Apparent Absence of Pneumocystis jirovecii in Healthy Subjects

We prospectively investigated 30 healthy subjects with normal CD4+ T cell counts in blood and normal findings of spirometry and chest radiography for the presence of Pneumocystis jirovecii, by performing polymerase chain reaction on sputum specimens. Fifty patients with chronic obstructive pulmonary disease were investigated at the same time in the same manner; this group was used as controls for the diagnosis of pulmonary colonization with P. jirovecii. None of the healthy subjects had positive test results, whereas the fungus was detected in 8 patients with chronic obstructive pulmonary disease. The results suggest that in our region (Amiens, France), P. jirovecii is apparently uncommon in healthy subjects and that this population, therefore, plays a minor role in circulation of the fungus within human communities.

[Tuberculosis of the submandibular gland: a case report]

INTRODUCTION

Tuberculosis remains an important public health problem in France. After a certain decline, its incidence has remained unchanged since 1990. 30% of tuberculosis cases are extra-pulmonary form, most of them concern nodes especially in cervical areas.

CASE REPORT

This case of submandibular tuberculosis illustrates diagnostic and therapeutic difficulties.

DISCUSSION

There are few clinical signs or laboratory clues suggestive of tuberculosis, however a surgery cannot be avoided and must be performed in combination with antituberculosis chemotherapy.

[Evaluation of combined chemotherapy with vinorelbine, ifosfamide and cisplatin in the treatment of metastatic non-small cell bronchial carcinoma]

INTRODUCTION

In France, cancer of the bronchus is responsible for 25,000 deaths per year. Non small cell lung cancer (NSCLC) represents 80% of bronchial carcinoma of which 40-50% are mefastatic at the time of diagnosis. At present, although the therapeutic benefits are modest, it is now recognised that combination chemotherapy including platinum salts improves the survival of these patients.

METHODS

We analysed retrospectively a cohort of 57 patients suffering from stage IV NSCLC treated with chemotherapy combining cisplatin (80 mg/rn2 on day 1), vinorelbine (25 mg/rn2 on days 1 and 8) and ifosfamide (3000 mg/in 2 on day 1), (NIP), repeated every 21 days.

RESULTS

The population studied comprised 6 women and 51 men, of average age 59.8 +/- 9.1 years. A history tobacco use (smokers and ex-smokers) was identified in 93%. The WHO performance index was equal to or greater than 2 in 22.8%. All patients were studied in terms of toxicity and overall survival but only 40 (70%) were able to be evaluated in terms of response to treatment (on account of having received more than three cycles of NIP chemotherapy). For the group considered as a whole, the median survival was 6.7 months with a one year survival of 24.5%. Median survival without progression was 4.4 months. The most frequent toxicities were haematological and digestive. They were most common among patients over the age of 70 but had no effect on median survival. For the 40 patients for whom chemotherapy was evaluable, the objective response rate was 20%. This objective response was the only factor that was signiticantly correlated with one year survival: 62.5% in responders, 28.1% in non-responders (p < 0.05).

CONCLUSION

Treatment of stage IV NSCLC with NIP chemotherapy is effective and improves the survival of these patients independently of other prognostic factors such as age, the presence of cerebral metastases, performance status, histological type, the number of metastatic sites or the serum LOH level.

Community-acquired bacteraemic pneumococcal pneumonia in adults: effect of diminished penicillin susceptibility on clinical outcome

Pneumococcal pneumonia remains a common disease with a high mortality rate. Between 1995 and 2000, we prospectively analyzed 95 consecutive adult cases of community-acquired bacteraemic pneumococcal pneumonia treated in a single centre. The incidence of pneumococcal resistance to penicillin increased from 19 to 50% during the study period. Multivariate analysis showed that only age and recent hospitalization were independently associated with fatal outcome. The proportion of penicillin-resistant strains was slightly but not significantly higher among patients who died before the fourth hospital day than among those who died later. Patients who died before D4 were more likely to have a recent history of hospitalization, cancer and/or chemotherapy. It thus appears that infection by a resistant pneumococcal strain is not in itself a gravity factor in this setting, but that their acquisition is associated with pejorative clinical features.

