High-flow oxygen therapy versus noninvasive ventilation: a randomised physiological crossover study of alveolar recruitment in acute respiratory failure.

High-flow nasal cannula (HFNC) oxygen therapy has recently shown clinical benefits in hypoxaemic acute respiratory failure (ARF) patients, while the value of noninvasive ventilation (NIV) remains debated. The primary end-point was to compare alveolar recruitment using global end-expiratory electrical lung impedance (EELI) between HFNC and NIV. Secondary end-points compared regional EELI, lung volumes (global and regional tidal volume variation (V (T))), respiratory parameters, haemodynamic tolerance, dyspnoea and patient comfort between HFNC and NIV, relative to face mask (FM). A prospective randomised crossover physiological study was conducted in patients with hypoxaemic ARF due to pneumonia. They received alternately HFNC, NIV and FM. 16 patients were included. Global EELI was 4083 with NIV and 2921 with HFNC (p=0.4). Compared to FM, NIV and HFNC significantly increased global EELI by 1810.5 (95% CI 857-2646) and 826 (95% CI 399.5-2361), respectively. Global and regional V (T) increased significantly with NIV compared to HFNC or FM, but not between HFNC and FM. NIV yielded a significantly higher pulse oxygen saturation/inspired oxygen fraction ratio compared to HFNC (p=0.03). No significant difference was observed between HFNC, NIV and FM for dyspnoea. Patient comfort score with FM was not significantly different than with HFNC (p=0.1), but was lower with NIV (p=0.001). This study suggests a potential benefit of HFNC and NIV on alveolar recruitment in patients with hypoxaemic ARF. In contrast with HFNC, NIV increased lung volumes, which may contribute to overdistension and its potentially deleterious effect in these patients

Diagnosis and outcome of acute respiratory failure in immunocompromised patients after bronchoscopy

Objective: We wished to explore the use, diagnostic capability and outcomes of bronchoscopy added to noninvasive testing in immunocompromised patients. In this setting, an inability to identify the cause of acute hypoxaemic respiratory failure is associated with worse outcome. Every effort should be made to obtain a diagnosis, either with noninvasive testing alone or combined with bronchoscopy. However, our understanding of the risks and benefits of bronchoscopy remains uncertain. Patients and methods: This was a pre-planned secondary analysis of Efraim, a prospective, multinational, observational study of 1611 immunocompromised patients with acute respiratory failure admitted to the intensive care unit (ICU). We compared patients with noninvasive testing only to those who had also received bronchoscopy by bivariate analysis and after propensity score matching. Results: Bronchoscopy was performed in 618 (39%) patients who were more likely to have haematological malignancy and a higher severity of illness score. Bronchoscopy alone achieved a diagnosis in 165 patients (27% adjusted diagnostic yield). Bronchoscopy resulted in a management change in 236 patients (38% therapeutic yield). Bronchoscopy was associated with worsening of respiratory status in 69 (11%) patients. Bronchoscopy was associated with higher ICU (40% versus 28%; p<0.0001) and hospital mortality (49% versus 41%; p=0.003). The overall rate of undiagnosed causes was 13%. After propensity score matching, bronchoscopy remained associated with increased risk of hospital mortality (OR 1.41, 95% CI 1.08-1.81). Conclusions: Bronchoscopy was associated with improved diagnosis and changes in management, but also increased hospital mortality. Balancing risk and benefit in individualised cases should be investigated further

COVID-19 symptoms at hospital admission vary with age and sex: results from the ISARIC prospective multinational observational study

