ABSTRACT
INTRODUCTION: The second COPD Biennial organized by the COPD working group of the French Society of Respiratory Diseases took place in Paris (Cochin) on 13th December 2023. STATE OF THE ART: Major trends in 2023 were discussed; they encompassed concepts, definitions, biologics, care pathways, pulmonary rehabilitation and complex situations entailed by respiratory infections, cardiovascular comorbidities and pulmonary hypertension, and modalities of oxygen therapy and ventilation. PERSPECTIVES: The different talks underlined major changes in COPD including the concepts of pre-COPD, etiotypes, health trajectories and new definitions of exacerbation. Recent results in biologics for COPD open the door to new pharmacological options. Assessment of current care pathways in France highlighted some causes for concern. For example, pulmonary rehabilitation is a key but insufficiently practiced element. Respiratory infections require careful assessment and treatments. Diagnosis and treatment of cardiovascular comorbidities and pulmonary hypertension are of paramount importance. As of late, oxygen therapy and ventilation modalities have evolved, and are beginning to afford more personalized options. CONCLUSIONS: As regards COPD, a personalized approach is crucial, placing the patient at the center of the care pathway and facilitating coordination between healthcare providers.
Subject(s)
Critical Pathways , Pulmonary Disease, Chronic Obstructive , Societies, Medical , Humans , Pulmonary Disease, Chronic Obstructive/therapy , Pulmonary Disease, Chronic Obstructive/epidemiology , Pulmonary Disease, Chronic Obstructive/rehabilitation , France/epidemiology , Critical Pathways/organization & administration , Critical Pathways/standards , Critical Pathways/trends , Societies, Medical/organization & administration , Societies, Medical/standards , Patient-Centered Care/organization & administration , Patient-Centered Care/trends , Patient-Centered Care/standards , Pulmonary Medicine/organization & administration , Pulmonary Medicine/trends , Pulmonary Medicine/methods , Pulmonary Medicine/standards , Congresses as TopicABSTRACT
INTRODUCTION: Despite evidence of the benefits of the written asthma action plans (WAP) in asthma control, they remain poorly applied. The aim of our study was to assess the practices of French-speaking pulmonologists and paediatricians in their use of WAP for asthma control and to analyse the contents of several WAPs routinely consulted in treatment of asthma patients. METHODS: Members of three French medical societies (SPLF, G2A, SP2A) were requested to share their WAPs for asthma patients and to participate in an online survey about the possible influence of these documents on their practices. RESULTS: Most (95%) of the 41 WAPs taken into consideration were symptom-based and 34% included peak expiratory flow measurement. All of these action plans were in full compliance with current guidelines. Among the 110 survey respondents, while 65% systematically provided a WAP to their asthma patients, only 30% often or always supplemented the written document with therapeutic education sessions. In almost every case, it was the doctor who presented the WAP to the patient, generally devoting to less than 10minutes to explanation of what they were handing out. CONCLUSIONS: In France, WAPs are generally presented to the patient by the physician, which probably limits the time devoted to explanation of their contents. Furthermore, WAPs are rarely reinforced with therapeutic education. The current study suggests ways of improving the utilization of WAPs in asthma care and treatment.
Subject(s)
Asthma , Pulmonologists , Humans , Asthma/therapy , Asthma/drug therapy , Patient Compliance , Self Care , France/epidemiologyABSTRACT
INTRODUCTION: Mediastinal lymphadenopathy is a common cause of referral to the pulmonologist. In addition to more frequent aetiologies such as malignancy, sarcoidosis, tuberculosis and lymphoma, unusual causes must be considered, especially in specific contexts. CASE SERIES: We report the cases of three young patients referred to our pulmonology department for the assessment of hypermetabolic mediastinal lymphadenopathy. The context of the onset of symptoms (tick bite, contact with an infected animal) as well as paraclinical investigations (Francisella tularensis serology) made it possible to make a diagnosis of tularemia. The clinical and radiological evolution was favourable in all three cases. Tularemia is a rare but currently re-emerging infection caused by a Gram negative coccobacillus, Francisella tularensis. Human contamination occurs mainly through contact with infected animals or by tick bites. The diagnosis can be difficult because the symptoms (fever, diffuse myalgia) are non-specific, and is based on serology and an appropriate clinical context. Treatment is based on ciprofloxacin or doxycycline. CONCLUSION: The diagnosis of tularemia must be considered in the presence of lymphadenopathy occurring after a tick bite or contact with an infected animal.
