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Sessions Posters Réanimation (2009) 18S, S48—S187 Sessions posters SP001 Introduction.— La ventilation non invasive (VNI) est devenue une Facteurs prédictifs de succès de la ventilation non thérapeutique majeure de l’insuffisance respiratoire aiguë aux ser- invasive au cours des détresses respiratoires aiguës vices des urgences. L’objectif de notre travail est d’évaluer ce A. Bignon, L. Robriquet, F.Fourrier moyen thérapeutique et de repérer ses meilleures indications dans Service de réanimation polyvalente, CHRU de Lille, hôpital nos conditions de travail. Roger-Salengro, Lille Patients et méthodes.— Notre étude est prospective s’étalant sur une période d’une année (avril 2007—mars 2008) incluant tous les Objectif.— Identifier les facteurs prédictifs du succès de la ventila- patients hospitalisés à l’UHCD des urgences de Sfax et répondant à tion non invasive (VNI). Étude rétrospective et monocentrique. l’un des critères suivants : Matériels et méthodes.— De janvier 2002 à mars 2008, 191 patients — BPCO avec un pH inférieur à 7,35 ; hospitalisés pour détresse respiratoire aiguë dans un service de — OAP avec signes cliniques de détresse respiratoire majeure sans réanimation polyvalente au centre hospitalier régional et univer- chiffres gazométriques ; sitaire de Lille ont bénéficié de séances de VNI. La VNI était —ouPaCO2 > 45 mmHg ; administrée par l’intermédiaire d’une BiPAP vision. Des données cli- — ou non réponse au traitement médical ; niques, gazométriques et les paramètres de ventilation mécanique — immunodéprimé avec rapport PaO2/FiO2 < 200 + infiltrat pulmo- ont été recueillis à l’admission et au cours des 24 premières heures naire ; de traitement. — pneumopathie hypoxémiante avec rapport PaO2/FiO2 < 150. Résultats.— Le taux de succès de la VNI était de 60 %. En analyse Résultats.— Nous avons colligé 46 cas répondant à nos critères multivariée, quatre facteurs prédictifs de succès de la VNI étaient d’inclusion. Notre population se compose de 29 hommes (63 %) et retenus : un score de gravité (IGS II) bas à l’admission (OR 0,97 par 17 femmes (37 %). L’âge moyen est de 63,1 ± 13,9 ans (minimum point, 95 % CI 0,95—0,99), une exacerbation de bronchopneumopa- 19 ans, maximum 87 ans). Le SAPS II moyen est de 25,8 ± 13,5 points. thie chronique obstructive (OR 3,53, 95 % CI 1,05—11,8), un nombre L’indication de la VNI était un OAP dans 20 cas, une BPCO dans 17 cas plus élevé de séances de VNI quotidiennes (OR 2,2 par séance sup- et une pneumopathie dans les 9 cas restants. La VNI était par venti- plémentaire, 95 % CI 1,56—3,13) et l’absence de modification de la lation à double niveau de pression chez 89 % des BPCO et par CPAP pression inspiratoire entre la première et la deuxième séance de chez 90 % des patients présentant un OAP. VNI (OR 1,36, 95 % CI 0,34—5,53). Aucune pneumopathie nosoco- Le bénéfice gazométrique a été noté dans tous les cas et essentiel- miale n’était retrouvée dans le groupe succès de VNI versus 18 % lement en cas d’OAP. dans le groupe échec (p<0,0001). La publication des recomman- L’intubation était indiquée dans 20 % des cas d’OAP et chez 33,3 % dations de la conférence de consensus commune d’octobre 2006 sur des pneumopathies hypoxémiantes. Chez les BPCO en décompen- les modalités d’application de la VNI n’avait pas modifié de manière sation aiguë, il n’y a pas eu de recours à l’intubation, mais significative les indications et le taux de succès de la VNI (55,9 % sans différence significative. La mortalité globale est de 24 % versus 70 %, p=0,07). (11 patients). Elle est de 20 % chez les patients présentant un OAP, Conclusion.— Notre travail suggère un bénéfice à l’utilisation de la 11 % chez les BPCO et de 50 % chez le reste des patients sans diffé- VNI sous forme de séances courtes et fréquentes. rence significative entre les trois catégories de patients. Conclusion.— Il semble que le bénéfice de la VNI dans la prise en charge des insuffisances respiratoires aiguës est de plus en plus SP002 prouvé quelle que soit l’étiologie. Notre population est cependant La ventilation non invasive pour insuffisance limitée pour pouvoir juger de l’effet de la VNI sur le pronostic de respiratoire aiguë aux urgences : étude chacune des catégories de patients inclus. prospective de 46 cas A. Chaaria, O. Chakrouna, H. Ksibia, L. Kammouna, W. Moknia, SP003 I. Rjaba, M. Bouazizb, N. Rekika a Service d’urgences et Samu, CHU Habib Bourguiba Safx, Sfax, Ventilation non invasive pour la prévention de la Tunisie; b service de réanimation médicale, CHU Habib Bourguiba détresse respiratoire aiguë post-extubation chez Safx, Sfax, Tunisie les patients à risque 1624-0693/$ – see front matter © 2008 Publie´ par Elsevier Masson SAS pour la Société de réanimation de langue française. doi:10.1016/j.reaurg.2008.10.004 Résumés S49 M. Grenouillet-Delacrea, U. Akhtara, F.Vargasb, H.N. Buib, Objectif.