Comparison of 2 maintenance doses (100 microg vs 200 microg) in Hymenoptera venom immunotherapy: influence of the maintenance dose on the immunologic response

BACKGROUND

In Hymenoptera venom immunotherapy, the maintenance dose is usually 100 microg. However, persistent systemic reactions to sting challenges could be treated by an increase in the maintenance dose to 200 microg with success, suggesting greater efficiency.

OBJECTIVE

To compare the effects of 2 monthly maintenance doses (100 microg vs 200 microg) on skin test sensitivity and venom specific IgE antibody levels.

METHODS

Twenty-two patients receiving Vespula venom immunotherapy were enrolled in this retrospective study. After rush therapy, the 100-microg maintenance dose initially administered was maintained (group 1, n = 13) or was increased to 200 microg (group 2, n = 9).

RESULTS

Levels of venom specific IgE antibody and skin test results measured before the onset of immunotherapy were comparable in both groups. Unlike in group 1, a maintenance dose of 200 microg resulted in significant decreases in venom specific IgE antibody levels and skin test sensitivity.

CONCLUSIONS

Increasing the monthly maintenance dose to 200 microg results in a greater degree of change in venom specific IgE antibody levels and skin test sensitivity than when maintaining a 100-microg dose. Our data strengthen those of previous clinical studies showing the usefulness of a 200-microg maintenance dose in the case of clinical failure of a 100-microg dose.

Oxygen consumption and PEEPe in ventilated COPD patients

The intrinsic positive-end-expiratory pressure (PEEPi) increases the inspiratory load, the cost of breathing and thus oxygen consumption (V(O2)). It has been shown that applying an extrinsic positive-end-expiratory pressure (PEEPe) reduces the inspiratory threshold load but the optimal PEEPe level is still in debate. We hypothesize that the best level of PEEPe could induce a decrease in V(O2) by reducing the V(O2) demands from PEEPi. Nine mechanically ventilated COPD patients were included. The level of PEEPe was determined in accordance with the static PEEPi. V(O2) was measured using an automatic gas analyser during synchronized intermittent mandatory ventilation (SIMV): without PEEPe, with a PEEPe equal to 50% of static PEEPi and with a PEEPe equal to 100% of static PEEPi. Static PEEPi appeared to be significantly correlated with the degree of airflow obstruction (FEV1) (P<0.05). Applying a PEEPe equal to static PEEPi resulted in a significant decrease in V(O2) (P<0.05) whereas the change in V(O2) proved to be unpredictable for a PEEPe level of 50% of static PEEPi. In conclusion, V(O2) decreases progressively when increasing PEEPe up to a level equal to 100% of static PEEPi. Thus, in mechanically ventilated COPD patients with a FEV1 < or = 1000 ml, applying a PEEPe of 5 cmH2O should be recommended.

[Aortobronchial fistulas]

INTRODUCTION

Aortobronchial fistulas are uncommon but generally fatal if not treated surgically. Haemoptysis is the main symptom of this pathology. STATES OF ART AND PERSPECTIVES: Aortobronchial fistulas occur most commonly in patients with thoracic aneurysms (atherosclerosis, mycotic, aortic surgery's complication...). Main investigation is CT angiography with 2 D and 3 D reconstructions.

CONCLUSION

Endovascular exclusion can be efficient treatment option.

Étude BPCO-EP : prévalence et prédiction de l’embolie pulmonaire dans l’exacerbation de la broncho-pneumopathie obstructive chronique

INTRODUCTION

Patients suffering from chronic obstructive pulmonary disease (COPD) are often admitted to hospital with an exacerbation of their disease that manifests itself with an increase in cough and/or sputum, increased dyspnoea and sometimes chest pain. These episodes are most often attributed to an acute exacerbation of bronchial infection but the real cause is often unknown. COPD is considered a risk factor for pulmonary embolism (PE) and PE is part of the differential diagnosis of an acute exacerbation of COPD. However, the symptoms of these two conditions overlap to a considerable extent and the investigation of PE is often ignored in these patients. Therefore the true prevalence of PE in this situation is unknown. Nevertheless several small series suggest that up to 30% of patients seen as emergencies with exacerbations of COPD may have a deep vein thrombosis or PE. The aims of this study are therefore: 1. To evaluate the prevalence of PE in patients admitted as emergencies with exacerbations of COPD; and 2. To attempt to develop a prediction guide for PE in this population in order to identify the patients in whom PE should be investigated.

