Revue des maladies respiratoires
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Caval interruption has been, historically, the first "treatment" of venous thromboembolic disease. Following ligation, plication, then clips, and finally intracaval filters constituted the successive improvements of this procedure, which can now be considered reasonably safe. However, reliable and clinically relevant data regarding long-term safety are lacking; recent data suggest that caval filters might increase the risk of recurrent deep venous thrombosis. ⋯ Although the PREPIC study, first prospective controlled trial on caval filters, confirmed their efficacy for preventing pulmonary embolism, the addition of caval filters to preventive or curative anticoagulant treatment in high-risk patients is still a matter of debate, because "very high-risk" settings despite anticoagulant treatment remain poorly defined. Finally, the risk-benefit ratio of caval interruption in addition to medical thrombolysis, or as an alternative to preventive or curative anticoagulant treatment appears unfavorable. The relevance of debatable indications, the precise identification of "very high-risk" patients, and the determination of the "best" filter should be assessed in specific prospective clinical trials.
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Comparative Study
[Control of respiration by inspiratory pressure support].
A reduction in arterial PCO2 is an important cause of respiratory muscle inhibition during pressure support (PS). A nonchemical inhibition of respiratory activity during PS has also been demonstrated. ⋯ Currently, PS is the ventilatory support technique which provides the highest initial inspiratory flow. However, these new physiological findings should facilitate the development of more effective ventilatory support techniques.
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Post intubation tracheal stenosis (STPI) is a rare but serious complication of tracheal intubation and/or tracheotomy. The epidemiology has changed over the last twenty years. The diagnosis is sometimes difficult to establish on clinical grounds alone. ⋯ Rigid bronchoscopy enables mechanical dilatation of the STPI which can be associated with Nd-Yag laser ortracheal endoprostheses. In certain cases interventional bronchoscopy may be curative. However in all cases the management of such lesions remains multi-disciplinary involving pulmonologists, thoracic surgeons, otolaryngologists and anaesthetists.
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Interventional rigid bronchoscopy requires the same careful anesthetic management as any type of surgery. Furthermore, access to airways for both endoscopist and anaesthetist raises difficult problems. Hypoventilation with its consequences is a major risk, especially for patients with impaired ventilatory capacity. ⋯ Flexible fiberoptic bronchoscopy is systematically performed before extubation. Interventional rigid bronchoscopy is ideally performed in an operating room or an adjacent area or in an intensive care unit in case of complication. Postoperative supervising in a recovery room is mandatory.
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A 49-year-old man with disseminated histoplasmosis (pulmonary and central nervous system involvement) successfully treated with ketoconazole and fluconazole combination is reported. Histoplasma capsulatum infection of the central nervous system is extremely rare in France partly because the organism is not endemic. Oral treatment with newer triazoles may be useful for central nervous system histoplasmosis, but additional information is needed to establish their effectiveness.