Search

International audience

Chronic obstructive pulmonary disease (COPD) is a main cause of death due to interplaying factors, including comorbidities that interfere with symptoms and response to therapy. It is now admitted that COPD management should be based on clinical symptoms and health status and should consider the heterogeneity of patients’ phenotypes and treatable traits. This precision medicine approach involves a regular assessment of the patient's status and of the expected benefits and risks of therapy. The cornerstone of COPD pharmacological therapy is inhaled long-acting bronchodilation. In patients with persistent or worsened symptoms, factors likely to interfere with treatment efficacy include the patient's non-adherence to therapy, treatment preference, inhaler misuse and/or comorbidities, which should be systematically investigated before escalation is considered. Several comorbidities are known to impact symptoms, physical and social activity and lung function. The possible long-term side-effects of inhaled corticosteroids contrasting with their over-prescription in COPD patients justify the regular assessment of their benefits and risks, and de-escalation under close monitoring after a sufficient period of stability is to be considered. While commonly used in clinical trials, the relevance of routine blood eosinophil counts to guide therapy adjustment is not fully clear. Patients’ characteristics, which define phenotypes and treatable traits and thus guide therapy, often change during life, forming the basis of the concept of clinical trajectory. The application of individual trajectory-based management of COPD in clinical practice therefore implies that the benefit:risk ratio is regularly reviewed according to the evolution of the patient's traits over time to allow optimised therapy adjustments., In the current era of precision medicine, COPD management needs to be regularly adjusted based on the patient's personal clinical trajectory, i.e. the evolution of their treatable traits over time. https://bit.ly/3kxVgC7

While asthma patients' treatment adherence (TA) generally leaves to be desired, few data exist on TA evolution from age group to another. During the meeting of a working group of pneumo-pediatricians and adult pulmonologists, we reviewed the literature on adherence according to age group, examined explanations for poor adherence, and explored ways of improving adherence via new technologies. Asthma is a chronic disease for which TA is particularly low, especially during adolescence, but also among adults. Inhaled medications are the least effectively taken. Several explanations have been put forward: cost and complexity of treatments, difficulties using inhalation devices, poor understanding of their benefits, erroneous beliefs and underestimation of the severity of a fluctuating disease, fear of side effects, neglect, and denial (especially among teenagers). Poor TA is associated with risks of needless treatment escalation, aggravated asthma with frequent exacerbations, increased school absenteeism, degraded quality of life, and excessive mortality. Better compliance is based on satisfactory relationships between caregivers and asthmatics, improved caregiver training, and more efficient transmission to patients of relevant information. The recent evolution of innovative digital technologies opens the way for enhanced communication, via networks and dedicated applications, and thanks to connected inhalation devices, forgetfulness can be limited. Clinical research will also help to ameliorate TA. Lastly, it bears mentioning that analysis of the existing literature is hampered by differences in terms of working definitions and means of TA measurement.

Resume Introduction L’objectif de cette etude etait d’evaluer, en pratique courante, par une methode originale, l’observance du traitement de fond de patients asthmatiques. Methodes Cette etude observationnelle a ete conduite en France aupres de patients adultes traites depuis au moins trois mois pour asthme persistant. L’observance etait evaluee d’apres les donnees du releve de consommation (RC) de l’assurance maladie, par quantification de la concordance entre prescription et delivrance des traitements en pharmacie, et par l’autoquestionnaire valide de Morisky. Resultats Quatre-vingt-un medecins qualifies en pneumologie ou generalistes ont inclus 488 patients, d’âge moyen de 51 ans avec 55 % de femmes. Le RC etait disponible pour 35 % des patients, mais le questionnaire de Morisky (85 % des patients) montrait une observance similaire entre les patients avec ou sans RC. Le taux de bons observants (observance ≥ 80 %) etait de 51 % selon le RC et de 38 % selon le questionnaire de Morisky. Parmi les facteurs classiquement predictifs, seule l’obesite etait retrouvee chez les mauvais observants (19 % vs 7 %, p Conclusions Le RC s’est avere un outil utile pour obtenir une mesure quantitative de l’observance en pratique courante.