MATERIALS AND METHODS

600 consecutive patients admitted as emergencies with exacerbations of COPD will be included in a cross sectional study in three university hospitals (Geneva and Lausanne in Switzerland, and Amiens in France). Patients fulfilling the inclusion criteria will be investigated by a diagnostic algorithm appropriate for the study of PE, including D-dimer levels and, in those with abnormal results, ultrasonic scan of the deep veins of the legs and spiral CT scan. The patient characteristics on admission will be incorporated in a multivariate regression analysis in an attempt to identify the predictive factors for PE in these patients. The expected duration of the study is 24 months.

EXPECTED RESULTS

This study should determine the prevalence of PE in patients admitted as emergencies with exacerbations of COPD and therefore help decide when, and in which patients, a systematic search for PE should be undertaken.

Pneumocystis jirovecii dihydropteroate synthase genotypes in immunocompetent infants and immunosuppressed adults, Amiens, France

To date, investigations of Pneumocystis jiroveci circulation in the human reservoir through the dihydropteroate synthase (DHPS) locus analysis have only been conducted by examining P. jirovecii isolates from immunosuppressed patients with Pneumocystis pneumonia (PCP). Our study identifies P. jirovecii genotypes at this locus in 33 immunocompetent infants colonized with P. jirovecii contemporaneously with a bronchiolitis episode and in 13 adults with PCP; both groups of patients were monitored in Amiens, France. The results have pointed out identical features of P. jirovecii DHPS genotypes in the two groups, suggesting that in these two groups, transmission cycles of P. jirovecii infections are linked. If these two groups represent sentinel populations for P. jirovecii infections, our results suggest that all persons parasitized by P. jirovecii, whatever their risk factor for infection and the form of parasitism they have, act as interwoven circulation networks of P. jirovecii.

Similar genotypes of Pneumocystis jirovecii in different forms of Pneumocystis infection

This study describes the genotyping of Pneumocystis jirovecii organisms isolated from three groups of patients that developed diverse forms of P. jirovecii infection; the patients were monitored in the same French hospital. Forty archival specimens from 13 adults with Pneumocystis pneumonia, eight adults colonized by P. jirovecii and 19 immunocompetent infants infected with the fungus contemporaneously with a bronchiolitis episode were analysed retrospectively. Genotyping was performed by analysis of sequences of the internal transcribed spacer (ITS)1 and ITS2 regions, and of the dihydropteroate synthase (DHPS) locus. At the ITS regions, a high diversity of genotypes, identical main genotypes (B1a3 and B2a1) and the occurrence of mixed infections (more than one genotype) were observed in the three patient groups. At the DHPS locus, the results indicated the presence of mutants in the two adult groups, as well as in the infant group. Consequently, at these two independent genomic regions, P. jirovecii isolates from patients who developed different forms of infection and who lived in the same geographical region presented common characteristics. These results suggest that patients infected with P. jirovecii, whatever the form of infection they present, are part of a common human reservoir for P. jirovecii.

Assistance ventilatoire à domicile : justifications et contraintes physiopathologiques

INTRODUCTION

Domiciliary assisted ventilation (DAV) may be undertaken invasively or non-invasively. Non-invasive DAV is used for patients suffering from alveolar hypoventilation due to restrictive pathology. Invasive DAV is reserved for "indications of necessity" that is when non-invasive ventilation is contraindicated due to the absence of adequate cough and for alveolar hypoventilation leading to hypercapnoea during spontaneous ventilation.

