Detection of disturbances in pulmonary gas exchanges during exercise from arterialized earlobe PO2.

Blood sampling from the arterialized earlobe is widely used in clinical exercise testing but Fajac et al. (1998) (Eur. Respir. J. 11, 712-715) have shown that arterialized P(O2) Pc(CO2) is not a valid surrogate for Pa(O2). In the present study, in order to detect disturbances in pulmonary gas exchanges during clinical exercise testing from the alveolar-arterial gradient of P(O2) (P[Ai-a](O2)), a correction factor for Pc(O2) was validated from data on a large cohort (107 patients at one or two levels of exercise: 172 pairs of samples). Pulmonary gas exchanges and pH, P(O2), P(CO2), PA(iO2) and P(Ai-a)(O2) from arterial and arterialized blood were measured or computed. Arterial and arterialized pH and P(CO2) (and thus PA(iO2)) were similar but P(CO2) was lower than arterial P(O2) (Pa(O2)). However, when corrected for the systematic bias between Pa(O2) and Pc(O2), which increased with Pc(O2), Pc(O2) adequately detected disturbances in pulmonary gas exchanges with a very high sensibility and specificity (predictive values of a negative or positive test ∼95%).

Use of intensive care in patients with nonresectable lung cancer.

BACKGROUND: Admission of patients with lung cancer to the ICU has been criticized. We evaluated whether ICU admission improved 3-month survival in patients with nonresectable lung cancer. Factors associated with survival were identified. METHODS: A retrospective study was conducted in consecutive nonsurgical patients with lung cancer admitted to three ICUs in France between 2000 and 2007, 2005 and 2007, and 2005 and 2006. RESULTS: We included 103 patients with a median (interquartile range) Simplified Acute Physiology Score II of 33 (25-46) and logistic organ dysfunction (LOD) score of 3 (1-4). Invasive mechanical ventilation was required in 41 (40%) patients. Sixty-three (61%) patients had metastasis and 26 (25%) an Eastern Cooperative Oncology Group performance status (ECOG-PS) > 2. The reason for ICU admission was acute respiratory failure in 58 (56%) patients. Three-month survival rate was 37% (95% CI, 28%-46%). By multivariate analysis, variables associated with mortality were ECOG-PS > 2 (hazard ratio [HR], 2.65; 95% CI, 1.43-4.88), metastasis at admission (HR, 1.90; 95% CI, 1.08-3.33), and worse LOD score (HR, 1.19; 95% CI, 1.08-1.32). An LOD score decrease over the first 72 h was associated with survival. CONCLUSIONS: Survival in nonsurgical patients with lung cancer requiring ICU admission was 37% after 90 days. Our results provide additional evidence that ICU management may be appropriate in patients with nonresectable lung cancer and organ failure.

Computed tomography measurements for airway stent insertion in malignant airway obstruction.

BACKGROUND: Metallic airway stents for malignant airway obstruction are considered safe, yet are not without complications. This study reviews the role of computed tomography (CT) airway measurements for planning stent placement in malignant airway obstruction before the actual therapeutic procedure to avoid invasive diagnostic evaluation before the stent placement and to reduce complications. METHODS: This study is a retrospective review of information from a stent order database and medical records of patients receiving stents for malignant airway obstruction at a university hospital over a 12-year period. CT scans were used to determine stent diameter by calculating mean diameters of healthy adjacent zones (proximal and distal), stent length (length of diseased airway), and location and number of potential stents. Results of CT planning before bronchoscopy were judged by complication rates. RESULTS: Patient population consisted of 69 patients, 61.7±14.0 years old, 40 males, in whom 92 stents were inserted. The most frequent cause of airway obstructions was tracheobronchial cancer (32). All patients had nitinol stent placement; 66 stents were covered and 26 were uncovered. Follow-up time was 1 to 1067 days (median: 35 days). Complication rate was 10.1% and mainly involved the patients with tracheal obstruction (6). Complications included stent fractures (2), migration (2), granuloma (1), and infectious tracheitis (2). One early death within 24 hours after the procedure was not related to stent placement. Five patients required follow-up therapeutic bronchoscopy to treat the complications. CONCLUSIONS: These results suggest that prestent planning by noninvasive method of obtaining CT scan provides optimal stent size and position, possibly avoiding a diagnostic bronchoscopy and reducing complications. Further prospective study is needed to confirm these results because of limitation of this study's design.

[Dyspnea and handicap in chronic obstructive pulmonary disease: interaction of their mechanisms]. / Mécanismes intégrés de la dyspnée et du handicap au cours de la bronchopneumopathie chronique obstructive.

Today, dyspnea in chronic obstructive pulmonary disease (COPD) is attributed to thoracic distention secondary to bronchial obstruction and hyperventilation. It inevitably occurs during exercise, even in patients with little obstruction, when they are capable of the elevated and prolonged power output that necessitates substantial hyperventilation. Exercise intolerance is due mainly to dyspnea, but muscle fatigue is also involved, especially in COPD patients who are malnourished. Deterioration of muscle function follows a substantial reduction in daily physical activity. In malnourished and hypoxemic subjects, however, responsibility for this is attributed to diverse aggravating biological processes related to chronic low-grade inflammation and to accentuated oxidative stress. The drastic diminution of physical activity results from ventilatory and muscle impairment and from symptoms that make movement painful. Improvement of ventilatory and muscle function, however, does not lead to recovery that allows sufficient physical activity. The spiral of disengagement, a morbid, psychodynamic process, accompanies chronic diseases and has the strongest effect in patients who were not highly physically active before becoming ill. Improvement of this handicap therefore requires a comprehensive management of patients, not confined to the prescription of physical activity under medical supervision. The aim is to offer diverse treatment propositions that can produce sustainable behavioral change.

[Supplemental oxygen for dyspnea for cancer patients in end-of-life palliative care]. / Intérêt de l'oxygénothérapie face à une dyspnée chez un patient atteint d'un cancer et relevant de soins palliatifs.

It is difficult to know which patients with dyspnea and terminal cancer will benefit most from supplemental oxygen. Supplemental oxygen treatment is cumbersome, can cause psychological dependence, impair the quality of life of the patient and family, and may even be dangerous for people with chronic respiratory insufficiency. It must therefore not be used routinely. It is necessary to insist on the fundamental role of symptomatic treatment, such as morphine, and on massage as well as other physical care, which is essential when no specific treatment is possible any longer. If supplemental oxygen is ordered, its effectiveness must be assessed: it should be maintained only if it produces improvement.

Wegener granulomatosis revealed by pleural effusion.

Pulmonary signs are common in Wegener's granulomatosis (WG). However, an initial presentation including pleural effusion has not been described. We describe a case of WG in which pleural effusion was the first clinical manifestation. A 45-year-old man with dorsal pain presented with pleural thickening and effusion, and a visible nodule on a thoracic scan. A dense chronic inflammatory infiltrate was obtained by pleural biopsy and an open lung biopsy revealed necrotizing granulomatous vasculitis. Serologies were positive for antineutrophil cytoplasmic antibodies and antiproteinase 3 antibodies. A diagnosis of WG was conducted and the patient was started on cyclophosphamide and methylprednisolone as an initial treatment, with a favorable evolution. Although pleural effusion is rarely described in WG, this pathology must be considered in the presence of this clinical manifestation.