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Background: LUS is a validated tool for the management of COVID-19 pneumonia. Chair positioning (CP) may have beneficial effects on oxygenation and lung aeration, and may be an easier alternative to PP. This study assessed the effects of a CP session on oxygenation and lung aeration (LA) changes in non-intubated COVID-19 patients. Methods: A retrospective multicenter study was conducted in an ICU. We analyzed data from LUS exams and SpO2:FiO2 performed before/after a CP session in non-intubated COVID-19 patients. Patients were divided into groups of responders or non-responders in terms of oxygenation or LA. Results: Thirty-three patients were included in the study; fourteen (44%) were oxygenation non-responders and eighteen (56%) were oxygenation responders, while thirteen (40.6%) and nineteen (59.4%) patients were classified as LA non-responders and responders, respectively. Changes in oxygenation and LA before/after a CP session were not correlated (r = −0.19, p = 0.3, 95% CI: −0.5–0.17). The reaeration scores did not differ between oxygenation responders and non-responders (1 (−0.75–3.75) vs. 4 (−1–6), p = 0.41). The LUS score was significantly correlated with SpO2:FiO2 before a CP session (r = 0.37, p = 0.04, 95% CI: 0.03–0.64) but not after (r = 0.17, p = 0.35, 95% CI: −0.19–0.50). Conclusion: A CP session was associated with improved oxygenation and LA in more than half of the non-intubated COVID-19 patients.

Purpose To compare the effects of two therapeutic bundles of management in SARS-CoV2 ICU patients. Materials and methods Our retrospective, observational study was performed in a university ICU from March to June 2020 (first wave) and from September 2020 to January 2021 (second wave). In first wave, patients received bundle 1 including early invasive ventilation, hydroxychloroquine, cefotaxime and azithromycin. In second wave, bundle 2 included non-invasive oxygenation support and dexamethasone. The main outcome was in-hospital mortality. Secondary outcomes included ICU and hospital length of stay, ICU supportive therapies, viral clearance and antimicrobial resistance emergence. Results 129 patients with SARS-CoV-2 pneumonia were admitted to our ICU. Thirty-five were treated according to bundle 1 and 76 to bundle 2. In-hospital mortality was similar in the two groups (23%, p = 1). The hospital (p = 0.003) and ICU (p = 0.01) length of stay and ventilator-free days at 28 days (p = 0.03) were significantly reduced in bundle 2. Increasing age, vasopressor use and PaO2/FiO2 ratio < 125 were associated with in-hospital mortality. Conclusion Within the limitations of our study, changes in therapeutic bundles for SARS-Cov-2 ICU patients might have no effect on in-hospital mortality but were associated with less exposure to mechanical ventilation and reduced hospital length of stay.

Background Lung ultrasound is increasingly used in critically ill patients as an alternative to bedside chest radiography, but the best training method remains uncertain. This study describes a training curriculum allowing trainees to acquire basic competence. Methods This multicenter, prospective, and educational study was conducted in 10 Intensive Care Units in Brazil, China, France and Uruguay. One hundred residents, respiratory therapists, and critical care physicians without expertise in transthoracic ultrasound (trainees) were trained by 18 experts. The main study objective was to determine the number of supervised exams required to get the basic competence, defined as the trainees’ ability to adequately classify lung regions with normal aeration, interstitial–alveolar syndrome, and lung consolidation. An initial 2-h video lecture provided the rationale for image formation and described the ultrasound patterns commonly observed in critically ill and emergency patients. Each trainee performed 25 bedside ultrasound examinations supervised by an expert. The progression in competence was assessed every five supervised examinations. In a new patient, 12 pulmonary regions were independently classified by the trainee and the expert. Results Progression in competence was derived from the analysis of 7,330 lung regions in 2,562 critically ill and emergency patients. After 25 supervised examinations, 80% of lung regions were adequately classified by trainees. The ultrasound examination mean duration was 8 to 10 min in experts and decreased from 19 to 12 min in trainees (after 5 vs. 25 supervised examinations). The median training duration was 52 (42, 82) days. Conclusions A training curriculum including 25 transthoracic ultrasound examinations supervised by an expert provides the basic skills for diagnosing normal lung aeration, interstitial–alveolar syndrome, and consolidation in emergency and critically ill patients. Editor’s Perspective What We Already Know about This Topic What This Article Tells Us That Is New

BackgroundLung ultrasound (LUS) is a validated tool for the management of coronavirus disease 2019 (COVID-19)-related pneumonia. An awake prone positioning (PP) improves oxygenation and outcomes in COVID-19 non-intubated patients, but its tolerance remains an issue. A chair positioning (CP) may have beneficial effects on oxygenation and lung aeration. Thus, CP could be an easier alternative to PP. This study assessed the effects of a CP session on oxygenation (using SpO2:FiO2 ratio) and lung aeration (using lung reaeration score) changes in non-intubated COVID-19 patients. Methods An observational multicenter study was conducted in three university hospital intensive care units (ICUs). We retrospectively analyzed prospectively collected data from LUS exams performed before and after a CP session in non-intubated COVID-19 patients. Patients were divided into groups of responders or non-responders in terms of oxygenation and lung aeration.ResultsOf the 33 patients included in the study, 14 (44%) were oxygenation non-responders and 18 (56%) were oxygenation responders, and 13 (40.6%) and 19 (59.4%) patients were classified as lung aeration non-responders and responders, respectively. Changes in oxygenation and lung aeration before and after a CP session were not correlated (Pearson’s r = -0.19, p = 0.3, 95% CI: -0.5–0.17). The reaeration scores did not differ between oxygenation responders and non-responders (1 [-0.75–3.75] vs. 4, [-1–6], p = 0.41). The LUS score was significantly correlated with SpO2:FiO2 ratio before a CP session (Pearson’s r = 0.37, p = 0.04, 95% CI: 0.03–0.64) but not after (Pearson’s r = 0.17, p = 0.35, 95% CI: -0.19–0.50). Conclusion A CP session was associated with improved oxygenation and lung aeration in more than half of the non-intubated COVID-19 patients. However, oxygenation and lung aeration changes were not associated, suggesting that a CP session induces a ventilation:perfusion matching alteration.