Subject(s)
Francisella tularensis , Lymphadenopathy , Tularemia , Animals , Doxycycline , Fever , HumansABSTRACT
Bone location is uncommon in both sarcoidosis and in neck cancer (HNC). Diagnosis of a bone lesion is therefore challenging to distinguish its nature in a patient suffering from both diseases. We report the case of a 69-years-old woman referred for P16 positive HPV-HNC. Magnetic Resonance Imaging (MRI) showed T2 hypo-signal on iliac crest and spine. 18FDG-PET demonstrated radiotracer uptake on these locations suggesting bone metastasis. However, bone biopsy showed epithelioid granuloma without malignant cells compatible with sarcoidosis location. The diagnosis of both localized advanced HPV-HNC and systemic sarcoidosis (bone, central nervous system) were retained. The patient received corticosteroid regimen at 0.5mg/kg/day and Methotrexate for sarcoidosis and radiation and chemotherapy with platins for carcinoma. As granulomatous bone marrow infiltration may have an uptake on 18FDG-PET, bone sarcoidosis can mimic metastatic disease. In addition, MRI often fails to distinguish sarcoidosis lesions from metastatic lesion in bones. As no reliable imaging test can decipher both diseases, the description of our case reinforces the necessity to perform bone biopsy in a patient suffering from both conditions to expertise the nature of bone lesions.
Subject(s)
Bone Diseases/diagnostic imaging , Human papillomavirus 16 , Oropharyngeal Neoplasms/diagnostic imaging , Sarcoidosis/diagnostic imaging , Adrenal Cortex Hormones/therapeutic use , Aged , Bone Diseases/drug therapy , Chemoradiotherapy/methods , Female , Humans , Ilium/diagnostic imaging , Immunosuppressive Agents/therapeutic use , Magnetic Resonance Imaging , Methotrexate/therapeutic use , Oropharyngeal Neoplasms/therapy , Oropharyngeal Neoplasms/virology , Sarcoidosis/drug therapy , Spinal Diseases/diagnostic imagingSubject(s)
COVID-19/complications , Critical Illness , Pulmonary Embolism , Respiratory Distress Syndrome , Acute Disease , Adult , Aged , COVID-19/epidemiology , COVID-19/therapy , Comorbidity , Critical Illness/epidemiology , Critical Illness/therapy , Female , Humans , Male , Middle Aged , Pandemics , Pulmonary Embolism/epidemiology , Pulmonary Embolism/therapy , Pulmonary Embolism/virology , Respiratory Distress Syndrome/epidemiology , Respiratory Distress Syndrome/therapy , Respiratory Distress Syndrome/virology , SARS-CoV-2/physiologyABSTRACT
INTRODUCTION: Hypersensitivity pneumonitis (HP) is an interstitial lung disease due to an immunological reaction to exposure, by inhalation, to a large variety of antigens. The patho-physiological mechanism remains poorly understood. The diagnosis can be challenging and requires a detailed medical history taking especially when the clinical presentation is atypical or when the causal agent remains unknown. CASE REPORT: We report the case of a 75-year-old woman with a history of mammary carcinoma who presented with recently identified intramammary adenopathy. Biopsy of the adenopathy revealed non-necrotising, giant cell epithelioid granuloma. A diagnosis of hot tub lung with extra-pulmonary granulomatous lymph node involvement was made based on the clinical, functional, radiological and microbiological investigations. The evolution was favorable following antigen avoidance. CONCLUSION: Extrapulmonary lymph node involvement is rare in HP, suggesting a systemic inflammatory involvement.
