Search

International audience; BackgroundThe present article is an English-language version of the French National Diagnostic and Care Protocol, a pragmatic tool to optimize and harmonize the diagnosis, care pathway, management and follow-up of lymphangioleiomyomatosis in France.MethodsPractical recommendations were developed in accordance with the method for developing a National Diagnosis and Care Protocol for rare diseases of the Haute Autorité de Santé and following international guidelines and literature on lymphangioleiomyomatosis. It was developed by a multidisciplinary group, with the help of patient representatives and of RespiFIL, the rare disease network on respiratory diseases.ResultsLymphangioleiomyomatosis is a rare lung disease characterised by a proliferation of smooth muscle cells that leads to the formation of multiple lung cysts. It occurs sporadically or as part of a genetic disease called tuberous sclerosis complex (TSC). The document addresses multiple aspects of the disease, to guide the clinicians regarding when to suspect a diagnosis of lymphangioleiomyomatosis, what to do in case of recurrent pneumothorax or angiomyolipomas, what investigations are needed to make the diagnosis of lymphangioleiomyomatosis, what the diagnostic criteria are for lymphangioleiomyomatosis, what the principles of management are, and how follow-up can be organised. Recommendations are made regarding the use of pharmaceutical specialties and treatment other than medications.ConclusionThese recommendations are intended to guide the diagnosis and practical management of pulmonary lymphangioleiomyomatosis.

Purpose: In severe chronic obstructive pulmonary disease (COPD) patients, the application of an inspiratory pressure support (IPS) during exercise increases exercise tolerance and the benefit of exercise training during pulmonary rehabilitation (PR). Moreover, it improves quadriceps endurance after a session of cycling exercise suggesting a reduced muscle fatigue. We looked for the persistence of this effect after PR and sought an association between the improved quadriceps endurance with IPS and the training load during PR.Patients and methods: We studied 20 patients with severe COPD (6 in stage 3and 14 in stage 4 of GOLD) before and after PR. As part of a PR program, patients completed 16 cycling sessions over 6 weeks with the addition of IPS during exercise. As a surrogate of muscular fatigue, quadriceps endurance was measured at 70% of maximal strength in a control condition, after a constant work rate exercise test (CWR) with IPS (TlimQ IPS) or with a sham ventilation (TlimQsham), in a random order. These tests were repeated similarly at the end of PR.Results: PR was associated with a significant increase in maximal power output, cycling endurance, quadriceps strength and endurance. Session training load (power output x duration of the session) increased by 142% during the course of the program. Before PR, CWR duration increases with IPS compared to sham ventilation (Δtime = +244s, p = 0.001). Compared to control condition, post-exercise TlimQ reduction was lower with IPS at isotime than at the end of CWR or than with sham ventilation (−9 ± 21%, −18 ± 16% and −23 ± 18%, respectively, p = 0.09, p < 0.0001 and p < 0.0001). After PR, the post-exercise decrease of TlimQ was reduced after IPS compared to sham (−9 ± 18% vs. −21 ± 17%, respectively, p = 0.004). No relationship was found between the prevention of quadriceps fatigue and the training load.Conclusion: In severe COPD patients, the beneficial effect of a ventilator support on quadriceps endurance persisted after PR with IPS. However, it was not related to the increase in training load, and could not predict the training response to non-invasive ventilation during exercise.

It is unknown what role chest ultrasound plays in distinguishing the various usual interstitial pneumonia (UIP) patterns of high-resolution chest tomography (HRCT). The purpose of this study was to see if there was a link between the results of chest ultrasound (u/s) and HRCT in patients with idiopathic pulmonary fibrosis (IPF). We performed chest u/s in 16 patients with UIP and probable UIP patterns to indeterminate UIP and alternative diagnosis patterns in this single center prospective study to determine any possible relationship with the HRCT findings. A chest radiologist reviewed each HRCT to determine the pattern in accordance with the American Thoracic Society (ATS) / European Respiratory Society (ERS) Guidelines. The local multidisciplinary committee validated the patients' diagnoses before they were included. When compared to the indeterminate for UIP or alternative diagnosis pattern group, there was a trend (p=0.07) toward the presence of more B lines in UIP or probable UIP patterns. There was no statistically significant difference in the presence of small, large, white lung, or pleural line thickening >5mm. Subgroup analysis revealed that patients with honeycombing were more likely to have a fragmented pleural line (p=0.04). To summarize, in our pilot study, chest u/s appears unable to differentiate UIP and probable UIP patterns from indeterminate UIP and alternative diagnosis patterns. However, it appears that this technique can be used to recognize the honeycombing pattern.

BackgroundStandard of care for interstitial lung disease (ILD) with a nonspecific interstitial pneumonia (NSIP) pattern proposes mycophenolate mofetil (MMF) as one of the first step therapies while rituximab is used as rescue therapy.MethodsIn a randomised, double blind, two-parallel group, placebo-controlled trial (NCT02990286), patients with connective tissue disease-associated ILD or idiopathic interstitial pneumonia (with or without autoimmune feature) and a NSIP pattern (defined on NSIP pathological pattern or on integration of clinico-biological data and a NSIP-like HRCT pattern) were randomly assigned in a 1:1 ratio to receive rituximab (1000 mg) or placebo on day 1 and day 15 in addition to MMF (2 g daily) for six months. The primary endpoint was the change in percent of predicted forced vital capacity (FVC) from baseline to 6 months analysed by a linear mixed model for repeated measures analysis. Secondary endpoints included progression-free survival (PFS) up to 6 months and safety.FindingsBetween January 2017 and January 2019, 122 randomised patients received at least one dose of rituximab (n=63) or placebo (n=59). The least-squares mean change from baseline to 6 months in FVC (% predicted) was +1.60 (se1.13) in the rituximab+MMF group and −2.01 (se1.17) in the placebo+MMF group (between-group difference, 3.60 [95% CI 0.41 to 6.80]; p=0.0273). PFS was better in the rituximab+MMF group (crude HR 0.47 [95%CI 0.23 to 0.96]; p=0.03). Serious adverse events occurred in 26 patients of the rituximab+MMF group (41%) and in 23 of the placebo+MMF group (39%). Nine infections were reported in the rituximab+MMF group (five bacterial infections, 3 viral infections, 1 other) and four bacterial infections in the placebo+MMF group.InterpretationCombination of rituximab and MMF was superior to MMF alone in patients with ILD and a NSIP pattern. The use of this combination must consider the risk of viral infection.

