Ventilator-induced lung injury: historical perspectives and clinical implications

Mechanical ventilation can produce lung physiological and morphological alterations termed ventilator-induced lung injury (VILI). Early experimental studies demonstrated that the main determinant of VILI is lung end-inspiratory volume. The clinical relevance of these experimental findings received resounding confirmation with the results of the acute respiratory distress syndrome (ARDS) Network study, which showed a 22% reduction in mortality in patients with the acute respiratory distress syndrome through a simple reduction in tidal volume. In contrast, the clinical relevance of low lung volume injury remains debated and the application of high positive end-expiratory pressure levels can contribute to lung overdistension and thus be deleterious. The significance of inflammatory alterations observed during VILI is debated and has not translated into clinical application. This review examines seminal experimental studies that led to our current understanding of VILI and contributed to the current recommendations in the respiratory support of ARDS patients

3D cloud envelope and cloud development velocity from simulated CLOUD (C3IEL) stereo images

A method to derive the 3D cloud envelope and the cloud development velocity from high spatial and temporal resolution satellite imagery is presented. The CLOUD instrument of the recently proposed C3IEL mission lends itself well to observing at high spatial and temporal resolutions the development of convective cells. Space-borne visible cameras simultaneously image, under multiple view angles, the same surface domain every 20 s over a time interval of 200 s. In this paper, we present a method for retrieving cloud development velocity from simulated multi-angular, high-resolution top of the atmosphere (TOA) radiance cloud fields. The latter are obtained via the image renderer Mitsuba for a cumulus case generated via the atmospheric research model SAM and via the radiative transfer model 3DMCPOL, coupled with the outputs of an orbit, attitude, and camera simulator for a deep convective cloud case generated via the atmospheric research model Meso-NH. Matching cloud features are found between simulations via block matching. Image coordinates of tie points are mapped to spatial coordinates via 3D stereo reconstruction of the external cloud envelope for each acquisition. The accuracy of the retrieval of cloud topography is quantified in terms of RMSE and bias that are, respectively, less than 25 and 5 m for the horizontal components and less than 40 and 25 m for the vertical components. The inter-acquisition 3D velocity is then derived for each pair of tie points separated by 20 s. An independent method based on minimising the RMSE for a continuous horizontal shift of the cloud top, issued from the atmospheric research model, allows for the obtainment of a ground estimate of the velocity from two consecutive acquisitions. The mean values of the distributions of the stereo and ground velocities exhibit small biases. The width of the distributions is significantly different, with higher a distribution width for the stereo-retrieved velocity. An alternative way to derive an average velocity over 200 s, which relies on tracking clusters of points via image feature matching over several acquisitions, was also implemented and tested. For each cluster of points, mean stereo and ground positions were derived every 20 s over 200 s. The mean stereo and ground velocities, obtained as the slope of the line of best fit to the mean positions, are in good agreement.</p

Near-infrared spectroscopy StO monitoring to assess the therapeutic effect of drotrecogin alfa (activated) on microcirculation in patients with severe sepsis or septic shock

Sepsis is a leading cause of death despite appropriate management. There is increasing evidence that microcirculatory alterations might persist independently from macrohemodynamic improvement and are related to clinical evolution. Future efforts need to be directed towards microperfusion monitoring and treatment. This study explored the utility of thenar muscle oxygen saturation (StO) and its changes during a transient vascular occlusion test (VOT) to measure the microcirculatory response to drotrecogin alfa (activated) (DrotAA) in septic patients. A prospective, observational study was performed in three general intensive care units at three university hospitals. We studied 58 patients with recent onset of severe sepsis or septic shock and at least two organ dysfunctions. Thirty-two patients were treated with DrotAA and 26 were not treated because of formal contraindication. StO was monitored using near-infrared spectroscopy (NIRS), and VOT was performed to obtain deoxygenation (DeOx) and reoxygenation (ReOx) slopes. Measurements were obtained before DrotAA was started and were repeated daily for a 96-hour period. Patients' characteristics, outcome, severity, and baseline values of StO, DeOx, and ReOx did not differ between groups. Treated patients significantly improved DeOx and ReOx values over time, whereas control patients did not. In treated patients, ReOx improvements were correlated to norepinephrine dose reductions. Early clinical response (SOFA improvement after 48 hours of treatment) was not associated to changes in VOT-derived slopes. In the treated group, the relative improvement of DeOx within 48 hours was able to predict mortality (AUC 0.91, p < 0.01). In patients with severe sepsis or septic shock, DrotAA infusion was associated with improvement in regional tissue oxygenation. The degree of DeOx amelioration after 2 days in treated patients predicted mortality with high sensitivity and specificity. Thus, StO derived variables might be useful to evaluate the microcirculatory response to treatment of septic shock

