1
|
Allena N, Khanal S, Jog A, Duran MJ, Paulino S, Bojja S, Soliman M. Decoding the Chronic Obstructive Pulmonary Disease (COPD) Puzzle: Investigating the Significance of Exacerbation Scores in Triage Decision-Making. Cureus 2023; 15:e41975. [PMID: 37593292 PMCID: PMC10427510 DOI: 10.7759/cureus.41975] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/16/2023] [Indexed: 08/19/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a complex disease pathology of the lungs that has a significant impact on global health. It has been a major contributor to global mortality and morbidity, with COPD exacerbations posing a substantial economic burden on the healthcare systems. Appropriate triaging of patients with COPD exacerbation is crucial to reduce the burden of hospitalization, especially in the intensive care unit (ICU). Understanding the significance of exacerbation scores in triage decision-making is essential for improving outcomes and optimizing patient care. To aid this triage decision-making, several scoring systems have been developed. This review article aims to discuss the different scores, including assessment of Confusion, Urea, Respiratory rate, Blood pressure, and Age (≥65 years) (CURB-65); Dyspnoea, Eosinopenia, Consolidation, Acidaemia and atrial Fibrillation (DECAF), Neutrophil to lymphocyte ratio (NLR); Platelet-lymphocyte ratio (PLR); Pneumonia severity index/Pneumonia Patient Outcomes Research Team (PSI/PORT); and elevated BUN, Altered mental status, Pulse, Age (>65 years) (BAP-65), and their role in triaging COPD exacerbations. Proper triaging allows for the appropriate allocation of resources and timely interventions based on severity. Further research and validation are needed to establish the optimal use and integration of these scores in clinical practice, particularly in ICU settings.
Collapse
Affiliation(s)
| | - Sneha Khanal
- Internal Medicine, BronxCare Health System, Bronx, USA
| | - Abhishrut Jog
- Pulmonary Medicine, BronxCare Health System, Bronx, USA
| | - Maria J Duran
- Internal Medicine, Bronx Care Health System, Bronx, USA
| | | | | | - Maryam Soliman
- Pulmonary and Critical Care Medicine, BronxCare Health System, Bronx, USA
| |
Collapse
|
2
|
Burghi G, Metaxa V, Pickkers P, Soares M, Rello J, Bauer PR, van de Louw A, Taccone FS, Loeches IM, Schellongowski P, Rusinova K, Antonelli M, Kouatchet A, Barratt-Due A, Valkonen M, Pène F, Mokart D, Jaber S, Azoulay E, De Jong A. End of life decisions in immunocompromised patients with acute respiratory failure. J Crit Care 2022; 72:154152. [PMID: 36137351 DOI: 10.1016/j.jcrc.2022.154152] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/29/2022] [Revised: 08/23/2022] [Accepted: 09/05/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To identify patient, disease and organizational factors associated with decisions to forgo life-sustaining therapies (DFLSTs) in critically ill immunocompromised patients admitted to the intensive care unit (ICU) for acute respiratory failure. MATERIAL AND METHODS We performed a secondary analysis of the international EFRAIM prospective study, which enrolled 1611 immunocompromised patients with acute respiratory failure admitted to 68 ICUs in 16 countries between October 2015 and June 2016. Multivariate logistic analysis was performed to identify independent predictors of DFLSTs. RESULTS The main causes of immunosuppression were hematological malignancies (50%) and solid tumor (38%). Patients had a median age of 63 yo (54-71). A pulmonologist was involved in the patient management in 38% of cases. DFLSTs had been implemented in 28% of the patients. The following variables were independently associated with DFLSTs: 1) patient-related: older age (OR 1.02 per one year increase, 95% confidence interval(CI) 1.01-1.03,P < 0.001), poor performance status (OR 2.79, 95% CI 1.98-3.93, P < 0.001); 2) disease-related: shock (OR 2.00, 95% CI 1.45-2.75, P < 0.001), liver failure (OR 1.59, 95% CI 1.14-2.21, P = 0.006), invasive mechanical ventilation (OR 1.79, 95% CI 1.31-2.46, P < 0.001); 3) organizational: having a pulmonologist involved in patient management (OR 1.85, 95% CI 1.36-2.52, P < 0.001), and the presence of a critical care outreach services (OR 1.63, 95% CI 1.11-2.38, P = 0.012). CONCLUSIONS A DFLST is made in one in four immunocompromised patient admitted to the ICU for acute respiratory failure. Involving a pulmonologist in patient's management is associated with less non beneficial care.
