Presse Med
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Editorial Comment Review
[Use of non-invasive positive pressure ventilation for cardiogenic pulmonary edema in emergency care units].
The work reported by L'Her et al. in this issue of La Presse Médicale demonstrates the feasibility of applying simple intensive care techniques in situations frequently encountered in emergency care units. These authors used a face mask for continuous positive pressure ventilation in patients over 70 years of age admitted for respiratory distress related to cardiogenic pulmonary edema. In these elderly patients, the authors noted an improvement in blood gases, respiratory rate and heart rate and did not observe any secondary effect. ⋯ Symptomatic treatment in this type of disorder is mechanical and continuous positive airway pressure diminishes this work. Cardiogenic pulmonary edema in the elderly is thus an excellent indication for spontaneous ventilation with positive expiratory pressure. Improvement in these simple techniques, their widespread use and a better understanding of their limitations remain important challenges for the future.
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In diabetic patients, blood glucose should be controlled to a level which prevents acute metabolic complications, forestalls the development of micro and macroangiopathic complications and remains compatible with good quality of life. Recent interventional trials in both insulin-dependent and non-insulin-dependent patients have helped identify this target glucose level. ⋯ The ideal system includes patient education, renewed training for general practitioners who care for most of the non-insulin-dependent as well as a large number of insulin-dependent diabetic patients in France, close follow-up with regular consultations (calling upon specialists when therapeutic adaptations are required) and an organized system of nursing care by specially trained caregivers. The extra cost of this combined organization is to be balanced against expenditures for complications of diabetes.
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Experimental and clinical evidence has led to a revision of conventional techniques used for mechanical ventilation in the treatment of respiratory failure due to severe asthma and acute respiratory distress syndrome. A common feature in these two clinical situations is the heterogeneous nature of the lesions, causing mechanical alterations which vary from one region to another. Thus the tidal volume is not equally distributed throughout the lungs and can lead to overdistension in some regions or functional exclusion in others. ⋯ Controlled hypoventilation-or permissive hypercapnia-is a new approach aimed at preventing complications by supplying adequate oxygen while accepting or provoking a certain degree of hypercapnia by alveolar hypoventilation. The technique is based on restricting tidal volume and respiratory rate as long as is necessary to recover more favorable mechanical conditions. Results obtained with this method have been convincing for the treatment of decompensated asthma but preliminary data obtained in acute respiratory distress syndrome remain to be validated.
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When first developed in the fifties and sixties during the major polio epidemics, artificial ventilation was a major advance in medical care. The negative pressure perithoracic "iron lungs" had however many disadvantages and were widely replaced by positive pressure ventilation with intubation. This invasive technique allows normalization of gas exchange but has the disadvantage of requiring artificial sedation of the respiratory muscles in many cases in addition to the risk of secondary complications. ⋯ Other inconveniences include leaks around the mask and the need for careful surveillance by the health care workers. Today, there are several arguments based on prospective clinical studies showing that intubation may be avoided in certain patients by using non-invasive positive pressure ventilation with a nasal mask. Careful patient selection is however essential in addition to knowledge of the limitations of the technique.
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High blood pressure in black subjects has been recognized as a clinical entity because of high prevalence, frequent severe complications and pathophysiological and therapeutic specificities. Results from 52 centers in 32 countries show wide variability. In the black population in United States, mean systolic and diastolic blood pressure levels are high, 128/81 mmHg, with a prevalence of hypertension reaching 33.5%, while an ethnic population in Kenya has low mean levels, 110/68 mmHg, with a hypertension prevalence of only 5%. ⋯ However, risk factors including over-weight, alcohol consumption, sodium intake and the socioeconomic environment have been shown to explain most of the differences between the white and the black populations. Differences in diagnosis and management may also play a role. Indeed, while genetic selection may have had an effect, there is no current scientific data which would justify using the colour of the skin as a genetic marker for high blood pressure.