Le sarcome artériel pulmonaire est une pathologie rare dont les symptômes ne sont pas spécifiques. La présentation clinique et radiologique peut mimer une embolie pulmonaire avec hypertension pulmonaire post-embolique. Sa prise en charge est essentiellement chirurgicale mais le pronostic de cette pathologie reste sombre. Nous rapportons le cas d’un patient dont la présentation initiale était celle d’une embolie pulmonaire. L’évolution clinique était défavorable sous traitement par anti-vitamine K bien conduit avec une extension des images endovasculaires et une majoration de l’hypertension pulmonaire. Les résultats suspects de la tomographie par émission de positons avaient permis d’orienter le diagnostic vers un sarcome artériel pulmonaire, confirmé lors de la prise en charge chirurgicale. Cependant, l’évolution était défavorable, conduisant au décès du patient. Ce cas conforte l’idée que les présentations cliniques et scanographiques du sarcome artériel pulmonaire et de l’hypertension pulmonaire post-embolique sont similaires. La tomographie par émission de positons est un examen potentiellement intéressant pour distinguer ces deux diagnostics. Pulmonary artery sarcoma is a rare disease with non-specific symptoms. The clinical and radiological presentation can mimic pulmonary embolism with chronic thromboembolic pulmonary hypertension. Management is essentially surgical but the prognosis remains poor. A patient presented with symptoms of pulmonary embolism. Despite vitamin K antagonist therapy, he suffered from extension of the endovascular defects and his pulmonary hypertension increased. Suspicious results of positron emission tomography suggested the diagnosis of pulmonary artery sarcoma that was confirmed by surgery. However, the outcome was unfavourable, leading to death of the patient. This case reinforces the idea that the clinical and tomodensitometric presentations of pulmonary arterial sarcoma and chronic thromboembolic pulmonary hypertension are similar. The positron emission tomography seems to be a key to distinguishing these two diagnoses.

Introduction. - Pulmonary artery sarcoma is a rare disease with non-specific symptoms. The clinical and radiological presentation can mimic pulmonary embolism with chronic thromboembolic pulmonary hypertension. Management is essentially surgical but the prognosis remains poor.Case report. - A patient presented with symptoms of pulmonary embolism. Despite vitamin K antagonist therapy, he suffered from extension of the endovascular defects and his pulmonary hypertension increased. Suspicious results of positron emission tomography suggested the diagnosis of pulmonary artery sarcoma that was confirmed by surgery. However, the outcome was unfavourable, leading to death of the patient.Conclusion. - This case reinforces the idea that the clinical and tomodensitometric presentations of pulmonary arterial sarcoma and chronic thromboembolic pulmonary hypertension are similar. The positron emission tomography seems to be a key to distinguishing these two diagnoses. (C) 2015 SPLF. Published by Elsevier Masson SAS. All rights reserved.

Venous thromboembolism (VTE) affects about 9% of ICU patients but is frequently asymptomatic. VTE increases ventilation duration, length of stay and mortality in intensive care unit (ICU) patients. Risk factors for VTE in critically ill patients are multiple, including obesity (body mass index [BMI]>30 kg/m). As obesity concerns about 25% of ICU patients, VTE prophylaxis for ICU obese patients (OP) remains an important issue. Because of lack of large randomized and adequately powered trials, no specific guidelines are available in ICU OP. As those patients have an increased VTE risk, pharmacological prophylaxis is necessary. Using low molecular weight heparin (LWMHs) is logical, because LWMHs remain the best-documented anticoagulant class in OP. Benefit of weight based dosing regimens for LMWH in VTE prevention is not proven for OP in ICU or in bariatric surgery. Pharmacodymanic approach using anti-Xa monitoring has not been studied in ICU OP. Mechanical methods, such as graduated compression stockings or intermittent pneumatic compression devices, have not been sufficiently studied but remain underused in potentially suitable patients. In the absence of specific clinical trial about VTE prophylaxis in overweight patients, we suggest to follow the 9 American College of Chest Physicians guidelines by using LWMHs with standard dose. The routine association of mechanical methods cannot be recommended.

