Impact of a nurses' protocol-directed weaning procedure on outcomes in patients undergoing mechanical ventilation for longer than 48 hours: a prospective cohort study with a matched historical control group

INTRODUCTION: The aim of the study was to determine whether the use of a nurses' protocol-directed weaning procedure, based on the French intensive care society (SRLF) consensus recommendations, was associated with reductions in the duration of mechanical ventilation and intensive care unit (ICU) length of stay in patients requiring more than 48 hours of mechanical ventilation. METHODS: This prospective study was conducted in a university hospital ICU from January 2002 through to February 2003. A total of 104 patients who had been ventilated for more than 48 hours and were weaned from mechanical ventilation using a nurses' protocol-directed procedure (cases) were compared with a 1:1 matched historical control group who underwent conventional physician-directed weaning (between 1999 and 2001). Duration of ventilation and length of ICU stay, rate of unsuccessful extubation and rate of ventilator-associated pneumonia were compared between cases and controls. RESULTS: The duration of mechanical ventilation (16.6 ± 13 days versus 22.5 ± 21 days; P = 0.02) and ICU length of stay (21.6 ± 14.3 days versus 27.6 ± 21.7 days; P = 0.02) were lower among patients who underwent the nurses' protocol-directed weaning than among control individuals. Ventilator-associated pneumonia, ventilator discontinuation failure rates and ICU mortality were similar between the two groups. DISCUSSION: Application of the nurses' protocol-directed weaning procedure described here is safe and promotes significant outcome benefits in patients who require more than 48 hours of mechanical ventilation

Comorbidities of COPD

International audienceBy 2020, chronic obstructive pulmonary disease (COPD) will be the third cause of mortality. Extrapulmonary comorbidities influence the prognosis of patients with COPD. Tobacco smoking is a common risk factor for many comorbidities, including coronary heart disease, heart failure and lung cancer. Comorbidities such as pulmonary artery disease and malnutrition are directly caused by COPD, whereas others, such as systemic venous thromboembolism, anxiety, depression, osteoporosis, obesity, metabolic syndrome, diabetes, sleep disturbance and anaemia, have no evident physiopathological relationship with COPD. The common ground between most of these extrapulmonary manifestations is chronic systemic inflammation. All of these diseases potentiate the morbidity of COPD, leading to increased hospitalisations and healthcare costs. They can frequently cause death, independently of respiratory failure. Comorbidities make the management of COPD difficult and need to be evaluated and treated adequately. Extrapulmonary comorbidities are common in COPD and influence prognosis; we propose an exhaustive comorbidities revie

[Indications and practical issues concerning oxygen therapy].

International audienceINTRODUCTION: The initiation of oxygen therapy for acute or chronic respiratory failure is a common medical intervention, both for hospital in-patients and in out-of-hospital emergency settings. Oxygen therapy is also frequently initiated by paramedics or nurses, without any initial medical prescription, in acutely ill patients. STATE OF THE ART/PERSPECTIVES: It is important to remember that oxygen is a pharmaceutical drug, and its prescription should therefore be considered within treatment guidelines. Two main pathological situations may be encountered: tissue hypoxia and acute/chronic hypoxemia. CONCLUSION: Physicians should be aware of the clinical signs that may indicate the presence of hypoxia and the pathological situations that may lead to hypoxemia. They must also be aware of the potential complications, in particular CO(2) retention in patients with chronic type II respiratory failure as well as the overall indications, and practical issues concerning oxygen therapy

[Indications and practical issues concerning oxygen therapy].

International audienceINTRODUCTION: The initiation of oxygen therapy for acute or chronic respiratory failure is a common medical intervention, both for hospital in-patients and in out-of-hospital emergency settings. Oxygen therapy is also frequently initiated by paramedics or nurses, without any initial medical prescription, in acutely ill patients. STATE OF THE ART/PERSPECTIVES: It is important to remember that oxygen is a pharmaceutical drug, and its prescription should therefore be considered within treatment guidelines. Two main pathological situations may be encountered: tissue hypoxia and acute/chronic hypoxemia. CONCLUSION: Physicians should be aware of the clinical signs that may indicate the presence of hypoxia and the pathological situations that may lead to hypoxemia. They must also be aware of the potential complications, in particular CO(2) retention in patients with chronic type II respiratory failure as well as the overall indications, and practical issues concerning oxygen therapy

[Care of acute pulmonary embolism].

