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ABSTRACT: Exacerbations of COPD are common and cause a considerable burden to the patient and the healthcare system. To optimize the hospital care of patients with exacerbations of COPD, clinicians should be aware of some key points: management of exacerbations is broadly based on clinical features and severity. Initial clinical evaluation is crucial to define those patients requiring hospital admission and those who could be managed as outpatients. In hospitalized patients, the appropriate level of care should be determined by the initial severity and response to initial medical treatment. Medical treatment should follow recent recommendations, including rest, titrated oxygen therapy, inhaled or nebulized short-acting bronchodilators (Beta2-agonists and anticholinergic agents), DVT prevention with LMWH, steroids in most severely ill patients, unless there are contraindications and antibiotics in the case of a clear bacterial infectious aetiology. Severe exacerbations may lead to acute hypercapnic respiratory failure. Unless contraindicated, non-invasive ventilation (NIV) should be the first line ventilatory support for these patients. NIV should be commenced early, before severe acidosis ensues, to avoid the need for endotracheal intubation and to reduce mortality and treatment failures. Several randomised controlled clinical trials support the use of NIV in the management of acute exacerbations of COPD, demonstrating a decreased need for mechanical ventilation and an improved survival. In most severe cases, NIV should be provided in ICU. Although it has been shown that for less severe patients (with pH values>7.30), NIV can be administered safely and effectively on general medical wards, a lead respiratory consultant and trained nurses are mandatory. Mechanical ventilation through an endotracheal tube should be considered when patients have contraindications to the use of NIV or fail to improve on NIV. The duration of mechanical ventilation should be shortened as much as possible by an early weaning process, including preventive post-extubation NIV in hypercapnic patients. hospital stay could be shortened by non-invasive treatments. Future exacerbations should be avoided by respiratory specialist management of the patients, including education, optimization of long-term medical treatment, vaccinations, nutritional support, and pulmonary rehabilitation.
Revue des Maladies Respiratoires 10/2010; 27(8):939-53. · 0.59 Impact Factor
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ABSTRACT: A 60 year old male patient was admitted to hospital with pulmonary and cerebral abscesses. A percutaneous lung biopsy under CT scanning showed actinomycosis. After 4 weeks antibiotic therapy with ceftriaxone and metronidazole there was an improvement in the pulmonary lesion but new cerebral lesions appeared. A neurosurgical cerebral biopsy showed evidence of metastatic squamous carcinoma, probably of pulmonary origin. The diagnosis had been delayed by the presence of the actinomycosis. His general condition did not permit anti-tumour treatment and the patient soon afterwards. In the presence of pulmonary actinomycosis an associated malignancy should be excluded.
Revue des Maladies Respiratoires 11/2009; 26(9):1003-6. · 0.59 Impact Factor
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R Borie,
M Wislez,
G Thabut,
M Antoine, A Rabbat,
L-J Couderc,
I Monnet,
H Nunes,
F-X Blanc,
H Mal,
A Bergeron,
D Dusser,
D Israël-Biet,
B Crestani,
J Cadranel
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ABSTRACT: Mucosa-associated lymphoid tissue-derived (MALT) lymphoma, a low grade B-cell extranodal lymphoma, is the most frequent subset of primary pulmonary lymphoma. Our objective was to evaluate the initial extent of disease and to analyse the characteristics and long-term outcome of these patients. All chest and pathological departments of teaching hospitals in Paris were contacted in order to identify patients with a histological diagnosis of primary pulmonary lymphoma of the MALT subtype. 63 cases were identified. The median age was 60 yrs. 36% of cases had no symptoms at diagnosis. 46% of patients had at least one extrapulmonary location of lymphoma. The estimated 5- and 10-yr overall survival rates were 90% and 72%, respectively. Only two of the nine observed deaths were related to lymphoma. Age and performance status were the only two adverse prognostic factors for survival. Extrapulmonary location of lymphoma was not a prognostic factor for overall survival or for progression-free survival. Treatment with cyclophosphamide or anthracycline was associated with shorter progression-free survival, when compared with chlorambucil. The survival data confirm the indolent nature of pulmonary MALT lymphoma. Better progression-free survival was observed with chlorambucil when compared with cyclophosphamide or anthracycline.