The key pathophysiological feature of chronic obstructive pulmonary disease (COPD) is an abnormal inflammatory bronchial reaction after inhalation of toxic substances. The priority is the avoidance of such toxic inhalations, but the use of anti-inflammatory drugs also seems appropriate, especially corticosteroids that are the sole anti-inflammatory drug available for this purpose in France. The risks associated with the prolonged use of these parenteral drugs are well known. Inhalation is therefore the optimal route, but inhaled drugs may also lead to adverse consequences. In COPD, there is an inhaled corticosteroids overuse, and a non-satisfactory respect of the guidelines. Consequently, their withdrawal should be considered. We reviewed seven clinical studies dealing with inhaled corticosteroids withdrawal in patients with COPD and found that included populations were heterogenous with different concomitant treatments. In non-frequent exacerbators receiving inhaled corticosteroids outside the recommendations, withdrawal appears to be safe under a well-managed bronchodilator treatment. In patients with severe COPD and frequent exacerbations, the risk of acute respiratory event is low when they receive concomitant optimal inhaled bronchodilators. However, other risks may be observed (declining lung function, quality of life) and a discussion of each case should be performed, especially in case of COPD and asthma overlap.

Resume Introduction Les etudes cliniques ont montre que les corticosteroides inhales ont un effet benefique sur la frequence des exacerbations et sur la qualite de vie des malades atteints de bronchopneumopathie chronique obstructive (BPCO). Cependant, ces medicaments n’ont pas ou peu d’effet sur le declin de la fonction respiratoire et sur la mortalite. Etat de l’art Les corticosteroides inhales sont indiques uniquement chez une minorite de patients atteints de BPCO : ceux ayant une maladie severe et des exacerbations repetees ainsi que probablement ceux ayant une forme frontiere « asthme et BPCO ». Les enquetes medicoeconomiques montrent que ces medicaments sont prescrits de maniere inappropriee chez un grand nombre de patients atteints de BPCO. La prescription abusive de corticosteroides inhales expose ces patients a des effets indesirables potentiellement graves tels que pneumonies, osteoporose et candidose oropharyngee. De plus, elle represente des depenses de sante inutiles considerables. Conclusion Il importe d’ameliorer les connaissances des medecins generalistes et des pneumologues a propos des benefices prouves cliniquement, des effets secondaires et du cout des corticosteroides inhales.

Summary Introduction Alpha-1 antitrypsin, secreted by the liver, inhibits neutrophil elastase. Its deficiency favours the development of emphysema. Restoring a “protective” serum level in deficient patients should make it possible to inhibit the development of emphysema. State of the art Human plasma-derived alpha-1 antitrypsin is a blood-derived drug sold in France under the name Alfalastin®. The recommended posology is an I.V. administration of 60 mg/kg once a week. Human plasma-derived alpha-1 antitrypsin restores anti-elastase protection in the lower lung and prevents experimental emphysema induced by the elastasis of human neutrophils in hamster. The low number of patients with alpha-1 antitrypsin deficiency is one of the difficulties to perform sufficiently powerful randomised studies. However, randomised studies have reported the efficacy of human plasma-derived alpha-1 antitrypsin perfusions on mortality, FEV1 decline and the frequency of exacerbations. Randomised control trials have demonstrated the efficacy of human plasma-derived alpha-1 antitrypsin perfusions on the loss of lung density assessed by CT scan. Conclusion Augmentation therapy is simple in its conception and implementation, but it is expensive. However, there are currently no other solutions.

National audience; La fibrose pulmonaire idiopathique (FPI) est la forme la plus fréquente de pneumopathie interstitielle diffuse (PID) idiopathique chronique chez l’adulte. Il s’agit d’une maladie fibroproliférative, irréversible, de cause inconnue, dont l’évolution est habituellement progressive, survenant principalement à partir de 60 ans et limitée aux poumons. Qualifiée de maladie orpheline notamment en raison de l’absence de traitement ayant fait la preuve formelle de son efficacité jusqu’à une période très récente, la FPI est une maladie rare dont la prévalence a été évaluée aux États-Unis entre 14 et 28/100 000 personnes [1], ce qui correspondrait à un minimum de 9000 patients en France et une incidence entre 6,8 et 9/100 000 par an [1,2], soit un minimum de 4400 nouveaux patients par an en France.

