[Therapeutic patient education in respiratory rehabilitation]. / Éducation thérapeutique du patient au cours de la réadaptation respiratoire.

INTRODUCTION: Therapeutic patient education (TPE) is an essential component of pulmonary readaptation in chronic respiratory diseases. Numerous and varied patient education projects offer heterogeneous contents and methods, which render them difficult to analyze and to compare. The objective of this review was to provide perspective on the main principles of patient education, using a non-exhaustive approach. STATE OF KNOWLEDGE: This review is focused on patient education using a patient-centered approach, physician-patient partnership and self-management, which are presented at once pragmatically and conceptually. One of the main objectives of TPE is the acquisition of self-management skills by patients with a chronic disease, which will be considered from a clinical standpoint. Lastly, TPE will be assessed in the overall framework of patient-centered pulmonary readaptation. PERSPECTIVES: TPE needs to be structured in view of assessing its effects. It is consequently essential for caregivers to receive continuous training so as to more clearly understand the methods employed, the objective being to build evaluable contents contributing to performance of multicentric trials. CONCLUSION: Current literature on TPE emphasizes the extent to which the patient remains the central actor in his or her care pathway. If patients are called upon to modify their behaviors, it is equally necessary that caregivers proceed likewise, adopting postures favoring the acquisition and appropriation by the patient of skills that shall be required as he or she learns to live with chronic disease.

[The role of written action plans in the management of asthma]. / Apports du plan d'action écrit dans la prise en charge de l'asthme.

The Written Action Plan is a tool designed to help people with asthma to manage their condition when they experience an exacerbation. Asthma guidelines are consistent in their recommendation that action plans are useful for all people with asthma, but implementation is not systematic. The evidence base for such plans is limited because of methodological biases, but does support their effectiveness. The recommended action plan involves different color-coded zones which advise patients to adjust their management, such as increasing the level of daily treatment, or introducing oral corticosteroids based on symptoms and peak expiratory flow measurements. Recommendations are much less clear as to how to encourage patients to adopt and take ownership of their plan, although they all recommend that written action plans be incorporated into therapeutic education programs. The published literature shows that those caring for people with asthma may not support action plans because they are uncomfortable with the necessary educational posture and as a consequence of this they are under-utilized by patients. Patient-centered therapeutic education principles help us understand both how to encourage the patient want to have a written action plan and how to co-create it with them so that it is useful and meaningful in their life in order to make it more than just a disconnected tool.

[Woman's asthma throughout life: Towards a personalized management?] / Asthme de la femme au fil du temps : vers une prise en charge personnalisée ?

In a woman's life, asthma can affect her in a variety of ways, with the onset of premenstrual asthma currently under-diagnosed. It is estimated that about 20% of women with asthma have premenstrual asthma, which is more common in patients with severe asthma. Women with asthma are at high risk of exacerbations and of severe asthma. Asthma is the most common chronic disease during pregnancy with potential maternal and foetal complications. Asthma medications are safe for the foetus and it is essential to continue pre-existing treatment and adapt it to the progress of asthma during the pregnancy. Sex steroids modulate the structure and function of bronchial and immune cells. Understanding their role in asthma pathogenesis is complicated by the ambivalent effects of bronchodilating and pro-inflammatory oestrogens as well as the diversity of response to their association with progesterone. Menopausal asthma is a clinical entity and is part of one of the phenotypes of severe non-allergic and low steroid-sensitive asthma. Targeted assessment of the domestic and professional environment allows optimization of asthma management.

[Role of therapeutic education for patients with COPD participating in respiratory rehabilitation programs]. / Place de l'éducation thérapeutique du patient atteint de BPCO en réhabilitation respiratoire.

National and international guidelines confirm that therapeutic education should be an integral part of respiratory rehabilitation programs. Here we outline the pathophysiological foundation of respiratory rehabilitation in order to better apprehend the underlying rationale while taking into consideration each patient's symptoms, the real justification of any therapeutic intervention. Therapeutic education points out the fact that it is the patient who is being treated, not the illness. It is also the occasion to recall that long-term efficacy implies patient-centered interventions. Therapeutic education thus plays a central role in respiratory rehabilitation. It is implicated in all phases of rehabilitation and particularly for disease-specific indications. It optimizes the chances of long-term success, a clinical, if not evidence-based, observation.

[Chronic obstructive pulmonary disease (COPD) in the elderly]. / La bronchopneumopathie chronique obstructive (BPCO) du sujet âgé en huit questions/réponses.

