Dysfonction cardiaque au décours d’un épisode d’insuffisance respiratoire aigüe hypercapnique chez le patient atteint de bronchopneumopathie chronique obstructive ayant nécessité un traitement par ventilation non invasive (VNI) et son évolution sous traitement par VNI versus oxygénothérapie au long cours : analyse intermédiaire échocardiographique de l’étude ancillaire de NIVOLD

La bronchopneumopathie chronique obstructive (BPCO) est une pathologie très fréquente. Elle retentit sur l’appareil cardiocirculatoire par augmentation de la post charge ventriculaire droite et la compression mécanique des cavités cardiaques. Objectif : L’objectif de l’étude était de déterminer la prévalence de la dysfonction cardiaque droite et gauche au décours d’un épisode d’insuffisance respiratoire aigüe hypercapnique (IRAH) chez le patient atteint de BPCO ayant nécessité un traitement par VNI en aigu et analyser l’évolution de sa= fonction cardiaque à 6 mois. Méthode : Il s’agit des résultats préliminaires de l’étude ancillaire de l’étude NIVOLD (non invasive ventilation in obstructive lung disease, NCT 03221101). Nous avons inclus des patients atteints de BPCO ayant été pris en charge en soins intensifs respiratoires au CHU de Rouen pour IRAH. Le patient devait être sevré de la VNI depuis au moins 5 jours, sans récidive de l’acidose mais avec une hypercapnie persistante. Une randomisation était effectuée dans le groupe VNI ± OLD versus OLD dans le cadre de l’étude NIVOLD. Les données hémodynamiques échocardiographiques réalisées à l’inclusion et à 6 mois étaient comparées aux données des épreuves fonctionnelles respiratoires et aux résultats des scanners thoraciques. Résultats : A partir de la cohorte NIVOLD de Rouen, comprenant 60 patients, nous avons inclus 18 patients. Notre population était âgée de 66 ans et présentait un VEMS moyen à 37%. Cinq patients (27%) avaient un rapport STDVD/STDVG augmenté, en faveur d’un cœur pulmonaire aigu. Six patients (33%) présentaient une PAPS> 35mmHg. La fonction ventriculaire droite était en moyenne altérée avec un index de Tei à 0,64 ± 0,34, une fraction de raccourcissement ventriculaire droite de 33%, un pic du Strain global à 15 ± 5% et un index de désynchronisation ventriculaire droite de 24 ± 16ms. L’emphysème pulmonaire, quantifié au moyen du volume de basse atténuation scanographique, était corrélé en analyse univariée à la PAPS (p = 0,01), au VR (p = 0,01) et inversement corrélé au VEMS (p = 0,01), à l’IMC (p = 0,006). En analyse multivariée, il était inversement corrélé à la surface de l’oreillette droite (p = 0,02). Une amélioration significative du remodelage ventriculaire droit était constatée à 6 mois (p = 0,05), en parallèle d’une amélioration significative de la capnie (p Conclusion : br>Dans une population de patients atteints de BPCO grave post IRAH ayant nécessité une VNI, le profil cardiaque des patients en post aigu immédiat et l’évolution est dépendante du phénotype de BPCO. L’existence d’un emphysème ou d’une obstruction bronchique va conditionner la sévérité de l’atteinte cardiaque droite. Le profil emphysémateux s’accompagne d’avantage d’altération du gradient de pression de retour veineux, de la précharge cardiaque droite et des pressions pulmonaires. L’amélioration de l’hématose et notamment de la capnie semble s’accompagner d’une amélioration du remodelage des cavités cardiaques droites. Ces conclusions préliminaires seront consolidées par l’analyse de l’ensemble des données de l’étude NIVOLD et la comparaison des bras de randomisation VNI ± OLD versus OLD seule

Appréhender l’objet archéologique hors contexte : le cas de la collection Mercier

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Appréhender l’objet archéologique hors contexte : le cas de la collection Mercier

International audienc

De Corinthe à la rue d'Ulm. La collection Paul et Yvonne Mercier

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Continuous Positive Airway Pressure (CPAP) face-mask ventilation is an easy and cheap option to manage a massive influx of patients presenting acute respiratory failure during the SARS-CoV-2 outbreak: A retrospective cohort study.

