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BACKGROUND: Compared with usual care, noninvasive ventilation (NIV) lowers the risk of intubation and death for subjects with respiratory failure secondary to COPD exacerbations, but whether administration of NIV by a specialized, dedicated team improves its efficiency remains uncertain. Our aim was to test whether a dedicated team of respiratory therapists applying all acute NIV treatments would reduce the risk of intubation or death for subjects with COPD admitted for respiratory failure. METHODS: We carried out a retrospective study comparing subjects with COPD admitted to the ICU before (2001-2003) and after (2010 -2012) the creation of a dedicated NIV team in a regional acute care hospital. The primary outcome was the risk of intubation or death. The secondary outcomes were the individual components of the primary outcome and ICU/hospital stay. RESULTS: A total of 126 subjects were included: 53 in the first cohort and 73 in the second. There was no significant difference in the demographic characteristics and severity of respiratory failure. Fifteen subjects (28.3%) died or had to undergo tracheal intubation in the first cohort, and only 10 subjects (13.7%) in the second cohort (odds ratio 0.40, 95% CI 0.16 -0.99, P ‫؍‬ .04). In-hospital mortality (15.1% vs 4.1%, P ‫؍‬ .03) and median stay (ICU: 3.1 vs 1.9 d, P ‫؍‬ .04; hospital: 11.5 vs 9.6 d, P ‫؍‬ .04) were significantly lower in the second cohort, and a trend for a lower intubation risk was observed (20.8% vs 11% P ‫؍‬ .13). CONCLUSIONS: The delivery of NIV by a dedicated team was associated with a lower risk of death or intubation in subjects with respiratory failure secondary to COPD exacerbations. Therefore, the implementation of a team administering all NIV treatments on a 24-h basis should be considered in institutions admitting subjects with COPD exacerbations.

Summary: Percutaneous transluminal coronary angioplasty (PTCA) is a widely performed and effective therapy for com nary artery disease. Evolution of the dilatation instruments during the last decade has led toan increased success rate of F E A and to the development of newer techniques such as recanalimtion of totally occluded coronary arteries. We report a case of coronary artery recanalization complicated by fatal coronary artery rupture.Key words: percutanmus mslurninal coronary angioplasty, coronary artery perforation, coronary artery rupture Case ReportA 65-year-old man with a 48-h history of progressive dyspnea was admitted to our hospital. He had an unremarkable med~cal history, smoking being his sole cardiovascular risk factor. He did not complain of chest pain, but clinical examination on admission revealed severe respiratory distress, tachycardia (1 30 beatdmin), and hypotension (W60 mmHg).The electrocardiogram showed the presence of an acute anterior myocadal infarction and an old inferior ischemic injury. Right heart catheterization further established the diagnosis of cadogenic shock (pulmonary capillary wedge pmsure 32 mmHg, cardiac index 1.9 Ymin/mz). After initial therapy with diuretics, vasoactive amines, and orotracheal intubation, it was decided, in view of a possible angioplasty, to perform an emergency coronary arteriography. This p d u r e revealed a 75% stenosis in the middle part of the right coronary artery (RCA) and a proximal occlusion of the left anterior descending artery (LAD). Inc., Ternecula, CA) was passed h m an 8 French Judkins guiding catheter through the occlusion of the LAD. Subsequently, a "Speedy" 3 mm balloon (Schneider Medintag AG, Ziirich) was advanced over the guidewire in the occluded LAD. After two inflations at a maximal pressure of 6 bar, the balloon was withdrawn and a control injection was made. This showed patency of the proximal segment of the LAD, however with a "no flow" situation and an important exmvasation of the contrast medium into the pericardium (Fig. 1). The clinical course deteriorated quickly and fatal cardiac arrest ensued, At nmpsy, a hemoperi&um of 130 ml was found. The source of hemomhage was located on the anterior wall of the heart where the epicardial fat showed interstitial bleeding along the LAD. serial histological examination of this artery disclosed a disrupted plaque as well as a dissection of the coronary wall 3.5 cm from its origin (Fig. 2). A total rupture of the vascular wall had occurred 1.5 cm more distally (Fig. 3). The myocardium of the left ventricle presented a scarred inferior transmural and a fresh anteroseptal subendocardial infarction. DiscussionCmnary artery rupture is a rare complication of prCG with only 11 papers between 1982 and 1991 in the literature. The National Heart, Lung, and Blood Institute registry on PTCA reports two cases of perforation and one case of coronary artery rupture without further information.'.2 A detailed case history of 14 patients is available?-''Coronary artery perforation and rupture were re...

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