International audience; no abstract

International audience; no abstract

The aim of the study was to assess, compliance with maintenance treatment in patients with persistent asthma in clinical practice.This observational, cross-sectional, prospective, multicenter study was conducted in metropolitan France on patients with persistent asthma under the care of a representative sample of general practitioners and pneumologists. Compliance was determined via access to the Health Insurance database allowing comparison between the actual consumption of medications and the corresponding theoretical consumption related to prescription. Additional compliance data were obtained using the validated Morisky questionnaire.Eighty one physicians included 488 patients, mean age of 51 years, 55% women. The statement of consumption (SC) was available for 35% of patients however the Morisky questionnaire (present for 85% of patients) showed a similar compliance between patients with or without SC. The good compliance rate (compliance ≥80%) was observed in 51% based on the SC and in 38% based on the Morisky questionnaire. Among possible predictive factors, only obesity was associated with a bad compliance (19% vs 7%, P0.05). Patients with poor compliances displayed more severe symptoms and a higher rate of non-control (21.7% vs 5.7%, P0.01).The statement of consumption is a useful tool to provide quantitative measurement of compliance in daily practice.

Resume Cette observation illustre l’interet de la tomographie par emission de positons/tomodensitometrie (TEP/TDM) au fluoro-desoxy-glucose (FDG) (18F) en cas de lâcher de ballons pulmonaire pour aider au diagnostic etiologique et guider la biopsie chirurgicale decouvrant une granulomatose sarcoidosique necrosante alors que la biopsie sous TDM n’est pas contributive.

Introduction La bronchopneumopathie chronique obstructive (BPCO) est sous-diagnostiquee en raison de la mauvaise connaissance de la maladie et de la banalisation des symptomes. Methodes L’enquete IBIS (Information sur la BPCO pour un Impact Sanitaire) a ete menee aupres d’un echantillon representatif de la population francaise de plus de 40 ans (N = 2 758), pour evaluer les symptomes respiratoires et le niveau de connaissance de la maladie chez les sujets a risque ou presentant une BPCO (N = 860 soit 31 % de l’echantillon initial). Resultats Dans cet echantillon, 40 % des sujets presentaient une dyspnee de grade MRC ≥ 1 mais seuls 9 % rapportaient spontanement une gene respiratoire. Chez ces derniers, 72 % rapportaient une limitation de leurs activites quotidiennes mais seulement 14 % consideraient etre severement atteints. Une tres faible proportion de sujets (N = 220, 8 %) connaissait le terme BPCO et seuls 66 % dʼentre eux associaient la BPCO a une maladie respiratoire. Conclusions Il existe donc un ecart important entre la forte proportion de sujets a risque dans la population, la frequence de l’essoufflement chez ces sujets, la mauvaise connaissance de la maladie et la faible perception des symptomes. Ces resultats incitent a intervenir pour augmenter la connaissance de la BPCO dans la population.

Background: Chronic obstructive pulmonary disease (COPD) is markedly under-diagnosed, which may be related to the under-reporting of symptoms and poor awareness of the disease. We hypothesized that written information on COPD may help increase awareness of the disease in people at risk of developing it. Objectives: To evaluate the impact of an information leaflet sent by postal mail on the level of knowledge of COPD in subjects with or at risk of COPD. Methods: A total of 860 subjects with or at risk of COPD were selected by using a phone questionnaire. All subjects who reported a known diagnosis of COPD, a chronic cough and sputum production, or a smoking history of at least 15 pack-years were eligible for selection. Their knowledge of COPD was assessed during a telephone interview (baseline). They were randomized into 2 groups, with only 1 group receiving the information leaflet, and were then contacted 3 months later for a second interview. The changes in the knowledge of COPD from baseline were compared between subjects who reported receiving and reading the leaflet (true sensitized group) and subjects to whom the leaflet was not sent (control group). Results: At the follow-up interview, the proportion of patients who spontaneously mentioned ‘respiratory difficulties’, when asked about the meaning of COPD, significantly increased in the true sensitized group (+11.9%) compared with the control group (+2.6%, p < 0.05). In addition, the frequency of patients who cited lung function test as the primary diagnostic tool for COPD increased by +14.4% in the true sensitized group versus+2.0% in the control group (p < 0.05). However, there was no short-term leaflet-dependent improvement in smoking behaviour or utilization of health-care resources. Conclusions: This study shows that an information leaflet sent by postal mail to subjects with or at risk of COPD can significantly improve their knowledge of COPD; however, it has no significant impact on their behaviour.