— Évaluer l’incidence des prescriptions de VNI réalisées B. Clouzeaub, J. Youssefa, C.C. Balick-Webera, D. Grusonb, en dehors d’un accord fort du consensus franc¸ais et l’incidence des G. Hilbertb administrations non réalisées pourtant recommandées. a Service de réanimation médicale, CHU Pellegrin Tripode, Patients et méthodes.— Entre janvier 2007 et juin 2008, les indi- Bordeaux ; b service de réanimation médicale et de médecine cations de VNI ont été analysées rétrospectivement. Elles ont été hyperbare, CHU Pellegrin Tripode, Bordeaux regroupées en : intérêt certain, intérêt non établi et aucun avan- tage démontré. Les indications avec intérêt certain, pourtant non Introduction.— L’intérêt de la ventilation non invasive (VNI) utilisée réalisées, ont aussi été répertoriées a posteriori. précocement de fac¸on préventive après extubation a été démon- Résultats.— En 18 mois, 1093 patients ont été admis. L’utilisation trée, chez certains patients à risque, pour éviter la survenue d’une de la VNI a été faite chez 228 patients (21 %) : IGS2 : 47 ± 16, durée nouvelle détresse respiratoire aiguë et prévenir ainsi la réintuba- moyenne de séjour : 10 j ; 94/228 (41 %) patients, toutes indications tion, facteur de mauvais pronostic [1,2]. L’objectif de cette étude de VNI confondues, seront intubés. était d’évaluer la VNI dans la prévention de réintubation parmi la population de patients à risque de détresse respiratoire aiguë après Intérêt certain : 88/228 Intérêt non établi : 37/228 (16 %) extubation. (39 %) Patients et méthodes.— Cette étude prospective observationnelle Exacerbation OAP ID1 Post op NM2 a été réalisée en réanimation médicale au centre universitaire de BPCO chronique Bordeaux. Les patients inclus avaient été intubés ventilés pendant n patients (%) 73/228 (32) 15/228 (6) 25/228 (11) 4/228 (2) 8/228 (4) Durée VNI (j) 5 3 4 2 4 une période de 48 h minimum, présentaient au moins un facteur de Intubation n 16/73 (22) 5/15 (33) 11/25 (44) 2 (50) 2 (25) risque de détresse respiratoire après extubation (âge supérieur à patients (%) 65 ans, score Apache II supérieur à 12, insuffisance cardiaque, bron- Décès (%) 6/73 (6) 0 7/25 (28) 2 (50) 1 (12) chopneumopathie chronique obstructive (BPCO) hypercapnique, VNI post-extubation 9/16 (56 %) 0 1 0 1 pathologie neuromusculaire, toux inefficace, ventilation mécanique 1 : ID = patients immunodéprimés ; 2 : NM : neuromusculaire chronique ; autre indication dans « intérêt non établi » : traumatisme thoracique fermé : 1 patient, prévention en post- prolongée plus de 21 jours, PaCO2 supérieure à 6 kPa au cours du extubation (patients tous confondus : BPCO, ID, NM) : 9 patients. test de sevrage avant extubation) [1,2]. La VNI était réalisée avec un masque facial sur un ventilateur de réanimation selon un mode Aucun avantage démontré de la VNI : 93/228 (41 %) séquentiel (minimum de 45 min toutes les 3 h, au moins le 1◦ jour) Pneumonie IRA Post extub2 NM aigu3 IRA—AVC4 [2] pendant les 72 h après extubation. Le critère de jugement prin- hypoxémiante1 cipal était la réintubation au cours des 72 h après extubation. Les n patients (%) 43 (19) 23 (10) 5 (2) 22 (10) caractéristiques des patients ré intubés ont été comparées à celles Durée VNI (j) 4 3 4 (1 — 4) 2 (1 — 5) des autres patients. Intubation n 25 (58) 8 (35) 4 (80) 18 (82) patients (%) Résultats.— Parmi les 52 patients inclus (dont 56 % d’hommes), l’âge Décès (%) 6 (14) 4 (17) 0 4 (18) médian était de 59 ans (18—82). Neuf patients (17 %) avaient une 1 : IRA et SDRA, patient immunocompétent ; 2 : traitement de l’IRA post extubation (pas sa insuffisance cardiaque, 11 (21 %) une toux peu efficace, 12 (23 %) une prévention) ; 3 : neuromusculaire ; 4 : groupe individualisé de pneumonies hypoxémiantes : BPCO avec hypercapnie, 23 (43 %) une pathologie neuromusculaire patient avec AVC et inhalation. et 22 (42 %) avaient eu une ventilation mécanique prolongée. La durée de ventilation mécanique médiane avant extubation était de Parmi les 865 autres patients admis en réa, la VNI dans une 15 jours (3—60). Dans 24 cas (46 %), la VNI a été débutée immédiate- indication avec intérêt certain n’a pas été faite dans seulement ment après l’extubation, dans 7 cas (13 %) dans les trois premières 5 cas. heures et dans les 24 premières heures après extubation chez les Conclusion.— Utilisation de la VNI : 41 % d’indications où aucun avan- autres patients. Les patients ont réalisé en moyenne 6 h de VNI tage n’a pourtant été démontré ; très peu de non utilisation dans par jour. Neuf patients (17 %) ont présenté des signes de détresse des indications bien reconnues. respiratoire aiguë et 7 (13 %) ont été réintubés. Dans 2 cas, un œdème laryngé a nécessité une réintubation en urgence. Parmi les 5 autres patients, 3 ont été réintubés pour épuisement respi- SP005 ratoire, 1 pour coma et 1 pour choc.
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