Background: The ISARIC prospective multinational observational study is the largest cohort of hospitalized patients with COVID-19. We present relationships of age, sex, and nationality to presenting symptoms. Methods: International, prospective observational study of 60 109 hospitalized symptomatic patients with laboratory-confirmed COVID-19 recruited from 43 countries between 30 January and 3 August 2020. Logistic regression was performed to evaluate relationships of age and sex to published COVID-19 case definitions and the most commonly reported symptoms. Results: ‘Typical’ symptoms of fever (69%), cough (68%) and shortness of breath (66%) were the most commonly reported. 92% of patients experienced at least one of these. Prevalence of typical symptoms was greatest in 30- to 60-year-olds (respectively 80, 79, 69%; at least one 95%). They were reported less frequently in children (≤ 18 years: 69, 48, 23; 85%), older adults (≥ 70 years: 61, 62, 65; 90%), and women (66, 66, 64; 90%; vs. men 71, 70, 67; 93%, each P &lt; 0.001). The most common atypical presentations under 60 years of age were nausea and vomiting and abdominal pain, and over 60 years was confusion. Regression models showed significant differences in symptoms with sex, age and country. Interpretation: This international collaboration has allowed us to report reliable symptom data from the largest cohort of patients admitted to hospital with COVID-19. Adults over 60 and children admitted to hospital with COVID-19 are less likely to present with typical symptoms. Nausea and vomiting are common atypical presentations under 30 years. Confusion is a frequent atypical presentation of COVID-19 in adults over 60 years. Women are less likely to experience typical symptoms than men

High-flow nasal cannula oxygen therapy: P-SILI or not P-SILI?

The risk of P-SILI with HFNC is controversial and may be less than with NIV. Some physiological mechanisms of the protective effect of HFNC are hypoxaemia correction, reduction of inspiratory efforts and homogeneity of lung volume distribution. https://bit.ly/3skOEK

Apport de l'échocardiographie pour le diagnostic et le suivi de l'hypertension pulmonaire (étude comparative contre cathétérisme artériel pulmonaire)

L'échocardiographie (ETT) a été validée pour le dépistage de l'hypertension pulmonaire (HTP). Sa place dans le diagnostic et le suivi de l'HTP reste toutefois mal définie. Plusieurs études récentes mettent en doute la pertinence clinique de l'estimation de la pression artérielle pulmonaire systolique (PAPs) par ETT. Objectif. Les but de l'étude sont d'analyser la corrélation entre les mesures, à l'ETT et au cathétérisme artériel pulmonaire, de PAPs et de débit cardiaque, et de définir des indices échocardiographiques de dysfonction ventriculaire droite dans l'HTP. Méthodes: Il s'agit d'une étude prospective monocentrique, dans laquelle les CAP et ETT ont été réalisés pour chaque patient dans un intervalle de moins d'une heure. Résultats: Cinquante neuf patients ont été inclus dans l'étude. Cent vingt neuf évaluations hémodynamiques ont été réalisées par CAP et ETT. Pour la mesure de la PAPs par les 2 techniques, le biais était de 4,48 mmHg et les limites d'aggrément 95% étaient de -25,11 et 34,09 mmHg, avec une corrélation de r=0,62 (p2.94 m/s permet de prédire la présence d'une HTP avec une sensibilité et une spécificité de 86% et 93% respectivement (AUC=0,924). Le calcul de la PAP moyenne à partir de la PAPs ETT permet de faire le diagnostic d'HTP avec une sensibilité et une spécificité de 84% et 93% respectivement (AUC=0,925). Nous avons montré qu'une valeur de l'excursion systolique du plan de l'anneau tricuspide (TAPSE) 0,78 est associée au diagnostic d'HTP avec une sensibilité et une spécificité de 66% et 93% respectivement (AUC=0,828) et à une dyspnée de stade III ou IV dans 85% des cas. Nous avons montré que la mesure de la vélocité de l'onde S tricuspidienne ne permettait pas de prédire la présence d'une HTP (p=0.8 et AUC=0.53). Nous avons mis en évidence une absence de corrélation entre les mesures de débits cardiaque à l'ETT et au CAP (biais de -0,54 L/min, limites d'aggrément 95% entre 3,55 et -4,64, r=0.2, p=0,002). Nous n'avons pas retrouvé de corrélation entre l'évaluation ETT de la PAPO, à l'aide de l'analyse en Doppler pulsé du flux mitral et du Doppler tissulaire mitral, et sa mesure invasive par le CAP (r=0,04, p=0,16). Neuf patients ont bénéficié d'une réévaluation dans le cadre de leur suivi d'HTP. Nous avons montré une bonne corrélation entre les mesures de PAPs et de débit cardiaque à l'ETT et au CAP chez ces patients mais ces résultats restent à confirmer sur un effectif plus important. Conclusion: Nos résultats ont permis de confirmer l'utilité de l'ETT pour le dépistage de l'HTP. Elle permet d'étudier des paramètres de la fonction ventriculaire droite comme le TAPSE et le rapport STDVD/STDVG, prédictifs d'une HTP et associé à une dyspnée de stade III ou IV. Ces indices pourraient être utilisés dans l'algorithme de prise en charge thérapeutique de ces patients. L'utilité de l'ETT pour le suivi des patients atteints d'HTP reste à confirmer.ROUEN-BU Médecine-Pharmacie (765402102) / SudocSudocFranceF

