[Pulmonary embolism with overflow pulmonary edema]. / OEdème pulmonaire d'hyperperfusion lors d'embolies pulmonaires.

We report the case of a patient with a febrile acute respiratory failure associated with alveolar opacities localized in the left upper lobe on chest-X-ray. Diagnosis was related to pulmonary embolism with overflow pulmonary edema. Complete recovery was obtained after mechanical ventilation, anticoagulation and a short course of intra venous dobutamine.

[Acute respiratory failure responsive to cotrimoxazole and corticosteroïds in an AIDS patient]. / Détresse respiratoire aiguë d'évolution favorable sous cotrimoxazole et corticoïdes chez un patient atteint d'un SIDA.

We report a case of acute respiratory failure due to Toxoplasma gondii mimicking pneumocystosis in an AIDS patient. Empirical antibiotic therapy with cotrimoxazole is discussed. Active research and identification of pathogens with adapted laboratory tests is mandatory.

[Candida albicans fungemia with pulmonary localization treated with fluconazole. A case report]. / Septicémie à Candida albicans avec localisation pulmonaire traitée par fluconazole. A propos d'un cas.

We report a case of Candida albicans fungemia complicated by a pulmonary localization in a non-immunocompromised patient. Complete recovery was obtained after a long course of high-dose fluconazole in spite of in vitro resistance of the Candida to fluconazole. The usefulness of fluconazole therapy, the best dosage regimen and the in vitro and in vivo correlations are discussed.

Expiratory washout versus optimization of mechanical ventilation during permissive hypercapnia in patients with severe acute respiratory distress syndrome.

The aim of this study was to compare three ventilatory techniques for reducing PaCO2 in patients with severe acute respiratory distress syndrome treated with permissive hypercapnia: (1) expiratory washout alone at a flow of 15 L/min, (2) optimized mechanical ventilation defined as an increase in the respiratory frequency to the maximal rate possible without development of intrinsic positive end- expiratory pressure (PEEP) combined with a reduction of the instrumental dead space, and (3) the combination of both methods. Tidal volume was set according to the pressure-volume curve in order to obtain an inspiratory plateau airway pressure equal to the upper inflection point minus 2 cm H2O after setting the PEEP at 2 cm H2O above the lower inflection point and was kept constant throughout the study. The three modalities were compared at the same inspiratory plateau airway pressure through an adjustment of the extrinsic PEEP. During conventional mechanical ventilation using a respiratory frequency of 18 breaths/min, respiratory acidosis (PaCO2 = 84 +/- 24 mm Hg and pH = 7.21 +/- 0.12) was observed. Expiratory washout and optimized mechanical ventilation (respiratory frequency of 30 +/- 4 breaths/min) had similar effects on CO2 elimination (DeltaPaCO2 = -28 +/- 11% versus -27 +/- 12%). A further decrease in PaCO2 was observed when both methods were combined (DeltaPaCO2 = -46 +/- 7%). Extrinsic PEEP had to be reduced by 5.3 +/- 2.1 cm H2O during expiratory washout and by 7.3 +/- 1.3 cm H2O during the combination of the two modes, whereas it remained unchanged during optimized mechanical ventilation alone. In conclusion, increasing respiratory rate and reducing instrumental dead space during conventional mechanical ventilation is as efficient as expiratory washout to reduce PaCO2 in patients with severe ARDS and permissive hypercapnia. When used in combination, both techniques have additive effects and result in PaCO2 levels close to normal values.

A simple automated method for measuring pressure-volume curves during mechanical ventilation.

Measurement of respiratory compliance is advocated for assessing the severity of acute respiratory failure (ARF). Recently, the administration of an automated constant flow of 15 L/min was proposed as a method easier to implement at the bedside than supersyringe or inspiratory occlusions methods. However, pressure-volume (P-V) curves were shifted to the right because of the resistive properties of the respiratory system. The aim of this study was to compare the P-V curves obtained using two constant flows-3 and 9 L/min-during volume-controlled mechanical ventilation with those obtained with the supersyringe and the inspiratory occlusions methods. Fourteen paralyzed patients with ARF were studied. The supersyringe and the inspiratory occlusions methods were performed according to usual recommendations. The new automated method was performed during volume-controlled mechanical ventilation by setting the inspiratory:expiratory ratio at 80%, the respiratory frequency at 5 breaths/min, and the tidal volume at 500 or 1,500 ml. These peculiar ventilatory settings were equivalent to administering a constant flow of 3 or 9 L/min during a 9.6-s inspiration. Esophageal and airway pressures were recorded. P-V curves obtained by the 3-L/min constant-flow method were identical to those obtained by the reference methods, whereas the P-V curve obtained by the 9-L/min constant flow was slightly shifted to the right. The slopes of the P-V curves and the lower inflection points were not different between all methods, indicating that the resistive component induced by administering a constant flow equal to or less than 9 L/min is not of clinical relevance. Because the 3-L/min constant-flow method is not artifacted by the resistive properties of the respiratory system and does not require any other equipment than a ventilator, it is an easy-to-implement, inexpensive, safe, and reliable method for measuring the thoracopulmonary P-V curve at the bedside.

