Non-steroidal Anti-inflammatory Drugs may Worsen the Course of Community-Acquired Pneumonia: A Cohort Study

PURPOSE

Non-steroidal anti-inflammatory drugs (NSAIDs) are frequently prescribed or used as self-medication in cases of community-acquired pneumonia (CAP). Nevertheless, the consequences of such medication on the risk of pleuroparenchymal complications are not well known. The aim was to investigate whether exposure to NSAIDs prior to hospital admission among patients suffering from CAP is associated with the development of pleural complications or a lung abscess.

METHODS

All consecutive non-immunocompromised patients with CAP and admitted to a university hospital were prospectively included (2-year period). The risk of pleuropulmonary complications was analyzed according to previous exposure to NSAIDs.

RESULTS

Of the 221 included patients, 40 (18.1%) had developed a pleuropulmonary complication. NSAIDs intake prior to admission was reported for 24 patients (10.9%) who were younger (50.6 ± 18.5 vs. 66.5 ± 16.4 years; p = 0.001), had less comorbidities (60 vs. 25.1%; p = 0.001), had a longer duration between the first symptoms of CAP and the start of an antibiotic therapy (6.1 ± 7.6 vs. 2.8 ± 3.8 days; p = 0.001), and who had a higher incidence of pleuropulmonary complications (33.3 vs. 16.2%; p = 0.048). In multivariate analyses, two factors were independently associated with the development of pleuroparenchymal complications: NSAIDs intake [Odds Ratio (OR) = 2.57 [1.02-6.64]; p = 0.049] and alcohol abuse (OR = 2.68 [1.27-5.69]; p = 0.01).

CONCLUSIONS

Our findings suggest that NSAIDs, often taken by young and healthy patients, may worsen the course of CAP with delayed therapy and a higher rate of pleuropulmonary complications.

[Lung cancer screening with low-dose thoracic CT-scan in the Somme area]

RATIONALE

This feasibility trial proposes to set up in the department of the Somme an annual screening for lung cancer with low-dose thoracic CT. It responds to the first objective of the third cancer plan and follows the publication of the results of the National Lung Screening Trial in 2011.

METHODS

The method of this study is to use the existing networks among and between healthcare professionals and the departmental cancer screening structure. The inclusion criteria will be those of the National Lung Screening Trial. Screening will be proposed by treating physicians and chest physicians. The CT-scan will be performed in radiological centers that adhere to the good practice charter for low radiation scanning. A copy of CT results will be sent to the departmental structure of cancer screening (ADEMA80) which will ensure traceability and will perform statistical analysis. The study received funding from the Agence régionale de santé de la Picardie and la ligue contre le cancer.

EXPECTED RESULTS

The primary endpoints of this screening will be the number of cancers diagnosed and the survival of the patients. The follow-up of positive examinations, delays in management and the level of participation will also be assessed.

Home Environment as a Source of Life-Threatening Azole-Resistant Aspergillus fumigatus in Immunocompromised Patients

A case of fatal aspergillosis due to a TR₄₆/Y121F/T289A azole-resistant Aspergillus fumigatus is reported. Environmental investigations at the patient's residence led to the recovery of TR₄₆/Y121F/T289A isolates, genotypically indistinguishable from the clinical isolate, supporting for the first time the direct role of household as potential source of azole-resistant invasive aspergillosis.

Lung Volume Reduction Coil Treatment vs Usual Care in Patients With Severe Emphysema: The REVOLENS Randomized Clinical Trial

IMPORTANCE

Therapeutic options for severe emphysema are limited. Lung volume reduction using nitinol coils is a bronchoscopic intervention inducing regional parenchymal volume reduction and restoring lung recoil.

OBJECTIVE

To evaluate the efficacy, safety, cost, and cost-effectiveness of nitinol coils in treatment of severe emphysema.

DESIGN, SETTING, AND PARTICIPANTS

Multicenter 1:1 randomized superiority trial comparing coils with usual care at 10 university hospitals in France. Enrollment of patients with emphysema occurred from March to October 2013, with 12-month follow-up (last follow-up, December 2014).