Collapse
Affiliation(s)
- Gaston Burghi
- Terapia Intensiva, Hospital Maciel - Montevideo, Uruguay
| | | | - Peter Pickkers
- The Department of Intensive Care Medicine (710), Radboud University Medical Centre, Nijmegen, the Netherlands
| | - Marcio Soares
- Terapia Intensiva, Hospital Maciel - Montevideo, Uruguay
| | - Jordi Rello
- CIBERES, Universitat Autonòma de Barcelona, European Study Group of Infections in Critically Ill Patients (ESGCIP), Barcelona, Spain
| | - Philippe R Bauer
- Pulmonary and Critical Care Medicine, Mayo Clinic, Rochester, MN, USA
| | - Andry van de Louw
- Penn State University College of Medicine, Division of Pulmonary and Critical Care, Hershey, PA, USA
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - Ignacio Martin Loeches
- Department of Intensive Care Medicine, Multidisciplinary Intensive Care Research Organization (MICRO), St. James's Hospital, Dublin, Ireland
| | | | - Katerina Rusinova
- Department of Anesthesiology and Intensive Care Medicine and Institute for Medical Humanities, 1st Faculty of Medicine, Charles University in Prague and General University Hospital, Prague, Czech Republic
| | - Massimo Antonelli
- Agostino Gemelli University Hospital, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Achille Kouatchet
- Department of Medical Intensive Care Medicine, University Hospital of Angers, France
| | - Andreas Barratt-Due
- Department of Emergencies and Critical Care, Oslo University Hospital, Oslo, Norway
| | - Miia Valkonen
- Division of Intensive Care Medicine, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki 00014, Finland
| | - Frédéric Pène
- Medical ICU, Cochin Hospital, Assistance Publique-Hôpitaux de Paris and University Paris Descartes, Paris, France
| | - Djamel Mokart
- Réanimation Polyvalente et Département d'Anesthésie et de Réanimation, Institut Paoli-Calmettes, Marseille, France
| | - Samir Jaber
- Department of Anesthesia and Intensive Care unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, Phymedexp, Université de Montpellier, Inserm, CNRS, CHRU de Montpellier, Montpellier, France
| | - Elie Azoulay
- Medical Intensive Care Unit, Hôpital Saint-Louis and Paris Diderot Sorbonne University, 1 avenue Claude Vellefaux, cedex 10 75475, Paris
| | - Audrey De Jong
- Department of Anesthesia and Intensive Care unit, Regional University Hospital of Montpellier, St-Eloi Hospital, University of Montpellier, Phymedexp, Université de Montpellier, Inserm, CNRS, CHRU de Montpellier, Montpellier, France.
| | | |
Collapse
|
3
|
Serresse L, Guerder A, Dedonder J, Nion N, Lavault S, Morélot-Panzini C, Gonzalez-Bermejo J, Benoit L, Similowski T. 'You can't feel what we feel': Multifaceted dyspnoea invisibility in advanced chronic obstructive pulmonary disease examined through interpretative phenomenological analysis. Palliat Med 2022; 36:1364-1373. [PMID: 36154535 DOI: 10.1177/02692163221118198] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND More than a symptom, dyspnoea is an existential experience shaping the lives of those afflicted, particularly when its persistence despite maximal pathophysiological treatments makes it pervasive. It is, however, insufficiently appreciated by concerned people themselves, family members, healthcare professionals and the public (dyspnoea invisibility), limiting access to appropriate care and support. AIM To provide a better understanding of dyspnoea experiences and its invisibility. DESIGN Interpretative phenomenological analysis of data collected prospectively through in-depth semi-structured interviews. SETTING/PARTICIPANTS Pulmonary rehabilitation facility of a tertiary care university hospital; 11 people (six men, five women) with severe chronic obstructive pulmonary disease (stages 3 and 4 of the 4-stage international GOLD classification) admitted for immediate post-exacerbation rehabilitation. RESULTS We identified several types of dyspnoea invisibility depending on temporality and interlocutors: (1) invisibility as a symptom to oneself; (2) invisibility as a symptom to others; (3) invisibility as an experience that cannot be shared; (4) invisibility as an experience detached from objective measurements; (5) invisibility as an experience that does not generate empathic concern. The notion of invisibility was present in all the identified experiential dimensions of dyspnoea. It was seen as worsening the burden of the disease and as self-aggravating through self-isolation and self-censorship. CONCLUSIONS The study confirmed that dyspnoea invisibility is a reality for people with advanced chronic obstructive pulmonary disease. It shows dyspnoea invisibility to be a multifaceted burden. Future research should aim at identifying individual and collective measures to overcome dyspnoea invisibility.