Background The issue of contact precautions as contributory factors for reducing Pseudomonas aeruginosa (Pa) infections in intensive care units (ICUs) remains questioned. We evaluated the impact of the addition of contact precautions to standard precautions for Pa-positive patients on incidence of ICU-acquired Pa infections. Methods In this multicenter, cluster-randomized crossover trial, 10 French ICUs were randomly assigned (1:1) to sequence 0–1 (6-month control period [CP]/3-month washout period/6-month intervention period [IP]) or sequence 1–0 (6-month IP/3-month washout period/6-month CP). A surveillance screening program for Pa was implemented. Competing-risks regression models were built with death and discharge without the occurrence of ICU-acquired Pa infection (the primary outcome) as competing events. Models were adjusted for within-ICU correlation and patient- and ICU-level covariates. The Simpson diversity index (SDI) and transmission index (TI) of Pa isolates were derived from pulsed-field gel electrophoresis typing. Results Within recruited ICUs, the cumulative incidence and incidence rate of ICU-acquired Pa infections were 3.38% (55/1625) versus 3.44% (57/1658) and 3.31 versus 3.52 per 1000 patient-days at risk during the CP and IP, respectively. Multivariable models indicated that the intervention did not significantly change the cumulative incidence (subdistribution hazard ratio, .91; 95% confidence interval [CI], .49–1.67; P = .76) or rate (cause-specific hazard ratio, 1.36; 95% CI, .71–2.63; P = .36) of the primary outcome. SDI and TI did not significantly differ between CP and IP. Conclusions The addition of contact precautions to standard precautions for Pa-positive patients with a surveillance screening program does not significantly reduce ICU-acquired Pa infections in non-outbreak situations. Clinical Trials Registration. ISRCTN92710225.

Background Acute chest syndrome (ACS) is the main cause of morbi-mortality in patients with sickle-cell disease in the intensive care unit (ICU). ACS definition encompasses many types of lung damage, making early detection of the most severe forms challenging. We aimed to describe ACS-related lung ultrasound (LU) patterns and determine LU performance to assess ACS outcome. Results We performed a prospective cohort study including 56 ICU patients hospitalized for ACS in a tertiary university hospital (Paris, France). LU and bedside spirometry were performed at admission (D0) and after 48 h (D2). Complicated outcome was defined by the need for transfusion of ≥ 3 red blood cell units, mechanical ventilation, ICU length-of-stay > 5 days, or death. A severe loss of lung aeration was observed in all patients, predominantly in inferior lobes, and was associated with decreased vital capacity (22 [15–33]% of predicted). The LU Score was 24 [20–28] on D0 and 20 [15–24] on D2. Twenty-five percent of patients (14/56) had a complicated outcome. Neither oxygen supply, pain score, haemoglobin, LDH and bilirubin values at D0; nor their change at D2, differed regarding patient outcome. Conversely, LU re-aeration score and spirometry change at D2 improved significantly more in patients with a favourable outcome. A negative LU re-aeration score at D2 was an independent marker of severity of ACS in ICU. Conclusions ACS is associated with severe loss of lung aeration, whose resolution is associated with favourable outcome. Serial bedside LU may accurately and early identify ACS patients at risk of complicated outcome.

Introduction Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) outbreaks have led to massive admissions to intensive care units (ICUs). An ultrasound examination of the thorax is widely performed on admission in these patients. The primary objective of our study was to assess the performance of the lung ultrasound score (LUS) on ICU admission to predict the 28-day mortality rate in patients with SARS-CoV-2. The secondary objective was to asses the performance of thoracic ultrasound and biological markers of cardiac injury to predict mortality. Methods This multicentre, retrospective, observational study was conducted in six ICUs of four university hospitals in France from 15 March to 3 May 2020. Patients admitted to ICUs because of SARS-CoV-2-related acute respiratory failure and those who received an LUS examination at admission were included. The area under the receiver-operating characteristics (ROC) curve was determined for the LUS score to predict the 28-day mortality rate. The same analysis was performed for the Simplified Acute Physiology Score, left ventricular ejection fraction, cardiac output, brain natriuretic peptide and ultra-sensitive troponin levels at admission. Results In 57 patients, the 28-day mortality rate was 21%. The area under the ROC curve of the LUS score value on ICU admission was 0.68 [95% CI 0.54–0.82; p = 0.05]. In non-intubated patients on ICU admission (n = 40), the area under the ROC curves was 0.84 [95% CI 0.70–0.97; p = 0.005]. The best cut-off of 22 corresponded to 85% specificity and 83% sensitivity. Conclusions LUS scores on ICU admission for SARS-CoV-2 did not efficiently predict the 28-day mortality rate. Performance was better for non-intubated patients at admission. Performance of biological cardiac markers may be equivalent to the LUS score. Supplementary Information The online version contains supplementary material available at 10.1007/s12325-021-01702-0.

Background The Radiographic Assessment of Lung Edema (RALE) score is associated with the severity of ARDS, and treatments targeted at reducing pulmonary edema such as conservative fluid management cause a reduction in RALE score over time. Research Question Are early changes in RALE score over time associated with survival in patients with ARDS? Study Design and Methods Data from patients enrolled in three centers in the Lung Imaging for Ventilation sEtting in ARDS (LIVE) trial with available chest radiographs at baseline (day 0) and days 2 or 3 were used. The RALE was scored by two independent reviewers. The primary end point was death by day 90, considering RALE score both at baseline and as a time-varying covariate in a marginal Cox survival model. Results RALE was scored from 135, 64, and 88 radiographs on days 0, 2, and 3, respectively. Both baseline RALE (hazard ratio [HR] for each one-point increment, 1.04; 95% CI, 1.01-1.08; P = .006) and the change in RALE over time (HR for each one-point decrease per unit of time, 0.99; 95% CI, 0.99-0.99; P = .03) were associated with death by day 90, even after adjustment for age, sex, BMI, Simplified Acute Physiology Score II, vasopressor use, and total volume of fluids received since study entry. Interpretation The change in RALE during the first days after ARDS onset is independently associated with survival and may be useful as a surrogate end point in future clinical trials of new therapeutics in ARDS.

Objectives Nebulized colistimethate sodium (CMS) can be used to treat ventilator-associated pneumonia caused by MDR bacteria. The influence of the diluent volume of CMS on aerosol delivery has never been studied. The main objectives of the study were to compare aerosol particle characteristics and plasma and urine pharmacokinetics between two diluent volumes in patients treated with nebulized CMS. Methods A crossover study was conducted in eight patients receiving nebulized CMS every 8 h. After inclusion, nebulization started with 4 million international units (MIU) of CMS diluted either in 6 mL (experimental dilution) or in 12 mL (recommended dilution) of normal saline in a random order. For each diluent volume, CMS aerosol particle sizes were measured and plasma and urine samples were collected every 2 h. Nebulization time and stability of colistin in normal saline were assessed. Results The mass median aerodynamic diameters were 1.4 ± 0.2 versus 0.9 ± 0.2 μm (P

Objectives Microaspiration of subglottic secretions plays a pivotal role in ventilator-associated pneumonia. Impact of endotracheal tube cuff material and shape on tracheal sealing performance remains debated. The primary objective was to compare the tracheal sealing performance of polyvinyl chloride tapered, cylindrical and spherical cuffs. Secondary objectives were to determine the impact of continuous cuff pressure control on sealing performance and pressure variability. Design Prospective randomized ex vivo animal study. Setting French research laboratory. Subjects Seventy-two ex vivo pig tracheal two-lung blocks. Interventions Blocks were randomly intubated with cylindrical (n = 26), tapered (n = 24), or spherical (n = 22) polyvinyl chloride endotracheal tube cuffs. Two milliliter of methylene blue were instilled above the cuff to quantify microaspirations, and lungs were ventilated for 2 hours. Continuous cuff pressure control was implemented in 33 blocks. Measurements and main results Cuff pressures were continuously recorded, and after 2 hours, a microaspiration score was calculated. Tapered cuffs improved cuff sealing performance compared with spherical cuffs with or without continuous cuff pressure control. Compared with spherical cuffs, tapered cuffs reduced the microaspiration score without and with continuous pressure control by 65% and 72%, respectively. Continuous cuff pressure control did not impact sealing performance. Tapered cuffs generated higher cuff pressures and increased the time spent with overinflation compared with spherical cuffs (median [interquartile range], 77.9% [0-99.8] vs. 0% [0-0.5]; p = 0.03). Continuous cuff pressure control reduced the variability of tapered and spherical cuffs likewise the time spent with overinflation of tapered and cylindrical cuffs. Conclusions Polyvinyl chloride tapered cuffs sealing enhanced performance at the cost of an increase in cuff pressure and in time spent with overinflation. Continuous cuff pressure control reduced the variability and normalized cuff pressures without impacting sealing performance.