IntroductionBecause of the COVID-19 pandemic, intensive care units (ICU) can be overwhelmed by the number of hypoxemic patients.Material and methodsThis single centre retrospective observational cohort study took place in a French hospital where the number of patients exceeded the ICU capacity despite an increase from 18 to 32 beds. Because of this, 59 (37%) of the 159 patients requiring ICU care were referred to other hospitals. From 27th March to 23rd April, consecutive patients who had respiratory failure or were unable to maintain an SpO2 > 90%, despite receiving 10-15 l/min of oxygen with a non-rebreather mask, were treated by continuous positive airway pressure (CPAP) unless the ICU physician judged that immediate intubation was indicated. We describe the characteristics, clinical course, and outcomes of these patients. The main outcome under study was CPAP discontinuation.ResultsCPAP was initiated in 49 patients and performed out of ICU in 41 (84%). Median age was 65 years (IQR = 54-71) and 36 (73%) were men. Median respiratory rate before CPAP was 36 (30-40) and median SpO2 was 92% (90-95) under 10 to 15 L/min oxygen flow. Median duration of CPAP was 3 days (IQR = 1-5). Reasons for discontinuation of CPAP were: intubation in 25 (51%), improvement in 16 (33%), poor tolerance in 6 (12%) and death in 2 (4%) patients. A decision not to intubate had been taken for 8 patients, including the 2 who died while on CPAP. Two patients underwent less than one hour CPAP for poor tolerance. In the end, 15 (38%) out of 39 evaluable patients recovered with only CPAP whereas 24 (62%) were intubated.ConclusionsCPAP is feasible in a non-ICU environment in the context of massive influx of patients. In our cohort up to 1/3 of the patients presenting with acute respiratory failure recovered without intubation

Nicotine patches in patients on mechanical ventilation for severe COVID-19: a randomized, double-blind, placebo-controlled, multicentre trial

International audienceEpidemiologic studies have documented lower rates of active smokers compared to former or non-smokers in symptomatic patients affected by coronavirus disease 2019 (COVID-19). We assessed the efficacy and safety of nicotine administered by a transdermal patch in critically ill patients with COVID-19 pneumonia

Characterisation of a high-risk profile for maternal thrombotic and severe haemorrhagic complications in pregnant women with antiphospholipid syndrome in France (GR2): a multicentre, prospective, observational study

International audienceBackgroundProspective data about the risks of thrombotic and severe haemorrhagic complications during pregnancy and post partum are unavailable for women with antiphospholipid syndrome. We aimed to assess thrombotic and haemorrhagic events in a prospective cohort of pregnant women with antiphospholipid syndrome.MethodsThis multicentre, prospective, observational study was done at 76 centres in France. To be eligible for this study, women had to have diagnosis of antiphospholipid syndrome; have conceived before April 17, 2020; have an ongoing pregnancy that had reached 12 weeks of gestation; and be included in the study before 18 weeks of gestation. Exclusion criteria were active systemic lupus erythematosus nephropathy, or a multifetal pregnancy. Severe haemorrhage was defined as the need for red blood cell transfusion or maternal intensive care unit admission because of bleeding or invasive procedures, defined as interventional radiology or surgery, to control bleeding. The GR2 study is registered with ClinicalTrials.gov, NCT02450396.FindingsBetween May 26, 2014, and April 17, 2020, 168 pregnancies in 27 centres met the inclusion criteria for the study. 89 (53%) of 168 women had a history of thrombosis. The median term at inclusion was 8 weeks gestation. 16 (10%) of 168 women (95%CI 5–15) had a thrombotic (six [4%] women; 95% CI 1–8) or severe haemorrhagic event (12 [7%] women; 95% CI 4–12). There were no deaths during the study. The main risk factors for thrombotic events were lupus anticoagulant positivity at inclusion (six [100%] of six women with thrombosis vs 78 [51%] of 152 of those with no thrombosis; p=0·030) and placental insufficiency (four [67%] of six women vs 28 [17%] of 162 women; p=0·013). The main risk factors for severe haemorrhagic events were pre-existing maternal hypertension (four [33%] of 12 women vs 11 [7%] of 156 women; p=0·014), lupus anticoagulant positivity at inclusion (12 [100%] of 12 women vs 72 [49%] of 146 women; p<0·0001) and during antiphospholipid history (12 [100%] of 12 women vs 104 [67%] of 156 women; p=0·019), triple antiphospholipid antibody positivity (eight [67%] of 12 women vs 36 [24%] of 147 women; p=0·0040), placental insufficiency (five [42%] of 12 women vs 27 [17%] of 156 women; p=0·038), and preterm delivery at 34 weeks or earlier (five [45%] of 11 women vs 12 [8%] of 145 women; p=0·0030).InterpretationDespite treatment adhering to international recommendations, a proportion of women with antiphospholipid syndrome developed a thrombotic or severe haemorrhagic complication related to pregnancy, most frequently in the post-partum period. Lupus anticoagulant and placental insufficiency were risk factors for these life-threatening complications. These complications are difficult to prevent, but knowledge of the antenatal characteristics associated with them should increase awareness and help physicians manage these high-risk pregnancies