Collapse
Affiliation(s)
- Laure Serresse
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, Fédération 'Soins Palliatifs, Accompagnement et Soins de Support', Paris, France.,Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France
| | - Antoine Guerder
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Soins de Suite et de Réadaptation Respiratoire, Département R3S, Paris, France
| | - Jonathan Dedonder
- Institute for the Analysis of Change in Contemporary and Historical Societies (IACCHOS), Université Catholique de Louvain, Louvain-La-Neuve, Belgium
| | - Nathalie Nion
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département R3S, Paris, France
| | - Sophie Lavault
- AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département R3S, Paris, France
| | - Capucine Morélot-Panzini
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Pneumologie, Département R3S, Paris, France
| | - Jésus Gonzalez-Bermejo
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Service de Soins de Suite et de Réadaptation Respiratoire, Département R3S, Paris, France
| | - Laelia Benoit
- Yale School of Medicine, Child Study Center, QUALab qualitative and mixed methods lab, New Haven, CT, USA.,Inserm U1018, Team DevPsy, Maison de Solenn, Hôpital Cochin, AP-HP, Paris, France
| | - Thomas Similowski
- Sorbonne Université, INSERM, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,AP-HP, Groupe Hospitalier Universitaire APHP-Sorbonne Université, site Pitié-Salpêtrière, Département R3S, Paris, France
| |
Collapse
|
4
|
Epidemiology and outcome of pressure injuries in critically ill patients with chronic obstructive pulmonary disease: A propensity score adjusted analysis. Int J Nurs Stud 2022; 129:104222. [PMID: 35344836 DOI: 10.1016/j.ijnurstu.2022.104222] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2021] [Revised: 02/28/2022] [Accepted: 03/01/2022] [Indexed: 02/02/2023]
Abstract
BACKGROUND Pressure injuries are a frequent complication in intensive care unit (ICU) patients, especially in those with comorbid conditions such as chronic obstructive pulmonary disease (COPD). Yet no epidemiological data on pressure injuries in critically ill COPD patients are available. OBJECTIVE To assess the prevalence of ICU-acquired pressure injuries in critically ill COPD patients and to investigate associations between COPD status, presence of ICU-acquired pressure injury, and mortality. STUDY DESIGN AND METHODS This is a secondary analysis of prospectively collected data from DecubICUs, a multinational one-day point-prevalence study of pressure injuries in adult ICU patients. We generated a propensity score summarizing risk for COPD and ICU-acquired pressure injury. The propensity score was used as matching criterion (1:1-ratio) to assess the proportion of ICU-acquired pressure injury attributable to COPD. The propensity score was then used in regression modeling assessing the association of COPD with risk of ICU-acquired pressure injury, and examining variables associated with mortality (Cox proportional-hazard regression). RESULTS Of the 13,254 patients recruited to DecubICUs, 1663 (12.5%) had documented COPD. ICU-acquired pressure injury prevalence was higher in COPD patients: 22.1% (95% confidence interval [CI] 20.2 to 24.2) vs. 15.3% (95% CI 14.7 to 16.0). COPD was independently associated with developing ICU-acquired pressure injury (odds ratio 1.40, 95% CI 1.23 to 1.61); the proportion attributable to COPD was 6.4% (95% CI 5.2 to 7.6). Compared with non-COPD patients without pressure injury, mortality was no different among patients without COPD but with pressure injury (hazard ratio [HR] 1.07, 95% CI 0.97 to 1.17) or COPD patients without pressure injury (HR 1.13, 95% CI 1.00 to 1.27). Mortality was higher among COPD patients with pressure injury (HR 1.35, 95% CI 1.15 to 1.58). CONCLUSION AND IMPLICATIONS Critically ill COPD patients have a statistically significant higher risk of pressure injury. Moreover, those that develop pressure injury are at higher risk of mortality. As such, pressure injury may serve as a surrogate for poor prognostic status to help clinicians identify patients at high risk of death. Also, delivery of interventions to prevent pressure injury are paramount in critically ill COPD patients. Further studies should determine if early intervention in critically ill COPD patients can modify development of pressure injury and improve prognosis.
Collapse
|
5
|
Bassford C, Griffiths F, Svantesson M, Ryan M, Krucien N, Dale J, Rees S, Rees K, Ignatowicz A, Parsons H, Flowers N, Fritz Z, Perkins G, Quinton S, Symons S, White C, Huang H, Turner J, Brooke M, McCreedy A, Blake C, Slowther A. Developing an intervention around referral and admissions to intensive care: a mixed-methods study. HEALTH SERVICES AND DELIVERY RESEARCH 2019. [DOI: 10.3310/hsdr07390] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
BackgroundIntensive care treatment can be life-saving, but it is invasive and distressing for patients receiving it and it is not always successful. Deciding whether or not a patient will benefit from intensive care is a difficult clinical and ethical challenge.ObjectivesTo explore the decision-making process for referral and admission to the intensive care unit and to develop and test an intervention to improve it.MethodsA mixed-methods study comprising (1) two systematic reviews investigating the factors associated with decisions to admit patients to the intensive care unit and the experiences of clinicians, patients and families; (2) observation of decisions and interviews with intensive care unit doctors, referring doctors, and patients and families in six NHS trusts in the Midlands, UK; (3) a choice experiment survey distributed to UK intensive care unit consultants and critical care outreach nurses, eliciting their preferences for factors used in decision-making for intensive care unit admission; (4) development of a decision-support intervention informed by the previous work streams, including an ethical framework for decision-making and supporting referral and decision-support forms and patient and family information leaflets. Implementation feasibility was tested in three NHS trusts; (5) development and testing of a tool to evaluate the ethical quality of decision-making related to intensive care unit admission, based on the assessment of patient records. The tool was tested for inter-rater and intersite reliability in 120 patient records.ResultsInfluences on decision-making identified in the systematic review and ethnographic study included age, presence of chronic illness, functional status, presence of a do not attempt cardiopulmonary resuscitation order, referring specialty, referrer seniority and intensive care unit bed availability. Intensive care unit doctors used a gestalt assessment of the patient when making decisions. The choice experiment showed that age was the most important factor in consultants’ and critical care outreach nurses’ preferences for admission. The ethnographic study illuminated the complexity of the decision-making process, and the importance of interprofessional relationships and good communication between teams and with patients and families. Doctors found it difficult to articulate and balance the benefits and burdens of intensive care unit treatment for a patient. There was low uptake of the decision-support intervention, although doctors who used it noted that it improved articulation of reasons for decisions and communication with patients.LimitationsLimitations existed in each of the component studies; for example, we had difficulty recruiting patients and families in our qualitative work. However, the project benefited from a mixed-method approach that mitigated the potential limitations of the component studies.ConclusionsDecision-making surrounding referral and admission to the intensive care unit is complex. This study has provided evidence and resources to help clinicians and organisations aiming to improve the decision-making for and, ultimately, the care of critically ill patients.Future workFurther research is needed into decision-making practices, particularly in how best to engage with patients and families during the decision process. The development and evaluation of training for clinicians involved in these decisions should be a priority for future work.Study registrationThe systematic reviews of this study are registered as PROSPERO CRD42016039054, CRD42015019711 and CRD42015019714.FundingThe National Institute for Health Research Health Services and Delivery Research programme. The University of Aberdeen and the Chief Scientist Office of the Scottish Government Health and Social Care Directorates fund the Health Economics Research Unit.
