[Show abstract][Hide abstract] ABSTRACT: Rationale: Diaphragmatic insults occurring during intensive care unit (ICU) stays have become the focus of intense research. However, diaphragmatic abnormalities at the initial phase of critical illness remain poorly documented in humans. Objective: To determine the incidence, risk factors, and prognostic impact of diaphragmatic impairment on ICU admission. Methods: Prospective, six-month, observational cohort study in two ICUs. Mechanically ventilated patients were studied within 24 hours following intubation (day-1) and 48 hrs later (day-3). Seventeen anesthetized intubated control anesthesia patients were also studied. The diaphragm was assessed by twitch tracheal pressure (Ptr,stim) in response to bilateral anterior magnetic phrenic nerve stimulation. Main Results: Eighty-five consecutive patients aged 62 [54-75] (median [interquartile range]) were evaluated (medical admission 79%; SAPS II, 54 [44-68]). On day 1, Ptr,stim was 8.2 [5.9-12.3] cmH2O and 64% of patients had Ptr,stim <11cmH2O. Independent predictors of low Ptr,stim were sepsis (linear regression coefficient, -3.74; standard error, 1.16; p = 0.002) and SAPS II (linear regression coefficient, -0.07; standard error, 1.69; p = 0.03). Compared to non-survivors, ICU survivors had higher Ptr,stim (9.7 [6.3-13.8] vs. 7.3 [5.5-9.7] cmH2O, p=0.004). This was also true for hospital survivors vs. non-survivors (9.7 [6.3-13.5] vs. 7.8 [5.5-10.1] cmH2O, p=0.004). Day 1 and day 3 Ptr,stim were similar. Conclusions: A reduced capacity of the diaphragm to produce inspiratory pressure (diaphragm dysfunction) is frequent upon ICU admission. It is associated with sepsis and disease severity, suggesting that it may represent another form of organ failure. It is associated with a poor prognosis.
American Journal of Respiratory and Critical Care Medicine 05/2013; · 11.04 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: BACKGROUND: The safety of fiberoptic bronchoscopy (FOB) in nonintubated critically ill patients with acute respiratory failure has not been extensively evaluated. We aimed to measure the incidence of intubation and the need to increase ventilatory support following FOB and to identify predictive factors for this event. METHODS: A prospective multicenter observational study was carried out in eight French adult intensive care units. The study included 169 FOB performed in patients with a PaO(2)/FiO(2) ratio ≤300. The main end-point was intubation rate. The secondary end-point was rate of increased ventilatory support defined as an increase in oxygen requirement >50 %, the need to start noninvasive positive pressure ventilation (NI-PPV) or increase NI-PPV support. RESULTS: Within 24 h, an increase in ventilatory support was required following 59 bronchoscopies (35 %), of which 25 (15 %) led to endotracheal intubation. The existence of chronic obstructive pulmonary disease (COPD; OR 5.2, 95 % CI 1.6-17.8; p = 0.007) or immunosuppression (OR 5.4, 95 % CI 1.7-17.2; p = 0.004] were significantly associated with the need for intubation in the multivariable analysis. None of the baseline physiological parameters including the PaO(2)/FiO(2) ratio was associated with intubation. CONCLUSIONS: Bronchoscopy is often followed by an increase in ventilatory support in hypoxemic critically ill patients, but less frequently by the need for intubation. COPD and immunosuppression are associated with the need for invasive ventilation in the 24 h following bronchoscopy.
European Journal of Intensive Care Medicine 10/2012; · 5.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Retrospective study of prospectively collected data to assess the reliability of cervical magnetic stimulation (CMS) to detect prolonged phrenic nerve (PN) conduction time at the bedside. Because PN injuries may cause diaphragm dysfunction, their diagnosis is relevant in intensive care units (ICU). This is achieved by studying latency and amplitude of diaphragm response to PN stimulation. Electrical stimulation (ES) is the gold standard, but it is difficult to perform in the ICU. CMS is an easy noninvasive tool to assess PN integrity, but co-activates muscles that could contaminate surface chest electromyographic recordings.
In a first set of 56 ICU patients with suspected PN injury, presence and latency of compound motor action potentials elicited by CMS and ES were compared. With ES as the reference method, CMS was evaluated as a test designed to indicate presence or absence of PN injury. In eight additional patients, intramuscular diaphragm recordings were compared with surface diaphragm recordings and with the electromyograms of possible contamination sources.