Subject(s)
Alveolitis, Extrinsic Allergic/complications , Alveolitis, Extrinsic Allergic/diagnosis , Breast Neoplasms/complications , Carcinoma, Ductal, Breast/complications , Lymphadenopathy/diagnosis , Aged , Breast Neoplasms/diagnosis , Breast Neoplasms/pathology , Carcinoma, Ductal, Breast/diagnosis , Carcinoma, Ductal, Breast/pathology , Diagnosis, Differential , Female , Humans , Lymphadenopathy/complications , Mycobacterium avium Complex/immunology , Mycobacterium avium-intracellulare Infection/complications , Mycobacterium avium-intracellulare Infection/diagnosisABSTRACT
INTRODUCTION: Pulmonary arteriovenous malformations (PAVM) are abnormal communications between arteries and pulmonary veins without interposition of capillaries. Embolization is effective both in reducing lifetime complications associated with PAVM and in improving arterial oxygenation. Embolization is however not recommended in patients with pulmonary hypertension (PH) as it abolishes low resistance pathways for pulmonary blood flow and therefore might be expected to elevate pulmonary arterial pressure (PAP). CASE REPORT: We report the case of a 70-year-old patient with a large PAVM as well as group 3 PH [mean PAP=21mmHg, pulmonary vascular resistance (PVR) at 3.4 Wood units] secondary to stage 2 chronic obstructive pulmonary disease (COPD) with emphysema. According to the measured shunt flow (26% of cardiac output), predicted post-embolization PVR was estimated at 4.6 Wood units. These values were considered compatible with embolization of the PAVM. Dyspnea and gas exchange improved after PAVM embolization, without worsening PH. CONCLUSION: Embolization of a PAVM can be considered in patients with stable PH but requires careful prior hemodynamic assessment. The estimation of the shunt flow and predicted post-embolization PVR may guide the therapeutic decision.
Subject(s)
Arteriovenous Malformations/complications , Arteriovenous Malformations/diagnosis , Hypertension, Pulmonary/diagnosis , Pulmonary Veins/abnormalities , Aged , Female , Humans , Hypertension, Pulmonary/etiology , Hypertension, Pulmonary/physiopathology , Pulmonary Disease, Chronic Obstructive/diagnosis , Pulmonary Disease, Chronic Obstructive/etiology , Pulmonary Veins/pathology , Pulmonary Veins/physiopathology , Vascular Resistance/physiologyABSTRACT
Coronavirus disease 19 (Covid-19) is a new emerging virus responsible for pandemic and death. High blood pressure, diabetes, obesity have been described as poor prognosis factors. Few data have been reported in patient with immunocompromised status (solid tumor, hematological malignancy, rheumatoid conditions or organ transplant). We evaluated the characteristics of patients, including the outcome, with immunodepression hospitalized in Besancon University hospital (East of France). We wanted to identify if a type of immunosupression influences the course of Covid-19. In a cohort of 80 patients with immunosupression (42 solid tumors, 20 hematological malignancy and 18 non neoplastic immunosupression), poor outcomes (Intensive care unit hospitalization and or deaths) was frequent (38%) and tended to be more frequent in patients with hematological malignancy.
Subject(s)
Betacoronavirus , Coronavirus Infections/epidemiology , Pandemics , Pneumonia, Viral/epidemiology , Adult , COVID-19 , Child , France , Humans , SARS-CoV-2ABSTRACT
INTRODUCTION: Proper diagnosis of COPD remains a challenge. Spirometry testing in primary care may help to reduce misdiagnosis, but its reliability as a diagnostic instrument needs to be assessed. OBJECTIVES: To investigate (1) the validity of spirometry testing performed in primary care and (2) the accuracy of the diagnostic of airflow limitation obtained by these tests. METHODS: Subjects attending a COPD screening programme had screening spirometry performed either by general practitioners (GPs) or by trained nurses or technicians, who had all received two 3-hour training sessions. Subjects with airflow limitation and a subset of subjects with normal spirometry at screening were invited to undergo confirmatory spirometry performed by trained nurses in a pulmonary function laboratory. RESULTS: Of the 4610 subjects who attended the screening sessions, 96.5% had a valid screening spirometry test. A total of 392 subjects attended the confirmatory sessions. Values measured by screening spirometry were satisfactory compared with those of confirmatory spirometry (rc=0.83). Taking confirmatory spirometry as reference, the positive predictive value of screening spirometry for the diagnosis of persistent airflow limitation was 93% with a specificity of 95%. Agreement for the diagnosis of persistent airflow limitation was substantial (k=0.80). CONCLUSION: Spirometry performed in primary care by trained personnel reliably identifies persistent airflow limitation. This may encourage pulmonologists to collaborate with primary care providers with the aim of improving appropriate diagnosis of COPD.