Permissive hypercapnia with and without expiratory washout in patients with severe acute respiratory distress syndrome.

BACKGROUND: Permissive hypercapnia is a ventilatory strategy aimed at avoiding lung volutrauma in patients with severe acute respiratory distress syndrome (ARDS). Expiratory washout (EWO) is a modality of tracheal gas insufflation that enhances carbon dioxide removal during mechanical ventilation by reducing dead space. The goal of this prospective study was to determine the efficacy of EWO in reducing the partial pressure of carbon dioxide (PaCO2) in patients with severe ARDS treated using permissive hypercapnia. METHODS: Seven critically ill patients with severe ARDS (lung injury severity score, 3.1 +/- 0.3) and no contraindications for permissive hypercapnia were studied. On the first day, hemodynamic and respiratory parameters were measured and the extent of lung hyperdensities was assessed using computed tomography. A positive end-expiratory pressure equal to the opening pressure identified on the pressure-volume curve was applied. Tidal volume was reduced until a plateau airway pressure of 25 cm H2O was reached. On the second day, after implementation of permissive hypercapnia, EWO was instituted at a flow of 15 l/min administered during the entire expiratory phase into the trachea through the proximal channel of an endotracheal tube using a ventilator equipped with a special flow generator. Cardiorespiratory parameters were studied under three conditions: permissive hypercapnia, permissive hypercapnia with EWO, and permissive hypercapnia. RESULTS: During permissive hypercapnia, EWO decreased PaCO2 from 76 +/- 4 mmHg to 53 +/- 3 mmHg (-30%; P < 0.0001), increased pH from 7.20 +/- 0.03 to 7.34 +/- 0.04 (P < 0.0001), and increased PaO2 from 205 +/- 28 to 296 +/- 38 mmHg (P < 0.05). The reduction in PaCO2 was accompanied by an increase in end-inspiratory plateau pressure from 26 +/- 1 to 32 +/- 2 cm H2O (P = 0.001). Expiratory washout also decreased cardiac index from 4.6 +/- 0.4 to 3.7 +/- 0.3 l.min-1.m-2 (P < 0.01), mean pulmonary arterial pressure from 28 +/- 2 to 25 +/- 2 mmHg (P < 0.01), and true pulmonary shunt from 47 +/- 2 to 36 +/- 3% (P < 0.01). CONCLUSIONS: Expiratory washout is an effective and easy-to-use ventilatory modality to reduce PaCO2 and increase pH during permissive hypercapnia. However, it significantly increases airway pressures and lung volume through expiratory flow limitation, reexposing some patients to a risk of lung volutrauma if the extrinsic positive end-expiratory pressure is not substantially reduced.

Accessory soleus muscle. Two case-reports, with a review of the literature.

The accessory soleus muscle is a supernumerary leg muscle that is rare and usually clinically silent. The best diagnostic strategy is not agreed on. We report two cases in which magnetic resonance imaging contributed significantly to the diagnosis and to the pretreatment evaluation.

Fusidic acid induced acute immunologic thrombocytopenia.

Fusidic acid is used in hospitals as second-line therapy for multidrug-resistant staphylococcal infections. We report the first fully documented case of fusidic acid induced thrombocytopenia, in a 48-year-old patient. The thrombocytopenia was abrupt and severe but resolved spontaneously 7 d after drug withdrawal. The thrombocytopenia transiently relapsed 6 d later, when fusidic acid was reintroduced. Haemorrhagic signs were observed, but no severe bleeding occurred. Platelet transfusions failed to increase the platelet count. We detected an IgG platelet antibody in the patient's serum, that specifically recognized platelet glycoprotein IIb/IIIa only in the presence of fusidic acid. Fusidic acid induced thrombocytopenia should be considered as a possible cause for the thrombocytopenia frequently seen in the intensive care setting.