Resume Environ 10 % des patients sont tracheotomises dans un service de reanimation. Il reste difficile de definir un delai de realisation de la tracheotomie mais il ne semble pas raisonnable de l’envisager avant le 4e jour de ventilation mecanique (en dehors des patients brules et traumatises au niveau cervicofacial). Il faut privilegier la tracheotomie percutanee chez les patients de reanimation selon une procedure prealablement ecrite et comprise par tous. Le choix d’une canule de tracheotomie depend des objectifs qui peuvent varier dans le temps selon que le patient est en phase de ventilation mecanique permanente ou de sevrage. La decanulation est une etape a risque. La decision est prise sur l’avis conjoint de l’ensemble des intervenants (reanimateurs, ORL, kinesitherapeute, etc.). Lorsque la decanulation n’est pas possible, il conviendra d’orienter les patients vers des structures adaptees en s’aidant du systeme de gestion informatise mis en place par la cooperation des 21 Agences regionales de sante sur l’ensemble du territoire national.

BACKGROUND: The value of ultrasound in assessing lung aeration of patients with ARDS who require venovenous extracorporeal membrane oxygenation (ECMO) has, to our knowledge, never been studied. The objective of the study was to evaluate by using ultrasound lung aeration at ECMO initiation and withdrawal in subjects with severe ARDS supported by venovenous ECMO. METHODS: Fifty subjects were included in this pilot retrospective study. The lung ultrasound aeration score (LUS) and respiratory variables were collected at ECMO initiation (T0) and ECMO withdrawal (T1). The LUS at T0 between the subjects who survived to ICU discharge and those who died in ICU was compared. The relationship between changes in LUS and changes in PaO2/FIO2 from T0 to T1 was assessed. RESULTS: The ICU mortality was 34%. The LUS at T0 did not differ between survivors and non-survivors (median 22 [interquartile range] {IQR} 19–26 vs median 24 [IQR, 19–28]; P = .60). From T0 to T1, the LUS decreased significantly in survivors (median 22 [IQR, 19–26] vs median 16 [IQR, 13–19]; P CONCLUSION: At the time of ECMO placement, the subjects who survived ARDS had aeration loss close to that observed in the subjects who did not survive. At the time of ECMO withdrawal, there was a significant improvement in lung aeration in the survivors, whereas a severe loss of lung aeration persisted in the non-survivors, although some were weaned off ECMO. Lung ultrasound provided a valuable tool for bedside assessment of lung aeration in subjects supported by ECMO.

Background Postoperative pneumonia is a frequent complication after cardiac surgery, and its diagnosis is difficult. Little is known about the diagnostic accuracy of lung ultrasound (LUS) in the detection of pneumonia in cardiac surgical patients. The substitution of chest radiography by colour Doppler LUS (LUS-sCPIS) in the simplified clinical pulmonary infection score (sCPIS) could improve the diagnosis of pneumonia following cardiac surgery. Objective The aim of this study was to compare the diagnostic accuracy of LUS-sCPIS and of sCPIS alone in the detection of postoperative pneumonia after cardiac surgery. Design A prospective study of diagnostic accuracy. Setting A Surgical Intensive Care Unit of a French University Hospital. Patients Fifty-one patients with acute respiratory failure within 72 h after cardiac surgery were enrolled between January and May 2015. Main outcome measure The two index tests, LUS-sCPIS and sCPIS, were calculated for all patients at the onset of acute respiratory failure. The reference standard for the diagnosis of pneumonia was based on the consensus of three physicians, blind to the sCPIS and LUS-sCPIS data, based on a posthoc review of all the clinical, radiological and microbiological evidence. The diagnostic accuracy of LUS-sCPIS was compared with that of sCPIS in the detection of postoperative pneumonia. Results Pneumonia was diagnosed in 26 out of 51 patients. The LUS-sCPIS detected the presence of pneumonia with a sensitivity of 92% (95% CI 0.85 to 0.99) and a specificity of 68% (95% CI 0.55 to 0.81). The sCPIS detected the presence of pneumonia with a sensitivity of 35% (95% CI 0.22 to 0.48) and a specificity of 84% (95% CI 0.74 to 0.94). The area under the curve (AUC) of LUS-sCPIS at 0.80 (95% CI 0.69 to 0.91) was higher than the AUC of sCPIS at 0.59 (95% CI 0.47 to 0.71; P = 0.0008). Conclusion Compared with sCPIS, LUS-sCPIS improved diagnostic accuracy in the detection of postoperative pneumonia in patients with acute respiratory failure after cardiac surgery. It could be a useful bedside tool to guide pneumonia management. Trial registration Clinicaltrials.gov identifier: NCT03279887.

Background Patients undergoing major vascular surgery often develop postoperative pneumonia that impacts their outcomes. Conflicting data exist concerning the potential benefit of tapered-shaped cuffs on tracheal sealing. The primary objective of this study was to assess the efficiency of a polyvinyl chloride tapered-cuff endotracheal tube at reducing the postoperative pneumonia rate after major vascular surgery. Secondary objectives were to determine its impact on microaspiration, ventilator-associated pneumonia rate, and inner cuff pressure. Methods This prospective randomized controlled study included 109 patients who were randomly assigned to receive either spherical- (standard cuff) or taper-shaped (tapered cuff) endotracheal tubes inserted after anesthesia induction and then admitted to the intensive care unit after major vascular surgery. Cuff pressure was continuously recorded over 5 h. Pepsin and α-amylase concentrations in tracheal aspirates were quantified on postoperative days 1 and 2. The primary outcome was the early postoperative pneumonia frequency. Results Comparing the tapered-cuff with standard-cuff group, respectively, postoperative pneumonia rates were comparable (42 vs. 44%, P = 0.87) and the percentage (interquartile range) of cuff-pressure time with overinflation was significantly higher (16.1% [1.5 to 50] vs. 0.6% [0 to 8.3], P = 0.01), with a 2.5-fold higher coefficient of variation (20.2 [10.6 to 29.4] vs. 7.6 [6.2 to 10.2], P < 0.001). Although microaspiration frequencies were high, they did not differ between groups. Conclusion For major vascular surgery patients, polyvinyl chloride tapered-cuff endotracheal tubes with intermittent cuff-pressure control did not lower the early postoperative pneumonia frequency and did not prevent microaspiration.