European Respiratory Journal 07/2009; 34(6):1408-16. · 5.89 Impact Factor
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ABSTRACT: In patients with hematological malignancy (HM) developing acute respiratory failure (ARF) bronchoalveolar lavage (BAL) is considered as a major diagnostic tool. However, the benefit/risk ratio of this invasive procedure is probably lower in the subset of patients with acute myeloid leukemia (AML). The study was to analyze the yield of BAL performed in HM patients (n=175) with AML or lymphoid malignancies (LM) admitted in intensive care unit (ICU) for ARF and pulmonary infiltrates. BAL was performed in 121 patients (53/73 AML patients (73%) and 68/102 LM patients (67%)) without a definite diagnosis at admission or contraindication for fiberoptic bronchoscopy. Life-threatening complications were noticed in 12/121 patients (10%). The overall diagnostic yield of BAL was 47% (25/53) in AML patients and 50% (34/68) in LM patients. A microorganism was recovered from BAL in 23% (12/53) of AML patients and 41% (28/68) of LM patients (P<0.005). BAL results induced significant therapeutic changes in 17% (9/53) of AML patients vs 35% (24/68) of LM patients (P=0.039). This study underlines the rather low diagnostic yield of BAL for infectious diagnosis and the low rate of therapeutic changes induced by its results in AML patients with ARF admitted in ICU.
Leukemia: official journal of the Leukemia Society of America, Leukemia Research Fund, U.K 07/2008; 22(7):1361-7. · 8.30 Impact Factor
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ABSTRACT: A multicentre retrospective study was undertaken to examine patients with interstitial lung disease (ILD) with the initial clinical manifestation of an anti-synthetase syndrome (anti-Jo-1 antibodies), and to analyse the characteristics and long-term outcome of these patients according to their clinical presentation (acute or gradual onset), treatment and adverse events related to treatment.
32 patients, 15 (47%) presenting with acute onset and associated respiratory insufficiency (group A) and 17 (53%) with gradual onset (group G) were examined. Myositis was diagnosed at admission in only 31% of cases and was observed during follow-up in 56% of cases, but the prevalence did not differ between the two groups.
Fever and radiological patterns including diffuse patchy ground-glass opacities, basal irregular lines and consolidation on high-resolution CT scan were more frequent in group A than in group G. More patients in group G had neutrophils in the bronchoalveolar lavage fluid and autoantibodies other than anti-Jo-1 (rheumatoid factor, anti SSa/SSb) than in group A. The percentage of patients in whom the ILD improved at 3 months was significantly higher in group A than in group G (13/15 vs 9/17; p = 0.006). In contrast, after 12 months, most patients with ILD progression were in group A and were treated with corticosteroids alone. A combination of corticosteroids and an immunosuppressive drug was required in most cases (84%) at the end of the follow-up period. Severe adverse effects of treatment were observed and varicella zoster virus infection was frequent.
Early testing for anti-synthetase antibodies, particularly anti-Jo-1, and creatine kinase determination are useful procedures in patients presenting with ILD. Treatment with corticosteroids and immunosuppressive drugs is required in most patients. At the end of the study, around two-thirds of patients had stable ILD while the other third had disease progression with respiratory insufficiency.
Thorax 02/2008; 63(1):53-9. · 6.84 Impact Factor
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ABSTRACT: Whether sputum microbiological examination should be performed systematically in hospitalized patients with chronic obstructive pulmonary disease (COPD) exacerbations remains unclear.
To assess the yield of sputum microbiological examination in COPD patients hospitalized in a medical ward for an acute exacerbation with purulent sputum.
Two hundred consecutive exacerbations in 118 patients were studied. Patients underwent sputum microbiological examination on admission and baseline lung function tests and CT scans were recorded. Factors associated with positive culture were analyzed.