STATE OF THE ART

The main pathophysiological limitation to non-invasive ventilation is the interference of the glottis. In this mode the glottis imposes a variable resistance to the ventilation delivered. Its behaviour is more predictable during Volume controlled than during pressure controlled ventilation. The control parameters of a Volume controlled ventilator are very different from those used in invasive ventilation during which the respiratory system may be regarded as a single compartment (provided a cuffed tube bypasses the upper airway). In non-invasive DAV: mode VCM, tidal volume 13 mls kg(-1), rate 20 cycles min(-1), insp/exp ratio 1/1.2. In invasive DAV: mode VCM, tidal volume 8-10 mls kg(-1), rate 12 cycles min(-1), insp/exp ratio depending on the pathology 1/2.

PERSPECTIVES

As non-invasive DAV is essentially delivered during sleep the parameters for each patient can be optimised during polysomnography because waking, leading to a partial glottic occlusion, interferes with the ventilation delivered.

CONCLUSIONS

Recent understanding of the way the glottis interferes with mechanical ventilation when delivered non-invasively should lead to a revision of earlier practices based on invasive ventilation.

[Medico-economic evaluation of a care management program for asthmatic patients]

This study aimed at measuring the medico-economic interest of a care management programme established for asthmatic patients in the Amiens region ("Action Asthma Amieris") by using and comparing different evaluation tools. Three tools were used in parallel: 1) a questionnaire for collecting information on healthcare received was completed monthly by 305 patients recruited by 73 physicians between November 1998 and January 1999; 2) data issued by the national insurance fund for the years 1998 and 1999, for those patients included after January 1999; and 3) data on all hospitalisations for 1998 and 1999 in the University Hospital Centre obtained from the French hospital information database (PMSI). Data from the national insurance fund and from the PMSI are essential to evaluate costs, since the patients' statements proved to under-estimate the amount of healthcare administered and received. Following the implementation of this asthma care management programme, an increase of pharmaceutical expenses and a decrease in the number of hospitalisations for asthmatic patients were observed.

[Lemierre syndrome: unusual, but still possible]

Lemierre syndrome is a rare disease, which was life-threatening before the antibiotics era. We report here two cases with favorable outcome. Clinical features are stereotypic: tonsillis, cervical pain revealing deep vein thrombosis, and pulmonary septic metastasis. The most frequent causal germ on blood cultures is Fusobacterium necrophorum but other anaerobial bacteries can be found. Cervical Doppler-ultrasonography, and thoracic tomodensitometry are useful. Medical treatment is antibiotic therapy and anticoagulation.

Multilocus Genotyping of Pneumocystis jirovecii in Patients Developing Diverse Forms of Parasitism: Implication for a Wide Human Reservoir for the Fungus

Pneumocystis jirovecii ITS and DHPS genotypes were identified in 3 patient groups developing diverse forms of P. jirovecii infections: 13 patients with Pneumocystis pneumonia, 8 patients merely colonized by the fungus, and 19 immunocompetent infants with bronchiolitis developing mild P. jirovecii infection. Common P. jirovecii genotypes were found in the 3 patient groups, suggesting that common sources of P. jirovecii were involved in the fungus acquisition, and that transmission cycles of P. jirovecii infections in these patient groups are not independent. Parasitized patients, whatever the form of parasitism they present, may be part of a common reservoir for P. jirovecii.

[Transudative pleural effusions and the ovarian hyperstimulation syndrome]

INTRODUCTION

Pleural effusions occurring in the ovarian hyperstimulation syndrome (OHS) are frequently associated with haemoconcentration.

OBSERVATIONS

We report three cases of symptomatic pleurisy with ascites, requiring therapeutic pleural aspiration. Biochemical analysis of these effusions may give rise to confusion as consideration of the pleural fluid protein levels in isolation may lead to the incorrect diagnosis of an exudate. On account of the electrolyte disorders and haemoconcentration seen in OHS a pleural fluid protein level of over 30 g per litre (the traditional definition of an exudative pleurisy) should be interpreted in relation of a serum concentration.