INTERVENTIONS

Patients randomized to usual care (n = 50) received rehabilitation and bronchodilators with or without inhaled corticosteroids and oxygen; those randomized to bilateral coil treatment (n = 50) received usual care plus additional therapy in which approximately 10 coils per lobe were placed in 2 bilateral lobes in 2 procedures.

MAIN OUTCOMES AND MEASURES

The primary outcome was improvement of at least 54 m in the 6-minute walk test at 6 months (1-sided hypothesis test). Secondary outcomes included changes at 6 and 12 months in the 6-minute walk test, lung function, quality of life as assessed by St George's Respiratory Questionnaire (range, 0-100; 0 being the best and 100 being the worst quality of life; minimal clinically important difference, ≥4), morbidity, mortality, total cost, and cost-effectiveness.

RESULTS

Among 100 patients, 71 men and 29 women (mean age, 62 years) were included. At 6 months, improvement of at least 54 m was observed in 18 patients (36%) in the coil group and 9 patients (18%) in the usual care group, for a between-group difference of 18% (1-sided 95% CI, 4% to ∞; P = .03). Mean between-group differences at 6 and 12 months in the coil and usual care groups were +0.09 L (95% CI, 0.05 L to ∞) (P = .001) and +0.08 L (95% CI, 0.03 L to ∞) (P = .002) for forced expiratory volume in the first second, +21 m (95% CI, -4 m to ∞) (P = .06) and +21 m (95% CI, -5 m to ∞) (P = .12) for 6-minute walk distance, and -13.4 points (95% CI, -8 points to ∞) and -10.6 points (95% CI, -5.8 points to ∞) for St George's Respiratory Questionnaire (1-sided P < .001 for both). Within 12 months, 4 deaths occurred in the coil group and 3 in the usual care group. The mean total 1-year per-patient cost difference between groups was $47,908 (95% CI, $47,879-$48,073) (P < .001); the incremental cost-effectiveness ratio was $782,598 per additional quality-adjusted life-year.

CONCLUSIONS AND RELEVANCE

In this preliminary study of patients with severe emphysema followed up for 6 months, bronchoscopic treatment with nitinol coils compared with usual care resulted in improved exercise capacity with high short-term costs. Further investigation is needed to assess durability of benefit and long-term cost implications.

TRIAL REGISTRATION

clinicaltrials.gov Identifier: NCT01822795.

[Results of endobronchial ultrasound-guided transbronchial needle aspiration in lung cancer: importance of the lymph node involvement prevalence]

OBJECTIVE

We studied the non-surgical invasive staging by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and we detailed the differences of our series, in order to understand the criteria allowing to achieve a better performance.

METHODS

Retrospective observational study conducted between 2007 and 2011, including all patients with proven NSCLC who underwent EBUS-TBNA.

RESULTS

For the 92 EBUS-TBNA performed, we found a sensitivity of 78%, a specificity of 93%, a positive predictive value (PPV) of 98%, a negative predictive value (NPV) of 45%, an accuracy of 80% and a prevalence of lymph node involvement at 84%. A learning curve has been demonstrated and a significant difference was found based on the number of punctures by procedure (P=0.02) or on histological type (P=0.02). By analyzing the data of the literature, we have been able to demonstrate that the accuracy and the negative predictive value are correlated with the prevalence. If we take into account this correlation, we can consider the results of our study close to those of the literature.

CONCLUSION

We highlighted a number of criteria that will influence the diagnostic yield of EBUS-TBNA. While some have already been described, other criteria such as histological type or patient selection criteria are less discussed. The key point is the correlation between the prevalence and EBUS-TBNA results. Results of the assessment of lymph node involvement techniques should be interpreted according to the prevalence of lymph node involvement.

The relationship between metformin therapy and sleep quantity and quality in patients with Type 2 diabetes referred for potential sleep disorders

AIMS

Given that sleep disorders are known to be related to insulin resistance, and metformin has favourable effects on insulin resistance and on ventilatory drive, we sought to determine whether metformin therapy was related to sleep variables in a group of patients with Type 2 diabetes.