Background: The 6-min walk test (6MWT) allows exercise tolerance to be assessed, and it has a significant prognostic value in COPD. The goal of this study was to analyse the determinants (obtained in routine practice) of a low 6-min walking distance (6MWD) and exercise-induced desaturation (EID) in COPD, including comorbidities. Methods: Patients were recruited from the real-life French COPD cohort "Initiatives BPCO". A low 6MWD was defined as 30 kg/m2), low BMI (BMI

Maéva Zysman,1 Gaëtan Deslee,2 Thierry Perez,3 Pierre-Régis Burgel,4 Olivier Le Rouzic,3 Graziella Brinchault-Rabin,5 Pascale Nesme-Meyer,6 Isabelle Court-Fortune,7 Gilles Jebrak,8 Pascal Chanez,9 Denis Caillaud,10 Jean-Louis Paillasseur,11 Nicolas Roche4 1Pulmonary Department, Pôle Cardio-thoracique, CHU Haut-Lévèque, INSERM U1045, Bordeaux, France; 2Pulmonary Department, Maison Blanche University Hospital, INSERM U01250, Reims, France; 3University Lille, CNRS, INSERM, CHU Lille, Institut Pasteur de Lille, U1019 – UMR 9017 – CIIL - Center for Infection and Immunity of Lille, Lille, France; 4Respiratory Medicine, Cochin Hospital, AP-HP and Université de Paris, Institut Cochin, INSERM U1016, Paris, France; 5Service de Pneumologie, Hôpital Pontchaillou, Rennes, France; 6Service de Pneumologie, Hôpital de la Croix-Rousse, Lyon, France; 7Service de Pneumologie, CHU Saint Etienne, Saint Etienne, France; 8Service de Pneumologie, Hôpital Bichat, AP-HP, Paris, France; 9Département des Maladies Respiratoires, AP-HM, Université de la Méditerranée, Marseille, France; 10Service de Pneumologie, Hôpital Gabriel Montpied, CHU, Clermont-Ferrand, France; 11EFFI-STAT, Paris, FranceCorrespondence: Maéva ZysmanAvenue de Magellan, Service des Maladies Respiratoires, CHU Haut Lévèque, Pessac, 33600, FranceTel +33 5 56 79 56 79Email maeva.zysman@chu-bordeaux.frBackground: Chronic respiratory failure may occur as a consequence of chronic obstructive pulmonary disease (COPD) and is associated with significant morbidity and mortality. Hypoxemia is determined by underlying disease characteristics and comorbidities. Severe hypoxemia is typically only found in subjects with severe airflow obstruction (FEV1< 50% predicted). However, how hypoxemia relates to disease characteristics is not fully understood.Methods: In the French Initiatives BPCO real-life cohort, arterial blood gases were routinely collected in most patients. Relationships between severe hypoxemia, defined by a Pa02< 60 mmHg (8 kPa) and clinical/lung function features, comorbidities and mortality were assessed. In subjects with severe hypoxemia, clinical characteristics and comorbidities were compared between those with non-severe versus severe airflow limitation. Classification and regression trees (CART) were used to define clinically relevant subgroups (phenotypes).Results: Arterial blood gases were available from 887 subjects, of which 146 (16%) exhibited severe hypoxemia. Compared to subjects with a PaO2≥ 60 mmHg, the severe hypoxemia group exhibited higher mMRC dyspnea score, lower FEV1, higher RV and RV/TLC, more impaired quality of life, lower 6-minute walking distance, less frequent history of asthma, more frequent diabetes and higher 3-year mortality rate (14% versus 8%, p=0.026). Compared to subjects with Pa02< 60 mmHg and FEV1< 50% (n=115, 13%), those with severe hypoxemia but FEV1≥ 50% predicted (n=31) were older, had higher BMI, less hyperinflation, better quality of life and a higher rate of diabetes (29% versus 13%, p=0.02). Severe hypoxemia was better related to CART-defined phenotypes than to GOLD ABCD classification.Conclusion: In this cohort of stable COPD subjects, severe hypoxemia was associated with worse prognosis and more severe symptoms, airflow limitation and hyperinflation. Compared to subjects with severe hypoxemia and severe airflow limitation, subjects with severe hypoxemia despite non-severe airflow limitation were older, had higher BMI and more diagnosed diabetes.Trial Registration: 04– 479.Keywords: chronic obstructive pulmonary disease, severe hypoxemia, airflow limitation

Introduction Mechanisms of postoperative sleep architecture disturbances and sleep-disordered breathing are uncertain. The authors hypothesised that patients undergoing surgery under regional anaesthesia without opioids used for postoperative analgesia would experience lesser changes in these parameters than patients operated under general anaesthesia with per- and postoperative opioids. Patients and methods After ethical approval and informed consent, patients undergoing total hip replacement were included in a prospective, randomised trial comparing 3 groups of patients: (1) S-LPB group receiving spinal anaesthesia and postoperative analgesia by lumbar plexus block; (2) GA-PCA group receiving general anaesthesia and postoperative analgesia by morphine patient-controlled analgesia; (3) GA-LPB group receiving general anaesthesia and postoperative analgesia by lumbar plexus block. Outcome measurements were polysomnographic parameters of sleep architecture and sleep-disordered breathing. Results Eighteen patients completed the 5-night study protocol (preoperative night: N-1, postoperative nights: N1 to N4). The percentage of rapid eye movement (REM) sleep decreased by 49% and 47% during N1 in the GA-PCA and GA-LPB groups respectively. A rebound phenomenon of more than 40% in the GA-PCA group and 25% in the GA-LPB group was observed during N2 and N3. Apnoea hypopnoea index (AHI) and the number of arousals per hour were significantly increased during N2 and N3 when compared with N-1 in the GA-groups. No sleep architecture disturbances and no sleep-disordered breathing were measured in the S-LPB group. Conclusion Postoperative sleep architecture and breathing pattern were disturbed in GA groups. Both were preserved under spinal anaesthesia associated with a free opioid postoperative analgesia.

Progression of amyotrophic lateral sclerosis (ALS) depends on several factors linked to the disease. However, both the patient's living place and care organization role need to be evaluated.We analysed the effect on survival of factors linked to ALS or the socio-geographical context in a prospective cohort of 203 patients followed between 2003 and 2011.Patients were 97 females and 106 males with a mean age of 65.5 years. Survival was longer in younger patients, in case of upper limb involvement, longer time to diagnosis, and initially higher forced vital capacity. Non-invasive positive pressure ventilation (NIPPV) and percutaneous gastrostomy (PEG) failed to demonstrate benefit. Patients who lived at home had longer survival. The nature of non-medical organization at home statistically influenced survival, which was longer with an organized network than with an unorganized one and shorter in absence of non-medical organization. In patients with indication of PEG and NIPPV, the proposition was statistically different according to the care givers.Besides the natural history of ALS, survival depended on home organization and the presence or the nature of a home-care system. Home organization was an important factor of decision for NIPPV and PEG proposals.

Background Although COPD affects both men and women, its prevalence is increasing more rapidly in women. Disease outcomes appear different among women with more frequent dyspnea and anxiety or depression but whether this translates into a different prognosis remains to be determined. Our aim was to assess whether the greater clinical impact of COPD in women was associated with differences in 3-year mortality rates. Methods In the French Initiatives BPCO real-world cohort, 177 women were matched up to 458 menon age (within 5-year intervals) and FEV1 (within 5% predicted intervals). 3-year mortality rate and survival were analyzed. Univariate and multivariate logistic regression analyses were performed. Results For a given age and level of airflow obstruction, women with COPD had more severe dyspnea, lower BMI, and were more likely to exhibit anxiety. Nevertheless, three-year mortality rate was comparable among men and women, respectively 11.2 and 10.8%. In a multivariate model, the only factors significantly associated with mortality were dyspnea and malnutrition but not gender. Conclusion Although women with COPD experience higher levels of dyspnea and anxiety than men at comparable levels of age and FEV1, these differences do not translate into variations in 3-year mortality rates. Trial registration 04–479.