Recently the DiversiLab® (DL) system (bioMérieux) was developed as an automated platform that uses repetitive element polymerase chain reaction (rep-PCR) technology for standardized, reproducible DNA fingerprinting of bacteria. The purpose of this study was to evaluate the usefulness of DL rep-PCR for typing Pseudomonas aeruginosa isolates. The performance of DL rep-PCR was compared with that of pulsed-field gel electrophoresis (PFGE) in a prospective multicenter study of patients with ventilator-associated pneumonia due to P. aeruginosa, conducted in 3 intensive care units over a 31-month period. In total, 203 P. aeruginosa isolates from 66 patients, from whom at least 2 consecutive respiratory samples each were collected more than 48 h apart, were typed using DL rep-PCR. Forty isolates (corresponding to 20 patients) were also typed using PFGE of SpeI-digested DNA. The typeability was 100% with DL rep-PCR and 95% with PFGE. The discriminatory power was close for DL rep-PCR and for PFGE (Simpson’s diversity indices of 0.901 and 0.947, respectively). Insufficient agreement between DL rep-PCR and PFGE typing results was observed for the 40 selected isolates (adjusted Rand coefficient of 0.419), mostly due to isolates of the same DL rep-PCR type but of different PFGE types (adjusted Wallace coefficients of 0.306 for DL rep-PCR with PFGE, and of 0.667 for PFGE with DL rep-PCR). Considered together with published data, DL rep-PCR results should be interpreted with caution for the investigation of outbreaks caused by P. aeruginosa and evaluated in conjunction with epidemiological data.

In the intensive care unit (ICU), the outcomes of patients with acute mesenteric ischemia (AMI) are poorly documented. This study aimed to determine the risk factors for death in ICU patients with AMI. A retrospective, observational, non-interventional, multicenter study was conducted in 43 ICUs of 38 public institutions in France. From January 2008 to December 2013, all adult patients with a diagnosis of AMI during their hospitalization in ICU were included in a database. The diagnosis was confirmed by at least one of three procedures (computed tomography scan, gastrointestinal endoscopy, or upon surgery). To determine factors associated with ICU death, we established a logistic regression model. Recursive partitioning analysis was applied to construct a decision tree regarding risk factors and their interactions most critical to determining outcomes. The death rate of the 780 included patients was 58 %. Being older, having a higher sequential organ failure assessment (SOFA) severity score at diagnosis, and a plasma lactate concentration over 2.7 mmol/l at diagnosis were independent risk factors of ICU mortality. In contrast, having a prior history of peripheral vascular disease or an initial surgical treatment were independent protective factors against ICU mortality. Using age and SOFA severity score, we established an ICU mortality score at diagnosis based on the cutoffs provided by recursive partitioning analysis. Probability of survival was statistically different (p

IF 2.323; International audience; Introduction: During liver transplantation, graft ischemia-reperfusion injury leads to a systemic inflammatory response producing postoperative organ dysfunctions. The aim of this observational and prospective study was to compare the impact of Solution deconservation des organeset tissus (SCOT) 15 and University of Wisconsin (UW) preservation solutions on early cytokine release, postreperfusion syndrome and postoperative organ dysfunctions.& para;& para;Methods: Thirty-seven liver transplantations were included: 21 in UW Group and 16 in SCOT 15 group. Five cytokines were measured in systemic blood after anesthetic induction, 30 minutes after unclamping portal vein and on postoperative day 1.& para;& para;Results: Following unclamping portal vein, cytokines were released in systemic circulation. Systemic cytokine concentrations were higher in UW than in SCOT 15 group: Interleukin-10, lnterleukine-6. In SCOT 15 group, significant reduction of postreperfusion syndrome incidence and acute kidney injury were observed. Alanine and aspartate aminotransferase peak concentrations were higher in SCOT 15 group than in UW group. However, from postoperative day 1 to day 10, aminotransferase returned to normal values and did not differ between groups.& para;& para;Conclusions: Compared to UW, SCOT 15 decreases systemic cytokine release resulting from graft ischemia-reperfusion injury and reduces incidence of postreperfusion syndrome and post operative renal failure. (C) 2017 Published by Elsevier Masson SAS.

En reanimation, le medecin recoit quotidiennement une multitude d’informations concernant chaque patient: donnees cliniques, biologiques, bacteriologiques et d’imagerie. Le dossier medical traditionnel « papier » expose a ignorer certaines informations et ne permet pas une synthese rapide des donnees disponibles. Le dossier medical informatise represente une reponse appropriee la gestion de la complexite, ceci a certaines conditions: 1) ne pas simplement « reproduire » la pancarte traditionnelle en affichant des lignes et des colonnes de donnees numeriques; 2) afficher une representation graphique des principales donnees cliniques, biologiques, bacteriologiques et echographiques recueillies quotidiennement (ecran experts); 3) permettre l’affichage graphique sur une echelle de temps variant de la minute (pression arterielle, frequence cardiaque et respiratoire, SpO2) a 24 heures (autres parametres); 4) donner un acces rapide a l’imagerie complexe (tomodensitometrie et resonnance magnetique); 5) permettre la prescription medicale securisee; 6) permettre la redaction du compte-rendu d’hospitalisation a partir de l’observation medicale; 7) permettre le codage automatique des actes medicaux; 8) permettre la selection de patients a partir de mots cles (requete sur la base de donnees); 9) permettre le fonctionnement en reseau de differentes unites de reanimation et de soins continus. Les donnees concernant l’impact du dossier medical informatise sur la morbimortalite, la duree de ventilation et la duree d’hospitalisation sont actuellement peu nombreuses. Compte-tenu de la quasi-impossibilite d’effectuer des etudes randomisees prospectives, des etudes retrospectives castemoins avec un appariement strict des patients sont necessaires pour evaluer l’impact du dossier medical informatise sur la qualite des soins en reanimation.

IF 12.015; International audience; Prone position (PP) improves oxygenation and outcome of acute respiratory distress syndrome (ARDS) patients with a PaO2/FiO(2) ratio < 150 mmHg. Regional changes in lung aeration can be assessed by lung ultrasound (LUS). Our aim was to predict the magnitude of oxygenation response after PP using bedside LUS. We conducted a prospective multicenter study that included adult patients with severe and moderate ARDS. LUS data were collected at four time points: 1 h before (baseline) and 1 h after turning the patient to PP, 1 h before and 1 h after turning the patient back to the supine position. Regional lung aeration changes and ultrasound reaeration scores were assessed at each time. Overdistension was not assessed. Fifty-one patients were included. Oxygenation response after PP was not correlated with a specific LUS pattern. The patients with focal and non-focal ARDS showed no difference in global reaeration score. With regard to the entire PP session, the patients with non-focal ARDS had an improved aeration gain in the anterior areas. Oxygenation response was not associated with aeration changes. No difference in PaCO2 change was found according to oxygenation response or lung morphology. In ARDS patients with a PaO2/FiO(2) ratio aecurrency sign150 mmHg, bedside LUS cannot predict oxygenation response after the first PP session. At the bedside, LUS enables monitoring of aeration changes during PP.