METHODS

We performed a retrospective, observational study of our centre's database for patients referred for potential sleep disorders and then compared metformin-treated patients with those not treated with the drug. All study patients had undergone the same standard polysomnographic procedure. A multivariate analysis was performed to establish whether or not there was an independent relationship between metformin use and sleep variables (after adjusting for age, gender, BMI, neck circumference, cumulated risk factors and insulin use).

RESULTS

We studied 387 patients (mean ± sd age: 58.4 ± 10.8 years), of whom 314 had been treated with metformin. Total sleep time and sleep efficiency were higher in metformin-treated patients than in patients not treated with metformin [total sleep time: 6 h 39 min vs. 6 h 3 min, respectively (P = 0.002); sleep efficiency: 77.9 ± 12.3 vs. 71.5 ± 17.2%, respectively (P = 0.003)]. These differences persisted after adjustment for covariates and were observed even although metformin users had a higher BMI than did non-users (median 37.5 vs. 34.8 kg/m(2) ; P = 0.045).

CONCLUSION

We showed that metformin therapy is associated with a longer sleep duration and better sleep efficiency. Randomized clinical trials are needed to confirm metformin's favourable effect on sleep quality and quantity.

Does using pressure-controlled ventilation to rest respiratory muscles improve sleep in ICU patients?

PURPOSE

Sleep is commonly altered in critically ill patients. Ventilatory mode may impact on quality of sleep. The aim of our study was to evaluate the effect on sleep of pressure-controlled ventilation (PCV) to spontaneous ventilation with 6 cm H2O inspiratory pressure (low-PSV).

METHODS

Thirty-five patients intubated and mechanically ventilated for acute-on-chronic respiratory failure were included in this prospective randomized cross-over study. Nine were discarded, 13 received PCV first (10 p.m.-2 a.m.) and then low-PSV (2-6 a.m.) and 13 patients received low-PSV first and then PCV.

RESULTS

Sleep architecture was altered (50.4% of the night was spent in wakefulness). PCV was associated with significantly improved sleep quality and quantity compared to low-PSV: sleep efficiency (total sleep time/total recording time) was 63% (range: 9-100) vs. 37% (0-96; p = 0.0002), stage 2 NREM sleep was 33% vs. 13% (p = 0.0005), stages 3 and 4 NREM sleep were 9% vs. 3.5% (p = 0.003) and REM sleep was 6.5% vs. 0% (p = 0.003).

CONCLUSIONS

Sleep quantity and quality were significantly improved with PCV compared to low-PSV. Nocturnal respiratory muscles rest through PCV is recommended to improve sleep in ICU patients with acute-on-chronic respiratory failure.

[Cost-effectiveness of lung volume reduction coil treatment in emphysema. STIC REVOLENS]

BACKGROUND

Medical therapeutic options for the treatment of emphysema remain limited. Lung volume reduction surgery is infrequently used because of its high morbi-mortality. Endobronchial lung volume reduction coil (LVRC(®), PneumRx, Mountain View, CA) treatment has been recently developed and has been shown to be feasible and associated with an acceptable safety profile, while resulting in improvements in dyspnea, exercise capacity and lung function. The objective of this study is to analyze the cost effectiveness of LVRC treatment in severe emphysema.

METHODS

This prospective, multicenter study, randomized with a 1:1 ratio (LVRC vs conventional treatment) will include 100 patients who will be followed up for 1year. The primary outcome measure is the 6-month improvement of the 6-minute walk test: the percentage of patients showing an improvement of at least 54m will be compared between groups. A cost-effectiveness study will estimate the cost of LVRC treatment, the global cost of this therapeutic option and will compare the cost between patients treated by LVRC and by medical treatment alone.

EXPECTED RESULTS

This study should allow validating the clinical efficacy of LVRC in severe emphysema. The cost-effectiveness study will assess the medical-economic impact of the LVRC therapeutic option.

[Diagnosis and treatment of atypical mycobacterial infections of the respiratory tract]

INTRODUCTION

Non tuberculous mycobacteria (NTM), unlike tuberculous mycobacteria, are not strictly human pathogens. The diagnosis of infection and the choice of treatment remain difficult.