Respiratory Muscle Endurance (RME) is an alternative way to assess respiratory muscle impairment but normal values are lacking to use this test in a clinical perspective. Our objective was then to determine reference values of RME in healthy subjects. We recruited 161 healthy subjects (25-80 years old) who were distributed within 5 groups with a 10-year range. We measured vital capacity (VC) and maximal respiratory pressure (MIP, MEP). The RME test consisted of isocapnic hyperpnea at increasing levels of ventilation until exhaustion to determine Tlim (expressed in minutes and as percentage of maximal voluntary ventilation, MVV). A significant difference between age-groups was observed for both VC and MEP expressed as percentage of predicted value. Mean Tlim was 21.8±5.9min [95% confidence interval 20.9-22.8], 74.4±15.9% of predicted MVV [95% CI 71.8-76.9]. Tlim was similar among age groups. Tolerance to the RME test was excellent. This study provides normal values of RME in a large age range of healthy subjects and demonstrates that RME is preserved in the elderly.

Introduction Les metastases endobronchiques du cancer du rein sont des tumeurs visibles a la bronchoscopie, d’histologie identique au cancer primitif. Ces metastases peuvent etre traitees par bronchoscopie interventionnelle afin d’ameliorer la survie et la qualite de vie. Cet article vise a rendre compte du role potentiel de la bronchoscopie interventionnelle chez les patients presentant des metastases endobronchiques d’un cancer renal. Methodes Cette etude retrospective a inclus 41 patients ayant beneficie d’une bronchoscopie interventionnelle entre 1995 et 2020. Tous les patients avaient des metastases endobronchiques averees et ont ete traites par bronchoscopie interventionnelle. L’evaluation de l’histoire naturelle du carcinome renal metastatique et les options therapeutiques seront rapportees. Resultats Les metastases endobronchiques sont survenues a une mediane de 41 mois (rang 1–240) apres le diagnostic de la tumeur primitive. Vingt-huit patients (68 %) avaient d’autres sites metastatiques averes lors du diagnostic de l’atteinte endobronchique. Trente et un patients (76 %) avaient des metastases pulmonaires synchrones connues lors de la decouverte de lesions tracheobronchiques. Les symptomes les plus frequents etaient la dyspnee (78 %), l’hemoptysie (56 %) et la toux (54 %). L’atelectasie (54 %) etait une constatation radiologique courante. Tous les patients ont beneficie d’une bronchoscopie interventionnelle ayant pour but de soulager l’obstruction ; celle-ci a permis une amelioration clinique et spirometrique. Les techniques utilisees ont ete la resection mecanique (88 %), la thermocoagulation ou laser (58 %), la cryotherapie (12 %), et la pose de prothese endobronchique (19 %). La topographie initiale des lesions endobronchiques concernait l’arbre bronchique droit dans 46 % des cas, l’arbre bronchique gauche dans 36 % des cas, la trachee dans 10 % des cas ; l’atteinte endobronchique etait bilaterale dans 7 % des cas. Vingt-quatre patients (58 %) ont beneficie d’une prise en charge unique en bronchoscopie interventionnelle. Treize patients (31 %) ont beneficie de 2 a 5 prises en charge endoscopiques. Quatre patients (10 %) ont beneficie de plus de 5 prises en charge endoscopiques. L’analyse evolutive des lesions, l’impact du traitement systemique et les donnees de survie seront discutes. Conclusion Les metastases endobronchiques surviennent tardivement chez les patients presentant un cancer renal metastatique. Le traitement palliatif par bronchoscopie interventionnelle permet de prevenir l’asphyxie et peut ameliorer la qualite de vie de ces patients.

Gestational choriocarcinomas are highly malignant tumors with elevated serum human chorionic gonadotropin (hCG) levels. We report an extremely rare case of a 27-year-old woman who presented 4 months after normal delivery, with pulmonary, renal and intracardiac metastases of a choriocarcinoma. No primary uterine tumor was found. She was surgically treated for the renal and cardiac metastases as well as with cisplatin-etoposide chemotherapy. No recurrence has been observed 16 years after initial diagnosis, and the patient was able to have a second child. This case report shows that appropriate treatment of metastatic gestational choriocarcinoma can cure the patient without compromising her fertility.

Pierre Labeix,1,2 Mathieu Berger,3 Isabelle Court Fortune,4 Léonard Feasson,2,5 Samuel Verges,6 Frédéric Costes7,8 1Centre VISAS, Service de Physiologie Clinique et de l’Exercice, CHU St Etienne, France; 2Univ Lyon, UJM Saint-Etienne, Laboratoire Interuniversitaire de Biologie de la Motricité, EA 7424, Saint-Etienne F-42023, France; 3Univ Lyon, UJM Saint-Etienne, laboratoire SNA-EPIS, EA4607, Saint-Etienne, France; 4Service de Pneumologie et d’Oncologie Thoracique, CHU St Etienne, France; 5Unité de Myologie, CHU St Etienne, France; 6Université Grenoble Alpes, Inserm, Laboratoire HP2, Grenoble, France; 7Université Clermont Auvergne, INRA, UNH Clermont Ferrand, France; 8Service de Médecine du Sport et des Explorations Fonctionnelles, CHU Clermont Ferrand, FranceCorrespondence: Frédéric CostesService de Médecine du Sport et des Explorations Fonctionnelles CHU Gabriel Montpied, 58 rue Montalembert, F63002 Clermont Ferrand cedex 1, FranceTel +33473751665Email fcostes@chu-clermontferrand.frPurpose: Application of non-invasive ventilation (NIV) during exercise improves exercise tolerance in severe COPD patients; however, the underlying mechanism is only partially unraveled. As part of its known effect to unload the respiratory muscles, we looked for the influence of NIV on post-exercise quadriceps muscle endurance.Patients and methods: We included 25 severe COPD patients entering an outpatient pulmonary rehabilitation program. They performed, on successive days, three quadriceps endurance tests at 70% of the maximal strength (1RM) to task failure (TlimQ); 1) control condition; 2) following constant load cycling exercise to exhaustion without Inspiratory Pressure Support (TlimQ IPS-); 3) following the same cycling exercise with IPS (TlmQ IPS+).Results: Dyspnea Borg score was significantly reduced at the end of the constant load cycling exercise with IPS+ compared to IPS- (3.5±2.6 to 4.3±2.3, p

Background: The 6-min walk test (6MWT) allows exercise tolerance to be assessed, and it has a significant prognostic value in COPD. The goal of this study was to analyse the determinants (obtained in routine practice) of a low 6-min walking distance (6MWD) and exercise-induced desaturation (EID) in COPD, including comorbidities. Methods: Patients were recruited from the real-life French COPD cohort “Initiatives BPCO”. A low 6MWD was defined as 30 kg/m2), low BMI (BMI