Patients undergoing major vascular surgery often develop postoperative pneumonia that impacts their outcomes. Conflicting data exist concerning the potential benefit of tapered-shaped cuffs on tracheal sealing. The primary objective of this study was to assess the efficiency of a polyvinyl chloride tapered-cuff endotracheal tube at reducing the postoperative pneumonia rate after major vascular surgery. Secondary objectives were to determine its impact on microaspiration, ventilator-associated pneumonia rate, and inner cuff pressure.This prospective randomized controlled study included 109 patients who were randomly assigned to receive either spherical- (standard cuff) or taper-shaped (tapered cuff) endotracheal tubes inserted after anesthesia induction and then admitted to the intensive care unit after major vascular surgery. Cuff pressure was continuously recorded over 5 h. Pepsin and α-amylase concentrations in tracheal aspirates were quantified on postoperative days 1 and 2. The primary outcome was the early postoperative pneumonia frequency.Comparing the tapered-cuff with standard-cuff group, respectively, postoperative pneumonia rates were comparable (42 vs. 44%, P = 0.87) and the percentage (interquartile range) of cuff-pressure time with overinflation was significantly higher (16.1% [1.5 to 50] vs. 0.6% [0 to 8.3], P = 0.01), with a 2.5-fold higher coefficient of variation (20.2 [10.6 to 29.4] vs. 7.6 [6.2 to 10.2], P0.001). Although microaspiration frequencies were high, they did not differ between groups.For major vascular surgery patients, polyvinyl chloride tapered-cuff endotracheal tubes with intermittent cuff-pressure control did not lower the early postoperative pneumonia frequency and did not prevent microaspiration.

The aim of this review is to perform a critical analysis of experimental studies on aerosolized antibiotics and draw lessons for clinical use in patients with ventilator-associated pneumonia. Ultrasonic or vibrating plate nebulizers should be preferred to jet nebulizers. During the nebulization period, specific ventilator settings aimed at decreasing flow turbulence should be used, and discoordination with the ventilator should be avoided. The appropriate dose of aerosolized antibiotic can be determined as the intravenous dose plus extrapulmonary deposition. If these conditions are strictly respected, then high lung tissue deposition associated with rapid and efficient bacterial killing can be expected. For aerosolized aminoglycosides and cephalosporins, a decrease in systemic exposure leading to reduced toxicity is not proven by experimental studies. Aerosolized colistin, however, does not easily cross the alveolar-capillary membrane even in the presence of severe lung infection, and high doses can be delivered by nebulization without significant systemic exposure.

Resume Objectif Decrire les applications cliniques et les perspectives offertes par l’echographie pulmonaire en reanimation. Methodologie Rappel de la semiologie echographique pulmonaire et synthese des donnees publiees durant les cinq dernieres annees sur l’utilisation de l’echographie pleuropulmonaire en reanimation. La base de donnees Pubmed™ a ete utilisee. Les etudes cliniques publiees en langue francaise ou anglaise ont ete analysees. Synthese des donnees L’echographie permet le diagnostic et la quantification des epanchements pleuraux. En cas d’admission d’un patient en detresse respiratoire aigue d’origine medicale ou traumatique, elle participe au diagnostic etiologique, a la mise en route des traitements et a la surveillance de leur efficacite. Elle represente une aide a la prise en charge des pneumonies et des patients ayant un syndrome de detresse respiratoire aigue. L’etude de l’œdeme interstitiel apporte des informations hemodynamiques dont le role merite d’etre evalue. Conclusion L’echographie pulmonaire est une technique d’imagerie simple, non invasive, non irradiante et rapidement disponible. Elle apporte des informations au lit du patient hospitalise en reanimation. L’impact de cette technique sur le pronostic merite d’etre evalue dans de futures etudes.

To compare lung reaeration measured by bedside chest radiography, lung computed tomography, and lung ultrasound in patients with ventilator-associated pneumonia treated by antibiotics.Computed tomography, chest radiography, and lung ultrasound were performed before (day 0) and 7 days following initiation of antibiotics.A 26-bed multidisciplinary intensive care unit in La Pitié-Salpêtrière hospital (University Paris-6).: Thirty critically ill patients studied over the first 10 days of developing ventilator-associated pneumonia.: Antibiotic administration.Computed tomography reaeration was measured as the additional volume of gas present within both lungs following 7 days of antimicrobial therapy. Lung ultrasound of the entire chest wall was performed and four entities were defined: consolidation; multiple irregularly spaced B-lines; multiple abutting ultrasound lung "comets" issued from the pleural line or a small subpleural consolidation; normal aeration. For each of the 12 regions examined, ultrasound changes were measured between day 0 and 7 and a reaeration score was calculated. An ultrasound score5 was associated with a computed tomography reaeration400 mL and a successful antimicrobial therapy. An ultrasound score-10 was associated with a loss of computed tomography aeration400 mL and a failure of antibiotics. A highly significant correlation was found between computed tomography and ultrasound lung reaeration (Rho = 0.85, p.0001). Chest radiography was inaccurate in predicting lung reaeration.Lung reaeration can be accurately estimated with bedside lung ultrasound in patients with ventilator-associated pneumonia treated by antibiotics. Lung ultrasound can also detect the failure of antibiotics to reaerate the lung.

Whether cardiac ventricles can acutely dilate during septic myocardial dysfunction.A prospective echocardiographic study was performed to assess changes of left ventricular dimensions over time in patients with septic shock.A 20-bed surgical intensive care unit of Pitié-Salpêtrière university hospital in Paris.Forty-five patients were studied over the first 10 days of septic shock.None.Left ventricular end-diastolic area (LVEDA), fractional area change (FAC), velocity time integral of the aortic flow, echocardiographic indices of left ventricular relaxation, and cardiac troponin I (cTnI) were measured at day 1, 2, 3, 4, 7, and 10. Three groups were defined: 29 patients without increased cTnI and cardiac impairment (group 1), eight patients with increased cTnI and left systolic ventricular dysfunction (group 2), and eight patients with increased cTnI and isolated impairment of left ventricular relaxation (group 3). At day 1, LVEDA was significantly higher in group 2 (13 +/- 3 cm/m, p0.05) compared with groups 1 (10 +/- 2 cm/m) and 3 (11 +/- 2 cm/m). LVEDA did not change in groups 1 and 3. In group 2, LVEDA and FAC returned within 10 days to values observed in groups 1 and 2. A significant correlation was found between aortic velocity time integral and LVDEA (r =.78, p = 0.022) and FAC (r =.89, p = 0.003) only in group 2.Acute and reversible left ventricular dilation accompanies septic shock-induced systolic left ventricular dysfunction. When septic myocardial abnormalities are limited to reversible impairment of left ventricular relaxation, left ventricular dimensions remain unchanged.

