[A rare dyspnea in internal medicine: platypnea-orthodeoxia after pneumonectomy]. / Une dyspnée exceptionnelle en médecine interne: la platypnée-orthodéoxie après pneumonectomie.

BACKGROUND: A right-to-left shunting across a patent foramen ovale is a rare cause of acute respiratory failure after pneumonectomy. CASE REPORTS: We report two cases of posture dependent dyspnea (platypnea-orthodeoxia) secondary to postoperative right-to-left shunting across a patent foramen ovale. Both cases occurred three months after pneumonectomy, the first in a 63-year-old man and other in a 52-year-old man. CONCLUSION: A platypnea-orthodeoxia (dyspnea induced by the upright position with arterial deoxygenation relieved by recumbency) should lead to the diagnosis which is confirmed by echography or cardiac catheterization. The prognosis is good after surgical closure of the patent foramen ovale. The physiopathologic mechanism is poorly understood. We report two cases of platypnea-orthodeoxia.

[Secondary neuromuscular deficiencies in critical care patients]. / Déficits neuromusculaires secondaires en réanimation.

The authors report three cases of neuromuscular deficits occurring after a variable time of mechanical ventilation in ICU patients suffering from acute respiratory failure requiring sedation and neuromuscular blockade by pancuronium bromide. The clinical features of these deficits were similar : flaccid quadriparesia slowly reversible without sensory loss and difficult weaning from ventilation for two patients. The paraclinical investigations (measurements of creatine kinase, electrophysiological examination) permitted to distinguish two diseases: critical illness polyneuropathy (in patient with ARDS) and acute myopathy (in other patients with severe asthma) caused by corticosteroids and potentiated by neuromuscular blocking agents. This myopathy differs from the chronic myopathy caused by long term corticotherapy. After a status asthmaticus treated with corticosteroids and mechanical ventilation under muscle relaxants, creatine kinases should be measured in plasma and a neurological examination be performed. The value of neuromuscular blockade monitoring for the prevention of this myopathy should be assessed.

[Acute eosinophilic pneumopathy induced by minocycline]. / Pneumopathie aiguë à éosinophiles induite par la minocycline.

A 22-year-old patient was hospitalized for severe acute eosinophil pneumonia imputable to treatment with minocyclin chlorhydrate (Mynocine). Clinical manifestations began one week after onset of drug intake. The clinical picture included fever at 38 degrees C, polypnoea at 44/min, pulmonary crepitation and severe hypoxia at 4.5 kPa. Eosinophil blood counts were high (3.02 x 10(9)/l) Standard chest X-ray led to the diagnosis of eosinophil pneumonia. Approximately 50% of the polynuclears were eosinophils. The clinical course was rapidly favourable after withdrawal of minocyclin and administration of corticosteroids. This case was analysed and compared with other reports of minocylin induced pneumonia.

[Prognostic factors in the survival of patients with neuromuscular diseases after an episode of acute respiratory insufficiency]. / Facteurs pronostiques de la survie de patients atteints de maladies neuromusculaires après une insuffisance respiratoire aiguë.

We have studied the survival of 49 patients suffering from neuromuscular disease, who were hospitalised in the Respiratory Intensive Care Unit between 1981 and 1990 (29 males and 20 females with a mean age of 49.3 +/- 17 years with a range of 15 to 79). The neuromuscular diseases consisted of 8 with multiple sclerosis, 9 with amyotrophic lateral sclerosis, 8 with Steinert's disease, 11 myopathies, and 10 suffering from miscellaneous neurological diseases. Initially 27 of the 49 patients had been intubated and ventilated. During the hospital stay long-term ventilation was undertaken in 27 patients (21 by tracheotomy and 6 by nasal mask). The principal prognostic factor was the aetiology. Three groups of varying degrees of severity could be individualized: progressive neuromuscular disease (amyotrophic lateral sclerosis and multiple sclerosis), primary muscle disorders (myopathies and Steinert's disease), and neuromuscular disease with little or no evolution (survival at two years was 15%, 45% and 71% respectively for three groups. p = 0.001 by log-rank testing). The other factors which influence survival are age (p < 0.01), the presence of false route (p < 0.01), and the reason for hospitalisation (acute as opposed to chronic progressive deterioration, p < 0.05). In a multivariate analysis the most significant factors associated with the diagnosis were age, the reason for hospitalisation, and the existence of false routes. The initial treatment (intubation) and the prescription of long-term ventilation did not bring with it any significant further information as to prognosis, compared to the model which included these four factors.