Maeva Zysman,1 Gaëtan Deslee,2 Denis Caillaud,3 Pascal Chanez,4 Roger Escamilla,5 Isabelle Court-Fortune,6 Pascale Nesme-Meyer,7 Thierry Perez,8 Jean-Louis Paillasseur,9 Christophe Pinet,10 Gilles Jebrak,11 Nicolas Roche,12,* Pierre-Régis Burgel12,* On behalf of the Initiatives BPCO (broncho-pneumopathie chronique obstructive) Scientific Committee and Investigators 1Pulmonary Dpt, Nancy, Inserm U955, team 04, Créteil, France; 2Pulmonary Dpt, Maison Blanche University Hospital, INSERM U903, Reims, France; 3Pulmonary Dpt, Gabriel Montpied University Hospital, Auvergne University, Clermont-Ferrand, France; 4Pulmonary Dpt, APHM, INSERM U1077, CNRS UMR 7733 Aix Marseille Université, Marseille, France; 5Pulmonary Dpt, Larrey University Hospital, Toulouse, France; 6Pulmonary Dpt, University Hospital, Saint-Etienne, France; 7Pulmonary Dpt, La Croix Rousse University Hospital, Lyon, France; 8Clinique des Maladies Respiratoires, Albert Calmette University Hospital, Lille, France; 9EFFI-STAT, Paris, France; 10Service de pneumologie, polyclinique Les Fleurs, Ollioules, France; 11Pulmonary Dpt, Bichat Hospital, AP-HP, Paris, France; 12Respiratory and Intensive Care Medicine Dpt, Cochin Hospital, AP-HP and Paris Descartes University (EA2511), Sorbonne Paris Cité, Paris, France *These authors contributed equally to this work Abstract: In patients with COPD, there is controversy regarding the association of blood eosinophil (Eos) levels with 1) exacerbation frequency and 2) the effect of inhaled corticosteroids for prevention of exacerbations. To determine whether Eos define subgroups of patients exhibiting attributes of COPD clinical phenotypes, we compared clinical features and mortality rates in COPD patients from the Initiatives BPCO French cohort categorized using different thresholds of blood Eos levels. The following data were collected at inclusion: medical and smoking history, occupational exposures, dyspnea, cough and sputum production, exacerbations in the previous year, history of allergy and asthma, nasal symptoms, body mass index, St George Respiratory Questionnaire (SGRQ) total score, post-bronchodilator spirometry, comorbidities, and medications. Three-year survival between groups was compared using Kaplan–Meier analysis. Three sets of analyses were performed to compare patients with≥2% versus

Resume Introduction Nous avons etudie l’evolution des prescriptions medicamenteuses au cours de la BPCO et leur conformite aux recommandations en recensant les traitements des patients de la cohorte prospective francaise « Initiatives BPCO ». Methodes Huit cent quarante-six patients ont ete inclus, repartis entre une premiere periode, d’aout 2001 a mai 2006 (n = 425) et une seconde periode, de juin 2006 a juin 2012 (n = 421). La date charniere etait celle de la mise a disposition en France du tiotropium. Resultats Au cours de la premiere periode d’etude, nous avons identifie des patients plus âges (65 vs 64 ans), moins souvent de sexe feminin (19 vs 26 %) et avec une obstruction bronchique moindre (VEMS moyen 48 % vs 54 %). La prescription des corticosteroides inhales (CSI) diminuait dans les BPCO legeres, tandis que celle des β-adrenergiques inhales longue duree d’action (LABA) stagnait (68 %). L’utilisation de deux bronchodilatateurs longue duree d’action sans CSI augmentait (0,9 a 7 %) mais restait moindre que l’association fixe LABA + CSI, moins prescrite (26 %) que l’association triple LABA + CSI + LAMA (32,5 % en periode 2). L’utilisation des bronchodilatateurs longue duree d’action augmentait de 68 a 80 % entre les deux periodes. Vaccinations et rehabilitation restaient insuffisamment prescrites. Les anticholinergiques de longue duree d’action (LAMA) etaient ajoutes mais sans remplacer d’autres traitements medicamenteux.

Introduction L’ACO est controverse. Representant entre 10 % et 15 % des asthmatiques ou BPCO, ces patients se situent a la frontiere des deux entites. Ne remplissant pas les criteres strictes d’asthme ou des BPCO, les ACO sont exclus des essais cliniques, donc meconnus. Dans ce contexte, une description appropriee des ACO est essentielle. Notre etude visait a depister les patients ACO dans une large population regionale puis determiner des clusters dans le but de definir des sous-groupes. Methodes Grâce a une evaluation systematique des patients asthmatiques et BPCO de 7 centres de pneumologie regionaux (CHU de St-Etienne et Croix-Rousse, Centre hospitalier de Villefranche, Annecy, St-Chamond, Bourg-en-Bresse, et le Centre Parot), d’octobre 2016 a janvier 2018, 176 patients ont ete identifies ACO et 172 inclus. Ce depistage s’appuyait sur les recommandations GINA-GOLD 2015. Un deuxieme questionnaire a ete rempli pour chaque sujet, avec des donnees cliniques, fonctionnelles, radiologiques et biologiques. Nous avons utilise l’Analyse par Correspondances Multiples (ACM) pour determiner des clusters grâce a 9 variables (âge, âge de debut des symptomes respiratoires, sexe, IMC, tabagisme, VEMS, score mMRC, exacerbations, comorbidites). Finalement, les clusters ont ete compares avec le reste des donnees collectees pour decrire des phenotypes. Resultats L’ACM des 172 patients etudies a permis de generer 2 axes. L’abscisse represente la severite clinique, et l’ordonnee represente l’âge et l’âge de debut de leurs symptomes respiratoires. 6 clusters ont ete ainsi decrits et compares, et 4 phenotypes interpretes ( Tableau 1 ). Le phenotype A, les clusters 1 et 3, represente des patients ACO etant rentres tot dans leur maladie respiratoire. Ils ont un handicap respiratoire majeur, sont obeses et souffrent d’anxio-depression. Le phenotype B (le cluster 5) regroupe des patients dont les symptomes respiratoires ont debute apres 40 ans, et qui sont eux aussi severement handicapes. Ils sont en surpoids, souffrent d’anxio-depression. Les phenotypes C et D sont moins graves cliniquement. Le phenotype C (le cluster 2) represente des petits fumeurs ayant eu de l’asthme dans l’enfance. Les patients du phenotype D (les clusters 4 et 6) sont entres dans leur maladie respiratoire au contraire apres 40 ans. Conclusion En fournissant pour la premiere fois des clusters cliniques au sein de la population ACO, notre etude confirme que l’ACO est complexe et heterogene. Des analyses longitudinales prospectives sont necessaires pour confirmer ces resultats.