CONCLUSIONS

Measurement of the pleural and serum protein and LDH levels, complemented by a serum-effusion albumin gradient, should permit confirmation of the transudative nature of the pleural effusions. It seemed important to us to confirm this concept in three personal cases, as the data reported in the literature are more often reported as evidence for an exudates. Furthermore, a favourable response to symptomatic treatment tends to confirm the transudative nature of the effusions in OHS.

Pneumocystis jiroveci internal transcribed spacer types in patients colonized by the fungus and in patients with pneumocystosis from the same French geographic region

Pneumocystis jiroveci (human-derived Pneumocystis) infections can display a broad spectrum of clinical presentations, of which pulmonary colonization with the fungus may represent an important part, occurring frequently in patients with various underlying diseases and presenting alternative diagnoses of acute pneumocystosis (Pneumocystis carinii pneumonia [PCP]). There are few data concerning the P. jiroveci genotypes involved in pulmonary colonization, whereas several genotypes responsible for PCP in immunocompromised patients have been described. In this study, P. jiroveci genotypes have retrospectively been investigated and compared in 6 colonized patients and in 11 patients with PCP who were in the same hospital. Seventeen archival bronchoalveolar lavage samples were genotyped at internal-transcribed spacer 1 (ITS1) and ITS2 of the nuclear rRNA operon. Fourteen different genotypes were identified, of which 1 was found only in colonized patients, 10 were found only in patients with PCP, and 3 were found in both patient populations. Mixed infections were diagnosed in 2 of the 6 colonized patients and in 6 of the 11 patients with PCP. The results show that similar genotypes can be responsible for PCP as well as pulmonary colonization. There is a high diversity of genotypes in colonized patients and in patients with PCP. Mixed infections may occur in these two patient populations. These shared features of P. jiroveci ITS genotypes in colonized patients and patients with PCP suggest that human populations infected by P. jiroveci, whatever the clinical manifestation, may play a role as a common reservoir for the fungus.

[Pulmonary embolism and sibilant types of chronic obstructive pulmonary disease decompensations]

Pulmonary Embolism (PE) poses an important diagnostic problem in patients with chronic obstructive pulmonary disease (COPD). Indeed PE may aggravate the already precarious respiratory state of these fragile patients. Moreover, these two conditions share common symptoms: dyspnoea, wheezing, pleural pain, haemoptysis, palpitations and signs of right cardiac insufficiency. In two studies, one retrospective and the other prospective, we investigated the incidence of PE in patients with non-infective exacerbations of their COPD. The retrospective study was carried out over two years and involved 50 COPD patients with non-infective respiratory exacerbations. In this population, 10 patients out of 50 (20%) had a documented PE. No predictive factor was identified. The prospective study was conducted over one year and COPD patients admitted to hospital with exacerbations were included in the study if they had a positive D-dimer blood test and no evidence of acute respiratory infection. 31 patients were studied with Doppler ultra-sound examination of the legs and a lung perfusion scan. The presence or absence of PE was determined and the two groups were compared. 9 patients out of 31 (29%) had a documented PE. Six of these nine patients had a deep venous thrombosis (DVT). Two predictive factors of PE were identified: existence of a DVT and a significant fall in PaO(2) from baseline state (DeltaPaO(2) > 22 mmHg). We conclude that PE is a frequent (20 to 30%) of non-infective respiratory decompensation in COPD patients. Faced with an unexplained respiratory exacerbation in these patients, a lung perfusion scan should be routinely undertaken to rule out a PE when the D-dimers are positive.

Effects of intermittent negative pressure ventilation on effective ventilation in normal awake subjects

RATIONALE

Previous studies have shown that an increase in inspiratory pressure during nasal intermittent positive pressure ventilation (IPPV) does not result in increased effective minute ventilation (E) due to glottic interference.

STUDY OBJECTIVES

To test the consequences of increases in negative pressure ventilation (NPV) on V(E).