[Sleep apnea syndrome in intensive care]. / Le syndrome d'apnée du sommeil en réanimation.

The aim of this work was to study the existence of special characteristics in the sleep apnoea syndrome (SAS) discovered following a stay on the Intensive Care Unit. This retrospective study of 25 casenotes of SAS patients who were resuscitated has enabled a comparison with 182 SAS patients who have never had acute respiratory failure. The intensive care consisted of controlled ventilation, following intubation, in a clinical context of acute respiratory failure with major problems of conscious level. The diagnosis of SAS was made using conventional or computerised polysomnography, or a computerised study of transcutaneous SaO2 (SaO2TC) which had been validated before. The results show that patients with SAS in an Intensive Care Unit, differs significantly from other patients with SAS by the permanent presence of alveolar hypoventilation in a stable state, associated with a significant decrease in the FEV1 (VEMS) in relation to the group that had not been in intensive care. However, the FEV1/VC ratio did not differ between the two groups which were expressed in absolute values or as a percentage of the theoretical value defined on the basis of their age. There was no difference on the data from the sleep studies and notably the hypoapnoeic indices, nor on age, the index of body mass or the sex ratio. We conclude that there is a need to look for SAS in the presence of acute respiratory failure in the obese without a recognised cause.

[Predictive factors in maintaining nocturnal continuous positive pressure in patients with sleep apnea syndrome]. / Facteurs prédictifs de l'observance de la pression positive continue nocturne chez les patients porteurs d'un syndrome d'apnées du sommeil.

A retrospective study was carried out on 347 case notes involving 303 men and 44 women who were suffering from a sleep apnea syndrome (SAS). The mean age was 57 plus or minus 10 years, and the diagnosis was made between 1982 and 1992. We have carried out the research to examine if there were clinical factors or factors related to respiratory function which would predict the acceptance in the short or long term and the correct observation in a daily time-table of nocturnal continuous positive pressure (PPC). The diagnosis of SAS was made using conventional polygraphy (35%), computerised cardiorespiratory recording 38%, or limited to transcutaneous saturation 27%. The mean number of respiratory nocturnal events in the three groups were respectively 48 plus or minus 25 per hour during sleep, and 45 plus or minus 23 and 51 plus or minus 20 per hour by the recording techniques. We have suggested a treatment by PPC in 235 patients: 86 patients refused at the outset (37%), 26 stopped secondarily (11%), and 108 (46%) continued until the end point 1992 with a mean duration of treatment of 24 (plus or minus 17), months and a mean duration of nocturnal usage of 6.2 (plus or minus 2.5) hours a mean level of positive pressure of 11 (plus or minus) 2) centimetres. The primary acceptance of PPC is significantly linked to the understanding of the patient of the functional signs (p less than 0.001) and of the severity of diurnal hypersomnolence (p less than 0.001). The acceptance in the long-term is linked in a weakly significant manner to the recognition by the patient of functional signs (p less than 0.04). None of the other 68 criteria used for assessing the severity of the patient and the SAS had any influence on the acceptance of PPC in short or long term. The compliance with a daily time-table is a weakly significant factor to the severity of the SAS judged by the number of nocturnal respiratory events (p less than 0.03).

[A rare and curable cause of acute respiratory insufficiency after a pneumonectomy. The platypnea-orthodeoxia syndrome by the reopening of the foramen ovale]. / Une cause rare et curable d'insuffisance respiratoire aiguë après pneumonectomie. Le syndrome de platypnée-orthodéoxie par réouverture du foramen ovale.