The key pathophysiological feature of chronic obstructive pulmonary disease (COPD) is an abnormal inflammatory bronchial reaction after inhalation of toxic substances. The priority is the avoidance of such toxic inhalations, but the use of anti-inflammatory drugs also seems appropriate, especially corticosteroids that are the sole anti-inflammatory drug available for this purpose in France. The risks associated with the prolonged use of these parenteral drugs are well known. Inhalation is therefore the optimal route, but inhaled drugs may also lead to adverse consequences. In COPD, there is an inhaled corticosteroids overuse, and a non-satisfactory respect of the guidelines. Consequently, their withdrawal should be considered. We reviewed seven clinical studies dealing with inhaled corticosteroids withdrawal in patients with COPD and found that included populations were heterogenous with different concomitant treatments. In non-frequent exacerbators receiving inhaled corticosteroids outside the recommendations, withdrawal appears to be safe under a well-managed bronchodilator treatment. In patients with severe COPD and frequent exacerbations, the risk of acute respiratory event is low when they receive concomitant optimal inhaled bronchodilators. However, other risks may be observed (declining lung function, quality of life) and a discussion of each case should be performed, especially in case of COPD and asthma overlap.

Clinical trials have provided some evidence of a favorable effect of inhaled corticosteroids on the frequency of exacerbations and on the quality of life of patients with chronic obstructive pulmonary disease (COPD). In contrast, ICS have little or no impact on lung function decline and on mortality.Inhaled corticosteroids are recommended only in a minority of COPD patients, those with severe disease and repeated exacerbations and probably those with the COPD and asthma overlap syndrome. However, surveys indicate that these drugs are inappropriately prescribed in a large population of patients with COPD. Overtreatment with inhaled corticosteroids exposes these patients to an increased risk of potentially severe side-effects such as pneumonia, osteoporosis, and oropharyngeal candidiasis. Moreover, it represents a major waste of health-care spending.Primary care physicians as well as pulmonologists should be better aware of the benefits as well as the side-effects and costs of inhaled corticosteroids.

Introduction Consideree comme mediocre avec un taux de bons observants estime entre 45–60 % [1] , l’observance du patient asthmatique n’est pas aisement mesurable en vie reelle. L’objectif de cette etude etait d’evaluer en pratique courante, via une methode originale, l’observance du traitement de fond de patients asthmatiques. Methodes Cette etude observationnelle, transversale, a ete conduite en France aupres de patients adultes traites depuis au moins 3 mois pour asthme persistant. L’observance etait evaluee d’apres les donnees du releve de consommation (RC) de l’Assurance Maladie, par quantification de la concordance entre prescription et delivrance des traitements en pharmacie sur les 3 mois precedents. Cette evaluation etait completee par le questionnaire valide de Morisky renseigne par le patient. Resultats Entre avril et decembre 2014, 81 medecins qualifies en pneumologie ou generalistes ont inclus 488 patients, d’âge moyen de 51 ans avec 55 % de femmes. L’asthme, diagnostique en moyenne depuis 19 ans, etait partiellement controle pour 57 % et non controle pour 14 %. Le RC etait disponible pour 35 % des patients, mais le questionnaire de Morisky (85 % des patients) montrait une observance similaire entre les patients avec ou sans RC. Le taux de bons observants (observance ≥ 80 %) etait de 51 % selon le RC. Parmi les facteurs classiquement predictifs, seule l’obesite etait retrouvee chez les mauvais observants (19 % vs 7 %, p Conclusion Le releve de consommation s’est avere un outil utile pour obtenir une mesure quantitative de l’observance en pratique courante. Il confirme le lien entre mauvaise observance et mauvais controle de l’asthme, d’ou l’interet d’investiguer ce parametre face a un patient non repondeur avant d’envisager une modification du traitement.