Chronic obstructive pulmonary disease (COPD) is a chronic disease characterized by incompletely reversible airflow limitation, measured by a decrease of FEV(1)/FVC ratio. International consensus does not agree on a single threshold for this ratio, which can define airflow obstruction. Although the prevalence of COPD in the elderly population varies according to the definition used, it definitely increases with age and could reach 15% in those over 65 years of age. Therefore, ageing of the population should result in increased prevalence and socioeconomical costs of COPD during coming years. In France, diagnosis of COPD in the elderly is difficult, late and insufficient. Management, which has the same goals as in younger populations, has to be global and coordinated. Some points should be considered with particular attention considering the cumulative risks related on the one hand to COPD and on the other to ageing: pharmacological side-effects, decreased physical and social autonomy, nutritional impairment, comorbidities. Given the lack of specific data in elderly populations, pharmacological indications are generally considered to be the same as in younger populations, but some additional precautionary measures are necessary. Pulmonary rehabilitation seems to be beneficial at any age. Palliative care comes up against important difficulties: an indefinite beginning of the palliative stage in COPD; insufficient palliative care resources; insufficient communication; insufficient utilization of palliative care resources. Global COPD management in elderly requires coordination, best reached in health care network organizations involving medical and/or social professionals.

[Physical activity and exercise training for patients with cystic fibrosis]. / Activité physique et réentraînement à l'effort du patient atteint de mucoviscidose.

In France patients with cystic fibrosis benefit from a multidisciplinary follow-up in Cystic Fibrosis Centres. In this follow-up, despite the numerous therapeutic benefits of exercise in this disease, little emphasis is placed on the promotion of physical activity. The aim of this article is to improve this aspect of management, giving advice from a working group of experts, based on the medical literature and clinical experience. These proposals include quantification of physical activity, evaluation of exercise, training and rehabilitation programs and finally, modification of behaviour to include physical activity in the overall cystic fibrosis treatment strategy. It is intended to set up multicentre studies to evaluate the impact of these proposals.

[Study of cellularity in bronchoalveolar fluid and bronchial reactivity to histamine in a model of asthma in guinea pig]. / Etude de la cellularité bronchoalvéolaire et de la réactivite des voies aériennes a l'histamine dans un modèle d'asthme chez le cobaye.

INTRODUCTION: Several studies showed that the guinea pig represents the animal of choice in the study of the asthma and more exactly in the study of the bronchial hyperreactivity. MATERIALS AND METHOD: In our model of asthma, guinea pigs were made sensitive with ovalbumine (OVA), a protein extracted from the white of egg, and provoked in a way repeated with aerosol challenge of OVA for the group OVA (1 challenge a day during six days). This group was compared with the group controls (C), animals injected with a salt solution (NaCl 0.9%) and receiving aerosol challenge of salt solution. The OVA group was subdivided into two groups: A studied group 6 hours after the aerosol challenge of OVA. A studied group 24 hours after the aerosol challenge of OVA. RESULTS: We showed an increasing increase of airway hyperresponsiveness to increasing doses of histamine in all groups of animals. This increase was significantly more important 6 hours after the last aerosol challenge of OVA (early airway hyperreactivity, OVA-6 group, n = 8) that at 24 hours after the last aerosol challenge (late airway hyperreactivity, OVA-24 group, n = 8). We had also noted a modification of cellularity in bronchoalveolar lavage fluid with an increase of the total number of cells essentially by increase of the rate of eosinophilia in OVA-6 group (n = 6) compared with OVA-24 group (n = 6) and Control group (n = 6). CONCLUSION: The model of bronchial hyperreactivity and modification of cellularity in guinea pig will allow us to envisage studies on the origin of differences of ability to react in the group OVA-6 and OVA-24 and to study the medicinal efficiency of plants used in Senegal in the treatment of the asthma.

[Home-based pulmonary rehabilitation: the evidence, practical issues and medico-economics]. / La réhabilitation respiratoire à domicile: données de la littérature, aspects pratiques et médico-économiques.

INTRODUCTION: Pulmonary rehabilitation is an established part of the management of chronic obstructive airway disease. For longer-term effects, extending rehabilitation into domiciliary care settings may be necessary. There are few studies evaluating precisely this modality of management in a home setting. STATE OF THE ART: This review analyses the current literature on home based rehabilitation. The benefits of pulmonary rehabilitation, the practical aspects of its application, and its advantages and limitations are detailed. The few data on economic aspects of home rehabilitation are also discussed. PERSPECTIVES: Home-based pulmonary rehabilitation is effective with positive short-term effects on quality of life, breathlessness and effort tolerance. Its practical application needs to be defined. CONCLUSION: Home-based pulmonary rehabilitation appears to be an effective intervention in patients with COPD but more studies are necessary to evaluate it fully.

Economic arguments for the immediate management of moderate-to-severe obstructive sleep apnoea syndrome.