We describe a case of a 54 year old patient who had developed a right to left shunt due to a patent foramen ovale as a late consequence of a pneumonectomy; this was responsible for acute respiratory insufficiency and respiratory failure. This is a rare complication, but its clinical presentation as platypnea-orthodeoxia should lead to the correct diagnosis. The diagnosis can be rapidly confirmed by a non-invasive examination, namely contrast echocardiography, coupled with color doppler. The treatment is surgical with excellent results. The pathophysiological mechanism is also discussed.

[Phrenic stimulation in C1-C2 tetraplegia. Apropos of a case]. / Stimulation phrénique dans les tétraplégies C1-C2. A propos d'un cas.

The authors report a case of post traumatic tetraplegia at the C1-C2 level in a young man of 16 with total respiratory paralysis treated with mechanical ventilation and a tracheotomy. Thirty months after the accident, an Avery S 232(1) diaphragmatic pacemaker was surgically implanted by the mediastinal approach. The technique was rapidly successful and enabled satisfactory ventilation and phonation two months after the implantation. The patient is currently treated at home with no signs of diaphragmatic fatigue 20 months after the implantation of the stimulator.

[Reliability of transcutaneous PO2 measurements and ear oximetry at different levels of exercise]. / Fiabilité de la PO2 transcutanée et de l'oxymétrie par pince d'oreille à différents niveaux d'exercice.

Measurement of transcutaneous PO2 (PtcO2) and of the saturation of hemoglobin by ear oximetry (StcO2) are two non-invasive methods which can be used when performing exercise tests in patients with respiratory failure. To evaluate their reliability, we have compared 18 patients recording the PtcO2 (Radiometer electrode TCM1) and of StcO2 (Biox II A) with arterial samples using a radial artery catheter at rest and at a level corresponding to 50% of the maximal predicted effort and at maximal power (Wmax) obtained at the time of a triangular exercise (increasing the charge at 15 watts/min). The PtcO2 was significantly lower than the PaO2 at rest and on exercise: the variation between PaO2 and PtcO2 was 1.85 kPa at rest (confidence interval -0.25 to 3.96 kPa) but decreased with exercise reaching 1.22 kPa at the last level of exercise (confidence interval -1.2 to 3.65 kPa). The relative raising of PtcO2 in relation to the PaO2 masks a fall in the observed PaO2 on average for the entire group (the PaO2 falls from 9.49 kPa to 8.62 kPa whereas the PtcO2 only falls from 7.64 kPa to 7.39 kPa). The mean StcO2 does not differ from th SaO2 at rest as on exercise. However, the confidence interval of the scatters between SaO2 and StcO2 increase considerably at maximal power: whereas it ranges between -5.5 and 3.5% at rest and in the middle range effort, and is between -13.4 and 11.1% at the last stage.(ABSTRACT TRUNCATED AT 250 WORDS)

[Bacteriological aspects of 64 cases of severe pneumonia seen in a respiratory intensive care unit]. / Aspects bactériologiques de 64 pneumopathies graves observées en réanimation respiratoire.

We report on the bacterial aspects of 64 cases of severe pneumonia in an intensive care over a two year period, excluding cases occurring during artificial ventilation. In all the cases, the grave respiratory and haemodynamic signs, the blood gas and radiological findings justified admission of these patients to an intensive care unit. Specimens for bacteriology, virology and parasitology enabled a precise microbiological diagnosis 43 times (63%); in 44% of these diagnosis the possibility of the protected specimens (trans-tracheal, protected brushing) were confirmed by another specimen (pleural or blood). The germs identified were: Streptococcus pneumoniae (13), Staphylococcus aureus (9), Haemophilus influenzae (6), other gram negatives (12), Mycoplasma pneumoniae (1), Koch's bacillus (1), Aspergillus fumigatus, Cytomegalovirus, Myxovirus, Pneumocystis carinii (5). Twenty eight patients died of whom eight had marrow failure following chemotherapy; amongst the non-leukopenic patients an analysis of the records allowed certain presumptions as to the causative organism according to the patients mode of referral and immune state. The prognosis of these pneumonias remains serious in spite of improved bacteriological diagnosis, above all in the elderly, poorly nourished or with marrow aplasia.