The sensitivity of CMS to diagnose abnormal PN conduction was 0.91, and specificity was 0.84, whereas positive and negative predictive values were 0.81 and 0.92, respectively. Passing-Bablok regression analysis suggested no differences between the two measures. The correlation between PN latency in response to CMS and ES was significant. The "diaphragm surface" and "needle" latencies were close, and were significantly different from those of possibly contaminating muscles. One hemidiaphragm showed likely signal contamination.
CMS provides an easy reliable tool to detect prolonged PN conduction time in the ICU.
European Journal of Intensive Care Medicine 12/2011; 37(12):1962-8. · 5.17 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: A non-neutropenic man living in Senegal was repatriated to France for liver amebic abscesses associated with brain abscesses presumed to be of amebic origin. Surprisingly, the post-mortem examinations of brain abscesses showed Aspergillus flavus. The route of infection by A. flavus in this particular context is discussed.
The American journal of tropical medicine and hygiene 10/2009; 81(4):583-6. · 2.53 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: Opportunistic invasive fungal infections are increasingly frequent in intensive care patients. Their clinical spectrum goes beyond the patients with malignancies, and for example invasive pulmonary aspergillosis has recently been described in critically ill patients without such condition. Liver failure has been suspected to be a risk factor for aspergillosis.
We describe three cases of adult respiratory distress syndrome with sepsis, shock and multiple organ failure in patients with severe liver failure among whom two had positive Aspergillus antigenemia and one had a positive Aspergillus serology. In all cases bronchoalveolar lavage fluid was positive for Aspergillus fumigatus. Outcome was fatal in all cases despite treatment with voriconazole and aggressive symptomatic treatment.
Invasive aspergillosis should be among rapidly raised hypothesis in cirrhotic patients developing acute respiratory symptoms and alveolar opacities.
[Show abstract][Hide abstract] ABSTRACT: To evaluate the efficacy of a simple mechanical device to maintain constant endotracheal cuff pressure (Pcuff) during mechanical ventilation (large encased inflatable cuff connected to the endotracheal cuff and receiving constant pressure from a heavy mass attached to an articulated arm).
Single-center, prospective, randomized, crossover, pilot study in a medical intensive care unit.
Nine consecutive mechanically ventilated patients (age 62+/-20 years, SAPS II score 39+/-15).
Control day: Pcuff monitored and adjusted with a manometer (Hi-Lo, Tyco Healthcare) according to current recommendations (twice a day and after each intervention on the tracheal tube); initial target Pcuff 22-28 cmH20. Prototype day: test device connected to the endotracheal cuff; same initial target. Continuous Pcuff recording during both days. Control and prototype days in random order.
Pcuff values over 50 cmH20 were recorded in six patients during the control day (178+/-159min), never during the prototype day. During the control day, Pcuff was between 30 and 50 cmH20 for 29+/-25% of the time, vs 0.3+/-0.3% during the prototype day (p<0.01). Pcuff was between 15 and 30 cmH20 for 56+/-36% of the time during the control day, vs 95+/-14% during the prototype day p<0.01). During the control day, Pcuff was below 15 cmH20 for 15+/-17% of the time, vs 4.7+/-15% during the prototype day (p<0.05).
The tested device successfully controlled Pcuff with minimal human resource consumption. Prospective studies are required to assess its clinical impact.
Intensive Care Medicine 01/2007; 33(1):128-32. · 5.26 Impact Factor
[Show abstract][Hide abstract] ABSTRACT: The diaphragm is the main agonist of normal inspiration. To ensure an alveolar ventilation adequately balancing the production of carbon dioxyde, the diaphragm must be able to overcome the impedance of the respiratory system and must have an adequate endurance. If this is not the case, hypercapnic respiratory failure can occur. Studying diaphragm function in critically ill patients implies a careful clinical examination of the thoraco-abdominal movements during tidal breathing. Spirometry, inspiratory pressures (static and dynamic – “sniff test”) and blood gases must be measured. Phrenic nerve stimulation quantifies diaphragmatic dysfunction and is helpful to understand its mechanisms. Transcranial magnetic stimulation can ascertain the central origin of such abnormality. A careful description of diaphragm function can be useful in diseases impairing the neuromuscular function of the respiratory system, to investigate the mechanisms of difficult weaning from the ventilator or to assess the respiratory repercussions of ICU acquired polyneuropathies. Modern techniques for phrenic stimulation, both non-invasive and easy to apply, should in the future promote diaphragm studies in the clinical setting, in these indications.