To estimate the prevalence of treated chronic obstructive pulmonary disease (COPD) and its associated costs by stage of severity.The study was conducted on the 2011 data of the french general beneficiary sample database (EGB). EGB is a 1/97th sample of the whole population of the beneficiaries of the main compulsory national health insurances. COPD cases and the level of severity of the disease have been identified using new algorithms established from the available parameters in EGB. Costs were estimated using a collective perspective.The minimal prevalence of treated COPD was estimated at 3.8% in patients of 40 years and older and 1.9% regardless of the age of individuals. This population was predominantly male (58.2%) with a mean age of 68.8 years (±12.7). A total of 6.2% of patients had a health-care utilization suggestive of a very severe stage of COPD and 8.1%, 13.8% and 71.9% suggestive of severe, moderate and mild stages respectively. Over one year, 28.8% of patients visited a specialist respiratory physician, 5.0% were hospitalized (≥24h) for COPD and 6.7% died. Patients experienced an average of 1.7 (±1.5) exacerbations per year and only 61.4% received specific pharmacological treatment for COPD during the year. The average yearly health-care cost of a patient with COPD was estimated at €9382, with €5342 directly related to COPD.This study based on medico-administrative databases confirms the high epidemiological and economic burden of COPD in France.

Resume Des etudes recentes ont montre que la prevalence de la coqueluche serait de l'ordre de 10 a 20 % chez les patients adultes souffrant d'une toux chronique d'une duree superieure a huit jours et inferieure a deux mois. Confronte a ce symptome tres banal, le clinicien doit penser a la coqueluche et tenter d'etayer ce diagnostic par cinq elements cles : 1) le caractere paroxystique et astheniant de la toux ; 2) la chronologie particuliere des symptomes, la toux s'aggravant apres une banale phase catarrhale initiale ; 3) la normalite de l'examen physique entre les acces de toux ; 4) l'identification dans l'entourage d'un possible contaminateur ; 5) la normalite de la radiographie thoracique. Une suspicion clinique renforcee doit en effet conduire a demander les examens biologiques susceptibles d'affirmer le diagnostic (PCR chez l'adulte vaccine, serologie par immunoempreinte) et a discuter une antibiotherapie adequate (macrolides).

Chronic obstructive pulmonary disease (COPD) is markedly under-diagnosed, which may relate to under-reporting of symptoms and poor awareness of the disease.A survey was conducted in a sample of the French general population aged 40-75 years (n=2758) to assess respiratory symptoms and level of knowledge of the disease in subjects with or at-risk of COPD (n=860, 31%).The high frequency of dyspnoea (MRC dyspnoea gradeor =1: 40%) contrasted with that of subjects spontaneously reporting respiratory problems (9%). Among these, 72% reported limitations in daily-life activities but only 14% considered that they were severely affected by their respiratory status. A very low proportion of subjects knew the term COPD (8%) and only 66% of these associated COPD with a respiratory disease.There is a wide gap between the high number of subjects at risk of COPD in the general population and the frequency of breathlessness in these subjects on one hand, and the poor knowledge of the disease, poor perception of symptoms, and under-diagnosis and under-use of spirometry on the other. Increasing awareness of COPD in the population is needed.

Summary Introduction Chronic obstructive pulmonary disease (COPD) is underdiagnosed because of limited disease awareness with trivialization of the symptoms in the general population. Methods A survey was conducted in a representative sample ( n = 2758) of individuals older than 40 years of age in the general population of France. Respiratory symptoms and knowledge about COPD were assessed in individuals with or at risk for COPD ( n = 860, 31% of the sample). Results In the overall sample, 40% of individuals had a Medical Research Council dyspnea grade of 1 or more but only 9% spontaneously reported shortness of breath. Of these 9%, 72% reported limitations to their daily activities but only 14% believed they had severe lung disease. In the overall sample, only 220 (8%) individuals knew the term COPD and only 66% associated the term COPD with respiratory disease. Conclusions Despite a large proportion of individuals at risk for COPD or having COPD and a high prevalence of breathlessness, awareness of respiratory symptoms and knowledge of COPD were limited. These findings indicate a need for educating the general population about COPD.

The main purpose of this study was to assess whether pharmacological treatments prescribed by respiratory physicians to patients with chronic obstructive pulmonary disease (COPD) were consistent with the guidelines. The treatments prescribed by respiratory physicians to 631 consecutive patients with COPD, compared to 879 asthmatics were prospectively recorded. All subjects underwent peak expiratory flow rate measurement, spirometry and assessment of recent evolution and dyspnoea (visual analogue and Medical Research Council scales). Patients with COPD received more treatments than asthmatics (mean+/-SD: 2.6+/-0.5 versus 2.2+/-0.4, p