L'embolie pulmonaire (EP) est une pathologie fréquente qui concerne le médecin généraliste (MG), impliqué dans la stratégie diagnostique initiale (évaluation de la probabilité clinique (PC) et dosage quantitatif des D-dimères). L'objectif principal est d'évaluer la connaissance de l'algorithme diagnostique de l'EP chez les MG. Enquête prospective auprès de 524 MG de Paris (15e et 16e), d'Issy-les-Moulineaux et de Vanves. Douze questions évaluant les connaissances sur l'EP et deux cas cliniques (CC). Les facteurs associés à des réponses justes aux CC ont été analysés en multivariée. Le taux de réponse était de 30 %. Parmi les 155 MG, 86 étaient des hommes 118 (86 %) exerçaient depuis plus de 20 ans. Une EP avait été suspectée au moins une fois par 92 % des MG. Les facteurs de risque et les symptômes d'EP étaient connus des MG à l'exception de l'âge et du traitement hormonal substitutif, respectivement cités dans 55 % et 53 % des cas. La stratégie diagnostique n'était pas maîtrisée : 55 % ignoraient l'existence de scores de PC et 35 % ne savaient pas que des D-dimères négatifs éliminent une EP en cas de PC non forte. Un quart (24 %) des MG avaient les 2 cas cliniques justes ; 20 % des examens proposés n'étaient pas recommandés. En analyse multivariée, la participation à une formation spécifique sur l'EP était prédictive de réponses justes (p < 0,017). Bien que le diagnostic d'EP soit une problématique de leur exercice, les MG n'en maîtrisent pas l'algorithme diagnostique. La probabilité clinique est rarement évaluée et l'utilisation des D-dimères non maîtrisée. Des formations spécifiques pourraient améliorer le niveau de connaissance.

Le plus souvent asymptomatique, la maladie veineuse thromboembolique (MVTE) est fréquente (9 %) en réanimation et altère le pronostic des patients. Le risque de MVTE en réanimation est multifactoriel et inclut l’obésité. Plus de la moitié des patients de réanimation sont en surpoids et un quart est obèse (index de masse corporelle [IMC]>30 kg/m2). La thromboprophylaxie de ces patients est donc un problème quotidien.

La broncopneumopatia cronica ostruttiva (BPCO) è un problema importante di salute pubblica sia per la morbilità e la mortalità che per i costi sanitari che essa genera. Tenuto conto delle frequenti comorbilità (in particolare cardiovascolari), la gestione deve essere multidisciplinare. L’evoluzione di questa malattia è costellata di episodi acuti che aggravano la prognosi a lungo termine e che, nei casi più gravi, mettono in gioco la prognosi vitale. Il trattamento sintomatico degli scompensi è stato oggetto di numerose raccomandazioni basate, per la maggior parte, su degli studi disomogenei, il cui elemento più dibattuto resta quello dei corticosteroidi sistemici. Viceversa, i broncodilatatori per via inalata hanno dimostrato la loro efficacia. Il trattamento del fattore eziologico dello scompenso è fondamentale: il fattore più frequente è un’infezione respiratoria. L’utilizzo degli antibiotici è ampiamente diffuso, ma deve limitarsi ai casi di polmoniti o di riacutizzazioni di BPCO con sovrainfezione nei pazienti agli stadi GOLD (global initiative for chronic obstructive lung disease) più gravi (stadi definiti in funzione del volume espiratorio massimo durante il primo secondo [VEMS]). Diversi lavori si interessano ai dosaggi di bioindicatori per orientare la prescrizione della terapia antibiotica; nessuno è consigliato di routine a tutt’oggi. A proposito degli scompensi più gravi che giustificano un ricovero in terapia intensiva, l’avvento della ventilazione non invasiva da più di due decenni ha trasformato la gestione e la prognosi di questi pazienti. Essa deve restare la metodica di assistenza ventilatoria di elezione, sempre rispettando le sue indicazioni e controindicazioni per non ritardare l’instaurazione di una ventilazione invasiva, in caso di necessità. L’esperienza delle equipe che praticano queste tecniche è garanzia della loro efficacia. Infine, dopo la fase acuta, occorrerà pensare all’implementazione di un follow-up e dei mezzi di prevenzione delle esacerbazioni e, all’occorrenza, a una riabilitazione respiratoria nel quadro di una gestione globale e multidisciplinare.

