone positioning would prevent lung worsening in these patients. Design: Prospective, randomized, controlled study. Setting: Sixteen-bed intensive care unit. Patients: Fifty-one patients who required invasive mechanical ventilation because of coma with Glascow coma scores of 9 or less. Interventions: In the prone position (PP) group: prone positioning for 4 h once daily until the patients could get up to sit in an armchair; in the supine position (SP) group: supine positioning. Measurements and results: The primary end point was the incidence of lung worsening defined by an increase in the Lung Injury Score of at least 1 point since the time of randomization. The secondary end point was the incidence of ventilator-associated pneumonia (VAP). A total of 25 patients were randomly assigned to the PP group and 26 patients to the SP group. The characteristics of the patients from the two groups were similar at randomization. The incidence of lung worsening was lower in the PP group (12%) than in the SP group (50%) (p=0.003). The incidence of VAP was 20% in the PP group and 38.4% in the SP group (p=0.14). There was no serious complication attributable to prone positioning, however, there was a significant increase of intracranial pressure in the PP. Conclusion: In a selected population of comatose ventilated patients, daily prone positioning reduced the incidence of lung worsening.

Acute respiratory distress syndrome (ARDS) is a clinical and pathophysiologic entity characterized by an acute and diffuse injury of the endothelial and epithelial surfaces of the lung, leading to respiratory failure. During the late phase of ARDS, glucocorticoids could have a beneficial effect on lung fibroproliferation but predispose to the development of pneumonia and sepsis. Alterations in cellular immunity observed in intensive care unit patients facilitate the progression from Candida colonization to Candida infection. However, in these critically ill patients, it remains difficult to distinguish colonization from invasive infection. As illustrated by this case report of a late ARDS successfully treated by glucocorticoids, the presence of Candida in bronchoalveolar lavage of ARDS in non-neutropenic patients should be considered with care before interpreting it as a colonization of the airways.

The treatment of hypoxaemia is one of the main goals of intensive care to patients with severe head injury. In the case reported here, the appearance of early pneumonia was accompanied by a severe deterioration of blood gases with worsening of intracranial hypertension. Prone position allowed rapid improvement of blood gases which contributed to the control of intracranial hypertension.

The treatment of hypoxaemia is one of the main goals of intensive care to patients with severe head injury. In the case reported here, the appearance of early pneumonia was accompanied by a severe deterioration of blood gases with worsening of intracranial hypertension. Prone position allowed rapid improvement of blood gases which contributed to the control of intracranial hypertension.

The observation of pulmonary mucormycosis occurring in a patient presenting with aplasia induced therapeutically during treatment for acute myeloblastic leukaemia, has led to a review of the characteristics of this rare opportunistic fungal infection: it occurs in a particular condition; the clinical manifestations are characterised by the thrombotic character and the rapidly necrosing nature of the histological lesions; the diagnosis is usually very difficult to make and is linked to the rarity of the pathology and the frequently negative mycological specimens apart from tissue biopsies; the value of a medicosurgical therapeutic strategy on which the prognosis of the infection depends.

Sarcoma of the common pulmonary artery are rare malignant tumors which can mimic pulmonary embolism. In the case presented here, the inaugural signs were particularly misleading: multiple pulmonary lacunae on computed tomography. The unusual aspect and asymmetric localizations at pulmonary angiography then suggested the doubtful nature of the embolism etiology. Magnetic resonance imaging findings suggested the diagnosis of sarcoma of the pulmonary artery. Certain diagnosis was obtained at pathology examination of the surgical specimen after thoracotomy. A malignant fibrous histiocytoma was identified. Curative resection was not possible and chemotherapy was performed. Unusual parenchymal lesions were then evidenced on the radiography. Better and better magnetic resonance imaging criteria are described in the literature and help distinguish between thromboembolism and sarcoma of the pulmonary artery. Follow-up of the clinical course is thus improved. It is nevertheless necessary to evaluate intravascular extension to determine whether curative surgery is possible.