Near-infrared spectroscopy StO2 monitoring to assess the therapeutic effect of drotrecogin alfa (activated) on microcirculation in patients with severe sepsis or septic shock

BACKGROUND: Sepsis is a leading cause of death despite appropriate management. There is increasing evidence that microcirculatory alterations might persist independently from macrohemodynamic improvement and are related to clinical evolution. Future efforts need to be directed towards microperfusion monitoring and treatment. This study explored the utility of thenar muscle oxygen saturation (StO(2)) and its changes during a transient vascular occlusion test (VOT) to measure the microcirculatory response to drotrecogin alfa (activated) (DrotAA) in septic patients. METHODS: A prospective, observational study was performed in three general intensive care units at three university hospitals. We studied 58 patients with recent onset of severe sepsis or septic shock and at least two organ dysfunctions. Thirty-two patients were treated with DrotAA and 26 were not treated because of formal contraindication. StO(2) was monitored using near-infrared spectroscopy (NIRS), and VOT was performed to obtain deoxygenation (DeOx) and reoxygenation (ReOx) slopes. Measurements were obtained before DrotAA was started and were repeated daily for a 96-hour period. RESULTS: Patients’ characteristics, outcome, severity, and baseline values of StO(2), DeOx, and ReOx did not differ between groups. Treated patients significantly improved DeOx and ReOx values over time, whereas control patients did not. In treated patients, ReOx improvements were correlated to norepinephrine dose reductions. Early clinical response (SOFA improvement after 48 hours of treatment) was not associated to changes in VOT-derived slopes. In the treated group, the relative improvement of DeOx within 48 hours was able to predict mortality (AUC 0.91, p < 0.01). CONCLUSIONS: In patients with severe sepsis or septic shock, DrotAA infusion was associated with improvement in regional tissue oxygenation. The degree of DeOx amelioration after 2 days in treated patients predicted mortality with high sensitivity and specificity. Thus, StO(2) derived variables might be useful to evaluate the microcirculatory response to treatment of septic shock

Effect of a musical intervention on tolerance and efficacy of non-invasive ventilation in the ICU: study protocol for a randomized controlled trial (MUSique pour l’Insuffisance Respiratoire Aigue - Mus-IRA)

NIV protocol. (DOCX 103 kb

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

Modélisation à haute résolution : des pluies intenses dans les Cévennes Le système convectif Des 13 et 14 octobre 1995

Les cyclones de l’océan Atlantique ont défrayé la chronique au cours des mois d’août et septembre 2004. Certains ont cru voir dans cette activité renforcée un signe du changement climatique planétaire. Il s?agit plus vraisemblablement d?une manifestation de la variabilité climatique multidécennale qui, depuis 1995, génère des conditions favorables à la cyclogenèse sur l?Atlantique tropical. Après la période calme du point de vue cyclonique entre 1970 et 1995, l’océan Atlantique est probablement revenu à des conditions plus actives, susceptibles de se prolonger encore dix à vingt ans. Il faudra donc apprendre à vivre avec ce risque.During August and September 2004, the media devoted a lot of attention to the tropical storms over the Atlantic. Some saw this reinforced activity as a sign of global climate change. It is more probably a signature of multidecadal climatic variability which, since 1995, has been more favourable to cyclogenesis over the tropical Atlantic. After the relatively quiet cyclonic period between 1970 and 1995, the Atlantic has probably returned to a more active state which could last for 10 to 20 years. Thus, we must learn to cope with this threa