BACKGROUND

Evidence of a NTM in a pulmonary sample is not synonymous with infection. The diagnosis depends on the association of clinical, radiological and microbiological factors. If a NTM is isolated from a respiratory sample, the probability of infection depends on the species. The main NTMs responsible for pulmonary infection in France are Mycobacterium avium intracellulare, Mycobacterium xenopi, Mycobacterium kansasi and Mycobacterium abscessus. Their management is difficult and poorly understood. Treatment is well established for M. avium intracellulare and M. kansasii, with combinations of clarithromycin-rifampicin-ethambutol and isoniazid-rifampicin-ethambutol respectively. For M. xenopi, the optimal treatment is not known and a combination of clarithromycin-rifampicin-ethambutol, with moxifloxacin as an alternative, is currently recommended. In general, treatment is prolonged and often associated with problems of tolerance.

VIEWPOINT AND CONCLUSION

The management of NTM infection, taking into account of the increase in patients "at risk", is an important issue. Further studies are needed to improve the criteria for infection and to find the optimal therapeutic combinations.

Respiratory-gated 18F-FDG PET imaging in lung cancer: effects on sensitivity and specificity

BACKGROUND

Respiratory motion is known to deteriorate positron emission tomography (PET) images and may lead to potential diagnostic errors when a standardized uptake value (SUV) cut-off threshold is used to discriminate between benign and malignant lesions.

PURPOSE

To evaluate and compare ungated and respiratory-gated 18F-fluorodeoxyglucose PET/computed tomography (CT) methods for the characterization of pulmonary nodules.

MATERIAL AND METHODS

The list-mode acquisition during respiratory-gated PET was combined with a short breath-hold CT scan to form the CT-based images. We studied 48 lesions in 43 patients. PET images were analyzed in terms of the maximum SUV (SUV(max)) and the lesion location.

RESULTS

Using receiver-operating characteristic (ROC) curves, the optimal SUV cut-off thresholds for the ungated and CT-based methods were calculated to be 2.0 and 2.2, respectively. The corresponding sensitivity values were 83% and 92%, respectively, with a specificity of 67% for both methods. The two methods gave equivalent performance levels for the upper and middle lobes (sensitivity 93%, specificity 62%). They differed for the lower lobes, where the CT-based method outperformed the ungated method (sensitivity values of 90% and 70%, respectively, and a specificity of 73% with both methods) - especially for lesions smaller than 15 mm.

CONCLUSION

The CT-based method increased sensitivity and did not diminish specificity, compared with the ungated method. It was more efficient than the ungated method for imaging the lower lobes and smallest lesions, which are most affected by respiratory motion.

Bacterial infection profiles in lung cancer patients with febrile neutropenia

Background

The chemotherapy used to treat lung cancer causes febrile neutropenia in 10 to 40% of patients. Although most episodes are of undetermined origin, an infectious etiology can be suspected in 30% of cases. In view of the scarcity of data on lung cancer patients with febrile neutropenia, we performed a retrospective study of the microbiological characteristics of cases recorded in three medical centers in the Picardy region of northern France.

Methods

We analyzed the medical records of lung cancer patients with neutropenia (neutrophil count < 500/mm³) and fever (temperature > 38.3°C).

Results

The study included 87 lung cancer patients with febrile neutropenia (mean age: 64.2). Two thirds of the patients had metastases and half had poor performance status. Thirty-three of the 87 cases were microbiologically documented. Gram-negative bacteria (mainly enterobacteriaceae from the urinary and digestive tracts) were identified in 59% of these cases. Staphylococcus species (mainly S. aureus) accounted for a high proportion of the identified Gram-positive bacteria. Bacteremia accounted for 60% of the microbiologically documented cases of fever. 23% of the blood cultures were positive. 14% of the infections were probably hospital-acquired and 14% were caused by multidrug-resistant strains. The overall mortality rate at day 30 was 33% and the infection-related mortality rate was 16.1%. Treatment with antibiotics was successful in 82.8% of cases. In a multivariate analysis, predictive factors for treatment failure were age >60 and thrombocytopenia < 20000/mm³.