BACKGROUND:Diagnostic algorithms for pulmonary embolism (PE) have been validated in patients attending hospital emergency departments. However, general practitioners (GPs) are often the professionals of first resort for the majority of non-critical cases of PE. AIM:To evaluate the knowledge of the diagnostic algorithm for PE among GPs in France. DESIGN AND SETTING:Questionnaire-based survey of GPs with a private practice. METHOD:All GPs in the study area were sent a questionnaire including several questions on the diagnosis of PE and two clinical cases scenario with suspected PE. Factors associated with knowledge of the diagnostic algorithm were analysed by univariate and multivariate analyses. RESULTS:Five-hundred and eight questionnaires were distributed and 155 (30.5%) were available for analysis. Only 55% of the GPs did know about clinical scores for the assessment of clinical probability of PE and 42% of the GPs were aware that clinical probability is needed to interpret the result of D-dimer testing. Forty GPs (26%) gave valid responses to both clinical cases, 54 GPs (35%) had one valid case out of the two and 61 (39%) gave invalid responses to both clinical cases. Participation in specific training on PE was significantly associated with valid responses to the two clinical cases in multivariate analysis (p<0.017). CONCLUSION:The majority of GPs were unaware of the diagnostic algorithm for PE. Clinical probability was rarely assessed and knowledge about D-dimers was poor. Specific training on PE and greater awareness of clinical probability scores may promote knowledge of PE algorithm diagnosis.

La enfermedad pulmonar obstructiva crónica (EPOC) es un grave problema de salud pública, tanto por la morbilidad y la mortalidad como por los costes que genera. Debido a las comorbilidades frecuentes (sobre todo cardiovasculares), el tratamiento debe ser multidisciplinario. La evolución de la enfermedad incluye episodios agudos que agravan el pronóstico a largo plazo y que, en los casos más graves, comprometen el pronóstico vital. El tratamiento sintomático de las descompensaciones ha sido objeto de numerosas recomendaciones que, en su mayoría, se basan en estudios heterogéneos cuyo punto más controvertido sigue siendo la corticoterapia sistémica. En cambio, los broncodilatadores por inhalación han demostrado ser eficaces. Tratar el factor etiológico de la descompensación es primordial: el factor más frecuente es una infección respiratoria. El uso de los antibióticos está ampliamente extendido, pero debe limitarse a las neumonías o a las exacerbaciones de la EPOC con otra infección añadida en los pacientes de los estadios GOLD (global initiative for chronic obstructive lung disease) más graves (estadios definidos en función del volumen espiratorio máximo en el primer segundo [VEMS]). Existen varios trabajos relativos a la determinación de la concentración de biomarcadores para guiar la prescripción de la antibioticoterapia, pero hasta ahora ninguno de ellos se recomienda de rutina. En lo que se refiere a las descompensaciones más graves que justifican la hospitalización en cuidados intensivos, la disponibilidad de la ventilación no invasiva desde hace más de dos décadas ha modificado el tratamiento y el pronóstico. Debe seguir siendo el método de asistencia ventilatoria de elección, respetando las indicaciones y las contraindicaciones para no retrasar, llegado el caso, el comienzo de la ventilación invasiva. La experiencia de los equipos que usan estas técnicas garantiza su eficacia. Por último, después de la fase aguda, habrá que pensar en el seguimiento, los medios de prevención de las exacerbaciones y, si fuera necesario, la rehabilitación respiratoria en el contexto de un tratamiento general y multidisciplinario.

Aerosoltherapy is a first-line treatment for chronic obstructive respiratory diseases such as asthma and COPD. Treatment modalities and devices are varied and the choice of the device must be adapted to and optimized for every patient. Spacers can be used for some categories of patients for whom the use of other devices turns out to be complicated. The improvement of these treatments requires the optimization of the lung deposition of inhaled particles; lung modeling plays an essential role in the understanding of the mechanisms of flow in the airways. Regulations must frame prescription of inhaled treatments to optimize its quality and, thus, the care for these chronic diseases. Many generally-accepted ideas concerning these treatments turn out to be false. Inhaled treatments are constantly evolving, both pharmacologically and technologically. (C) 2012 SPLF. Published by Elsevier Masson SAS. All rights reserved.