Sputum culture was positive (>or=10(7) CFU/ml) in 59% of samples, Haemophilus influenzae and Streptococcus pneumoniae being the most frequent pathogens. Factors associated with positive culture were bronchiectasis, long-term oxygen therapy and low FEV1. Pseudomonas spp. were found in 8.5% of all patients, who all had a FEV1<50% of predicted and were older. Only 25% of sputum samples satisfied all quality criteria. Sputum culture was positive in a high proportion of these samples (80.5%), but also in one half of samples with >25 leukocytes but >10 epithelial cells per field. Microbiological results induced a change in antibiotic therapy in 43.9% of cases with both quality criteria but also in 25.2% of cases with only one quality criterion. Finally, a predominant aspect after Gram stain was found in all positive samples.
These data suggest that sputum microbiological examination with direct examination and leukocyte count should be performed routinely in patients hospitalized for COPD exacerbations with purulent sputum, especially when FEV1 is less than 50% predicted and in patients with bronchiectasis.
Respiration 01/2007; 74(1):19-25. · 2.26 Impact Factor
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ABSTRACT: Respiratory complications are common following pulmonary resection and cause a significant mortality. The use of non-invasive ventilation (NIV) in acute respiratory insufficiency (ARI) is now well recognised. The prophylactic use of NIV in the absence of ARI and/or hypercapnia may be equally justified for the physiological benefits expected in the post-operative period following pulmonary surgery. The aim of our study therefore is to evaluate the effectiveness of NIV in the prevention of pulmonary complications in the immediate post-operative care of patients with moderate and severe COPD.
It will be a multicentre, prospective, randomised, parallel, open ended study of patients with moderate and severe COPD admitted to hospital for pulmonary resection.
To determine whether the setting up of NIV immediately post-operatively reduces the incidence of acute respiratory events (acute respiratory insufficiency) and to identify any sub-groups who receive greater benefit from NIV. This study should establish the place of NIV in the immediate post operative care following pulmonary resection.
Revue des Maladies Respiratoires 03/2005; 22(1 Pt 1):127-34. · 0.59 Impact Factor
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Revue des Maladies Respiratoires 01/2005; 21(6 Pt 1):1187-90. · 0.59 Impact Factor
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Revue des Maladies Respiratoires 01/2005; 21(6 Pt 1):1191-6. · 0.59 Impact Factor
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ABSTRACT: Acute respiratory failure and infectious pneumonia are the major causes of death during induction chemotherapy of acute leukemia. However, the causes, incidence and prognostic value of all respiratory events (REs) occurring in this context have never been assessed prospectively. We recruited 65 consecutive patients with newly diagnosed acute leukemia into a 1-year prospective study (December 2000-November 2001) to evaluate the incidence and prognostic value of these events. REs were frequent: 38 were recorded in 30 patients. There was a significant relationship between REs and pre-existing respiratory disease and/or smoking. REs were caused by infection in 34% of cases, by an established cause other than infection in 42% and had an undetermined cause in 24%. Poor early outcome (death within 45 days of starting induction chemotherapy) in patients experiencing an RE was independently associated with a >25/min respiratory rate (P=0.003) and the nonachievement of complete remission (CR) (P<0.0001). Predictors of overall survival in the entire patient population were the absence of CR (P<0.0001), REs (P=0.02) and a > or =2 performance status (P=0.03). In conclusion, REs are frequent during induction chemotherapy of acute leukemia and represent an independent prognostic factor of poor outcome, regardless of their cause.
Leukemia 04/2004; 18(4):670-5. · 9.56 Impact Factor
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ABSTRACT: A 23-year-old man, intensively treated for acute lymphoblastic leukaemia in relapse and with documented pulmonary aspergillosis, was admitted to the intensive care unit for acute respiratory failure. The diagnosis of invasive tracheal aspergillosis was made by bronchoscopy and biopsy. The lesions consisted of extensive necrotizing bronchitis with transmural and peribronchial extension associated with tracheal and bronchial obstruction due to the presence of pseudomembranes almost entirely composed of fungal hyphae. Despite treatment with amphotericin B and itraconazole, mechanical ventilation and bronchoscopy, the patient died 3 weeks later of massive bleeding.