Conclusion

Gram-negative species were the most frequently identified bacteria in lung cancer patients with febrile neutropenia. Despite the success of antibiotic treatment and a low-risk neutropenic patient group, mortality is high in this particular population.

Admission of advanced lung cancer patients to intensive care unit: a retrospective study of 76 patients

BACKGROUND

Criteria for admitting patients with incurable diseases to the medical intensive care unit (MICU) remain unclear and have ethical implications.

METHODS

We retrospectively evaluated MICU outcomes and identified risk factors for MICU mortality in consecutive patients with advanced lung cancer admitted to two university-hospital MICUs in France between 1996 and 2006.

RESULTS

Of 76 included patients, 49 had non-small cell lung cancer (stage IIIB n = 20; stage IV n = 29). In 60 patients, MICU admission was directly related to the lung cancer (complication of cancer management, n = 30; cancer progression, n = 14; and lung-cancer-induced diseases, n = 17). Mechanical ventilation was required during the MICU stay in 57 patients. Thirty-six (47.4%) patients died in the MICU. Three factors were independently associated with MICU mortality: use of vasoactive agents (odds ratio [OR] 6.81 95% confidence interval [95%CI] [1.77-26.26], p = 0.005), mechanical ventilation (OR 6.61 95%CI [1.44-30.5], p = 0.015) and thrombocytopenia (OR 5.13; 95%CI [1.17-22.5], p = 0.030). In contrast, mortality was lower in patients admitted for a complication of cancer management (OR 0.206; 95%CI [0.058-0.738], p = 0.015). Of the 27 patients who returned home, four received specific lung cancer treatment after the MICU stay.

CONCLUSIONS

Patients with acute complications of treatment for advanced lung cancer may benefit from MCIU admission. Further studies are necessary to assess outcomes such as quality of life after MICU discharge.

[Pulmonary epithelioid haemangioendothelioma: reports of three cases and a review of the literature]

INTRODUCTION

Pulmonary epithelioid haemangioendothelioma (PEH) is a rare vascular tumour of intermediate malignancy that predominantly affects women.

CLINICAL CASE REPORTS

We report three cases of PEH. Though all three diagnoses were confirmed by surgical biopsy, it is notable that, in one case, a tracheal biopsy by flexible bronchoscopy was contributory. Two patients had undergone positron emission tomography, which showed the lesions to be well established. The three cases show that the evolution of this pathology can be very varied. In the first case, the disease was multifocal and needed to be treated with several pulmonary resections. In the second case no recurrence has been observed after surgery; in the third case the patient died following a haemothorax.

CONCLUSION

The discovery of a PEH is usually fortuitous. The diagnosis is confirmed by immuno-chemical analysis of a lung biopsy. No standard treatment has been validated and no treatment is necessary if the disease is asymptomatic. If there is only one nodule, surgery is the treatment of choice. The prognosis is variable. Usually the evolution is slow except when the disease is complicated by haemoptysis, pleural effusion, haemothorax, mediastinal lymphadenopathy or hepatic spread.

Mycobacterium xenopi pulmonary infections: a multicentric retrospective study of 136 cases in north-east France

BACKGROUND

Owing to its low incidence, the management of Mycobacterium xenopi pulmonary infections is not clearly defined. A multicentre retrospective study was performed to describe the features of the disease and to evaluate its prognosis.

METHODS

All patients with M xenopi satisfying the 1997 ATS/IDSA criteria from 13 hospitals in north-east France (1983-2003) were included in the study. Clinical, radiological and bacteriological characteristics and data on the management and outcome were collected.