Subject(s)
Mass Screening/methods , Pulmonary Disease, Chronic Obstructive/diagnosis , Spirometry , Aged , Case-Control Studies , Family Practice/statistics & numerical data , Female , Forced Expiratory Volume , General Practice/methods , General Practice/statistics & numerical data , General Practitioners/statistics & numerical data , Humans , Male , Middle Aged , Nurses/statistics & numerical data , Pulmonary Disease, Chronic Obstructive/epidemiology , Reproducibility of Results , Spirometry/methods , Spirometry/statistics & numerical data , Vital CapacityABSTRACT
Hypersensitivity pneumonitis and allergic bronchopulmonary aspergillosis are two forms of lung disease with presumed distinct immunoallergic mechanisms. We report the observation of a 38-year-old French farmer who, for one month, had fever and dyspnoea resistant to antibiotic therapy. A diagnosis of farmer's lung, and allergic bronchopulmonary aspergillosis was made on clinical, biological, functional and radiological evidence and according to the criteria established. The evolution was favorable with antigenic eviction and corticosteroid therapy. This observation is to our knowledge the 5th case that describes the association of hypersensitivity pneumonitis and allergic bronchopulmonary aspergillosis. It suggests the existence of risk factors and immunoallergic mechanisms common to both diseases and discusses the hypothesis that the same antigen(s) is (are) responsible for them.
Subject(s)
Aspergillosis, Allergic Bronchopulmonary/complications , Farmer's Lung/complications , Actinobacteria/isolation & purification , Adult , Aspergillosis, Allergic Bronchopulmonary/diagnosis , Aspergillosis, Allergic Bronchopulmonary/microbiology , Aspergillus fumigatus/isolation & purification , Coinfection , Farmer's Lung/diagnosis , Farmer's Lung/microbiology , Gram-Positive Bacterial Infections/complications , Gram-Positive Bacterial Infections/diagnosis , Gram-Positive Bacterial Infections/microbiology , Humans , MaleABSTRACT
The objective of our study was to evaluate the reliability of clinical examination paired with MRI to determine whether one or both of the superior C5 and C6 roots are graftable in cases of complete brachial plexus palsy. We conducted a retrospective study from 2013 to 2018. Twenty-seven patients who had total brachial plexus palsy and were more than 18 years of age were included. The Horner and the Tinel signs, potential phrenic nerve injury and anterior serratus muscle function were investigated. MRI with STIR 3D sequence was performed in each patient. Surgical exploration of the C5 and C6 roots confirmed if they were avulsed and, if found to be ruptured, assessed the possibility of grafting them. Serratus anterior testing had a specificity and a positive predictive value of 100% and diagnostic accuracy of 78%. The presence of the Tinel sign had a sensitivity and a negative predictive value of 100% and diagnostic accuracy of 93%. MRI had a sensitivity, specificity and diagnostic accuracy of 89%. A decision tree to determine whether or not C5 and/or C6 can be grafted has been developed. Its sensitivity and negative predictive value were 100%. This study provides initial validation of this diagnostic method for the diagnosis of graftable C5 and/or C6 roots. It could help prevent needless cervical exploration.