Collapse
Affiliation(s)
- Chris Bassford
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Anaesthesia, Critical Care and Pain, University Hospitals Coventry and Warwickshire NHS Trust, Coventry, UK
| | | | - Mia Svantesson
- University Health Care Research Center, Faculty of Medicine and Health, Örebro University, Örebro, Sweden
| | - Mandy Ryan
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Nicolas Krucien
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | - Jeremy Dale
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Sophie Rees
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Karen Rees
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Agnieszka Ignatowicz
- Warwick Medical School, University of Warwick, Coventry, UK
- Institute of Applied Health Research, College of Medical and Dental Sciences, University of Birmingham, Birmingham, UK
| | - Helen Parsons
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Nadine Flowers
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Zoe Fritz
- Warwick Medical School, University of Warwick, Coventry, UK
- Department of Acute Medicine, Cambridge University Hospitals NHS Trust, Cambridge, UK
- The Healthcare Improvement Studies (THIS) Institute, University of Cambridge, Cambridge, UK
| | - Gavin Perkins
- Warwick Medical School, University of Warwick, Coventry, UK
- Heartlands Hospital, University Hospitals Birmingham, Birmingham, UK
| | - Sarah Quinton
- Warwick Medical School, University of Warwick, Coventry, UK
- Health Economics Research Unit, Institute of Applied Health Sciences, University of Aberdeen, Aberdeen, UK
| | | | | | - Huayi Huang
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Jake Turner
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Mike Brooke
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Aimee McCreedy
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Caroline Blake
- Warwick Medical School, University of Warwick, Coventry, UK
| | - Anne Slowther
- Warwick Medical School, University of Warwick, Coventry, UK
| |
Collapse
|
6
|
Alkarn AF, Abdelghany MF, Khalaf MGA, Kamel EZ, Gadalla WAH. Effects of sedation on clinical, gasometric, and respiratory muscle parameters in critically ill chronic obstructive pulmonary disease patients. THE EGYPTIAN JOURNAL OF BRONCHOLOGY 2019. [DOI: 10.4103/ejb.ejb_79_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022] Open
|
7
|
Koulenti D, Parisella FR, Xu E, Lipman J, Rello J. The relationship between ventilator-associated pneumonia and chronic obstructive pulmonary disease: what is the current evidence? Eur J Clin Microbiol Infect Dis 2019; 38:637-647. [PMID: 30680576 DOI: 10.1007/s10096-019-03486-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2018] [Accepted: 01/10/2019] [Indexed: 02/06/2023]
Abstract
Chronic obstructive pulmonary disease (COPD) affects approximately 65 million people from which > 25% will require intensive care unit (ICU) admission. Ventilator-associated pneumonia (VAP) is the commonest ICU infection and results in increased morbidity/mortality and costs. The literature on the interaction between COPD and VAP is scarce and controversial. The project aimed to search the literature in order to address the following: (i) Is COPD a risk factor for VAP development? (ii) Does COPD impact the outcome of patients with VAP? (iii) Does VAP development impact the outcome of COPD patients? (iv) Does COPD impact the aetiology of VAP? Current evidence on the topic is controversial. Regarding the impact of VAP on COPD patients, the majority of the existing limited number of studies suggests that VAP development results in higher mortality and longer duration of mechanical ventilation and ICU stay. Also, the majority of the studies exploring the impact of COPD on VAP outcomes suggest that COPD is independently associated with a decrease in survival, although the number of such studies is limited. Regarding the aetiology, Pseudomonas aeruginosa is the most frequent pathogen in VAP patients with COPD. Noteworthy, one study suggests that P. aeruginosa is higher in COPD patients even in the early-onset VAP subgroup. This manuscript provides a comprehensive overview of the available literature on the interaction between COPD and VAP, highlighting the differences and limitations that may have led to controversial results, and it may act as a platform for further research with important clinical implications.
Collapse
Affiliation(s)
- Despoina Koulenti
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Royal Brisbane Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- 2nd Critical Care Department, Attikon University Hospital, Athens, Greece
| | - Francesca Romana Parisella
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia.