RESULTS

136 patients were included in the analysis, only 12 of whom presented with no co-morbidity. Three types of the disease were identified: (1) a classical cavitary form in patients with pre-existing pulmonary disease (n = 39, 31%); (2) a solitary nodular form in immunocompetent patients (n = 41, 33%) and (3) an acute infiltrate form in immunosuppressed patients (n = 45, 36%). 56 patients did not receive any treatment; the other 80 patients received first-line treatment containing rifamycin (87.5%), ethambutol (75%), isoniazid (66.2%), clarithromycin (30%) or fluoroquinolones (21%). After a follow-up of 36 months, 80 patients (69.1%) had died; the median survival was 16 months (range 10-22). Two independent prognostic factors were found: the acute infiltrate form was associated with a bad prognosis (hazard ratio 2.6, p = 0.001) and rifamycin-containing regimens provided protection (hazard ratio 0.325, p = 0.006). Clarithromycin-containing regimens did not improve the prognosis.

CONCLUSIONS

In contrast to recent guidelines, this study showed three different types of the disease (cavitary, nodular or diffuse infiltrate forms) with a different prognosis. In order to improve survival, all patients with M xenopi infection should be treated with a rifamycin-containing regimen. The usefulness of clarithromycin remains to be evaluated.

[Pneumothorax following recreational inhalation of nitrous oxide]

CASE REPORT

A 21 year old man was admitted to hospital as an emergency complaining of left sided chest pain. Chest radiograph revealed a complete non compressive left-sided pneumothorax which resolved following thoracic drainage. A more detailed history revealed repeated and regular use of nitrous oxide by inhalation, for its consciousness-altering effect during rave parties.

DISCUSSION

The principal side effects occurring as a consequence of repeated exposures to nitrous oxide are haematological, neuropsychiatric and teratogenic. Rare cases of pneumothorax have been described associated with the use of nitrous oxide occurring as complications of anaesthesia or during laparoscopy where gas diffuses from the abdominal to the pleural cavity. Illicit use of nitrous oxide is rare and usually occurs in medical workers. Its spreading to the public may lead to accidents and unanticipated side effects.

CONCLUSION

Inhaled nitrous oxide can reveal asymptomatic pneumothorax by worsening it. The consequences can be dramatic in case of illicit use because of ignorance of side effects.

Multimodal treatment of thymic carcinoma: Report of nine cases

Thymic carcinoma (TC) is thymic epithelial tumor which differs from thymoma because of its rarity, agressiveness and poor prognosis. We studied nine patients with TC according to the WHO (World Health Organization) criteria. Three of these nine patients had stage III disease and six patients had stage IV disease with the classification of Masaoka. Epidermoid TC was the most common subtype. Six patients received VIP chemotherapy comprising cisplatin, ifosfamide, uromitexan and etoposide. Five patients underwent surgical resection, preceded by neoadjuvant chemotherapy for four patients. After surgery, one patient received adjuvant radiotherapy and two patients received adjuvant radiochemotherapy. Six deaths were related to TC progression. The survival time ranged from 1 to 54 months with a median survival of 20 months for the group as a whole. Our descriptive study, based on nine stages III and IV TC, shows a documented efficacy of multimodal treatment (neoadjuvant chemotherapy, surgery and adjuvant treatment). VIP protocol was used for neoadjuvant chemotherapy. High-dose cisplatin (120mg/m(2)cycle), ifosfamide (6g/m(2)cycle) and etoposide (450mg/m(2)cycle) achieved better results than VIP (cisplatin 80mg/m(2)cycle), ifosfamide (4.8g/m(2)cycle) and etoposide (300mg/m(2)cycle). Surgical resection remains the main step in the treatment of TC and the modalities of adjuvant treatment must be defined in further studies.

Noninvasive Ventilation Using a Mouthpiece in Patients with Chronic Obstructive Pulmonary Disease and Acute Respiratory Failure

BACKGROUND

Noninvasive positive pressure ventilation (NPPV) delivered via a mouthpiece (mNPPV) has been successfully used in stable chronic restrictive respiratory insufficiency, but not in patients with chronic obstructive pulmonary disease (COPD) and acute respiratory failure (ARF).

OBJECTIVES

The purpose of this matched case-control study was to compare the usefulness of mNPPV to noninvasive ventilation using a nasal or oronasal mask (nNPPV) or standard medical treatment (SMT) in COPD patients with ARF.

METHODS

Twenty-nine patients receiving mNPPV were matched with 29 patients receiving nNPPV and 29 patients receiving SMT regarding age, SAPSII, admission PaCO(2) and pH.