Sequelae of Acute Respiratory Distress Syndrome: Interest of Rehabilitation

International audienc

The Use of Ferritin to Identify Critically Ill Patients With Secondary Hemophagocytic Lymphohistiocytosis*

International audienc

Pulmonary arterial hypertension.

International audiencePulmonary arterial hypertension (PAH) is a chronic and progressive disease leading to right heart failure and ultimately death if untreated. The first classification of PH was proposed in 1973. In 2008, the fourth World Symposium on PH held in Dana Point (California, USA) revised previous classifications. Currently, PH is devided into five subgroups. Group 1 includes patients suffering from idiopathic or familial PAH with or without germline mutations. Patients with a diagnosis of PAH should systematically been screened regarding to underlying mutations of BMPR2 gene (bone morphogenetic protein receptor type 2) or more rarely of ACVRL1 (activine receptor-like kinase type 1), ENG (endogline) or Smad8 genes. Pulmonary veno occusive disease and pulmonary capillary hemagiomatosis are individualized and designated as clinical group 1'. Group 2 'Pulmonary hypertension due to left heart diseases' is divided into three sub-groups: systolic dysfonction, diastolic dysfonction and valvular dysfonction. Group 3 'Pulmonary hypertension due to respiratory diseases' includes a heterogenous subgroup of respiratory diseases like PH due to pulmonary fibrosis, COPD, lung emphysema or interstitial lung disease for exemple. Group 4 includes chronic thromboembolic pulmonary hypertension without any distinction of proximal or distal forms. Group 5 regroup PH patients with unclear multifactorial mechanisms. Invasive hemodynamic assessment with right heart catheterization is requested to confirm the definite diagnosis of PH showing a resting mean pulmonary artery pressure (mPAP) of [greater than or equal to]25 mmHg and a normal pulmonary capillary wedge pressure (PCWP) of [less than or equal to]15 mmHg. The assessment of PCWP may allow the distinction between pre-capillary and post-capillary PH (PCWP [greater than or equal to] 15 mmHg). Echocardiography is an important tool in the management of patients with underlying suspicion of PH. The European Society of Cardiology and the European Respiratory Society (ESC-ERS) guidelines specify its role, essentially in the screening proposing criteria for estimating the presence of PH mainly based on tricuspid regurgitation peak velocity and systolic artery pressure (sPAP). The therapy of PAH consists of non-specific drugs including oral anticoagulation and diuretics as well as PAH specific therapy. Diuretics are one of the most important treatment in the setting of PH because right heart failure leads to fluid retention, hepatic congestion, ascites and peripheral edema. Current recommendations propose oral anticoagulation aiming for targeting an International Normalized Ratio (INR) between 1.5-2.5. Target INR for patients displaying chronic thromboembolic PH is between 2--3. Better understanding in pathophysiological mechanisms of PH over the past quarter of a century has led to the development of medical therapeutics, even though no cure for PAH exists. Several specific therapeutic agents were developed for the medical management of PAH including prostanoids (epoprostenol, trepoprostenil, iloprost), endothelin receptor antagonists (bosentan, ambrisentan, macitentan soon available) and phosphodiesterase type 5 inhibitors (sildenafil, tadalafil). This review discusses the current state of art regarding to epidemiologic aspects of PH, diagnostic approaches and the current classification of PH. In addition, currently available specific PAH therapy is discussed as well as future treatments