Observational case-control study of non-invasive ventilation in patients with ARDS

BACKGROUND

The application of non-invasive pressure support ventilation (NIPSV) in patients with acute lung injury or ARDS remains controversial despite recent promising results. Data in rather homogeneous ARDS groups is lacking.

OBJECTIVE

To compare the outcome of NIPSV-treated patients satisfying the diagnostic criteria for primary (pulmonary) ARDS (ARDSp) and presenting without distant organ failures at admission, with those of a matched control group treated in the same ICU with endotracheal mechanical ventilation (ETMV).

METHODS

We applied NIPSV in 12 immunocompetent and collaborative patients who met the above cited criteria. NIPSV failure rate, short-term oxygenation, length of stay, mortality rate and complications were analyzed and compared with a control group of 12 intubated ARDSp-patients matched for age, SAPS II, PaO2/FiO2 and pH at admission.

RESULTS

NIPSV failed in 4 patients developing distant organ failures. Compared to the ETMV control group, NIPSV success patients had reduced cumulative time on ventilation (p = 0.001) and length of ICU stay (p = 0.004). After the first 60' of ventilation, oxygenation improved more in the NIPSV than in the ETMV group (146 +/- 52 mmHg vs 109 +/- 34 mmHg; p = 0.05). The overall ICU mortality rate did not differ significantly between the groups but tended to be higher in the NIPSV group.

CONCLUSIONS

In ARDSp patients without distant organ failures at admission and during the disease course, NIPSV might be a suitable alternative to invasive ventilation; however, the real effects on outcome of NIPSV applied to stable homogeneous subgroups of ARDS patients merit further investigations in randomised studies.

Noninvasive pressure support ventilation in non-COPD patients with acute cardiogenic pulmonary edema and severe community-acquired pneumonia: acute effects and outcome

OBJECTIVE

To compare the acute effects of noninvasive pressure support ventilation (NIPSV) in non-COPD patients with acute cardiogenic pulmonary edema (CPE) and severe community-acquired pneumonia (CAP) presenting with a similar hypoxemic respiratory failure and exploring the ensuing impact on outcome. DESIGN. Prospective, observational study. SETTING. Multidisciplinary ICU, regional teaching hospital.

PATIENTS

Non-COPD patients with CPE or severe CAP.

MEASUREMENTS AND RESULTS

Fifteen patients with CPE and eighteen with CAP were included. Both groups had similar low PaO2/FiO2 ratios at admission; SAPS II, baseline pH(a) were lower in the CPE group than in the CAP group. Within the first NIPSV observation period (60 min), the oxygenation improved significantly in both CPE and CAP-groups; respiratory rate (RR) significantly decreased in the CPE group ( P=0.005), but it remained unchanged in the whole CAP group; heart rate and mean arterial pressure significantly decreased in both groups. One patient (6.6%) in the CPE group and seven patients (38%) in the CAP group were intubated ( P=0.04). The mean total time spent on NIPSV was 9.6+/-6.3 h in the CPE and 37.2+/-36 h in the CAP group ( P=0.01). Unit mortality rate was 6.6% in the CPE and 28% in the CAP group ( P=0.2). Upon inclusion, all but one CAP patients who were subsequently intubated had a bacteremic pneumonia; unit mortality rate was 57% in intubated- and 9% in non-intubated CAP patients ( P=0.05).

CONCLUSIONS

NIPSV equally and rapidly improved oxygenation in non-COPD patients with CPE and severe CAP presenting with a similar hypoxemic respiratory failure, but the subsequent outcome was definitely different in the two groups, depending on the nature of the acute lung injury.

[Endemic and imported severe leptospirosis (Weil's disease) in southern Switzerland]

We report on 4 cases of severe icteric leptospirosis. Three patients developed renal failure requiring haemodialysis and one required mechanic ventilation for 10 days. On entry all patients presented with severe myalgia, particularly in the calves, jaundice, oligo-anuria and severe thrombocytopenia. In one case an acute abdomen-like presentation led to exploratory laparotomy. We believe that the abdominal pain was mainly due to rhabdomyolysis of the abdominal wall. The outcome was favorable in all cases and recovery of renal function was observed after a few days to several weeks. Three out of 4 patients were infected in southern Switzerland. This observation underscores the importance of wild and domestic animals as a leptospira reservoir. Patients presenting with acute renal failure and jaundice, but only mild-to-moderate elevation of transaminases, are suspect for leptospirosis regardless of travel to a tropical or subtropical country.

Germ-line mutations of the p16INK4(MTS1) gene occur in a subset of patients with hepatocellular carcinoma

The molecular mechanisms of hepatocarcinogenesis are poorly understood. Only very recently has there been a suggestion of familial hepatocellular carcinoma (HCC). We have analyzed the status of the p16INK4(MTS1) gene, a cyclin-dependent kinase inhibitor, in 26 patients with HCC of different etiologies. Four patients carried hemizygous germ-line point mutations of the p16INK4(MTS1) gene, suggesting the existence of familial HCC involving this gene. The wild-type allele was lost in the tumor in 2 of these 4 patients. Three of the patients carrying a germ-line mutation had non-cirrhosis-associated HCC. No somatic mutations of p16INK4(MTS1) were observed in the 26 cases of HCC. The most common somatic alteration of the p16INK4(MTS1) gene in HCC was de novo methylation, which was detected in 48% of the cases. Low levels (21%) of p16INK4(MTS1) gene allele loss were observed. Altogether, these results indicate that alteration of the p16INK4(MTS1) gene plays an important role in the genesis of HCC.

Long-term effect of splenectomy on transfusion requirements in thalassemia major

Splenectomy reduces transfusion requirements in the first year after surgery in patients with thalassemia major and hypersplenism. To determine whether this response is maintained, we have studied transfusion requirements in 16 patients with thalassemia major for 2-17 years after splenectomy. Transfusion requirements remained stable (mean yearly change -0.1%) after the predictable fall in the first year after surgery. The mean change between the first postoperative year and the most recent year was -7 ml/kg. Transfusion requirements and the magnitude of change from year to year were unrelated to the time since splenectomy. These studies indicate that the effect of splenectomy on transfusion requirements is long-lasting and that large variations in annual transfusion requirements after splenectomy should prompt a search for accessory spleens or other causes of red cell destruction.