International audiencePulmonary embolism (PE) is common and potentially serious. Three stages are described: mild PE, moderate PE (associated with an ultrasound right ventricular dysfunction) and severe PE (associated with a shock). In the first category, the prognosis is highly favourable (mortality under 5%) and the initial phase of anticoagulant treatment is well documented and codified: the treatment is based on heparin therapy (non fractionated or derivatives) and oral anticoagulants. In the severe forms, fibrinolysis is indicated in addition to the heparin therapy, given the very high mortality (up to 50%). However, the optimum care of moderate PE (intermediate mortality between 10 and 15%) remains uncertain, due to the inability to demonstrate a benefits-risk ratio in favour of fibrinolysis. In addition, this entity is still poorly defined. Although cardiac ultrasound data is useful, other parameters, such as pro-BNP, provide a better identification of these forms of intermediate prognosis. Although the evaluation of the new oral and injectable anticoagulants is promising, it mainly concerns mild PE. In addition, trials are currently under way in patients with a gloomier prognosis. The purpose is to validate or invalidate the indication of classic treatments (fibrinolysis) or new treatments (optional caval filters)

Improvement of HIV-related pulmonary hypertension after the introduction of an antiretroviral therapy.

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[Contraception, therapeutic abortion, and pulmonary arterial hypertension].

International audienceDespite therapeutic advances, maternal mortality is high in pulmonary arterial hypertension (PAH). PAH treatment may interfere with the proposed method of contraception. Moreover, some treatments (endothelin receptor antagonists, anti-vitamin K) are teratogenic. If pregnancy is strictly not recommended in PAH, few specific contraceptive guidelines are available. The contraceptive method must be discussed on a case by case basis with the patient, the reference team for PAH, and the gynecology department.The advantages of the intrauterine device (IUD) with progesterone (reliability, simplicity, compliance, few contraindications and interactions, possibility of use in the nulliparous patient, reimbursement by the healthcare system) make it a good contraceptive choice in these circumstances. Therapeutic abortion is a situation of contraceptive failure, it must always be performed in hospitals. It must lead to effective contraceptive advice

Development of a clinical prediction score for congestive heart failure diagnosis in the emergency care setting: The Brest score.

International audienceTo derive and validate a clinical prediction rule of acute congestive heart failure obtainable in the emergency care setting.Derivation of the score was performed on a retrospective 927 patients cohort admitted to our Emergency Department for dyspnea. The prediction model was externally validated on an independent 206-patient prospective cohort.During the derivation phase, variables associated with acute congestive heart failure were included in a multivariate regression model. Logistic regression coefficients were used to assign scoring points to each variable. During the validation phase, every diagnosis was confirmed by an independent adjudication committee.The score comprised 11 variables: age ≥65 years (1 point), seizure dyspnea (2 points), night outbreak (1 point), orthopnea (1 point), history of pulmonary edema (2 points), chronic pulmonary disease (-2 points), myocardial infarction (1 point), crackles (2 points), leg edema (1 point), ST-segment abnormality (1 point), atrial fibrillation/flutter (1 point) on electrocardiography. In the validation step, 30 patients (14.6%) had a low clinical probability of acute congestive heart failure (score ≤3), of which only 2 (6.7%) had a proven acute cardiogenic pulmonary edema. The prevalence of acute congestive heart failure was 58.5% in the 94 patients with an intermediate probability (score of 4-8) and 91.5% in the 82 patients (39.8%) with a high probability (score ≥9).This score of acute congestive heart failure based on easily available and objective variables is entirely standardized. Applying the score to dyspneic adult emergency patients may enable a more rapid and efficient diagnostic process

Fenfluramine-like cardiovascular side-effects of benfluorex.

International audienceSince 1976, benfluorex has been approved in Europe as a hypolipidemic and hypoglycemic drug, and is commonly used in the treatment of the metabolic syndrome. As a derivative of fenfluramine with an appetite suppressant action, benfluorex is preferentially used in overweight patients. In contrast to fenfluramine and dexfenfluramine, to date, benfluorex has not been reported to be associated with frequent cardiovascular side-effects. The present study reports five cases of severe pulmonary arterial hypertension and one case of valvular heart disease occurring in patients exposed to benfluorex. These individuals were middle age, diabetic females with a body mass index ranging 24.2-49 kg x m(-2). No definite causal effect for cardiovascular disease with benfluorex can be drawn from such case reports. However, as benfluorex, like dexfenfluramine and fenfluramine, is metabolised into active metabolite norfenfluramine, further extensive assessment of drug exposure in newly diagnosed pulmonary arterial hypertension or valvular heart disease patients is warranted