MATERIAL AND METHODS

Eight healthy awake subjects underwent NPV delivered by an iron lung. First, NPV was started at a respirator frequency (f) of 15 cycles per minute with an inspiratory negative pressure (INP) of - 15 cm H(2)O (F15-P15). Then, f was increased to 20 cycles per minute and INP was kept at - 15 cm H(2)O. Next, f was kept at 20 cycles per minute and INP was reduced to - 30 cm H(2)O (F20-P30). Finally, f was decreased to 15 cycles per minute and INP was kept at - 30 cm H(2)O. At each step and for each breath, effective tidal volume (VT), V(E), and end-tidal carbon dioxide pressure were measured. In three subjects, the glottis width was assessed using fiberoptic bronchoscopy.

RESULTS

From spontaneous breathing to the first step of NPV (F15-P15), we observed an inhibition of the phasic inspiratory diaphragmatic electromyogram concomitant to a significant increase in V(E) (p < 0.0005). For the group as a whole, the increase in mechanical ventilation (from F15-P15 to F20-P30) resulted in significant increases in VT and V(E) leading to hypocapnia (p < 0.0005). Moreover, the glottis width did not decrease with the increase in mechanical ventilation.

CONCLUSIONS

We conclude that in normal awake subjects, NPV allowed a significant increase in V(E). These results differ from those previously obtained with nasal IPPV in which the glottic width interferes with the delivered mechanical ventilation.

[Bronchiolitis obliterans organizing pneumonia associated with dermatomyositis and antiphospholipid syndrome]

Dermatomyositis and antiphospholipid syndrome are rare diseases that can be associated pulmonary damage. We report a case of anti-phospholipid syndrome that presented with bilateral pulmonary embolism and subsequently developed pulmonary infiltrates in association with the characteristic muscular and cutaneous features of dermatomyositis. Histological examination of trans-bronchial biopsies revealed bronchiolitis obliterans organizing pneumonia.

Effects of hypocapnic hyperventilation on the response to hypoxia in normal subjects receiving intermittent positive-pressure ventilation

OBJECTIVE

To confirm the hypothesis that the ventilatory response to hypoxia (VRH) may be abolished by hypocapnia.

METHODS

We studied four healthy subjects during intermittent positive-pressure ventilation delivered through a nasal mask (nIPPV). Delivered minute ventilation (Ed) was progressively increased to lower end-tidal carbon dioxide pressure (PETCO(2)) below the apneic threshold. Then, at different hypocapnic levels, nitrogen was added to induce falls in oxygen saturation, a hypoxic run (N(2) run). For each N(2) run, the reappearance of a diaphragmatic muscle activity and/or an increase in effective minute ventilation (E) and/or deformations in mask-pressure tracings were considered as a VRH, whereas unchanged tracings signified absence of a VRH. For the N(2) runs eliciting a VRH, the threshold response to hypoxia (TRh) was defined as the transcutaneous oxygen saturation level that corresponds to the beginning of the ventilatory changes.

RESULTS

Thirty-seven N(2) runs were performed (7 N(2) runs during wakefulness and 30 N(2) runs during sleep). For severe hypocapnia (PETCO(2) of 27.1 +/- 5.2 mm Hg), no VRH was noted, whereas a VRH was observed for N(2) runs performed at significantly higher PETCO(2) levels (PETCO(2) of 34.0 +/- 2.1 mm Hg, p < 0.001). Deep oxygen desaturation (up to 64%) never elicited a VRH when the PETCO(2) level was < 29.3 mm Hg, which was considered the carbon dioxide inhibition threshold. For the 16 N(2) runs inducing a VRH, no correlations were found between PETCO(2) and TRh and between TRh and both Ed and E.

CONCLUSION

During nIPPV, VRH is highly dependent on the carbon dioxide level and can be definitely abolished for severe hypocapnia.

[Spontaneous rupture of the esophagus or Boerhaave syndrome. Report of 3 cases and review of the literature]

A triad of signs constitutes Boerhaave syndrome: forceful vomiting, chest pain and subcutaneous emphysema. The syndrome results from spontaneous rupture of the oesophageal wall leading to an oeso-pleural or oeso-mediastinal fistula. Positive diagnosis is established with a water-soluble swallow, sometimes coupled with computed tomography of the thorax. Boerhaave syndrome is a surgical emergency. We report three cases of spontaneous rupture of the oesophagus and analyze the importance of emergency surgery as well as emergency treatment of the sepsis, an important prognosis factor.