RESULTS

In the mNPPV group, admission PaCO(2) and pH were 78.6 +/- 12 mm Hg and 7.30 +/- 0.04, respectively. mNPPV and nNPPV avoided the need for endotracheal intubation in 27 and 25 patients, respectively (nonsignificant) whereas SMT resulted in a higher mechanical ventilation rate (13 patients). At the end of the treatment protocol, PaCO(2) was lower in the mNPPV group (62.2 +/- 9.6 mm Hg) than in the SMT group (72.4 +/- 20.4 mm Hg, p < 0.018) leading to a significantly higher pH. No significant differences were observed between the mNPPV and nNPPV groups.

CONCLUSIONS

In case of moderate respiratory acidosis, noninvasive ventilation using a mouthpiece significantly reduces the endotracheal intubation rate in comparison with SMT and therefore appears to be a second-line alternative to noninvasive ventilation delivered via a mask, especially when poorly tolerated.

Non-tuberculous mycobacteria pulmonary infection: Management and follow-up of 31 infected patients

BACKGROUND

The global number of non-tuberculous mycobacteria (NTM) pulmonary infections is increasing. Treatment decisions and management are difficult and the prognosis of these infections has been rarely evaluated.

METHODS

The aim of this study was to evaluate management and prognosis of patients with NTM pulmonary infection in a French teaching hospital. In this study, we evaluated management of patients satisfying the ATS (American Thoracic Society) criteria for NTM pulmonary infection in Amiens hospital from 1992 to 2002 and retrospectively compared this management to ATS guidelines. Short-term and long-term survival was also described.

RESULTS

Thirty-one patients satisfying the ATS criteria for NTM pulmonary infection were included: 15 patients were infected with Mycobacterium xenopi, nine with Mycobacterium avium intracellulare, four with Mycobacterium kansasii and three patients were infected with rapidly growing mycobacteria. Twenty-seven patients had past or concomitant diseases responsible for local or systemic immunosuppression. Eleven patients were not treated. In the 20 treated patients, 13 different antibiotic combinations were used, often comprising three or more drugs. The median survival was 15 months. Twenty-one patients (67%) died before 5 years of follow-up. Thirty per cent of deaths were attributed to NTM pulmonary infection. Adjusting treatment to the results of susceptibility tests or ATS guidelines was not associated with any significant difference in survival.

CONCLUSION

As the high mortality rate may be related to concomitant diseases, management of NTM pulmonary infection also depends on comorbidities, and should be defined according to the severity of underlying diseases.

Assist-control ventilation vs. low levels of pressure support ventilation on sleep quality in intubated ICU patients

OBJECTIVE

To compare the impact of assist-control ventilation (ACV) and pressure support ventilation with 6 cmH2O inspiratory pressure (low PSV) on sleep quality.

DESIGN

Prospective randomized cross-over study.

PATIENTS

Twenty intubated and mechanically ventilated patients for acute on chronic respiratory failure.

MEASUREMENTS

Patients were monitored by standard polysomnography at the end of their weaning period. Patients were assigned to receive either ACV from 10 p.m. to 2 a.m. and low PSV from 2 a.m. to 6 a.m. (ACV/low PSV group) or low PSV from 10 p.m. to 2 a.m. and ACV from 2 a.m. to 6 a.m. (low PSV/ACV group).

RESULTS

There were significant increases in stages 1 and 2 non-rapid eye movement (NREM) sleep and reduction in wakefulness during the first part of the night and significant increases in stages 3 and 4 NREM sleep during the second part of the night were observed with ACV compared to low PSV. A significant negative correlation was observed between the perceived sleep quality and the amount of wakefulness while the amount of stage 2 NREM sleep was positively correlated with perceived sleep quality.

CONCLUSIONS

ACV was significantly associated with a better sleep quality than those recorded during pressure support. The perception of sleep quality appeared to be better with ACV than with low PSV. On the basis of these results we recommend that intubated and mechanically ventilated patients for acute on chronic respiratory failure should be reventilated at night during their weaning period.