American journal of respiratory and critical care medicine
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Am. J. Respir. Crit. Care Med. · Nov 1997
Prognostic factors of severe Legionella pneumonia requiring admission to ICU.
Despite the fact that the epidemiology of community-acquired pneumonia and nosocomial Legionella infection is well known, there are no specific reports dealing with severe cases of Legionella pneumophila pneumonia admitted to intensive care units. We undertook a prospective study upon 84 patients with a reliable diagnosis of L. pneumophila pneumonia that required ICU admission. The study assessed the prognostic factors, clinical, radiological and outcome variables of both nosocomial (n = 33) and community-acquired (n = 51) cases of L. pneumophila pneumonia. ⋯ The logistic regression analysis demonstrated that APACHE II score > 15 at admission (RR: 11.5; 95% CI 1.75 to 76.1; p = 0.025), and serum Na levels < or = 136 (RR: 21.3; 95% CI 1.11 to 408; p = 0.023), were the only independent factors related to death. On the other hand, improving pneumonia is associated with better outcome in Legionnaires' disease than for patients not having improving pneumonia (RR: 0.019; 95% CI: 0.036 to 0.106; p < 0.0001). A better understanding of the prognostic factors in cases of severe Legionella pneumonia will optimize our therapeutic approach in this disease and help to decrease both its mortality and morbidity rates.
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Am. J. Respir. Crit. Care Med. · Nov 1997
Randomized Controlled Trial Clinical TrialTemporal hemodynamic effects of permissive hypercapnia associated with ideal PEEP in ARDS.
The associated use of permissive hypercapnia (PHY) and high PEEP levels (PEEP(IDEAL)) has been recently indicated as part of a lung-protective-approach (LPA) in acute respiratory distress syndrome (ARDS). However, the net hemodynamic effect produced by this association is not known. We analyzed the temporal hemodynamic effects of this combined strategy in 48 patients (mean age 34 +/- 13 yr) with ARDS, focusing on its immediate (after 1 h), early (first 36 h), and late (2nd-7th d) consequences. ⋯ A multivariate analysis suggested that these acute hyperdynamic effects were related to respiratory acidosis, with no depressant effects ascribed to high PEEP levels. In contrast, high plateau pressures were associated with cardiovascular depression. Thus, as long as sufficiently low distending pressures are concomitantly applied, the sudden installation of PHY plus PEEP(IDEAL) induces a transitory hyperdynamic state and pulmonary hypertension without harmful consequences to this young ARDS population.
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Am. J. Respir. Crit. Care Med. · Nov 1997
Comparative StudyComparison of train-of-four and best clinical assessment during continuous paralysis.
Train-of-four (TOF) monitoring is recommended in published guidelines during use of continuous-infusion neuromuscular blocking agents (NMB) in the intensive care unit (ICU). To test that recommendation, dual protocols were established in a medical ICU after intensive nursing education. Paralyzed patients received either TOF monitoring with a goal of three twitches or best clinical assessment while receiving atracurium by continuous infusion. ⋯ The time to clinical recovery was no different between groups (50 +/- 10 versus 45 +/- 12 min). Two complications occurred in the TOF group, with pulmonary emboli despite prophylaxis and an unrecognized cerebrovascular accident in one patient each. We conclude that careful titration of NMB using clinical bedside markers should remain the standard of care with these drugs.
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Am. J. Respir. Crit. Care Med. · Nov 1997
Empyema thoracis and lung abscess caused by viridans streptococci.
We retrospectively studied the bacteriology and clinical features of empyema thoracis and lung abscess caused by viridans streptococci in 72 patients seen from January 1984 to September 1996. A total of 76 strains of viridans streptococci were isolated, of which the most common isolates were Streptococcus constellatus (21 strains), S. intermedius (17), and S. sanguis (10). Species belonging to the S. milleri group accounted for the majority (68%) of isolates. ⋯ Although all viridans streptococcal isolates were susceptible to penicillin, the patients in the study had a high mortality (21%). Univariate and multivariate analysis of data for patients with empyema alone (n = 53) showed a significantly increased risk of death in those with underlying malignancy (OR = 16.0, p = 0.023) and those with non-S. milleri-group isolates (OR = 3.72, p = 0.030). These data imply a strong clinical significance of viridans streptococci in the pathogenesis of empyema and lung abscess, as well as the need for species identification of viridans streptococci in patients with pleuropulmonary diseases.
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Am. J. Respir. Crit. Care Med. · Nov 1997
The comet-tail artifact. An ultrasound sign of alveolar-interstitial syndrome.
Can ultrasound be of any help in the diagnosis of alveolar-interstitial syndrome? In a prospective study, we examined 250 consecutive patients in a medical intensive care unit: 121 patients with radiologic alveolar-interstitial syndrome (disseminated to the whole lung, n = 92; localized, n = 29) and 129 patients without radiologic evidence of alveolar-interstitial syndrome. The antero-lateral chest wall was examined using ultrasound. The ultrasonic feature of multiple comet-tail artifacts fanning out from the lung surface was investigated. ⋯ It was absent or confined to the last lateral intercostal space in 120 of 129 patients with normal chest X-ray (specificity of 93.0%). Tomodensitometric correlations showed that the thickened sub-pleural interlobular septa, as well as ground-glass areas, two lesions present in acute pulmonary edema, were associated with the presence of the comet-tail artifact. In conclusion, presence of the comet-tail artifact allowed diagnosis of alveolar-interstitial syndrome.