The objective of this study was to measure the impact of a 6-month delay in the diagnosis and treatment of patients with moderate obstructive sleep apnoea syndrome (OSAS) (apnoea/hypopnoea index (AHI) < 30) or severe OSAS (AHI > or = 30) on daytime sleepiness, cognitive functions, quality of life and healthcare expenditure (hospitalisations, medical visits, complementary tests, biological tests and drug prescriptions). In addition, this study aimed to analyse the incremental cost effectiveness ratios related to daytime sleepiness or quality of life following immediate introduction of treatment in these two populations. This study was conducted as a multicentre randomised controlled trial and carried out at two teaching hospitals in France. A total of 171 patients were followed for 6 months, with 82 patients randomised to group 1 "immediate polysomnography" and 89 in group 2 "polysomnography within 6 months". Patients with severe OSAS were deprived of a significant improvement of their daytime sleepiness (5.1 +/- 5.0 at the Epworth Sleepiness Scale score in group 1 versus 0.2 +/- 3.4 in group 2) and quality of life (12.4 +/- 13.3 at the Nottingham Health Profile score in group 1 versus 0.7 +/- 10.1 in group 2) during the waiting time. The impact of delayed management in subjects with less severe OSAS only concerned daytime sleepiness (1.1 +/- 3.3 in group 1 versus 0.3 +/- 4.3 in group 2). Delayed treatment did not affect cognitive functions or healthcare expenditure regardless of the severity of the disease. Incremental cost effectiveness ratios related to rapid introduction of treatment were significantly lower in the patients with more severe OSAS. These results provide fairly clear medical and economic arguments in favour of early management of patients with more severe forms of obstructive sleep apnoea syndrome.

Impaired glucose-insulin metabolism in males with obstructive sleep apnoea syndrome.

The aim of this cross-sectional study was to evaluate the frequency of type-2 diabetes and impaired glucose tolerance (IGT) in a large clinic-based male population presenting various degrees of obstructive sleep apnoea syndrome (OSAS) and to analyse the relationship between OSAS and glucose-insulin metabolism. Male patients (n=595) with suspected OSAS underwent both nocturnal polysomnography and a 2-h oral glucose-tolerance test with measurements of fasting and postload blood glucose and plasma insulin. Insulin sensitivity was evaluated by the ratio of fasting glucose to fasting insulin. OSAS was diagnosed in 494 patients, while 101 patients were nonapnoeic snorers. Type-2 diabetes was present in 30.1% of OSAS patients and 13.9% of nonapnoeic snorers. IGT was diagnosed in 20.0% of OSAS patients and 13.9% of nonapnoeic snorers. Fasting and postload blood glucose increased with severity of sleep apnoea. Insulin sensitivity decreased with increasing severity of sleep apnoea. In addition to body mass index and age, the apnoea/hypopnoea index independently influenced postload blood glucose and insulin sensitivity. The authors conclude that in a clinic-based sample of patients, obstructive sleep apnoea syndrome is associated with a high frequency of type-2 diabetes and impaired glucose tolerance. The relationship between sleep-disordered breathing and impaired glucose-insulin metabolism is independent of obesity and age.

Decreased pulmonary and tracheal smooth muscle expression and activity of type 1 nitric oxide synthase (nNOS) after ovalbumin immunization and multiple aerosol challenge in guinea pigs.

Pharmacological evidence supports a role of a transient decreased endogenous nitric oxide (NO) synthesis in ovalbumin (OVA)-induced early airway hyperresponsiveness in guinea pigs. However, no data are available regarding the expression and activity of the constitutive NO synthases (cNOS; NOS1 and NOS3, nNOS and eNOS, respectively) in this model. Therefore, we evaluated cNOS activity (conversion of L-[3H]arginine to L-[3H]citrulline in the presence of Ca2+ and calmodulin), nitrate and nitrite (NOx) concentration (modified Griess method), and NOS1 and NOS3 protein expression (Western blot) in lung homogenates and in the tracheal smooth muscle from OVA-immunized and multiple aerosol-challenged guinea pigs (six challenges, once daily). The expression and activity of the inducible NOS isoform (NOS2), the levels of exhaled NO, and the in vivo airway reactivity were also determined. Constitutive NOS activity and NO(x) concentration were significantly lower 6 h after the last OVA challenge as compared with saline exposure, being similar at 24 h. Expression of NOS1 paralleled cNOS activity, which was reduced 6, but not 24 h after OVA challenge. The decrease in NOS1 expression was accompanied by a significant decrease in the amounts of exhaled NO and by a maximal airway hyperresponsiveness to histamine. The levels of NOS3 were not modified at the two time points evaluated, and no NOS2 expression and activity were found at any time point. Similar modifications were observed in the tracheal smooth muscle. We conclude that OVA stimulation in immunized guinea pigs induced a transient reduction in NOS1 protein expression and activity in the respiratory system, which probably participates in airway hyperresponsiveness.

[Obstructive sleep apnea syndrome and cardiovascular risk]. / Syndrome d'apnées obstructives du sommeil et risque cardio-vasculaire.

Numerous studies have shown that obstructive sleep apnea syndrome (OSAS) is associated with an increased cardiovascular morbidity and mortality. Obstructive sleep apnea syndrome and cardiovascular disorders are frequent diseases. They share several risk factors such as age, gender, obesity, smoking, and alcohol. Therefore it is difficult to demonstrate that OSAS is a cardiovascular risk factor, independent of previously known factors. Recent epidemiological studies and trials, consistent with the results of previous studies, have demonstrated a strong association between OSAS and systemic hypertension. They also suggest that there is a possible cause-effect relation between OSAS and coronary artery disease or cardiac arrhythmias. Studies demonstrating that early recognition and treatment of OSAS may be effective in reducing these cardiovascular complications are still needed.