Objective: To assess the mechanisms through which an enlarged aortic root may facilitate right to left shunting through a patent foramen ovale. Patients: 19 patients with the platypnoea-orthodeoxia syndrome (POS) were compared with 30 control patients without platypnoea. Interventions: Multiplane transoesophageal echocardiography. Main outcome measures: The aortic root diameter, atrial septal dimension behind the aortic root, and amplitude of the phasic oscillation of the septum were measured. Four groups of patients were compared: 12 platypnoeic patients with a dilated aortic root (POS-D), 7 platypnoeic patients with a normal aortic root (POS-N), 15 control patients with a dilated aortic root (CONT-D), and 15 control patients with a normal aortic root (CONT-N). Results: In POS-D and CONT-D patients, the apparent atrial septal dimension was 16.3 (2.7) mm and 17.4 (5.9) mm respectively, compared with 24.4 (5.2) mm in POS-N patients and 25 (4) mm in CONT-N (p , 0.005). Furthermore, the amplitude of septal oscillation was 14.7 (2.5) mm in the POS-D group versus 5.8 (2.4) mm in CONT-N (p , 0.001) compared with 23.3 (3) mm in seven patients with an atrial septal aneurysm (p ,0.001). Conclusion: Patients with an enlarged aorta have an apparently smaller dimension and increased mobility of the atrial septum. These findings appear to result from compression by the aortic root and decreased septal tautness. Consequently, a ''spinnaker effect'' with the inferior vena caval flow may take place, opening the foramen ovale and leading to sustained right to left shunting.A patent foramen ovale (PFO) is a defect in the atrial septum that results from incomplete fusion of the septum primum to the septum secundum. The persistence of a PFO into adulthood may lead to several complications, including paradoxical embolism of thrombus, air or tumoural material, and refractory hypoxaemia.Normally, even if a potential channel between the atria remains, the higher left atrial pressure keeps the flap-like valve of the foramen ovale opposed to the septum secundum. Most cases of sustained right to left shunting through a PFO are seen in situations where right atrial pressure exceeds that of the left, forcing open the potentially patent foramen ovale.However, right to left shunting can be less often observed in the absence of any demonstrable pressure gradient between right and left atria. Right to left shunting despite normal right atrial pressure has been reported after right pneumonectomy 1 2 or in association with venous embryonic remnants. 3 4 In these situations, an altered relation between the caval veins and the atrial septum presumably accounts for flow related rather than pressure related shunting.A few cases of aneurysm of the ascending aorta associated with right to left shunting across a PFO have been reported, 5-10 but evidence for a non-fortuitous association is still lacking. Therefore, we conducted a study to further analyse factors facilitating right to left shunting in patients with PFO, with particular attention paid to t...

Empirically determined noninvasive ventilation (NIV) settings may not achieve optimal ventilatory support. Some ventilators include monitoring modules to assess ventilatory quality. We conducted a bench-to-bedside study to assess the ventilatory quality of the VPAP TM IIIResLink TM (ResMed, North Ryde, Australia).We tested the accuracy of minute ventilation (MV) and leak calculations given by VPAP TM IIIResLink TM compared to those measured by a bench model at varied leak levels and ventilator settings. We systematically assessed NIV efficacy using this system from 2003 to 2006. Ventilation was considered inadequate if leak (.24 L?min -1 ), continuous desaturation (.30% of the trace) or desaturation dips (.3%) were present. On the bench test, both methods were highly correlated (r50.947, p.0.0001 and r50.959, p,0.0001 for leak and MV, respectively). We performed 222 assessments in 169 patients (aged 66.42¡16 yrs, 100 males). Abnormalities were detected on 147 (66%) out of 222 occasions. Leak was the most common abnormality (34.2%) followed by desaturation dips (23.8%). The most effective therapeutic solutions were a chin strap if leak was detected (61.2%) and expiratory positive airway pressure increase for desaturation dips (59.5%). In 15.7% of cases, when abnormalities persisted, a polygraphy was performed.The systematic use of this device enables NIV to be optimised, limiting the indication of sleep studies to complex cases. KEYWORDS: Bench testing, bi-level positive airway pressure, clinical evaluation, monitoring, noninvasive ventilation, respiratory failure N oninvasive ventilation (NIV) has been demonstrated to be effective treatment in respiratory failure. In some cases, however, the clinical results may be less than expected, despite using the correct technique. When NIV is initiated, the ventilator settings are determined empirically based on clinical evaluation of underlying disease, patient tolerance when awake, and diurnal blood gas variations [1]. However, NIV is predominantly applied at night [2], when profound ventilatory changes may occur, particularly in patients with respiratory failure [3]. Such changes include modifications of ventilatory control, upper airway patency and respiratory muscle recruitment. Consequently, modulating NIV settings during the day and underestimating these physiological differences may lead to suboptimal patientventilator interaction that reduces NIV efficacy.Moreover, NIV uses a non-hermetic technique, which poses the possible risk of leak. Leakage may be absent or minimal when the patient is awake and may worsen during sleep as a result of the loss of voluntary control and decreased muscle tone. Thus, NIV settings chosen empirically on daytime evaluation may not predict optimal nocturnal ventilatory support. Consequently, NIV effectiveness may be more correctly assessed by sleep studies than through daytime assessment [1]. Ideally this requires complete polysomnography (PSG) or ventilatory polygraphy (PG) at the time of initiation to NIV. However, it is n...

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In multivariate analysis, a leukocyte score that adds 1 point each for neutropenia, lymphopenia and monocytopenia was associated with 30-day mortality in 192 patients with bacteremic pneumococcal pneumonia. By reflecting immunoparalysis, this score could improve clinical outcome predictions in BPP.

Acute lung toxicity is a rare but classical complication of amiodarone therapy. We report the case of a patient who developed an optic neuropathy after 15 years of amiodarone administration, and who was treated for 2 weeks with steroids. Following withdrawal of steroids, the patient rapidly developed an acute respiratory distress syndrome. Postmortem lung histologic examination was consistent with amiodarone-induced pneumonitis. Since this complication is thought to be of immunological origin, we speculate that the sudden withdrawal of steroids was implicated in the development of the acute lung injury.