Fiberoptic bronchoscopy during noninvasive positive-pressure ventilation in patients with chronic obstructive lung disease with hypoxemia and hypercapnia

OBJECTIVES: To assess the feasibility and safety of non invasive positive-pressure ventilation (NIPPV) via a face mask to performing fiberoptic bronchoscopy (FOB) in patients with COPD contraindicating FOB in spontaneous ventilation. STUDY DESIGN: Clinical, prospective, open, non comparative trial of feasibility. PATIENTS: Ten consecutive COPD patients (71 +/- 5 year-old, PaO2 = 53 +/- 13 mmHg and PaCO2 = 67 +/- 11 mmHg), without any sign of acute respiratory failure, admitted to the intensive care unit for pneumonia requiring a bronchoalveolar lavage (BAL). Including were: PaO2 < 70 mmHg despite nasal O2 delivered at 3 L.min-1, PaCO2 > 50 mmHg, improvement of SpO2 with NIPPV before FOB. METHODS: Topical anaesthesia of the nose and pharynx was obtained with a 5% lidocaine spray. NIPPV was administered using a ventilatory support system Evita 4 (Dr?ger) applied through a full facial mask secured to the patient with elastic straps. Patients were first allowed to acclimate for 5 min with NIPPV (IPAP = 16 cmH2O, EPAP = 0 and trigger of 0.3 cm H2O while a FIO2 kept at 0.7). A T-adapter Medisize (Péters) was attached to the facial mask. The tip of the FOB was inserted through the nose. Topical anaesthesia of the vocal cords was obtained with 1% lidocaine solution (3 mL). The FOB was inserted into the trachea up to a bronchial sub-segment. BAL was performed by instillation of 100 mL of saline solution. After FOB, the NIPPV was maintained for 5 min. Heart rate, SpO2 were measured continuously and arterial pressure at 2 min intervals. Arterial blood gas values were obtained just prior NIPPV and after 15 min and 60 min NIPPV disconnection. RESULTS: FOB duration was 11 +/- 4 min. SpO2 significantly improved during FOB (from de 91 +/- 4.7% to 97% +/- 1.7) without decrease of oxygen saturation lower than 90%. There were no changes in PaCO2 and PaO2 during the hour following the end of procedure. FOB under NIPPV was performed in all patients without complications and was very well tolerated in eight patients. After NPPV disconnecting, one patient required again NIPPV for 15 min. No patient required endotracheal intubation within 24 hours. All patients survived. CONCLUSION: Application of NIPPV during FOB is a safe technic for maintaining adequate gas exchange in hypoxaemic and hypercapnic COPD patients not in acute respiratory failure. After the end of the procedure a close surveillance in the intensive care unit is essential.     

Hypothermie majeure accidentelle

Two cases of severe accidental hypothermia (core temperature below 25 °C) are reported. Both occurred in an urban area during the same winter period. Both patients had the same age and similar clinical symptoms. In the first patient, the EEG, the echocardiography and the blood gases were in favour of a good tolerance of hypothermia, which led to choice a non aggressive rewarming method. The latter included the rewarming of inhaled gas mixture as well as i.v. fluids and gastro-intestinal lavage fluid. The outcome was uneventful. In the second patient, the visceral and biological consequences were more important (pH : 6.80, blood glucose concentration : 1.48 mmol · L⁻¹, major coagulation disorders). Therefore a rapid rewarming via a cardiopulmonary bypass was preferred. The patient died from a prolonged shock with disseminated intravascular coagulation. The use of cardiopulmonary bypass which is essential in case of cardiac arrest rhythm, is controversial in case of severe hypothermia with a still beating heart.     

Bruxism: A Literature Review

Bruxism is a movement disorder characterized by grinding and clenching of teeth. Awake bruxism is found more in females as compared to males while sleep bruxism shows no such gender prevalence. Etiology of bruxism can be divided into three groups psychosocial factors, peripheral factors and pathophysiological factors. Treatment modalities involve occlusal correction, behavioural changes and pharmacological approach. A literature search was performed using National Library of Medicine's (NLM) Medical Subject Headings (MeSH) Database, Pubmed and Google search engines. The search term 'Bruxism' yielded 2,358 papers out of which 230 were review papers. Most of the papers selected were recently published during the period of 1996-2010 and very few of them were published before 1996.     

