Biomedical subjects
Publications and source records attributed to J F Muir.
The authors record the case of a patient who was under review for pulmonary tuberculosis in whom an Abrikossof granular cell tumour and a cyst were found which had developed from an intrapulmonary lymph node. These two entities are rare and their association extremely unusual and have never been described until now. We review their histogenesis.
The authors report a case of a patient presenting with a bronchogenic mediastinal cyst, which presented as a super-infection of the cyst. The cyst was associated with malformation of the cervical vertebra, cardiovascular abnormalities and congenital deafness, placing this in the group of rare complex polymalformation syndrome with Klippel-Feil Syndrome. The authors also stress the value of computed tomography, and above all of nuclear magnetic resonance in the analysis of mediastinal tumours and in particular, of bronchogenic cysts.
The techniques of non-invasive ventilation have reappeared in force as an assortment of therapeutic techniques since the end of the 1980's. At the same time there was a transient renewed interest in perithoracic ventilation favouring the use of new methods of connection to the patient (e.g. poncho). The principal feature has been the use of intermittent positive pressure ventilation by the nasal route, which rapidly became essential for home therapy in patients with chronic restrictive respiratory failure notably in those secondary to thoracic deformation and to neuromuscular pathology. The concept of resting the respiratory muscles has been the basis for techniques of ventilatory assistance and in part the nasal route has now replaced home ventilation using a tracheotomy. Also in certain types of acute respiratory failure, nasal ventilation widely preferred over endotracheal ventilation.
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In France, home mechanical ventilation (HMV) is mainly organized through the public system, using a national network of 33 Regional Associations for home care of chronic respiratory insufficiency, which are federated on a national basis by The French National Home Care Association for Chronic Respiratory Insufficiency (ANTADIR). Twenty three thousand six hundred and twenty three patients were being treated at home through that organization at the end of 1991, 14,173 of whom received long-term oxygen therapy (LTO), 2,267 were ventilated by tracheostomy, 1,139 had nasal mask ventilation, and 3,322 received nasal continuous positive airway pressure (CPAP). In common practice, the association performs the installation of the respiratory apparatus at home, at no cost to the patient who is covered by the social security for all expenses. At the end of 1991, the total cost of home respiratory care delivered by ANTADIR rose to 78.6 millions US dollars.
An exceptional case of incarcerated para-hiatal hernia with gastric necrosis, developing 7 years a Toupet procedure, is reported. To our knowledge, this is the first reported case of this complication after a surgical anti-reflux procedure without diaphragmatic counter incision. The mechanism, diagnostic difficulties and treatment are discussed.
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In this study, 322 patients were evaluated with two aims: determination of identifiable factors at the time of admission to an ICU that predict short-term survival. Application of the SAPS to this population. Characteristics of patients were as follows: age, 65.5 +/- 14.5 years; COLD, 45 percent; restrictive, 13.4 percent; obstructive and restrictive CRI, 13 percent; asthma progressing to CRI, 11.2 percent; diffuse bronchiectasis, 7.2 percent; neuromuscular diseases, 2.2 percent; others, 8 percent. Cachectic patients, those confined to home, those with initial coma or those who required MV had a higher percentage of M. The SAPS at admission was higher in those patients who died; however, there was no link between the SAPS and M. Prognostic factors in ARF complicating CRI and identifiable at the time of admission to an ICU are few and reflect severity of chronic respiratory disease; SAPS appears to be less useful in ARF complicating CRI.
Nasal mask ventilation (NMV) has been used successfully in chronic restrictive respiratory failure and more recently in acute exacerbations of chronic obstructive pulmonary disease (COPD). This study aimed to evaluate the possible role of NMV in acute respiratory failure (ARF) episodes when mechanical ventilation with endotracheal intubation is questionable. Thirty patients (age, 76 +/- 8.1 years) were treated by NMV during ARF episodes (COPD, 20; other chronic respiratory failure [CRF], 5; chronic heart failure [CHF], 4). All patients were hypoxemic (PaO2, 5.85 +/- 1.62 kPa) and hypercapnic (PaCO2, 8.63 +/- 1.89 kPa) with respiratory acidosis (pH, 7.29 +/- 0.08). In all cases, clinical or physiologic parameters indicated the need for mechanical ventilation, but endotracheal intubation was either not applied because of the age and the physiologic condition of the patients (17 cases) or was postponed (13 cases). NMV was performed using a volume-cycled ventilator and a customized nasal mask. Ventilation was continuous during the first 12 hours and the following nights and was then intermittent during the day. Twenty-one patients improved clinically, within a few hours. Progressive correction of arterial blood gases was observed: PaO2 increased during the first hour, but PaCO2 decreased more slowly. Eighteen patients were able to be successfully weaned from NMV. Twelve patients failed to improve despite NMV: eight of them died and four required endotracheal intubation. There was no difference in the success rate between patients in whom endotracheal ventilation was contraindicated or postponed. Clinical tolerance was satisfactory in 23 patients and poor in seven patients. A return to the respiratory condition was observed in the surviving patients with subsequent discharge from hospital. NMV therefore successfully treated respiratory distress initially in 60 percent of the 30 patients. These results suggest that NMV could be a possible alternative in the treatment of ARF, even in very ill patients, when endotracheal ventilation is controversial or not immediately required.
