Extracorporeal circuit for Panton-Valentine leukocidin-producing Staphylococcus aureus necrotizing pneumonia.

OBJECTIVE: To describe two cases of Panton-Valentine leukocidin-producing Staphylococcus aureus (PVL-SA) necrotizing pneumonia treated with ECMO, and complete pulmonary evaluation at six months. METHODS: Retrospective analysis of two patients presenting with severe PVL-SA pneumonia who both underwent complete respiratory function testing and chest CT scan six months after hospital discharge. RESULTS: Indications for ECMO were refractory hypoxia and left ventricular dysfunction associated with right ventricular dilatation. Patients were weaned off ECMO after 52 and 5 days. No ECMO-related hemorrhagic complication was observed. Pulmonary function tests performed at six months were normal and the CT scan showed complete regression of pulmonary injuries. CONCLUSION: PVL-SA pneumonia is characterized by extensive parenchymal injuries, including necrotic and hemorrhagic complications. ECMO may be used as a salvage treatment without any associated hemorrhagic complication, provided anticoagulant therapy is carefully monitored, and may lead to complete pulmonary recovery at six months.

[Spontaneous positive end-expiratory pressure ventilation in elderly patients with cardiogenic pulmonary edema. Assessment in an emergency admissions unit]. / Ventilation spontanée en pression expiratoire positive au cours de l'oedème pulmonaire cardiogénique de la personne âgée. Etude dans un service d'accueil et d'urgence.

OBJECTIVES: Intubation and ventilatory assistance are often required in patients presenting severe hypoxemic respiratory distress, but may be contraindicated in elderly subjects due to an underlying condition. The aim of this study was to assess the feasibility, acceptability and contribution of early assistance with spontaneous positive end-expiratory pressure ventilation for elderly subjects admitted to an emergency unit for acute respiratory distress due to cardiogenic pulmonary edema. PATIENTS AND METHODS: In our emergency admission unit, all patients with life-threatening hypoxemic respiratory distress are initially assisted with noninvasive spontaneous positive end-expiratory pressure ventilation using a standardized commercial device. We retrospectively analyzed the the files of all patients aged over 70 years who were treated with this standard protocol for cardiogenic pulmonary edema from April 1996 through September 1997. RESULTS: During the study period, 36 patients aged over 70 years required ventilatory assistance according to the standard protocol. Intubation was not reasonable in most of the patients (n = 30). After 1 hour of ventilation, none of the patients developed clinical signs of life-threatening distress. Blood gases demonstrated improved oxygenation (AEPO2 = +184.9 +/- 105.4 mmHg; p < 0.000001). Thirty-two patients were considered to be cured (88.9%) and were discharged; the cardiovascular condition was fatal in 4 patients (11.1%). CONCLUSION: The rapid improvement in clinical signs and blood gases as well as the final outcome suggests that early assistance with spontaneous positive end-expiratory pressure ventilation is warranted at admission for elderly patients with respiratory distress due to cardiogenic pulmonary edema. Compared with a control group of hospitalized patients cared for during the preceding year and who were not treated with the standard protocol, we also demonstrated a clear improvement in mortality (11% versus 20%).

[Use of helium-oxygen gas mixtures in acute obstructive respiratory insufficiencies]. / Utilisation des mélanges gazeux hélium-oxygène au cours des insuffisances respiratoires aiguës obstructives.

Therapeutic use of helium has been described since 1930. Its main action is to reduce bronchial resistances and consequently overall respiratory work. Helium is substituted for nitrogen. The effects of inhaling a helium-oxygen mixture result exclusively from the physicochemical properties of helium: very low density, high kinetic viscosity. With the advent of selective bronchodilators, use of helium was rapidly abandoned until recently with new interest for the treatment of severe acute asthma. We review the literature on the physical properties of helium-oxygen mixtures and propose an analysis of their therapeutic use in severe acute asthma as well as other indications such as acute episodes of obstructive bronchopneumonia and obstruction of the upper airways. Due to the non-invasive nature of this technique, its easy use with spontaneous ventilation and the large body of theoretical data emphasizing its adaptation for therapeutic use, helium-oxygen gas mixtures offer an important therapeutic option for treating severe diseases with poor prognosis. A multicentric national study is under way to validate its use early by emergency ambulatory units for the treatment of severe acute asthma.

[Brachiocephalic trunk erosion by a tracheotomy cannula]. / Ulcération du tronc brachio-céphalique par une canule de trachéotomie.

We report the case of a 27-year-old severe head trauma patient who developed an erosion of the brachiocephalic artery, 19 days after the insertion of a tracheal cannula. Emergency treatment included overinflation of the tracheostomy cuff and surgery via sternotomy, with occlusion of the tracheostomy and the tracheo-arterial fistula and reimplantation of the brachiocephalic artery via a vascular prosthesis. This life-threatening complication is due to close anatomic relationships between the trachea and the brachiocephalic artery. In our case, the tip of the cannula eroded the anterior trachea wall resulting in a tracheo-arterial fistula with massive haemorrhage. Warning symptoms such as pulsations of the cannula and aspiration of blood must be recognised without delay and followed by an adequate pre-established management.