| | - Elena Xu
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
| | - Jeffrey Lipman
- UQ Centre for Clinical Research, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Royal Brisbane Clinical Unit, Faculty of Medicine, The University of Queensland, Brisbane, Australia
- Department of Intensive Care Medicine, Royal Brisbane and Women's Hospital, Brisbane, Australia
| | - Jordi Rello
- Vall d'Hebron Institute of Research (VHIR) & CIBERES, Instituto Salud Carlos III, Barcelona, Spain
| |
Collapse
|
8
|
Dupuis-Lozeron E, Soccal PM, Janssens JP, Similowski T, Adler D. Severe Dyspnea Is an Independent Predictor of Readmission or Death in COPD Patients Surviving Acute Hypercapnic Respiratory Failure in the ICU. Front Med (Lausanne) 2018; 5:163. [PMID: 29896476 PMCID: PMC5987049 DOI: 10.3389/fmed.2018.00163] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/20/2018] [Accepted: 05/08/2018] [Indexed: 11/13/2022] Open
Abstract
Background: Predicting outcome after index admission in the ICU for COPD-related acute hypercapnic respiratory failure (AHRF) is difficult. Simple tools to stratify this risk and to promote interventions to mitigate it are needed. Aim: To prospectively evaluate the ability of severe dyspnea (NYHAIII-IV) to predict hospital readmission or death in COPD patients surviving AHRF in the ICU. Methods: 50 consecutive COPD patients were recruited from a larger cohort of patients (n = 78) surviving AHRF in the ICU. All predictive variables were collected within 15 days after resolution of respiratory failure before hospital discharge. COPD was diagnosed by spirometry. Heart failure was diagnosed with clinical rules and echocardiography. NYHA was measured upon hospital discharge. Hospital readmission and death were recorded at regular intervals for 3 months. Results: 21/50 (42%) COPD patients died or were readmitted to the hospital during the observation period: 12 out of the 20 NYHA III-IV patients (60%) and 8 out of the 28 NYHA I-II patients (29%). NYHA III-IV was associated with risk of readmission or death (univariate HR: 2.73, IC95: 1.11-6.69, p = 0.028). After controlling for age, FEV1, heart failure and BMI, NYHA III-IV remained associated with readmission or death (multivariate HR: 2.71, IC95: 1.06-6.93, p = 0.038). Conclusions: Our findings suggest that severe dyspnea measured upon hospital discharge in COPD patients surviving AHRF can stratify patient's risk of 3-month readmission or death.
Collapse
Affiliation(s)
- Elise Dupuis-Lozeron
- Division of Clinical Epidemiology, Geneva University Hospitals, Geneva, Switzerland
| | - Paola M Soccal
- Division of Pulmonary Diseases, Geneva University Hospitals, Geneva, Switzerland.,Department of Internal Medicine Specialties, Geneva Medical School, Geneva, Switzerland
| | - Jean-Paul Janssens
- Division of Pulmonary Diseases, Geneva University Hospitals, Geneva, Switzerland.,Department of Internal Medicine Specialties, Geneva Medical School, Geneva, Switzerland
| | - Thomas Similowski
- Sorbonne Universités, UPMC Université Paris 06, Institut National de la Santé et de la Recherche Médicale, UMRS1158 Neurophysiologie Respiratoire Expérimentale et Clinique, Paris, France.,AP-HP, Groupe Hospitalier Pitié-Salpêtrière Charles Foix, Service de Pneumologie et Réanimation Médicale (Département "R3S"), Paris, France
| | - Dan Adler
- Division of Pulmonary Diseases, Geneva University Hospitals, Geneva, Switzerland.,Department of Internal Medicine Specialties, Geneva Medical School, Geneva, Switzerland
| |
Collapse
|
9
|
Laryionava K, Pfeil TA, Dietrich M, Reiter-Theil S, Hiddemann W, Winkler EC. The second patient? Family members of cancer patients and their role in end-of-life decision making. BMC Palliat Care 2018; 17:29. [PMID: 29454337 PMCID: PMC5816525 DOI: 10.1186/s12904-018-0288-2] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/05/2017] [Accepted: 02/09/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Family members are important companions of severely ill patients with cancer. However, studies about the desirability and difficulties of integrating relatives in the decision-making process are rare in oncology. This qualitative study explores the family role in decisions to limit treatment near the end of life from the professionals' point of view. METHODS Qualitative in-depth interviews were conducted with oncologists (n = 12) and nurses (n = 6) working at the Department of Hematology/Oncology at the University Hospital in Munich, Germany. The data were analyzed using a descriptive qualitative methodology and discussed from a medical ethics perspective. RESULTS Four major themes played a central role in the perception of the medical staff in regard to family members. (1) Family impact on patients' treatment preferences. (2) Strong family wish for further treatment. (3) Emotional distress of the family related to the involvement in end-of-life decision-making. (4) Importance of knowing family structures. CONCLUSIONS The important role of the family members in patients' disease process is recognized by oncologists and oncology nurses. However, this does not seem to lead to an early involvement of the family members. Developing and establishing a systematic assessment of family members' needs and wishes in order to provide a specific-tailored support should become a priority for interdisciplinary clinical research in the near future.
Collapse
Affiliation(s)
- Katsiaryna Laryionava
- National Center for Tumor Diseases, Department of Medical Oncology, Programme for Ethics and Patient-Oriented Care in Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
| | - Timo A Pfeil
- Department of Internal Medicine III (Haematology and Oncology), University Hospital Grosshadern, Munich, Germany
| | - Mareike Dietrich
- National Center for Tumor Diseases, Department of Medical Oncology, Programme for Ethics and Patient-Oriented Care in Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany
| | - Stella Reiter-Theil
- Department Clinical Ethics, Psychiatric Hospitals of the University Basel, University Hospital Basel, University of Basel, Basel, Switzerland
| | - Wolfgang Hiddemann
- Department of Internal Medicine III (Haematology and Oncology), University Hospital Grosshadern, Munich, Germany
| | - Eva C Winkler
- National Center for Tumor Diseases, Department of Medical Oncology, Programme for Ethics and Patient-Oriented Care in Oncology, Heidelberg University Hospital, Im Neuenheimer Feld 460, 69120, Heidelberg, Germany.