Many patients with septic shock and increased cardiac troponin I (cTnI) do not exhibit significant left ventricular systolic dysfunction. We hypothesized that an isolated and reversible impairment of ventricular relaxation may be associated with the increase in cTnI.Prospective, observational study.Surgical intensive care unit in a university hospital.Total of 54 patients with septic shock.Fractional area change, early diastolic velocity of mitral annulus, flow propagation velocity of early diastolic mitral inflow, cTnI, tumor necrosis factor-alpha, interleukin (IL)-6, -1beta, -8, and -10 were measured at days 1, 2, 3, 4, 7, and 10 after onset of septic shock. Patients were classified into three groups: normal cTnI (group 1), increased cTnI and fractional area change50% (group 2), and increased cTnI and fractional area change50% (group 3).A total of 22 patients had an increase in cTnI, 11 with both systolic and diastolic dysfunctions and 11 with isolated impairment of left ventricular relaxation. At day 1, early diastolic velocity of mitral annulus and flow propagation velocity of early diastolic mitral inflow were significantly lower and tumor necrosis factor-alpha, IL-8, and IL-10 significantly higher in groups 2 and 3 compared with group 1. With resolution of septic shock, early diastolic velocity of mitral annulus and flow propagation velocity of early diastolic mitral inflow measured in patients of groups 2 and 3 returned progressively to values observed in group 1, with a parallel normalization of tumor necrosis factor-alpha, IL-8, and IL-10.Isolated and reversible impairment of left ventricular relaxation, associated with transient increases in cTnI, tumor necrosis factor-alpha, IL-8, and IL-10, was observed in 20% of patients with septic shock.

Lung ultrasound at the bedside can provide accurate information on lung status in critically ill patients with acute respiratory distress syndrome.Lung ultrasound can replace bedside chest radiography and lung computed tomography for assessment of pleural effusion, pneumothorax, alveolar-interstitial syndrome, lung consolidation, pulmonary abscess and lung recruitment/de-recruitment. It can also accurately determine the type of lung morphology at the bedside (focal or diffuse aeration loss), and therefore it is useful for optimizing positive end-expiratory pressure. The learning curve is brief, so most intensive care physicians will be able to use it after a few weeks of training.Lung ultrasound is noninvasive, easily repeatable and allows assessment of changes in lung aeration induced by the various therapies. It is among the most promising bedside techniques for monitoring patients with acute respiratory distress syndrome.

Background In spontaneously breathing cardiac patients, pulmonary artery pressure (PAP) can be accurately estimated from the transthoracic Doppler study of pulmonary artery and tricuspid regurgitation blood flows. In critically ill patients on mechanical ventilation for acute lung injury, the interposition of gas between the probe and the heart renders the transthoracic approach problematic. This study was aimed at determining whether the transesophageal approach could offer an alternative. Methods Fifty-one consecutive sedated and ventilated patients with severe hypoxemia (arterial oxygen tension/fraction of inspired oxygen < 300) were prospectively studied. Mean PAP measured from the pulmonary artery catheter was compared with several indices characterizing pulmonary artery blood flow assessed using transesophageal echocardiography: preejection time, acceleration time, ejection duration, preejection time on ejection duration ratio, and acceleration time on ejection duration ratio. In a subgroup of 20 patients, systolic PAP measured from the pulmonary artery catheter immediately before withdrawal was compared with Doppler study of regurgitation tricuspid flow performed immediately after pulmonary artery catheter withdrawal using either the transthoracic or the transesophageal approach. Results Weak and clinically irrelevant correlations were found between mean PAP and indices of pulmonary artery flow. A statistically significant and clinically relevant correlation was found between systolic PAP and regurgitation tricuspid flow. In 3 patients (14%), pulmonary artery pressure could not be assessed echocardiographically. Conclusions In hypoxemic patients on mechanical ventilation, mean PAP cannot be reliably estimated from indices characterizing pulmonary artery blood flow. Systolic PAP can be estimated from regurgitation tricuspid flow using either transthoracic or transesophageal approach.

To describe current use and diagnostic and therapeutic impacts of point-of-care ultrasound (POCUS) in the intensive care unit (ICU). POCUS is of growing importance in the ICU. Several guidelines recommend its use for procedural guidance and diagnostic assessment. Nevertheless, its current use and clinical impact remain unknown. Prospective multicentric study in 142 ICUs in France, Belgium, and Switzerland. All the POCUS procedures performed during a 24-h period were prospectively analyzed. Data regarding patient condition and the POCUS procedures were collected. Factors associated with diagnostic and therapeutic impacts were identified. Among 1954 patients hospitalized during the study period, 1073 (55 %) POCUS/day were performed in 709 (36 %) patients. POCUS served for diagnostic assessment in 932 (87 %) cases and procedural guidance in 141 (13 %) cases. Transthoracic echocardiography, lung ultrasound, and transcranial Doppler accounted for 51, 17, and 16 % of procedures, respectively. Diagnostic and therapeutic impacts of diagnostic POCUS examinations were 84 and 69 %, respectively. Ultrasound guidance was used in 54 and 15 % of cases for central venous line and arterial catheter placement, respectively. Hemodynamic instability, emergency conditions, transthoracic echocardiography, and ultrasounds performed by certified intensivists themselves were independent factors affecting diagnostic or therapeutic impacts. With regard to guidelines, POCUS utilization for procedural guidance remains insufficient. In contrast, POCUS for diagnostic assessment is of extensive use. Its impact on both diagnosis and treatment of ICU patients seems critical. This study identified factors associated with an improved clinical value of POCUS.

International audience

International audience; IntroductionThe study was designed to assess the impact of fluid loading on lung aeration, oxygenation and hemodynamics in patients with septic shock and acute respiratory distress syndrome (ARDS).MethodsDuring a 1-year period, a prospective observational study was performed in 32 patients with septic shock and ARDS. Cardiorespiratory parameters were measured using Swan Ganz (n = 29) or PiCCO catheters (n = 3). Lung aeration and regional pulmonary blood flows were measured using bedside transthoracic ultrasound. Measurements were performed before (T0), at the end of volume expansion (T1) and 40 minutes later (T2), consisting of 1-L of saline over 30 minutes during the first 48 h following onset of septic shock and ARDS.ResultsLung ultrasound score increased by 23% at T2, from 13 at baseline to 16 (P