[Disseminated invasive aspergillosis associated with Mycoplasma pneumoniae infection]. / Aspergillose invasive disséminée associée à une infection à Mycoplasma pneumoniae.

Disseminated aspergillosis is rare in patients not suffering from haematological disorders and myelo-suppression. We report a case of pulmonary cardiac and renal aspergillosis diagnosed at autopsy in a patient with chronic respiratory failure dying in the intensive care unit during an acute exacerbation. The role of risk factors associated with invasive aspergillosis in patients not suffering from myelosuppression is discussed (steroid therapy, chronic respiratory disease, concomitant viral or bacterial infection). The discovery in this patient of a pulmonary infection associated with mycoplasma pneumonia (the micro-organisms were found in necropsy specimens of pulmonary tissue) does not seem to have been reported before in the literature.

[Reliability of the transcutaneous PO2 measurement in the adult by the TCM 1 radiometer electrode]. / Fiabilité de la mesure de la PO2 transcutanée chez l'adulte par l'électrode radiometer TCM 1.

The accuracy of transcutaneous PO2 measurements (PtcO2; Radiometer TCM 1) was evaluated by comparison with arterial PO2 (PaO2) on 115 recordings in 35 patients: 20 during exercise testing (group I) and 14 during assisted ventilation at different FIO2 values (group II). The correlation coefficient between PaO2 and PtcO2 was satisfactory (r = 0.977; n = 115). However PaO2 and PtcO2 mean values were significantly different in group I, and in group II at 45% FIO2. The analysis of variance showed that the difference between PaO2 and PtcO2 was significant among the patients but did not vary with exercise and FIO2 changes (group I: F19 = 6.28, p less than 0.001; group II: F19(19) = 2.54, p less than 0.025). In the adult, transcutaneous PO2 measurement by TCM 1 radiometer electrode seems to be interesting in the context of monitoring blood gases with exercise and assisted ventilation. The significant variation with arterial PO2 sometimes registered should make one cautious in the interpretation of accurate measurements.

[Contribution of nocturnal polygraphy to the diagnosis of Pickwickian syndrome. 10 cases]. / Apport de la polygraphie nocturne au diagnostic du syndrome de Pickwick. A propos de 10 observations.

The authors studied a series of 10 obese patients with respiratory failure referred for treatment because of sleep disorders and diurnal, sometimes uncontrollable, episodes of somnolence. 8 parameters were recorded in the polygraphic study performed during a night of hospitalization: electroencephalogram, electrocardiogram, electro-oculogram, chin electromyogram, thoracic movements, and nasal and buccal air flows. SaO2 and transcutaneous PO2 were recorded simultaneously. A sleep apnea syndrome was diagnosed in 6 of the 10 patients, whose apnea index was markedly above the limit of 5 apneas per hour. The apnea index was below 5 in the other 4 patients. Most patients with sleep apnea syndrome suffer from obstructive apneas of varying duration taking up as much as 48% of total sleep time. The cardiorespiratory effects of these events are apparent, with a drop in PO2 and SaO2 and a decrease in heart rate at the end of apnea. Polygraphic studies seem useful in the diagnosis of the pickwickian syndrome. They allow the type of apnea and its effects to be specified and thus guide treatment.

Effects of nifedipine on pulmonary arterial hypertension in patients with respiratory insufficiency without acute failure.

Permanent pulmonary arterial hypertension is a standard part of the prognosis for patients with chronic respiratory insufficiency. As a decrease of pulmonary arterial hypoxic vasoconstriction may be obtained by calcium antagonists, we studied the effects of nifedipine (10 mg sublingually) in 10 patients with chronic respiratory insufficiency without acute respiratory failure. Our results show that maximal expiratory air flow was not altered. The pulmonary antihypertensive action of this drug, which is less effective than oxygen breathing at low concentration, was associated with a constant decrease of arterial oxygen partial pressure; the oxygen transport was not sustained for every patient. This result suggests that considerable caution should be exercised in using this drug for the treatment of pulmonary arterial hypertension in patients with chronic respiratory insufficiency without acute failure.