| |
Collapse
|
10
|
Nassar AP, Dettino ALA, Amendola CP, Dos Santos RA, Forte DN, Caruso P. Oncologists' and Intensivists' Attitudes Toward the Care of Critically Ill Patients with Cancer. J Intensive Care Med 2017; 34:811-817. [PMID: 28675982 DOI: 10.1177/0885066617716105] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
BACKGROUND Patients with cancer represent an important proportion of intensive care unit (ICU) admissions. Oncologists and intensivists have distinct knowledge backgrounds, and conflicts about the appropriate management of these patients may emerge. METHODS We surveyed oncologists and intensivists at 2 academic cancer centers regarding their management of 2 hypothetical patients with different cancer types (metastatic pancreatic cancer and metastatic breast cancer with positive receptors for estrogen, progesterone, and HER-2) who develop septic shock and multiple organ failure. RESULTS Sixty intensivists and 46 oncologists responded to the survey. Oncologists and intensivists similarly favored withdrawal of life support measures for the patient with pancreatic cancer (33/46 [72%] vs 48/60 [80%], P = .45). On the other hand, intensivists favored more withdrawal of life support measures for the patient with breast cancer compared to oncologists (32/59 [54%] vs 9/44 [21%], P < .001). In the multinomial logistic regression, the oncology specialists were more likely to advocate for a full-code status for the patient with breast cancer (OR = 5.931; CI 95%, 1.762-19.956; P = .004). CONCLUSIONS Oncologists and intensivists share different views regarding life support measures in critically ill patients with cancer. Oncologists tend to focus on the cancer characteristics, whereas intensivists focus on multiple organ failure when weighing in on the same decisions. Regular meetings between oncologists and intensivists may reduce possible conflicts regarding the critical care of patients with cancer.
Collapse
Affiliation(s)
- Antonio Paulo Nassar
- 1 Intensive Care Unit, A.C. Camargo Cancer Center, São Paulo, Brazil.,2 Intensive Care Unit, Discipline of Medical Emergencies, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil
| | | | | | - Rodrigo Alves Dos Santos
- 4 Intensive Care Unit, Pio XII Foundation, Barretos Cancer Hospital, Barretos, Brazil.,5 Barretos School of Health Sciences, Barretos, Brazil
| | - Daniel Neves Forte
- 2 Intensive Care Unit, Discipline of Medical Emergencies, Hospital das Clínicas, University of São Paulo, São Paulo, Brazil.,6 Department of Palliative Care, Hospital Sírio Libanês, São Paulo, Brazil
| | - Pedro Caruso
- 1 Intensive Care Unit, A.C. Camargo Cancer Center, São Paulo, Brazil.,7 Pulmonary Division, Heart Institute (InCor), Hospital das Clínicas, Faculdade de Medicina da Universidade de São Paulo, São Paulo, Brazil
| |
Collapse
|
11
|
[Management of inpatients with acute COPD exacerbation. When to indicate mechanical ventilation?]. Rev Mal Respir 2017; 34:439-449. [PMID: 28502366 DOI: 10.1016/j.rmr.2017.03.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
|
12
|
Kang Y. Is It Essential to Consider Respiratory Dynamics? Korean J Crit Care Med 2017; 32:223-224. [PMID: 31723638 PMCID: PMC6786716 DOI: 10.4266/kjccm.2017.00276] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Youngjoon Kang
- Department of Emergency Medicine, Jeju National University Hospital, Jeju, Korea
| |
Collapse
|
13
|
Tavares N, Jarrett N, Hunt K, Wilkinson T. Palliative and end-of-life care conversations in COPD: a systematic literature review. ERJ Open Res 2017; 3:00068-2016. [PMID: 28462236 PMCID: PMC5407435 DOI: 10.1183/23120541.00068-2016] [Citation(s) in RCA: 47] [Impact Index Per Article: 6.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/09/2016] [Accepted: 12/10/2016] [Indexed: 11/23/2022] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a chronic life-limiting disorder characterised by persistent airflow obstruction and progressive breathlessness. Discussions/conversations between patients and clinicians ensure palliative care plans are grounded in patients' preferences. This systematic review aimed to explore what is known about palliative care conversations between clinicians and COPD patients. A comprehensive search of all major healthcare-related databases and websites was performed following Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Studies were quality assessed, employing widely used quality-assessment tools, with only papers scoring moderate-to-high quality included. All relevant data were extracted. A narrative synthesis was used to analyse, process and present the final data. The findings indicated that the frequency and quality of palliative care conversations is generally poor. Patients and physicians identified many barriers and important topics were not discussed. Patients and clinicians reported tension between remaining hopeful and the reality of the patients' condition. When discussions did happen, they often occurred at an advanced stage of illness and in respiratory wards and intensive care units. In conclusion, current care practices do not facilitate satisfactory conversations about palliative care between COPD patients and clinicians. This impacts upon the fulfilment of patients' preferences at the end of life. Conversations about palliative care in COPDhttp://ow.ly/NlKt307jgRs
Collapse
Affiliation(s)
- Nuno Tavares
- Portsmouth Hospitals NHS Trust, Portsmouth, UK.,NIHR CLAHRC Wessex, Southampton, UK.,Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Nikki Jarrett
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Katherine Hunt
- Faculty of Health Sciences, University of Southampton, Southampton, UK
| | - Tom Wilkinson
- NIHR CLAHRC Wessex, Southampton, UK.,Faculty of Health Sciences, University of Southampton, Southampton, UK
| |
Collapse
|
14
|