Background and objective Long-term non-invasive ventilation (NIV) has become a widespread modality of treatment in chronic obstructive pulmonary disease (COPD) patients with chronic respiratory failure. However, benefits in terms of patient-related outcomes are still under debate. Both NIV adherence and heterogeneous responses in different COPD phenotypes may contribute to the difficulty of demonstrating NIV benefits. Our aim was to assess the impact of NIV adherence on the rate of hospitalization for acute exacerbation and death. Methods This is a prospective multi-centre cohort study of COPD patients treated by long-term NIV. Comorbidities, anthropometrics, respiratory parameters were collected at inclusion in the study. Follow-up data included vital status, NIV adherence and hospitalizations. The influence of NIV adherence on prognosis was tested using an adjusted Cox model. Sensitivity analyses for obese and non-obese COPD subtypes were also conducted. Results Two hundred thirteen patients (48% obese) were included with 45.5% died during 47.7 [interquartile range = 27.8; 73] months' follow-up. Survival was better in obese COPD than non-obese COPD. The use of NIV > 9 h/day was associated with an increased risk of death or hospitalization for acute exacerbation [HR = 1.6; 95CI: 1.1–2.4]. In obese COPD, this risk described a U-shaped curve from >1 to >9 h/day NIV usage with an improvement in prognosis when NIV adherence was > 5 h/day [HR = 0.5; 95CI: 0.2–0.9]. Conclusions Adherence to NIV was associated with better prognosis only in obese COPD. NIV use > 9 h/day predicted poor outcomes.

Theprevalenceofsleep-disorderedbreathing(SDB)inchronicheartfailure (CHF) patients exceeds 60%, including both central sleep apnea(CSA)andobstructivesleepapnea(OSA)[1].Asobservedinthegeneralpopulation, SDB in CHF patients is associated with a poor prognosis [2]and a higher risk of nocturnal arrhythmia [3]. Continuous positiveairway pressure or adaptive servo-ventilation treatments might im-provebothLVEFandmortalityandreducetheriskofarrhythmicevents,but this remains debatable [4]. Nevertheless, at least 75% of severe SDBcasesremainundiagnosedanduntreatedduetotheabsenceofdaytimesymptoms, waiting lists in sleep laboratories, and diagnostic costs. Thehigh SDB prevalence in patients referred for cardiologic assessmentcalls for the development of automated screening tools based on ECG-derived parameters for use by cardiologists in routine practice.MethodsbasedonheartratevariabilityanalysisallowdetectingSDBpatients whopresentsinusal rhythm[5] butare not suitable for cardiacfailureordysautonomicpopulations,whofrequentlyexhibitprematureatrial or ventricular beat, are frequently implanted with permanentpacemakers, or present recurrent atrial fibrillation, bundle branchblocks, or flat heart rate variability [6]. ECG-derived respiration (EDR),a method based on the reconstruction of thoracic signals by analysingchangesinECGmorphologythatareinducedbyrespiratorymovements[7], is a promisingalternative,but has not yet been evaluatedincardiacpopulations [8].Werecruited105patientswithLVEFb45%andNYHAclass≥2fromroutine medical follow-ups of stable CHF patients (Saint-Etienne andGrenoble University Hospitals) to test an automated EDR method withreference to visually scored nocturnal in-home ventilatory polygraphy.This study (clinical trial NCT02116686) complies with the DeclarationofHelsinkiandwasapprovedbythelocalethicscommittee.Allpatientsgave their written informed consent to participate.Standard nocturnal in-home ventilatory polygraphy was performedusinganEmbladevice(Embla®,Broomfield,USA)andscoredaccordingto AASM recommendations using RemLogic® software. Based onpreviously published methods [7,9,10] and developed with Matlab®(Mathworks,Natick,USA),anEDRmethodwasusedasfollows:thoracicmovements derived from ECG signals were analysed in order toreconstruct respiratory movements. The two mechanisms involved,changesintheelectricalheartaxisandchangesintransthoracicimped-ance,areeasilyobservedintheQRSheightorarea,allowingreconstruc-tion of the thoracic signal, which is then used to score apnea andhypopnea events [7]. Analyses were performed on the portion of thepolygraphic ECG signal recorded when the light was turned off. TheECG baseline was removed, each R-peak was detected, and R-peakoutliers were excluded. The EDR signal was then calculated as thesuccessive surfaces of each QRS complex under the R-peak. An SDBevent was then scored when the algorithm detected either a 50%decrease in thepeak-to-peak EDR amplitudefor 10 s [9] or an invertedU-shape of the EDR trace corresponding to a baseline drift due torespiratory effort during obstruction [10].ECG results were subjected to automated analysis only, and poly-graph recordings were scored manually and blinded to EDR results. Uni-variate regression analysis for continuous variables and Bland–Altmanplot were used to assess the relationship between the polygraphicapnea/hypopnea index (AHI

Background and objective Previous studies suggested that chronic nasal symptoms (CNS) are frequent in chronic obstructive pulmonary disease (COPD) subjects, but their contribution to dyspnoea and quality-of-life (QoL) impairment is not clearly established. Methods Data from the French COPD cohort ‘Initiatives bronchopneumopathie chronique obstructive’ were analyzed to assess the frequency of CNS (rhinorrhea, obstruction, anosmia) in COPD patients and analyze their impact and associated risk factors. Univariate and multivariate analyses were performed to assess the relationship between CNS with sociodemographic and anthropometric characteristics, risk factors, respiratory symptoms, spirometry, QoL (Saint George's respiratory questionnaire (SGRQ)), dyspnoea (modified Medical Research Council (mMRC) scale), mood disorders (Hospital Anxiety and Depression Scale (HADS)), number of exacerbations and comorbid conditions. Results CNS were reported by 115 of 274 COPD subjects (42%). Among them, rhinorrhea and nasal obstruction were reported by 62% and 43%, respectively. In multivariate analysis, COPD patients with CNS had higher SGRQ total scores, corresponding to worse QoL (P = 0.01), while no independent association was found with exacerbations, lung function and HADS. Among SGRQ domains, an independent association was found with the activity score (P = 0.007). When SGRQ score was forced out of the model to avoid redundancy, mMRC score was independently associated with CNS (P = 0.01). Among risk factors, cumulative smoking, hay fever and atopic dermatitis but not occupational exposures were independently associated with CNS. Conclusions In this group of COPD subjects, CNS were frequently observed and associated with dyspnoea and poorer QoL. CNS should be systematically assessed and could be a potential target in the management of COPD.