BACKGROUND:We evaluated the ability of an infrared photoplethysmography arterial waveform (continuous non-invasive arterial pressure, CNAP) to estimate arterial pulse pressure variation (PPV). We compared the ability of non-invasive PPV to predict fluid responsiveness with invasive PPV, respiratory variation of pulse contour-derived stroke volume, and changes in cardiac index induced by passive leg raising (PLR) and end-expiratory occlusion (EEO) tests.METHODS:We measured the responses of cardiac index (PiCCO) to 500 ml of saline in 47 critically ill patients with haemodynamic failure. Before fluid administration, we recorded non-invasive and invasive PPVs, stroke volume variation, and changes in cardiac index induced by PLR and by 15 s EEO. Logistic regressions were performed to investigate the advantage of combining invasive PPV, stroke volume variation, PLR, and EEO when predicting fluid responsiveness.RESULTS:In eight patients, CNAP could not record arterial pressure. In the 39 remaining patients, fluid increased cardiac index by ≥15% in 17 'responders'. Considering the 195 pairs of measurements, the bias (sd) between invasive and non-invasive PPVs was -0.6 (2.3)%. The areas under the receiver operating characteristic (ROC) curves for predicting fluid responsiveness were 0.89 (95% confidence interval, 0.78-1.01) for non-invasive PPV compared with 0.89 (0.77-1.01), 0.84 (0.70-0.96), 0.95 (0.88-1.03), and 0.97 (0.91-1.03) for invasive pulse pressure, stroke volume variations, PLR, and EEO tests (no significant difference). Combining multiple tests did not significantly improve the area under the ROC curves.CONCLUSIONS:Non-invasive assessment of PPV seems valuable in predicting fluid responsiveness.

Communications from the 2011 meeting of the GAT are reported in this second article on the practical management of bronchial provocation tests and infectious risks associated with the use of nebulization. Recent advances on the role of nebulized hypertonic saline in the treatment of acute bronchiolitis in infants and of the nebulization in sinusal diseases are also reported.

Les communications de la réunion 2011 du GAT sont rapportées dans ce second article consacré aux modalités pratiques de la réalisation des tests de provocation bronchique et aux risques infectieux liés à la réalisation de l’aérosolthérapie. Les récentes avancées sur la place du sérum salé hypertonique nébulisé dans le traitement de la bronchiolite aiguë du nourrisson et de la nébulisation en général dans les pathologies nasosinusiennes sont également décrites.

L’attention des réanimateurs n’est guère attirée par les bactéries atypiques ou les virus dans le cadre des pneumonies communautaires sévères. Seules classiquement, Legionella pneumophila et les virus influenza, du fait de la pandémie grippale récente H1N1, restent présents dans la réflexion diagnostique. Pourtant, les pneumonies bactériennes atypiques ne sont pas rares, représentant jusqu’à 44 % des pneumonies communautaires. Considérées comme moins sévères que les pneumonies à bactéries pyogènes « typiques », 25 % d’entre elles justifient une hospitalisation, et 15 % présentent des critères de sepsis sévères. Si Legionella pneumophila est plus fréquemment en cause dans les formes graves, Mycoplasma pneumoniae peut être responsable de véritables défaillances multiviscérales. Les outils diagnostiques sont aujourd’hui performants (antigénurie légionelle et recherche en polymerase chain reaction [PCR] de mycoplasme en particulier) et permettent un diagnostic rapide et précoce. Le traitement est bien codifié et repose sur les macrolides ou les fluoroquinolones, en association dans les formes graves de légionellose. Le rôle des virus au cours des pneumonies communautaires sévères, seuls ou associés à des bactéries, devient de plus en plus établi grâce aux méthodes de diagnostic rapide de biologie moléculaire. Ces techniques ont permis la mise en évidence dans ces pneumonies de nombreux et nouveaux virus. Toute la question est désormais à l’imputabilité clinique de ces résultats biologiques très performants et donc à la décision d’instaurer ou non un traitement antiviral dont l’efficacité dans les formes sévères reste discutable.