Vallabhajosyula S, Haddad TM, Sundaragiri PR, Ahmed AA, Nawaz MS, Rayes HAA, Devineni HC, Kanmanthareddy A, McCann DA, Wichman CS, Modrykamien AM, Morrow LE. Role of B-Type Natriuretic Peptide in Predicting In-Hospital Outcomes in Acute Exacerbation of Chronic Obstructive Pulmonary Disease With Preserved Left Ventricular Function: A 5-Year Retrospective Analysis. J Intensive Care Med 2016; 33:635-644. [PMID: 27913775 DOI: 10.1177/0885066616682232] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
BACKGROUND The role of B-type natriuretic peptide (BNP) is less understood in the risk stratification of patients with an acute exacerbation of chronic obstructive pulmonary disease (AECOPD), especially in patients with normal left ventricular ejection fraction (LVEF). METHODS This retrospective study from 2008 to 2012 evaluated all adult patients with AECOPD having BNP levels and available echocardiographic data demonstrating LVEF ≥40%. The patients were divided into groups 1, 2, and 3 with BNP ≤ 100, 101 to 500, and ≥501 pg/mL, respectively. A subgroup analysis was performed for patients without renal dysfunction. Outcomes included need for and duration of noninvasive ventilation (NIV) and mechanical ventilation (MV), NIV failure, reintubation at 48 hours, intensive care unit (ICU) and total length of stay (LOS), and in-hospital mortality. Two-tailed P < .05 was considered statistically significant. RESULTS Of the total 1145 patients, 550 (48.0%) met our inclusion criteria (age 65.1 ± 12.2 years; 271 [49.3%] males). Groups 1, 2, and 3 had 214, 216, and 120 patients each, respectively, with higher comorbidities and worse biventricular function in higher categories. Higher BNP values were associated with higher MV use, NIV failure, MV duration, and ICU and total LOS. On multivariate analysis, BNP was an independent predictor of higher NIV and MV use, NIV failure, NIV and MV duration, and total LOS in groups 2 and 3 compared to group 1. B-type natriuretic peptide continued to demonstrate positive correlation with NIV and MV duration and ICU and total LOS independent of renal function in a subgroup analysis. CONCLUSION Elevated admission BNP in patients with AECOPD and normal LVEF is associated with worse in-hospital outcomes and can be used to risk-stratify these patients.
Collapse
Affiliation(s)
- Saraschandra Vallabhajosyula
- 1 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA.,2 Multidisciplinary Epidemiology and Translational Research in Intensive Care (METRIC) Laboratory, Mayo Clinic, Rochester, MN, USA
| | - Toufik Mahfood Haddad
- 3 Division of Cardiovascular Diseases, Department of Internal Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Pranathi R Sundaragiri
- 4 Division of Hospital Internal Medicine, Department of Internal Medicine, Mayo Clinic, Rochester, MN, USA
| | - Anas A Ahmed
- 5 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Tufts University School of Medicine, Boston, MA, USA
| | - Muhammad Sarfraz Nawaz
- 6 Division of General Internal Medicine, Department of Internal Medicine, University of Iowa Carver College of Medicine, Iowa City, IA, USA
| | - Hamza A A Rayes
- 7 Department of Internal Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Harish C Devineni
- 7 Department of Internal Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Arun Kanmanthareddy
- 3 Division of Cardiovascular Diseases, Department of Internal Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Dustin A McCann
- 8 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Creighton University School of Medicine, Omaha, NE, USA
| | - Christopher S Wichman
- 9 Division of Clinical Research and Evaluative Sciences, Creighton University School of Medicine, Omaha, NE, USA
| | - Ariel M Modrykamien
- 10 Division of Pulmonary and Critical Care Medicine, Department of Internal Medicine, Baylor University Medical Center, Dallas, TX, USA
| | - Lee E Morrow
- 8 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Creighton University School of Medicine, Omaha, NE, USA.,11 Division of Pulmonary, Critical Care and Sleep Medicine, Department of Internal Medicine, Veterans Affairs Nebraska-Western Iowa Health Care System, Omaha, NE, USA
| |
Collapse
|
15
|
Sakhri L, Saint-Raymond C, Quetant S, Pison C, Lagrange E, Hamidfar Roy R, Janssens JP, Maindet-Dominici C, Garrouste-Orgeas M, Levy-Soussan M, Terzi N, Toffart AC. [Limitations of active therapeutic and palliative care in chronic respiratory disease]. Rev Mal Respir 2016; 34:102-120. [PMID: 27639947 DOI: 10.1016/j.rmr.2016.06.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/07/2015] [Accepted: 06/29/2016] [Indexed: 11/16/2022]
Abstract
The issue of intensive and palliative care in patients with chronic disease frequently arises. This review aims to describe the prognostic factors of chronic respiratory diseases in stable and in acute situations in order to improve the management of these complex situations. The various laws on patients' rights provide a legal framework and define the concept of unreasonable obstinacy. For patients with chronic obstructive pulmonary disease, the most robust decision factors are good knowledge of the respiratory disease, the comorbidities, the history of previous exacerbations and patient preferences. In the case of idiopathic pulmonary fibrosis, it is necessary to know if there is a prospect of transplantation and to assess the reversibility of the respiratory distress. In the case of amyotrophic lateral sclerosis, treatment decisions depend on the presence of advance directives about the use of intubation and tracheostomy. For lung cancer patients, general condition, cancer history and the tumor treatment plan are important factors. A multidisciplinary discussion that takes into account the patient's medical history, wishes and the current state of knowledge permits the taking of a coherent decision.