[Effects of a pressure support ventilation of 6 cm H2O on oxygen consumption of the respiratory muscles during weaning of mechanical ventilation]

OBJECTIVE

To determine the effects of a pressure support ventilation (PSV) of 6 cm H(2)O during spontaneous breathing on oxygen consumption of the respiratory muscles (VO(2) resp), gas exchange, respiratory rate, tidal volume and to determine if these low levels of PSV can reduce or cancel the increase in work of breathing induced by the resistances of the endotracheal tube and the circuit of the respirator.

PATIENTS AND METHODS

Prospective study. Twenty intubated patients were studied. The VO(2) resp was assessed by measurements of inspired and expired concentrations of oxygen (O(2)) and carbon dioxide (CO(2)) in patients during controlled ventilation and spontaneous breathing. Gas exchange, respiratory rate, minute ventilation, tidal volume and VO(2) resp were collected during spontaneous breathing with a PSV level of 6 cm H(2)O and without PSV.

SETTING

Respiratory Intensive Care Unit, Amiens, University Hospital 80054 Amiens.

RESULTS

A PSV level of 6 cm H(2)O significantly increased the spontaneous tidal volume (+12%) without any modification in respiratory rate, minute ventilation, tidal volume and gas exchange. No significant improvement in VO(2) resp was found when a PSV level of 6 cm H(2)O was added.

CONCLUSION

Despite a significant increase in spontaneous tidal volume, adding a PSV level of 6 cm H(2)O did not improve VO(2) resp. Thus, low level of PSV did not reduce the increased work of breathing induced by the resistances of the ventilator tubing and the endotracheal tube.

[Lipid pneumonia and pleural-pulmonary atypical mycobacteriosis]

We report a case of fat deposit pneumonia extending to the parietal pleura with a granulomatous reaction centered on the fat vaculoles. This case was complicated by an atypical and fatal mycobacterial infection caused by Mycobacterium chelonae. The severity of Mycobacterium chelonae infection in fat deposit pneumonia warrants early empirical antibiotic therapy.

[Traumatic pulmonary pseudocysts. Mechanisms of formation]

Pulmonary pseudocysts (PPC) classically relate to chest trauma. It is a rare entity in adults, with multiple differential diagnosis. PPC most often evolve favorably. The clinical diagnosis is difficult to assess due to the poor and non specific clinical data. Chest radiographs are usually unsufficient for the diagnosis and the imaging modality of choice is computed tomography (CT). CT patterns of PPC relate to single or numerous cavities surrounded by air space consolidations. The physiopathological mechanisms of PPC remains uncertain. The histological study of this reported case affords some worth data to highlight the pathogenesis of this acquired abnormality.

[Intensive care and respiratory sleep disorders]

The study of respiratory sleep disorders in intensive care is a developing field. Indeed sleep pathology concerns not only pneumologists and neurophysiologists but also numerous specialties including medicosurgical resuscitation. The advent of "portable" appliances should facilitate access to polysomnography (PSG) for diagnosis of sleep respiratory disorders (RDS) in the intensive care unit. This examination can be appropriate in two separate circumstances. RDS in life-threatening situations (generally respiratory and/or cardiac failure) or when RDS is worsened by the specific conditions of intensive care units: "intensive care-induced RDS". In both cases, easy diagnosis of RDS by PSG allows adjustment of the treatment (corrections of iatrogenic factors, continuous positive airway pressure [CPAP], noninvasive ventilation [NIV], oxygen [O2]. A specific treatment of the well documented RDS is most desirable, as the patients are considered to be at high risk for endotracheal intubation. If diagnosis of RDS is not made during the acute phase, the intensive care physician should be informed of the clinical and paraclinical elements leading to prescription of a delayed polysomnography in order to reduce the risk of further vital distress.