Ninety-six patients with nocturnal asthma (FEV1 = 60-90% pred, reversibility greater than or equal to 15%, at least 2 awakenings in the week preceding the trial) were included in a double-blind, randomized, crossover, multicenter study which compared the efficacy and side effects of inhaled salmeterol (50 micrograms morning and evening) to the association theophylline-ketotifen (300 mg and 1 mg morning and evening, respectively). The trial included a run-in period of 14 days and 2 periods of successive treatment of 28 days each. The efficacy was expressed in terms of therapeutic success, defined by the total disappearance of nocturnal symptoms during the treatment week. A statistically significant difference (p less than 0.01) was found between salmeterol and the association for this criteria: during the first period, 46% of subjects treated by salmeterol did not present nocturnal awakenings during the last treatment week by comparison with 15% of subjects taking the association; during the second period, corresponding figures were 39% for salmeterol by comparison with 26% for the association. Differences were also significant, favoring salmeterol, for other criteria (lung function tests, extra-need for salbutamol). Side effects were 5 times more frequent for the association (p less than 0.004). Salmeterol is clearly superior to the association theophylline-ketotifen in the treatment of nocturnal asthma.
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We wished to assess the efficacy of inhaled salmeterol (SML; 50 micrograms b.i.d.) compared to a combination of slow-release theophylline and ketotifen p.o. (TK; T 300 mg+K 1 mg b.i.d.) for the treatment of nocturnal asthma. Ninety six patients with nocturnal asthma, (forced expiratory volume in one second (FEV1) 60-90% of predicted value, reversibility > or = 15%, at least two nocturnal awakenings per week) were eligible for a multicentre, double-blind, double-dummy cross-over study (14-day run-in, two successive 28-day treatment periods). Efficacy was assessed as success/failure, success being defined as the complete disappearance of nocturnal symptoms/awakening during the last week of each treatment period. There was a statistically significant difference between SML and TK for this criterion: 46% and 39% success with SML during periods I (first 28-day period) and II (following the cross-over), compared to only 15% and 26% with TK, respectively (p < 0.01). SML was also significantly better for the other criteria (lung function, rescue salbutamol intake during day and night). Side-effects were five times less frequent in SML-treated patients (p < 0.004). Efficacy and tolerance of SML were obviously far better than those of TK in patients with nocturnal asthma.
Specific bacteriological diagnosis is the first condition for optimal treatment in bacterial pneumonias. Despite many attempts to improve its reliability, bacteriological examination of the sputum is a non-sensitive and non-specific examination. Transtracheal aspiration (TTA) and bronchoscopic protected brush (BPB) are more reliable examinations but their practice is limited because of their invasive characteristic. Then treatment of non-critical pneumonia is often based on the probable organism. BPB is carried out using a protected brush with a double catheter which is introduced into the bronchial tree under fiberscopic control. Although easy, such a technique must be accurate in its performance. Even if good reliability of this method is well establish in in vitro and in vivo studies, it remains that false positive results have been described in clinical studies, so that quantitative cultures are needed. Results are evident in non-intubated patients without bronchial disease in which identifying the responsive germ is the only purpose. But in intubated ventilated patients two problems are faced: firstly on establishing a positive diagnosis of bacterial pneumonia and secondly on identifying the responsive germ. TTA technique prevents pollution of the specimen with oropharyngeal flora: bronchial secretions are aspirated by a catheter introduced into the trachea via percutaneous route through crico-thyroid membrane. Its performance is easy, quick and severe complications are very rare when usual contraindications are taken into account (severe hypoxia, hemostatic disorders). Being of good sensitivity, the TTA shows false positive results in patients with chronic bronchial diseases. On a bacteriological point of view, these protected techniques have to be used only when pyogenic bacteria are suspected. Invasive techniques are needed when there are factors of specific severity or other risk factors. The choice (TTA or PBP) depends mostly on medical habits and material availability.
The saturation of oxygen (SaO2) using oxygen therapy with an oxygen saving system, Optimox (CFPO) or COS 5 (Puritan, Bennett) has been compared to the SaO2 using continuous oxygen therapy. The oxygen output using the oxygen saving system was regulated in such a way as to be equivalent to the oxygen flow without the economiser. Three situations were studied: the day, the night and during effort. Ninety four patients (84 men and 10 women), aged 65.3 +/- 9.7), who were hypoxaemic (SaO2: 84.5 +/- 6.4%) coming from twelve pneumology units were included in the study. The percentage of time spent above SaO2 (T greater than 90) was used to judge the criteria of the efficacy of the oxygen therapy. T greater than 90 without (SSECO) and with the oxygen saving system (AVECO) were compared in each subject. T greater than 90 AVECO was below T greater than 90 SSECO in 52% of patients and was greater in 23% of subjects. The nasal, auditory and respiratory comfort was good whatever the period of examination for more than half of the subjects. In conclusion for an equivalent oxygen flow the addition of an oxygen saving device significantly alters the quality of diurnal and nocturnal oxygen therapy in one patient out of two.
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We report the case of a man of 43 years old presenting with sarcoidosis which produced pulmonary hypertension and respiratory failure without radiological evidence of interstitial fibrosis. In spite of treatment with steroids and corticosteroids (1 mg/kg) there was progression over 2 1/2 years to respiratory failure and irreversible right heart failure and the death of the patient. At autopsy the pulmonary veins were obliterated by non caseating granulomas and there were minimal fibrotic parenchymal lesions. To our knowledge this is only the second case of sarcoidosis resulting in a veno occlusive pulmonary disorder.
A study on the living conditions of patients on long-term oxygen therapy or assisted ventilation at home was conducted in France in January 1988. At that date, 13,500 patients had been handled by 30 regional associations. Twenty-four regional associations (80%) representing 11,079 patients (82%) participated in the study. A total of 8,091 questionnaires were processed, accounting for 73% of patients interviewed and 60% of the population under treatment.