SummaryBackgroundComorbidities are frequent in subjects with COPD, but their contribution to health-related quality of life (HRQoL) impairment is not clearly established.MethodsCross-sectional analysis of data from the French COPD cohort Initiatives BPCO. Data were recorded in stable state and included spirometry, dyspnea (modified Medical Research Council – mMRC-scale), mood disorders (hospital anxiety–depression scale) and physician-diagnosed comorbidities including diabetes, hypertension, coronary artery disease, chronic heart failure, venous thromboembolism. HRQoL was assessed using the disease-specific St. George's Respiratory Questionnaire (SGRQ). Stepwise forward and backward multiple regression analyses were performed to examine the contribution of comorbidities to SGRQ scores.ResultsData are median [IQR]. 326 COPD subjects were analyzed: male 77%, age 65.0 [57.0; 72.0] years, FEV1 48.9 [34.7; 65.9]% predicted. SGRQ total score was 44.2 [30.0; 61.2]. In univariate analysis, positive correlations were found between SGRQ total scores and dyspnea and exacerbations/patient/year, whereas negative correlations were found with FEV1. SGRQ total scores were increased in women (P = 0.06), and in subjects with low BMI, anxiety or depression (each analysis, P

OBJECTIVE: To assess factors that predict good tolerance of noninvasive ventilation (NIV), in order to improve survival and quality of life in subjects with amyotrophic lateral sclerosis. METHODS: We conducted a prospective study in subjects with amyotrophic lateral sclerosis and requiring NIV. The primary end point was NIV tolerance at 1 month. Subjects, several of whom failed to complete the study, were classified as “tolerant” or “poorly tolerant,” according to the number of hours of NIV use (more or less than 4 h per night, respectively). RESULTS: Eighty-one subjects, 73 of whom also attended the 1-month follow-up visit, participated over 34 months. NIV tolerance after the first day of utilization predicted tolerance at 1 month (77.6% and 75.3% of subjects, respectively). Multivariate analysis disclosed 3 factors predicting good NIV tolerance: absence of airway secretions accumulation prior to NIV onset (odds ratio 11.5); normal bulbar function at initiation of NIV (odds ratio 8.5); and older age (weakly significant, odds ratio 1.1). CONCLUSION: Our study reveals 3 factors that are predictive of good NIV tolerance, in particular the absence of airway secretion accumulation, which should prompt NIV initiation before its appearance.

Background: Several studies suggest that, in patients with COPD, Eos is associated with (i) exacerbation frequency and (ii) the effect of inhaled corticosteroid for exacerbation prevention. Aim: To determine whether Eos defines patients9 groups exhibiting attributes of COPD clinical phenotypes, we compared the clinical features and mortality rate between COPD patients with ≥2% (Eos+) and Methods: The following data were collected at inclusion: medical and smoking history, occupational exposures, dyspnea, cough and sputum production, exacerbations in the previous year, history of allergy and asthma, nasal symptoms, BMI, SGRQ score, post-bronchodilator spirometry and plethysmography, comorbidities, CRP and medications. Three-year survival was available for all patients. BOD and ADO scores were calculated. Results: Eos was available in 458 patients (mean age: 62 years, 72% male, mean FEV1: 51%), including 235 Eos+ patients (49%). No difference between Eos+ and Eos- groups was observed in univariate analyses except for diabetes (17% in Eos-, 8% in Eos+, p=0.02) and SGRQ score (mean, 48 units in Eos -, 40 units in Eos+, p=0.007). In particular, there was no difference in term of exacerbations rate (mean, 1.6/patient/year) or history of asthma (15% of the population). Three-year mortality rate was 17% in Eos- vs 13% in Eos+ (NS). Conclusion: Apart from differences in health-related quality of life and frequency of diabetes (which warrant further investigation), Eos+ COPD patients exhibit no specific clinical characteristic, especially regarding symptoms, lung function, exacerbations and prognosis.

Background : Some studies suggest that ACOS is associated with worse outcomes than COPD. The goal of this study was to further explore the clinical characteristics and survival of patients with ACOS identified in a real-life cohort of COPD patients. Methods : Data from the French COPD cohort “Initiatives BPCO” (n=998 patients) were analyzed to assess the frequency of ACOS defined as a physician diagnosis of asthma before the age of 40 years and to analyze its impact. Univariate analyses were performed to assess the relationship between ACOS and risk factors (smoking, occupational exposure, atopic diseases), symptoms (chronic bronchitis , dyspnea -modified Medical Research Council scale and baseline dyspnea index-), quality of life, mood disorders, exacerbations, comorbidities, lung function, prescribed treatment, and survival. Results : ACOS was diagnosed in 129 patients (13%). In multivariate analyses, ACOS was associated negatively with cumulative smoking (Odds Ratio –OR-: 0.992; 95%CI 0.984-1.000 per pack-year) and positively with obesity: OR: 1.97 [1.22-3.16], history of atopic disease (hay fever: OR: 5.50 [3.42-9.00] and atopic dermatitis: OR 3.76 [2.14-6.61]), and drug use (LABA+ ICS: 1.86 [1.27-2.74], anti-leukotrienes 4.83 [1.63-14.34], theophylline: 2.46; [1.23-4.91] and oral corticosteroids: [2.99;.1.26-7.08]). No independent association was found with dyspnea, QoL, exacerbations and mortality. Conclusions : Compared to “pure”COPD patients, patients with ACOS exhibit lower cumulative smoking, suffer more from obesity and atopic diseases and use more asthma treatments. Disease severity (dyspnea, QoL, exacerbations, comorbidities) and prognosis (mortality) are not different from “pure” COPD patients.

International audience; The use of recombinant antigens has been shown to improve both the sensitivity and the standardization of the serological diagnosis of Farmer's lung disease (FLD). The aim of this study was to complete the panel of recombinant antigens available for FLD serodiagnosis with antigens of Lichtheimia corymbifera, known to be involved in FLD. L. corymbifera proteins were thus separated by 2D electrophoresis and subjected to western blotting with sera from 7 patients with FLD and 9 healthy exposed controls (HEC). FLD-associated immunoreactive proteins were identified by mass spectrometry based on a protein database specifically created for this study and subsequently produced as recombinant antigens. The ability of recombinant antigens to discriminate patients with FLD from controls was assessed by ELISA performed with sera from FLD patients (n = 41) and controls (n = 43) recruited from five university hospital pneumology departments of France and Switzerland. Forty-one FLD-associated immunoreactive proteins from L. corymbifera were identified. Six of them were produced as recombinant antigens. With a sensitivity and specificity of 81.4 and 77.3% respectively, dihydrolipoyl dehydrogenase was the most effective antigen for discriminating FLD patients from HEC. ELISA performed with the putative proteasome subunit alpha type as an antigen was especially specific (88.6%) and could thus be used for FLD confirmation. The production of recombinant antigens from L. corymbifera represents an additional step towards the development of a standardized ELISA kit for FLD diagnosis. © 2016 Rognon et al. This is an open access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

International audience; BACKGROUND: In chronic respiratory failure (CRF), body composition strongly predicts survival. METHODS: A prospective randomised controlled trial was undertaken in malnourished patients with CRF to evaluate the effects of 3 months of home rehabilitation on body functioning and composition. 122 patients with CRF on long-term oxygen therapy and/or non-invasive ventilation (mean (SD) age 66 (10) years, 91 men) were included from eight respiratory units; 62 were assigned to home health education (controls) and 60 to multimodal nutritional rehabilitation combining health education, oral nutritional supplements, exercise and oral testosterone for 90 days. The primary endpoint was exercise tolerance assessed by the 6-min walking test (6MWT). Secondary endpoints were body composition, quality of life after 3 months and 15-month survival. RESULTS: Mean (SD) baseline arterial oxygen tension was 7.7 (1.2) kPa, forced expiratory volume in 1 s 31 (13)% predicted, body mass index (BMI) 21.5 (3.9) kg/m2 and fat-free mass index (FFMI) 15.5 (2.4) kg/m2. The intervention had no significant effect on 6MWT. Improvements (treatment effect) were seen in BMI (+0.56 kg/m2, 95% CI 0.18 to 0.95, p=0.004), FFMI (+0.60 kg/m2, 95% CI 0.15 to 1.05, p=0.01), haemoglobin (+9.1 g/l, 95% CI 2.5 to 15.7, p=0.008), peak workload (+7.2 W, 95% CI 3.7 to 10.6, p