Determinants of systolic pressure variation in patients ventilated after vascular surgery.

OBJECTIVE: To discover the predominant determinant of systolic pressure variation during positive-pressure ventilation in mechanically ventilated patients after a vascular surgical procedure. DESIGN: Case control study. SETTING: Postanesthesia care unit at a university hospital. PARTICIPANTS: Eleven patients who were sedated during mechanical ventilation after abdominal aortic surgery. INTERVENTIONS: Radial arterial pressure and airway pressure were simultaneously recorded. The systolic pressure variation was measured as the mean difference between the maximal and minimal systolic pressure values during five consecutive mechanical breaths. The delta down was measured as the difference between the systolic blood pressure during apnea and the minimal values of the systolic pressure after one mechanical breath. The velocity time integral, which is closely related to stroke volume, was measured throughout the systolic pressure measurements. MEASUREMENTS AND MAIN RESULTS: Positive correlation was found between changes in velocity time integral and the magnitude of both systolic pressure variation (r = 0.73) and delta down (r = 0.80). Volume loading did not significantly modify systolic blood pressure. However, it did not significantly decrease systolic pressure variation and delta down. The corresponding changes in velocity time integral provoked by mechanical ventilation decreased significantly as well. CONCLUSIONS: The decrease in systolic pressure provoked by positive-pressure inspiration reflects simultaneous decreases in stroke volume. This suggests that a decrease in left ventricular filling, associated with positive-pressure inspiration, is responsible for systolic pressure variation. This finding confirms the interest in considering systolic pressure variation to provide reliable information about the responsiveness of the heart to preload variations.

Cardiovascular consequences of severe hypophosphataemia in brain-dead patients.

Hypophosphataemia is known to induce reversible myocardial dysfunction, but the incidence of hypophosphataemia and its effect on myocardial function during brain death are unknown. In 90 consecutive brain-dead patients, we measured plasma concentrations of phosphate and left ventricular ejection fraction area (LVEFa), using transoesophageal echocardiography. In 15 severely hypophosphataemic (< 0.40 mmol litre-1), consecutive, brain-dead patients, haemodynamic status, LVEFa, and oxygen delivery and consumption were assessed before and after phosphorus loading (0.30 mmol kg-1). In 10 other brain-dead patients, urine elimination of phosphates was measured. Only 30 (33%) brain-dead patients had normal plasma phosphate concentrations, 22 (24%) had mild hypophosphataemia (0.40-0.80 mmol litre-1) and 38 (42%) had severe hypophosphataemia (< 0.40 mmol litre-1). There were no significant differences in LVEFa between these three groups (mean 53 (SD 16), 55 (12) and 51 (17)%, respectively) and no significant correlation between LVEFa and plasma phosphate concentration (r = 0.04). In 15 severely hypophosphataemic patients, phosphorus loading increased plasma phosphate concentration from 0.30 (0.10) to 1.06 (0.41) mmol litre-1, but did not modify haemodynamic status, LVEFa or oxygen delivery and consumption. In 10 other patients, urine phosphorus elimination was 16.8 (23.3) mmol/24 h while plasma phosphate concentration was at its highest level (0.80 (0.37) mmol litre-1), and only one of these patient had a slightly elevated phosphaturia. In conclusion, hypophosphataemia frequently occurs after brain death but has no significant cardiovascular consequences, suggesting that it is related to intracellular transfer and not phosphorus depletion.(ABSTRACT TRUNCATED AT 250 WORDS)

[Cell-mediated immunity in antibiotic therapy]. / Etude de l'immunité à médiation cellulaire au cours de l'antibiothérapie.

Should antibiotic therapy required in the treatment of acute infection be administered frequently in patients at risk with clinical conditions involving recurrent superinfection? The results of our ongoing investigations initiated in 1967 and the present study indicate that macrolides, particularly erythromycin depress the host defense system. In contrast in a study performed in subjects treated for 8 days using cell-immunity tests, we found that cefaclor and amoxicillin may have an enhancing effect on host defenses.

[Identification of common antigens of Phleum pollen and wheat. Preliminary study]. / Identification des antigènes communs pollen de phléole (Ph) et blé (B). Etude préliminaire.

The typing of common Phleol Pollen and wheat Antigen has been realized with these Antigens Fractions from PASTEUR Institute using FPLC PHARMACIA Chromatograph. The discover of commun Antigen has been obtained with RAST Inhibition technic. It exist common Antigen fractions between phleol and wheat, but no between wheat an phleol. The results are in favor of less allergic quality of wheat.