Carotid atheromatosis in nondiabetic renal transplant recipients: the role of prediabetic glucose homeostasis alterations

BACKGROUND: Prediabetic glucose homeostasis alterations are important cardiovascular risk factors but their role in renal transplant recipients (RTR) has not been established. METHODS: In 172 RTRs without pretransplant or de novo diabetes, we measured carotid intima media thickness (c-IMT) and performed an oral glucose tolerance test (OGTT). RESULTS: In multivariate analysis, age, hypertension and male sex were independently associated with a c-IMT in the third tertile. A significant interaction between gender and glucose homeostasis parameters was observed. Among male RTR, those with a c-IMT in the third tertile showed significantly higher plasma glucose and HbA1c levels (5+/-0.5% vs. 5.1+/-0.5% vs. 5.5+/-0.4%; P<0.01 tertile 3 vs. 2 or 1) than those in other tertiles. Insulin action parameters were not significantly different. The odds ratio of being in the higher c-IMT tertile was 2.9 (95% CI: 1.05-8.1) per each 1% increase of HbA1c. By contrast, glucose and HbA1c levels were not significantly different between c-IMT tertiles in female RTR. However, age-adjusted insulin levels after OGTT were higher (86+/-10 vs. 51.7+/-9.4; P=0.02) and the insulin sensitivity index lower (0.8+/-0.3 vs. 0.048+/-0.03; P=0.04) among females in the third tertile as compared to the first one. CONCLUSION: Prediabetic glucose homeostasis alterations in RTRs are related to carotid atherosclerosis, although there may be gender differences in the underlying alteration.     

Fat pulmonary embolism after liposuction

A 24-year-old woman undergoes buttock's liposuction as an outpatient procedure. As she went back home, progressive dyspnea, respiratory distress and collapse developed. At hospital admission, she was dyspneic with thoracic oppression, tachycardia and anguish. Chest X-ray and thoracic CT scan suggested a pulmonary localisation of fat emboli. Symptomatic treatment allowed complete recovery. This report discusses diagnosis of fat emboli after liposuction as well as epidemiology and physiopathology.     

Pharmacokinetics of recombinant human tumor necrosis factor-alpha in rats. Effects of size and number of doses and nephrectomy

The serum pharmacokinetics of recombinant human tumor necrosis factor-alpha (rHuTNF) were determined in male and female rats under various conditions. The clearance of rHuTNF after iv administration was determined to be saturable over the dose range of 10-63 micrograms/kg. Multiple iv administration did not significantly change the clearance of rHuTNF. Nephrectomy significantly reduced but did not eliminate the clearance of rHuTNF. The data suggest that sites other than the kidney also contribute to the elimination of rHuTNF. Female rats showed significantly reduced clearance of rHuTNF compared to male rats at all doses after single and multiple iv administration in control and nephrectomized animals.     

Hemophagocytic lymphohistiocytosis in a pancreas-kidney transplant recipient: response to dexamethasone and cyclosporine

We describe a severe case of hemophagocytic lymphohistiocytosis (HLH), secondary to a candida glabrata retroperitoneal abscess in a 41-year-old simultaneous pancreas-kidney transplantation (SPKT) recipient. Despite percutaneous abscess drainage and antifungal therapy, general status deteriorated with persistent fever, severe pancytopenia and liver dysfunction. Presence of hypertriglyceridemia, very high serum levels of ferritin and hemophagocytosis in a bone-marrow aspirate gave the diagnosis of HLH. Of note, change from tacrolimus to cyclosporine together with dexamethasone produced rapid response with status improvement. We concluded that HLH, a rare but often fatal condition characterized by excessive activation of lymphocytes and macrophages, is a diagnostic and therapeutic challenge in solid-organ transplanted patients and must be suspected in the presence of fever, blood cytopenia and liver dysfunction. Specific antiinfectious therapy together with cyclosporine and dexamethasone may be a therapeutic approach.