Chronic obstructive pulmonary disease (COPD) pharmacological treatment aims to reduce symptoms, represented mostly by dyspnoea and its impact on daily life, and future risk, i.e. lung function decline, mortality and exacerbations [1]. Inhaled therapies, including long-acting bronchodilators (LABD) and inhaled corticosteroids (ICS), are the main treatments recommended for COPD patients. LABD have been found not only to improve lung function, decrease dyspnoea, increase exercise tolerance and improve health status, but also to reduce the rate of exacerbations. In that respect, some studies suggested that long-acting antimuscarinic agents (LAMA) could be more effective than long-acting β2-agonists (LABA) [2]. In most countries, ICS are indicated only as part of fixed-dose combinations (FDC) with LABA and are used mostly to decrease the risk of exacerbations, which is associated with health status improvement [3]. Therefore, it appeared logical to restrict their use to patients at high risk of exacerbations. The long-term benefit of combining LAMA and FDC (triple therapy) is not strongly documented [4]. Many studies in various countries found discrepancies between guidelines and real-life practice regarding long-term maintenance treatment in patients with COPD [5–7]. Although the impact of nonadherence to guidelines on efficacy outcomes is controversial [8], it increases healthcare costs [9] and, New agents for COPD treatment appear to increase overall treatment intensity in all severity categories [http://ow.ly/BS6Wq][1] [1]: http://ow.ly/C95Ue

Gaëtan Deslee,1 Pierre-Régis Burgel,2 Roger Escamilla,3 Pascal Chanez,4 Isabelle Court-Fortune,5 Pascale Nesme-Meyer,6 Graziella Brinchault-Rabin,7 Thierry Perez,8 Gilles Jebrak,9 Denis Caillaud,10 Jean-Louis Paillasseur,11 Nicolas Roche2On behalf of the Initiatives BPCO Scientific Committee 1Department of Respiratory Diseases, INSERM UMR 903, Maison Blanche Hospital, University Hospital of Reims, Reims, 2Department of Respiratory Diseases, Cochin Hospital, AP-HP and University Paris Descartes, Sorbonne Paris Cité, Paris, 3Department of Respiratory Diseases, Larrey Hospital, Toulouse, 4Department of Respiratory Diseases, APHM, INSERM U1077, CNRS UMR 7733 Aix Marseille Université, Marseille, 5Department of Respiratory Diseases, University Hospital of St Etienne, 6Department of Respiratory Diseases, La Croix Rousse Hospital, Lyon, 7Department of Respiratory Diseases, Pontchaillou Hospital, University Hospital of Rennes, Rennes, 8Department of Respiratory Diseases, Calmette Hospital, University Hospital of Lille, Lille, 9Department of Respiratory Diseases, Bichat Hospital, AP-HP, Paris, 10Department of Respiratory Diseases, Gabriel Montpied Hospital, University Hospital of Clermont-Ferrand, Clermont-Ferrand, 11EFFI-STAT, Paris,FranceBackground: Cough and sputum production are frequent in chronic obstructive pulmonary disease (COPD). The objective of this study was to examine the relationship between cough and sputum production and health-related quality of life in COPD.Methods: A cross-sectional study was conducted in the French Initiatives COPD cohort and assessed cough and sputum production within the past 7 days using the cough and sputum assessment questionnaire (CASA-Q), health-related quality of life, spirometry, smoking status, dyspnea, exacerbations, anxiety and depression, and comorbidities.Results: One hundred and seventy-eight stable COPD patients were included (age, 62 [56–69]years, 128 male, forced expiratory volume in 1 second [FEV1]: 57 [37–72] % predicted) (median [Q1–Q3]). In univariate analyses, health-related quality of life (Saint George’s respiratory questionnaire total score) was associated with each CASA-Q domain and with chronic bronchitis, exacerbations, dyspnea, FEV1, depression, and anxiety. All four domains introduced separately were independently associated with health-related quality of life. When introduced together in multivariate analyses, only the cough impact domain remained independently associated with health-related quality of life (R2=0.60). With chronic bronchitis (standard definition) instead of the CASA-Q, the R2 was lower (R2=0.54).Conclusion: This study provides evidence that current cough in the previous 7 days is an important determinant of health-related quality of life impairment in stable COPD patients.Keywords: signs and symptoms, respiratory, sputum, questionnaires, dyspnea, multivariate analysis

Malignant pleural effusion as presenting manifestation in lung cancer is of poor prognosis. Therefore, diagnostic approach in this patient population is important. Pleural cytology (PC) and chest computed tomography findings (CCT) might be helpful as first line approach in the diagnosis of pleural metastasis. The aim of this study was to evaluate whether there is a correlation between PC and CCT pleural findings. Methods: Selection criteria from our electronic files were patients with lung cancer and pleural effusion at initial presentation. Data of PC, pleural biopsy (PB) and CCT have been recorded and analyzed. Results: 47 consecutive patients (34 males, 72%) were selected. Their mean age was 68.5±11 years. Final histological diagnosis was adenocarcinoma in 28 patients (59%), squamous in 7 (15%), small-cell in 7 (15%) and large cell in 5 (11%). No findings were found in 29 patients (61%), nodules or masses were observed in 6 patients (13%) while pleural thickening in 12 (26%) at CCT. Nodules and thickening were more likely to be associated (chi square=20, p

Introduction: Corticosteroids are a very effective treatment of cryptogenic organising pneumonia (OP), but the optimal regimen is unknown, side effects occur, and relapses are common. Small series suggested that macrolides are of interest in both treating OP and preventing relapses. Aims: To determine the efficacy of a 12-wk combined treatment (clarithromycin + prednisone) compared to a standard 24-wk prednisone regimen in OP. Methods: In a retrospective study, we included all patients with cryptogenic or radiation-induced OP who were treated with a pre-established 12-wk regimen consisting of clarithromycin (1000 mg/d for 10 days, then 500 mg/d until wk 8, then 250 mg/d until wk 12) and prednisone (0.75 mg/kg/d for 2 wk, 0.5 mg/kg/d for 2 wk, 20 mg/d for 2 wk, 10 mg/d for 3 wk and 5 mg/d for 3 wk, CLA+PRED group). These cases were compared to a historical group of cryptogenic OP which received a 24-wk prednisone only regimen (PRED only group, Lazor R et al, Am J Respir Crit Care Med 2000; 162:571-7). The outcomes were the percentage of complete cure and relapses. Results: 20 patients (age 63±13 yr) with cryptogenic (n=13) or radiation-induced (n=7) OP treated with CLA+PRED were compared to 14 patients with cryptogenic OP treated with PRED only. Complete cure occurred in 55% of the CLA+PRED group and 93% in the PRED only group. Relapses occurred in 85% in the CLA+PRED group, and in 57% in the PRED only group. No patient died or had respiratory failure. Conclusions: A 12-wk course of clarithromycin + prednisone led to lower complete cure rates and more frequent relapses in patients with cryptogenic or radiation-induced OP, compared to a 24-wk prednisone only regimen.

