En tant que vieux docteur, je peux dire que malheureusement j'intube beaucoup
plus rarement. Et moi, j'adore intuber. Alors vivement que la VNI cesse de
fonctionner!
Dominic Larose
----- Original Message -----
From: Martin Loranger
To: [EMAIL PROTECTED]
Sent: Tuesday, September 02, 2008 3:42 PM
Subject: URG-L: FW: InfoPOEM: CPAP and NIPPV no better than O2
inacutepulmonary edema (3CPO)
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
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Date: Tue, 2 Sep 2008 15:14:01 -0400
From: [EMAIL PROTECTED]
To: [EMAIL PROTECTED]
Subject: 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 AM
To: [EMAIL PROTECTED]
Subject: URG-L: FW: InfoPOEM: CPAP and NIPPV no better than O2 in acute
pulmonary edema (3CPO)
FAscinant quand même!
ALain
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éditoriale de amc.ca"
Sent: 2 septembre 2008 05:21
To: [EMAIL PROTECTED]
Subject: InfoPOEM: CPAP and NIPPV no better than O2 in acute pulmonary
edema (3CPO)
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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)
Funding
Government
Allocation
Concealed
Setting
Inpatient (any location)
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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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