Collapse
Affiliation(s)
- L Sakhri
- Institut de cancérologie Daniel-Hollard, groupe hospitalier Mutualiste, 38000 Grenoble, France
| | - C Saint-Raymond
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble, 38000 Grenoble, France
| | - S Quetant
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble, 38000 Grenoble, France
| | - C Pison
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble, 38000 Grenoble, France; Laboratoire de bioénergétique fondamentale et appliquée, Inserm 1055, 38400 Saint-Martin-d'Hères, France; Université Grenoble Alpes, 38400 Saint-Martin-d'Hères, France
| | - E Lagrange
- Pôle psychiatrie, neurologie et rééducation neurologique, clinique de neurologie, CHU de Grenoble, 38000 Grenoble, France
| | - R Hamidfar Roy
- Pôle urgences médecine aiguë, clinique de réanimation médicale, CHU de Grenoble, 38000 Grenoble, France
| | - J-P Janssens
- Service de pneumologie, hôpital Cantonal universitaire, Genève, Suisse
| | - C Maindet-Dominici
- Pôle anesthésie réanimation, centre de la douleur, CHU de Grenoble, 38000 Grenoble, France
| | - M Garrouste-Orgeas
- Service de médecine intensive et de réanimation, groupe hospitalier Paris Saint-Joseph, 75014 Paris, France
| | - M Levy-Soussan
- Unité mobile d'accompagnement et de soins palliatifs, hôpital universitaire Pitié-Salpêtrière, 75006 Paris, France
| | - N Terzi
- Université Grenoble Alpes, 38400 Saint-Martin-d'Hères, France; Pôle psychiatrie, neurologie et rééducation neurologique, clinique de neurologie, CHU de Grenoble, 38000 Grenoble, France; Inserm U1042, université Grenoble Alpes, HP2, CHU de Grenoble, 38000 Grenoble, France
| | - A-C Toffart
- Pôle thorax et vaisseaux, clinique universitaire de pneumologie, CHU de Grenoble, 38000 Grenoble, France; Université Grenoble Alpes, 38400 Saint-Martin-d'Hères, France; Institut pour l'avancée des biosciences, centre de recherche UGA, Inserm U 1209, CNRS UMR 5309, 38000 Grenoble, France.
| |
Collapse
|
16
|
Freymond N, Perrot E, Regal O, Fayet JM, Ragué P, Mottard N, Wallet F. [Patient's course requiring NIPPV in Centre Hospitalier Lyon-Sud]. REVUE DE PNEUMOLOGIE CLINIQUE 2016; 72:35-40. [PMID: 25727659 DOI: 10.1016/j.pneumo.2014.12.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 07/06/2014] [Accepted: 12/03/2014] [Indexed: 06/04/2023]
Abstract
Non-invasive positive pressure ventilation (NIPPV) has become a major therapeutic of acute respiratory failure. Thanks to technical progress, its use has become widespread in intensive care units and now in emergency and pneumology departments, for indications recognized and validated as decompensation of chronic obstructive pulmonary disease and acute cardiogenic pulmonary edema. Patients with this conditions transit in the hospital, from the emergency or pulmonology departments, sometimes through intensive care units. Knowledge of the NIPPV, its indications, contraindications, terms of use and surveillance requires trained teams. This training covers not only the technical but also the hardware, multiple ventilation modes, and interfaces. Other indications being evaluated, such as ventilation in the perioperative period, also require coordination between different actors. The establishment of a specific group of thinking and working around the NIPPV is clearly needed, allowing teams of hospital (emergency department, intensive care unit, pulmonology, anesthesia) to work together. This work deals with different areas: training, equipment, condition of receiving patients in the different services within the constraints of personnel and equipment. In this article, we trace the point of view of each of the professionals in this group and some of the actions implemented.
Collapse
Affiliation(s)
- N Freymond
- Service de pneumologie, pavillon médical, centre hospitaliser Lyon-Sud, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France.
| | - E Perrot
- Service de pneumologie, pavillon médical, centre hospitaliser Lyon-Sud, chemin du Grand-Revoyet, 69310 Pierre-Bénite, France
| | - O Regal
- Service d'accueil des urgences, centre hospitalier Lyon-Sud, 69310 Pierre-Bénite, France
| | - J M Fayet
- Service d'accueil des urgences, centre hospitalier Lyon-Sud, 69310 Pierre-Bénite, France
| | - P Ragué
- Service de réanimation, centre hospitalier Lyon-Sud, 69310 Pierre-Bénite, France
| | - N Mottard
- Service de réanimation, centre hospitalier Lyon-Sud, 69310 Pierre-Bénite, France
| | - F Wallet
- Service de réanimation, centre hospitalier Lyon-Sud, 69310 Pierre-Bénite, France
| |
Collapse
|