Introduction Les societes savantes recommandent l’utilisation de l’echographie pour les acces vasculaires et l’evaluation diagnostique [1,2] . Sa puissance diagnostique et son impact sur la prise en charge des patients sont demontres dans des etudes monocentriques [3] . Neanmoins, son utilisation et son impact en pratique clinique restent inconnus. L’objectif de cette etude etait de decrire l’utilisation, l’impact diagnostique et therapeutique des echographies pratiquees en reanimation. Materiel et methodes Etude prospective observationnelle multicentrique realisee dans 142 unites en France, Belgique et Suisse apres accord CPP. Pendant 24 h, chaque echographie etait analysee. Le type d’operateur et d’echographie, les conditions de realisation, la prevalence, l’impact diagnostique et therapeutique etaient mesures. Les facteurs associes a l’impact diagnostique et therapeutique etaient identifies. Resultats Parmi les 1954 patients hospitalises, 1073 echographies etaient realisees soit une prevalence de 55 % sur les 24 h. Sept cent neuf patients (un patient tous les 2,7) avaient au moins une echographie/24 h. Le type d’indication, l’impact diagnostique (87 %) et therapeutique (69 %) sont detailles sur la Fig. 1 . L’echographie transthoracique (ETT), l’echographie pulmonaire et le Doppler transcrânien representaient respectivement 51 %, 17 % et 16 % des echographies realisees. L’echographie etait utilisee pour la mise en place de catheter veineux central et catheter arteriel dans 54 % et 15 % des cas respectivement. Les facteurs significativement associes a l’impact diagnostique et therapeutique en analyse multivariee sont representes dans le Tableau 1 . L’echographie entrainait la realisation de 373 nouvelles interventions therapeutiques. Le remplissage vasculaire ( n = 115), la depletion hydrique ( n = 80) ou l’introduction de catecholamines ( n = 43), etaient les plus frequentes. Discussion En depit des recommandations [2] , l’utilisation de l’echo guidage reste insuffisante en reanimation. A l’inverse, l’echographie a visee diagnostique est tres utilisee puisque plus d’un tiers des patients a au moins une echographie/jour. L’echographie diagnostique modifie la prise en charge des patients dans 85 % des cas. L’instabilite hemodynamique, la realisation en urgence, l’ETT et un operateur reanimateur sont des facteurs associes a un impact diagnostique ou therapeutique. Les consequences en termes de morbi-mortalite des modifications engendrees par l’echographie doivent etre evaluees par des etudes controlees.

Introduction Les pneumonies postoperatoires (PPO) generent une morbi-mortalite et un surcout importants [1] . Leur physiopathologie reste semblable a celle des pneumonies acquises sous ventilation mecanique. Les proprietes d’etancheite du ballonnet des sondes d’intubation endotracheales (IET) constituent donc le facteur conditionnant la survenue de micro-inhalations repetees. Bien que prometteurs dans plusieurs etudes experimentales [2] , les etudes cliniques ayant evalue l’etancheite des ballonnets coniques ont montre des resultats contrastes [3] . D’autre part, ce type de ballonnet n’a jamais ete evalue en perioperatoire de chirurgie vasculaire majeure. Notre objectif a donc ete d’evaluer les performances des ballonnets coniques en polyvinylchloride (PVC) dans la prevention des episodes de PPO et de micro-inhalations perioperatoires, ainsi que dans leur profil d’evolution des pressions au cours du temps. Materiel et methodes Apres accord du Comite de Protection de la Personne, une etude randomisee, controlee en simple insu, de type « soins courants » a ete menee en reanimation chirurgicale. Une information ecrite etait remise au patient ou a un proche avant chaque inclusion. Tout patient requerant une prise en charge en reanimation dans les suites d’une chirurgie majeure aortique etait inclus et randomise au bloc operatoire soit dans le groupe « ballonnet standard » (spherique), soit dans le groupe « ballonnet conique ». Le critere de jugement principal etait l’incidence du premier episode de PPO. Les criteres de jugement secondaires etaient le delai de survenue des PPO, l’incidence du second episode de PPO, l’incidence des micro-inhalations detectees par le dosage de pepsine tracheale, la variation des pressions de ballonnet au cours du temps, les durees de ventilation mecanique, de sejour en reanimation et la mortalite a 28 jours. Resultats Sur 48 mois, 109 patients ont ete inclus ( n = 57 et n = 52 respectivement pour le groupe « ballonnet standard » et « ballonnet conique »). A l’inclusion, les caracteristiques demographiques etaient comparables. L’incidence du premier episode de PPO etait similaire (44 % versus 42 %, p = 0,87, respectivement pour le groupe « standard » versus « conique »). L’incidence globale des micro-inhalations peroperatoires s’elevait a 22 %. Le coefficient de variation de pression du ballonnet etait 2,5 fois superieur dans le groupe « conique », avec une augmentation des periodes de surpression significative. Aucune difference n’a ete retrouvee concernant les autres criteres de jugement secondaires. Discussion L’usage des sondes d’IET a ballonnet conique en PVC n’a pas permis de prevenir le premier episode de PPO de chirurgie aortique majeure. Les micro-inhalations peroperatoires ont ete frequentes et non prevenues par le ballonnet conique. La variabilite importante des pressions du ballonnet et l’augmentation des episodes de surpression devront etre confirmees par d’autres investigations.

In this issue of respiratory care, Wallet and co-workers bring convincing evidence that PEEP-induced alveolar recruitment can be inferred from regional changes in lung densities computed on frontal bedside digital chest radiographies obtained at 2 different PEEP levels in patients with ARDS.[1][1]

The aim of this review is to perform a critical analysis of experimental studies on aerosolized antibiotics and draw lessons for clinical use in patients with ventilator-associated pneumonia. Ultrasonic or vibrating plate nebulizers should be preferred to jet nebulizers. During the nebulization period, specific ventilator settings aimed at decreasing flow turbulence should be used, and discoordination with the ventilator should be avoided. The appropriate dose of aerosolized antibiotic can be determined as the intravenous dose plus extrapulmonary deposition. If these conditions are strictly respected, then high lung tissue deposition associated with rapid and efficient bacterial killing can be expected. For aerosolized aminoglycosides and cephalosporins, a decrease in systemic exposure leading to reduced toxicity is not proven by experimental studies. Aerosolized colistin, however, does not easily cross the alveolar-capillary membrane even in the presence of severe lung infection, and high doses can be delivered by nebulization without significant systemic exposure.

Postextubation distress after a successful spontaneous breathing trial is associated with increased morbidity and mortality. Predicting postextubation distress is therefore a major issue in critically ill patients. To assess whether lung derecruitment during spontaneous breathing trial assessed by lung ultrasound is predictive of postextubation distress.Prospective study in two multidisciplinary intensive care units within University Hospital.One hundred patients were included in the study. Lung ultrasound, echocardiography, and plasma B-type natriuretic peptide levels were determined before and at the end of a 60-min spontaneous breathing trial and 4 hrs after extubation. To quantify lung aeration, a lung ultrasound score was calculated. Patients were followed up to hospital discharge.Fourteen patients failed the spontaneous breathing trial, 86 were extubated, 57 were definitively weaned (group 1), and 29 suffered from postextubation distress (group 2). Loss of lung aeration during the successful spontaneous breathing trial was observed only in group 2 patients: lung ultrasound scores increased from 15 [13;17] to 19 [16; 21] (p.01). End-spontaneous breathing trial lung ultrasound scores were significantly higher in group 2 than in group 1 patients: 19 [16;21] vs. 10 [7;13], respectively (p.001) and predicted postextubation distress with an area under the receiver operating characteristic curve of 0.86. Although significantly higher in group 2, B-type natriuretic peptide and echocardiography cardiac filling pressures were not clinically helpful in predicting postextubation distress.Lung ultrasound determination of aeration changes during a successful spontaneous breathing trial may accurately predict postextubation distress.

