C'est un peu la même chose quand on parcourt la littérature sur la VNI concernant les MPOC: les étatsuniens traitents beaucoup plus précocément que nous les patients. Je pense que comme beaucoup de traitements dans les insuffisances respiratoires, plus la crise est sévère, plus le traitement est efficace. Parlez-en avec les "vieux" docteurs qui ont connu l'ère pré-Bipap. Ils intubaient beaucoup plus de patients, même ceux qui n'arrivaient pas in-extremis, surtout à cause de la fatigue respiratoire. Ça me semble évident que si l'on traite agressivement les pts peu malades, les traitements "de dernier recours" seront moins efficaces. Je ne sais pas ce que leur comité d'éthique ont exigés, ou peut-être que les chercheurs ont voulu recruter des pts moins malades pour accélérer l'étude, mais je suis cliniquement et gaz-veineux-parlant convaincu que les patients se fatiguent moins avec un BIPAP. Martin
Date: Tue, 2 Sep 2008 15:14:01 -0400From: [EMAIL PROTECTED]: [EMAIL PROTECTED]: URG-L: FW: InfoPOEM: CPAP and NIPPV no better than O2 in acutepulmonary edema (3CPO) J'ai la meme impression que Julie On Tue, Sep 2, 2008 at 1:02 PM, Julie Boyer <[EMAIL PROTECTED]> wrote: En effet, c'est surprenant. Les patients qui tolèrent sont tellement plus relax, plus rapidement avec le BiPap. En plus, la majorité tolère bien. J'ai toujours eu l'impression que le Bipap prévenait l'intubation…. Peut-être que l'on traite le docteur ??? Les patients ont l'air mieux. Julie From: Alain Vadeboncoeur [mailto:[EMAIL PROTECTED] Sent: Tuesday, September 02, 2008 10:01 AMTo: [EMAIL PROTECTED]: URG-L: FW: InfoPOEM: CPAP and NIPPV no better than O2 in acute pulmonary edema (3CPO) FAscinant quand même! ALain From: [EMAIL PROTECTED] [mailto:[EMAIL PROTECTED] On Behalf Of "Équipe éditoriale de amc.ca"Sent: 2 septembre 2008 05:21To: [EMAIL PROTECTED]: InfoPOEM: CPAP and NIPPV no better than O2 in acute pulmonary edema (3CPO) Pour assurer la livraison de ce courriel dans votre boîte de réception, veuillez ajouter [EMAIL PROTECTED] à votre carnet de contacts. CPAP and NIPPV no better than O2 in acute pulmonary edema (3CPO) Clinical question Does noninvasive ventilation improve outcomes in patients with acute cardiogenic pulmonary edema? Bottom line In patients with acute cardiogenic pulmonary edema, continuous positive airway pressure (CPAP) and noninvasive positive pressure support (NIPPV) do not reduce mortality or the risk of requiring intubation more than standard oxygen therapy. They may provide a small benefit in terms of greater relief of dyspnea. (LOE = 1b) Reference Gray A, Goodacre S, Newby DE, et al, for the 3CPO Trialists. Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J Med 2008;359(2):142-151. Study design Randomized controlled trial (nonblinded) FundingGovernment AllocationConcealed SettingInpatient (any location) Obtenez des crédits Mainpro Discutez de cet InfoPOEM Archives Bilan des crédits Plus de FMC / DPC Publicité Envoyez-nous vos commentaires Synopsis The optimal approach to noninvasive ventilation for patients with acute cardiogenic pulmonary edema remains unclear, with only a few small randomized controlled trials. CPAP provides the same level of positive airway pressure throughout the respiratory cycle, while NIPPV increases pressure more during inspiration than during expiration. There are theoretical reasons to think that NIPPV may be better, but it has also been associated with a greater risk of acute myocardial infarction. In this study, 1069 adults with acute cardiogenic pulmonary edema at 26 United Kingdom emergency departments were randomized to receive oxygen therapy, CPAP, or NIPPV. All patients had pulmonary edema on chest x-ray, a pH of less than 7.35, and a respiratory rate greater than 20 breaths per minute. Their mean age was 78 years and 57% were women. All patients received the assigned treatment for at least 2 hours, with the duration of further treatment determined by the treating physician. Groups were balanced at the start of the study and analysis was by intention to treat. Overall adherence to the assigned treatment was good, although patients initially assigned to oxygen were more likely to change therapy because of respiratory distress (8.4% vs 1.4% for CPAP and 3.4% for NIPPV; P < .001), while those assigned to NIPPV were more likely to change therapy because of patient discomfort (8.4% vs 5.2% for CPAP and 0.3% for oxygen; P < .001). After 7 days, there was no significant difference between groups regarding rates of mortality or need for intubation, or regarding mortality at 30 days. Patients receiving CPAP or NIPPV had a greater improvement on a 10-point dyspnea score than those receiving oxygen alone (4.6 vs 3.9 points), but this difference is of questionable clinical significance. There were also greater improvements in arterial pCO2 and pH, but again the clinical significance is uncertain. 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