Acta Haematologica 02/1998; 100(2):85-7. · 1.35 Impact Factor
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ABSTRACT: Severe veno-occlusive (VOD) disease is a major cause of morbidity and mortality in allogeneic bone marrow transplant recipients, and new approaches in managing patients who develop serious VOD is needed. In this report, we describe a patient who underwent transjugular intrahepatic portosystemic stent-shunt (TIPS) for life-threatening VOD are following allogeneic bone marrow transplantation for AML. Although the patient died of CMV-associated pneumonitis 5 weeks later, the TIPS functioned well until her death and permitted regression of the hepatic and renal symptoms. This report suggests that TIPS may be feasible and effective for managing patients with life-threatening liver dysfunction after marrow transplantation.
Bone Marrow Transplantation 09/1996; 18(2):443-45. · 3.75 Impact Factor
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ABSTRACT: Background
Respiratory complications are common following pulmonary resection and cause a significant mortality. The use of non-invasive ventilation (NIV) in acute respiratory insufficiency (ARI) is now well recognised. The prophylactic use of NIV in the absence of ARI and/or hypercapnia may be equally justified for the physiological benefits expected in the post-operative period following pulmonary surgery. The aim of our study therefore is to evaluate the effectiveness of NIV in the prevention of pulmonary complications in the immediate post-operative care of patients with moderate and severe COPD.Methods
It will be a multicentre, prospective, randomised, parallel, open ended study of patients with moderate and severe COPD admitted to hospital for pulmonary resection.Expected resultsTo determine whether the setting up of NIV immediately post-operatively reduces the incidence of acute respiratory events (acute respiratory insufficiency) and to identify any sub-groups who receive greater benefit from NIV. This study should establish the place of NIV in the immediate post operative care following pulmonary resection.
Revue des Maladies Respiratoires. 22(1):127-134.
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[show abstract]
[hide abstract]
ABSTRACT: Exacerbations of COPD are common and cause a considerable burden to the patient and the healthcare system. To optimize the hospital care of patients with exacerbations of COPD, clinicians should be aware of some key points: management of exacerbations is broadly based on clinical features and severity. Initial clinical evaluation is crucial to define those patients requiring hospital admission and those who could be managed as outpatients. In hospitalized patients, the appropriate level of care should be determined by the initial severity and response to initial medical treatment. Medical treatment should follow recent recommendations, including rest, titrated oxygen therapy, inhaled or nebulized short-acting bronchodilators (Beta2-agonists and anticholinergic agents), DVT prevention with LMWH, steroids in most severely ill patients, unless there are contraindications and antibiotics in the case of a clear bacterial infectious aetiology. Severe exacerbations may lead to acute hypercapnic respiratory failure. Unless contraindicated, non-invasive ventilation (NIV) should be the first line ventilatory support for these patients. NIV should be commenced early, before severe acidosis ensues, to avoid the need for endotracheal intubation and to reduce mortality and treatment failures. Several randomised controlled clinical trials support the use of NIV in the management of acute exacerbations of COPD, demonstrating a decreased need for mechanical ventilation and an improved survival. In most severe cases, NIV should be provided in ICU. Although it has been shown that for less severe patients (with pH values > 7.30), NIV can be administered safely and effectively on general medical wards, a lead respiratory consultant and trained nurses are mandatory. Mechanical ventilation through an endotracheal tube should be considered when patients have contraindications to the use of NIV or fail to improve on NIV. The duration of mechanical ventilation should be shortened as much as possible by an early weaning process, including preventive post-extubation NIV in hypercapnic patients. hospital stay could be shortened by non-invasive treatments. Future exacerbations should be avoided by respiratory specialist management of the patients, including education, optimization of long-term medical treatment, vaccinations, nutritional support, and pulmonary rehabilitation.
Revue des Maladies Respiratoires. 27(8):939-953.
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[show abstract]
[hide abstract]
ABSTRACT: A 60 year old male patient was admitted to hospital with pulmonary and cerebral abscesses. A percutaneous lung biopsy under CT scanning showed actinomycosis. After 4 weeks antibiotic therapy with ceftriaxone and metronidazole there was an improvement in the pulmonary lesion but new cerebral lesions appeared. A neurosurgical cerebral biopsy showed evidence of metastatic squamous carcinoma, probably of pulmonary origin. The diagnosis had been delayed by the presence of the actinomycosis. His general condition did not permit anti-tumour treatment and the patient soon afterwards. In the presence of pulmonary actinomycosis an associated malignancy should be excluded.
Revue des Maladies Respiratoires.