Aim: Evaluation of respiratory muscle function relies mainly on maximal inspiratory/expiratory pressures (MIP/MEP). However, their sensitivity to detect respiratory muscle weakness is low. Alternatively, it has been proposed to assess diaphragmatic performance through a progressive isocapnic hyperventilation test. However, normal values for this test are lacking precluding its use in a clinical setting. Subjects and methods: We measured spirometry, MIP, MEP and maximal pressure during a snif-test according to recommendations. Isocapnic hyperventilation was performed using a Spirotiger® device in healthy volunteers. The subjects were asked to breathe in a rebreathing bag at a fixed tidal volume and predetermined levels of ventilation were reached by changing breathing frequency (f b ). The test began at 30% of predicted maximal voluntary ventilation (MVV), and f b was then increased every 3 min to reach the target ventilation, up to MVV. The test was stopped when the subjects could no longer hyperventilate and sustain the target f b. Endurance time was expressed as Tlim in minutes and as the percentage of MVV sustained (%MVV). Results: We studied 58 subjects (23 males), aged 44±17 yrs [range 25-77]. Mean Tlim was 21±7 min [6-30] and reached on average 88±24% MVV. Tlim%MVV was significantly related to MIP (R=0.42, p=0.003) and MEP (R=0.34, p=0.02) but not to SNIP (p=0.975). Conclusions: These preliminary results showed that the evaluation of respiratory muscle endurance is feasible using this hyperventilation test using an incremental protocol up to task failure. Normative values according to age should be derived from a larger group of subjects, which will allow to detect diaphragmatic weakness in patients.

Resume La rehabilitation respiratoire constitue une approche therapeutique efficace dans la bronchopneumopathie chronique obstructive (BPCO) en terme d'amelioration de la qualite de vie, de la dyspnee et de la tolerance a l'effort. Elle a egalement un impact positif sur les depenses de sante en reduisant les exacerbations, le nombre et la duree des hospitalisations. Elle est actuellement recommandee chez les patients BPCO presentant une dyspnee d'effort (evaluee par une echelle visuelle analogique), une intolerance a l'exercice (evaluee par le test de marche de six minutes) ou une diminution de leur activite quotidienne en rapport avec leur maladie malgre une prise en charge optimale de la maladie (sevrage tabagique, traitement bronchodilatateur, prevention des infections hivernales). Ce programme de soins comporte, outre le volet de la rehabilitation a l'exercice, un programme d'education therapeutique et une prise en charge nutritionnelle. Il est recommande de realiser une evaluation nutritionnelle precise comportant outre l'histoire du poids recente, une mesure de l'index de masse corporelle (IMC) et une mesure de la masse non grasse par impedancemetrie si l'IMC est compris entre 21 et 26. L'arret du tabac, le traitement de l'infection bronchique, une alimentation fractionnee et dense en calories sont souhaitables au cours du programme de rehabilitation. Une supplementation nutritionnelle orale proche de 500 kcal/j, privilegiant les hydrates de carbone, est proposee en association avec le programme de reentrainement a l'exercice en cas d'IMC 2 . Cette supplementation associee a la rehabilitation est susceptible de facon inconstante d'ameliorer le benefice clinique et le pronostic. Les androgenes peuvent favoriser la prise de poids et l'augmentation de la masse non grasse en combinaison avec l'activite physique et permettre un gain sur la force des muscles respiratoires ou la tolerance a l'effort. Neanmoins, la place des androgenes au cours des programmes de rehabilitation est pour l'instant inconnue considerant les donnees de la litterature.

To the Editor: Clinical trials in chronic obstructive pulmonary disease (COPD) patients have shown that the long-term use of inhaled corticosteroids (ICS) in COPD patients reduced the number of exacerbations per patient per year and improved health status [1]. Early studies have suggested increased ICS efficacy in patients with low lung function and frequent exacerbations [2]. The efficacy was reinforced when ICS was used in conjunction with long-acting β2-agonists (LABA) [3]. In most countries, health authorities approved ICS/LABA combinations in COPD patients with severe airflow impairment and frequent exacerbations, as also recommended in the Global Initiative for Obstructive Lung Disease (GOLD) 2007 document [4]. However, several surveys found poor adherence to this proposal among primary care physicians and pulmonologists in “real life”, ICS being often prescribed at a milder stage of the disease. The GOLD 2011 document proposed a new multidimensional system for the assessment and management of patients with COPD [5]. This system classifies COPD patients into four categories (A, B, C and D) based on the level of symptoms (dyspnoea or global clinical impact) and the risk of future exacerbations, as assessed using the severity of airflow limitation and the past history …

Study objective: To determine the predictive factors of morbidity and mortality in patients with end-stage respiratory disease. Design: Prospective, multicenter cohort study. Setting: Thirteen outpatient chest clinics within the Association Nationale de Traitement a Domicile de l'Insuffisance Respiratoire. Participants: Stable adult patients with chronic respiratory failure receiving long-term oxygen therapy and/or home mechanical ventilation (n = 446; 182 women and 264 men; aged 68.5 ± 12.1 years [± SD]); Respiratory diseases were COPD in 42.8%, restrictive disorders in 36.3%, mixed respiratory failure in 13.5%, and bronchiectasis in 7.4%. Recruitment was performed during the yearly examination. Patients with neuromuscular diseases and sleeping apnea were excluded. Measurements and results: Hospitalization days and survival were recorded during a follow-up of 14.3 ± 5.6 months. Body mass index (BMI), serum albumin, and transthyretin levels were considered for their predictive value of outcome, together with demographic data, underlying respiratory disease, respiratory function, hemoglobin, C-reactive protein, smoking habits, oral corticosteroid use, and antibiotic treatment courses. Overall, 1.8 ± 1.7 hospitalizations (cumulative stay, 17.6 ± 27.1 days) were observed in 254 of 446 patients (57%). Independent predictors of hospitalization were oral corticosteroids, FEV1, and plasma C-reactive protein. One-year and 2-year cumulative survivals were 93% and 69%, respectively. Plasma C-reactive protein, BMI, Pa o 2 on room air, and oral corticosteroids independently predicted survival in multivariate analysis. Conclusion: Besides established prognosis factors such as FEV1 and Pa o 2, nutritional depletion as assessed by BMI and overall systemic inflammation as estimated by C-reactive protein appear as major determinants of hospitalization and death risks whatever the end-stage respiratory disease. BMI and C-reactive protein should be included in the monitoring of chronic respiratory failure. Oral corticosteroids as maintenance treatment in patients with end-stage respiratory disease are an independent risk factor of death, and should be avoided in most cases.