We applaud the British Thoracic Society (BTS) for its efforts to improve patient care through scientific evidence. We thus recognise the recent guidelines on pleural procedures and thoracic ultrasound (TUS) as an important attempt to develop a rational approach to chest sonography.1 However, we are concerned that the BTS has reached conclusions based on a less complete review of TUS. The guidelines state that ‘the utility of thoracic ultrasound for diagnosing a pneumothorax is limited in hospital practice due to the ready availability of chest x-rays (CXR) and conflicting data from published reports’.1 This conclusion appears to be based on a small (but landmark) study of 11 patients from 1986 to 1989, two small studies with only four pneumothoraces in …

Introduction L’echographie transthoracique permet un examen complet des poumons au lit du patient. Elle est plus precise que la radiographie thoracique et plus accessible que la tomodensitometrie [1] . Des echographes portatifs miniaturises ont montre de bonnes performances dans le cadre de l’echographie cardiaque [2] et pour la detection des epanchements pleuraux [3] . Le but de cette etude etait de comparer les performances d’un echographe miniaturise, le Vscan™ (GE Healthcare) a celles d’un echographe classique, l’Acuson CV70 (Siemens) dans le cadre de l’echographie pulmonaire en reanimation. Materiel et methodes Le critere d’inclusion etait tout patient majeur hospitalise en reanimation necessitant la realisation d’une echographie pulmonaire. Les criteres de non-inclusion etaient les facteurs rendant impossible l’etude du poumon en integralite. Chaque patient etait examine successivement avec le Vscan™ puis avec l’Acuson™ par deux operateurs independants. Le thorax etait divise en 12 regions d’interet. Chacune de ces regions etait examinee et un chiffre etait attribue en fonction du resultat : 0 pour le poumon normal, 1 en cas de syndrome interstitiel, 2 en cas de syndrome alveolaire et 3 pour les consolidations pulmonaires. Les scores de ces 12 regions etaient additionnes pour obtenir un Lung Ultrasound Score (LUS) allant de 0 a 36. La presence d’un epanchement pleural etait egalement notee. L’objectif principal etait de comparer les LUS mesures avec les deux echographes pour chaque patient, par la methode de Bland et Altman avec calcul du coefficient de correlation intraclasse. Les objectifs secondaires etaient d’evaluer la performance diagnostique du Vscan™ pour l’aeration pulmonaire normale, le syndrome alveolo-interstitiel, les consolidations pulmonaires et l’epanchement pleural en calculant le coefficient Kappa pour chacun de ces items. La variabilite intra- et inter-observateurs etait evaluee pour les deux echographes par calcul du Kappa. Resultats Soixante-neuf patients de reanimation on ete inclus sur 3 mois. L’analyse de Bland et Altman montrait un biais de 0,32 entre les deux appareils mais avec des limites d’agrement comprises entre -7,51 et 8,15. Le coefficient de correlation intra-classe etait de 0,80 [0,70–0,87]. La performance diagnostique du Vscan™ etait bonne pour la detection des consolidations pulmonaires et des epanchements pleuraux, moyenne pour l’aeration normale et mediocre pour le syndrome alveolo-interstitiel. La variabilite intra- et inter-observateurs etait satisfaisante : Kappa a 0,75 et 0,64 pour l’Acuson™ et Kappa a 0,71 et 0,72 pour le Vscan™. ( Tableau 1 , Fig. 1 ). Discussion Le Vscan™ apparait comme une alternative interessante aux echographes classiques, du fait de sa petite taille qui le rend facile a transporter et a nettoyer. Il ne peut pas remplacer l’echographe classique pour le calcul du LUS au vu des limites d’agrement elevees au Bland et Altman. Ses performances sont bonnes pour le diagnostic d’epanchement pleural, de consolidation pulmonaire et d’aeration pulmonaire normale.

In the critically ill patients, lung ultrasound (LUS) is increasingly being used at the bedside for assessing alveolar-interstitial syndrome, lung consolidation, pneumonia, pneumothorax, and pleural effusion. It could be an easily repeatable noninvasive tool for assessing lung recruitment.Our goal was to compare the pressure-volume (PV) curve method with LUS for assessing positive end-expiratory pressure (PEEP)-induced lung recruitment in patients with acute respiratory distress syndrome/acute lung injury (ARDS/ALI).Thirty patients with ARDS and 10 patients with ALI were prospectively studied. PV curves and LUS were performed in PEEP 0 and PEEP 15 cm H₂O₂. PEEP-induced lung recruitment was measured using the PV curve method.Four LUS entities were defined: consolidation; multiple, irregularly spaced B lines; multiple coalescent B lines; and normal aeration. For each of the 12 lung regions examined, PEEP-induced ultrasound changes were measured, and an ultrasound reaeration score was calculated. A highly significant correlation was found between PEEP-induced lung recruitment measured by PV curves and ultrasound reaeration score (Rho = 0.88; P0.0001). An ultrasound reaeration score of +8 or higher was associated with a PEEP-induced lung recruitment greater than 600 ml. An ultrasound lung reaeration score of +4 or less was associated with a PEEP-induced lung recruitment ranging from 75 to 450 ml. A statistically significant correlation was found between LUS reaeration score and PEEP-induced increase in Pa(O₂) (Rho = 0.63; P0.05).PEEP-induced lung recruitment can be adequately estimated with bedside LUS. Because LUS cannot assess PEEP-induced lung hyperinflation, it should not be the sole method for PEEP titration.

To assess the accuracy of a multiplane ultrasound approach to measure pleural effusion volume (PEV), considering pleural effusion (PE) extension along the cephalocaudal axis and PE area.Prospective study performed on 58 critically ill patients with 102 PEs. Thoracic drainage was performed in 46 patients (59 PEs) and lung computed tomography (CT) in 24 patients (43 PEs). PE was assessed using bedside lung ultrasound. Adjacent paravertebral intercostal spaces were examined, and ultrasound PEV was calculated by multiplying the paravertebral PE length by its area, measured at half the distance between the apical and caudal limits of the PE.Ultrasound PEV was compared to either the volume of the drained PE (59 PE) or PEV assessed on lung CT (43 PE). In patients with lung CT, the accuracy of this new method was compared to the accuracy of previous methods proposed for PEV measurement. Ultrasound PEV was tightly correlated with drained PEV (r = 0.84, p0.001) and with CT PEV (r = 0.90, p0.001). The mean biases between ultrasound and actual volumes of PE were -33 ml when compared to drainage (limits of agreement -292 to +227 ml) and -53 ml when compared to CT (limits of agreement -303 to +198 ml). This new method was more accurate than previous methods to measure PEV.Using a multiplane approach increases the accuracy of lung ultrasound to measure the volume of large to small pleural effusions in critically ill patients.