L’aérosolthérapie est un traitement de choix des pathologies respiratoires chroniques que sont l’asthme et la bronchopneumopathie chronique obstructive (BPCO). Les modalités de traitement et les dispositifs existant sur le marché sont variés et le choix du dispositif doit être optimisé pour chaque patient. Les chambres d’inhalation ont leur place chez certaines catégories de patients pour lesquelles l’utilisation des autres dispositifs s’avère compliquée. L’amélioration des traitements inhalés passe, entre autres, par l’optimisation du dépôt pulmonaire des particules inhalées ; la modélisation pulmonaire joue un rôle essentiel dans la compréhension des mécanismes de flux dans les voies aériennes. La prescription doit être encadrée d’une réglementation visant à améliorer sa qualité et donc la prise en charge de ces maladies chroniques. Il existe beaucoup d’idées reçues concernant l’inhalothérapie, peu d’entre elles sont vraies. Les traitements inhalés sont en constante évolution pharmacologique et technologique.

Objectives:We tested whether the poor ability of pulse pressure variation to predict fluid responsiveness in cases of acute respiratory distress syndrome was related to low lung compliance. We also tested whether the changes in cardiac index induced by passive leg-raising and by an end-expiratory occlusion test were better than pulse pressure variation at predicting fluid responsiveness in acute respiratory distress syndrome patients. Design:Prospective study. Setting:Medical intensive care unit. Patients:We included 54 patients with circulatory shock (63 ± 13 yrs; Simplified Acute Physiology Score II, 63 ± 24). Twenty-seven patients had acute respiratory distress syndrome (compliance of the respiratory system, 22 ± 3 mL/cm H2O). In nonacute respiratory distress syndrome patients, the compliance of the respiratory system was 45 ± 9 mL/cm H2O. Measurements and Main Results:We measured the response of cardiac index (transpulmonary thermodilution) to fluid administration (500 mL saline). Before fluid administration, we recorded pulse pressure variation and the changes in pulse contour analysis-derived cardiac index induced by passive leg-raising and end-expiratory occlusion. Fluid increased cardiac index ≥15% (44% ± 39%) in 30 “responders.” Pulse pressure variation was significantly correlated with compliance of the respiratory system (r = .58), but not with tidal volume. The higher the compliance of the respiratory system, the better the prediction of fluid responsiveness by pulse pressure variation. A compliance of the respiratory system of 30 mL/cm H2O was the best cut-off for discriminating patients regarding the ability of pulse pressure variation to predict fluid responsiveness. If compliance of the respiratory system was >30 mL/cm H2O, then the area under the receiver-operating characteristics curve for predicting fluid responsiveness was not different for pulse pressure variation and the passive leg-raising and end-expiratory occlusion tests (0.98 ± 0.03, 0.91 ± 0.06, and 0.97 ± 0.03, respectively). By contrast, if compliance of the respiratory system was ⩽30 mL/cm H2O, then the area under the receiver-operating characteristics curve was significantly lower for pulse pressure variation than for the passive leg-raising and end-expiratory occlusion tests (0.69 ± 0.10, 0.94 ± 0.05, and 0.93 ± 0.05, respectively). Conclusions:The ability of pulse pressure variation to predict fluid responsiveness was inversely related to compliance of the respiratory system. If compliance of the respiratory system was ⩽30 mL/cm H2O, then pulse pressure variation became less accurate for predicting fluid responsiveness. However, the passive leg-raising and end-expiratory occlusion tests remained valuable in such cases.

We report the case of a 61-year old man in whom a deep venous thrombosis was the presenting feature of disseminated lung carcinoma. A few days later, an arterial thrombosis occurred necessitating amputation. Within a few weeks, the lung cancer progressed dramatically and the patient died. While the association between venous thrombosis and cancer is well known, the relationship between cancer and arterial thrombosis has been less explored. This observation allows discussion of the pathophysiological and clinical aspects of this association, as well as the implications for patient care.