Subject(s)
Brachial Plexus Neuropathies/surgery , Brachial Plexus/diagnostic imaging , Magnetic Resonance Imaging , Neurologic Examination , Spinal Nerve Roots/diagnostic imaging , Adult , Brachial Plexus/injuries , Decision Trees , Female , Humans , Imaging, Three-Dimensional , Male , Middle Aged , Predictive Value of Tests , Preoperative Care , Retrospective Studies , Sensitivity and Specificity , Spinal Nerve Roots/injuries , Young AdultABSTRACT
Hypersensitivity pneumonitis (HP) is an interstitial lung disease caused by an immune response to a variety of antigens to which patients have been previously sensitised. It can occur at any age. In children, it is a rare disease, probably under-diagnosed, with an estimated prevalence of 4 per million. The paediatric forms are not really different from those of adults but present some particularities. Avian exposure is by far the most frequent cause of HP, accounting for nearly two-thirds of cases. Although there is no current recommendation for the diagnosis of HP, it is commonly considered that the diagnosis can be made with confidence on the combination of (1) compatible respiratory symptoms, (2) exposure to a known offending antigen, (3) lymphocytic alveolitis, (4) decreased transfer factor for carbon monoxide or hypoxia on exertion and (5) compatible radiologic features. The treatment is based on antigen avoidance that must be complete and definitive. Corticosteroids can be necessary in severe forms. The prognosis of HP in children is better than in adults, with a full clinical and functional recovery in the majority of cases after complete antigenic withdrawal.
Subject(s)
Alveolitis, Extrinsic Allergic , Pediatrics/methods , Age Factors , Age of Onset , Alveolitis, Extrinsic Allergic/diagnosis , Alveolitis, Extrinsic Allergic/epidemiology , Alveolitis, Extrinsic Allergic/therapy , Biopsy , Bronchial Provocation Tests , Bronchoalveolar Lavage , Child , Diagnosis, Differential , Humans , Prognosis , Respiratory Function TestsSubject(s)
Alveolitis, Extrinsic Allergic/immunology , Chinchilla/immunology , Animals , Humans , Male , Middle AgedABSTRACT
Community-acquired pneumonia (CAP) is a common infectious disease and one of the main causes of mortality worldwide. Despite an improvement in management globally, mortality remains high especially in severe forms of CAP. Adequate early antibiotics remain the cornerstone of the treatment but adjuvant corticosteroid administration is being considered to counterbalance the systemic inflammatory reaction and modulate the immune response. In the last ten years, several clinical trials and meta-analyses have been conducted in severe and non-severe CAP to assess the efficacy of corticosteroids. The benefits on the duration of hospitalization and the time to clinical stability are quite small and early mortality does not seem to be improved. Corticosteroids should not, therefore, be used routinely in patients with CAP, even in severe cases. However, new therapeutic trials are currently underway.
Subject(s)
Adrenal Cortex Hormones/therapeutic use , Community-Acquired Infections/drug therapy , Healthcare-Associated Pneumonia/drug therapy , Pneumonia/drug therapy , Anti-Bacterial Agents/therapeutic use , Community-Acquired Infections/epidemiology , Healthcare-Associated Pneumonia/epidemiology , Hospitalization , Humans , Pneumonia/epidemiologyABSTRACT
INTRODUCTION: Several studies have shown that eosinopenia less than 0.04g/L is a marker of bacterial infection in the presence of unexplained inflammatory syndrome. The aim of our study was to test this hypothesis and to propose a predictive score for bacterial infection (score CIBLE, C reactive protein, bacterial infections, levels of leucocytes and eosinophils). PATIENTS AND METHODS: This was a single-center observational study of patients admitted to an internal medicine department in the year 2015 and presenting with an inflammatory biological syndrome. Patients were divided into 2 groups: bacterial infections (group 1) and nonbacterial inflammatory diseases (group 2). RESULTS: One hundred and ninety patients were included: 92 men (48.4 %) and 98 women (51.6 %). Mean age was 73.5±18.2 years [19-104]. Group 1 consisted of 124 patients (65.2 %) and group 2 of 66 patients (34.8 %). ROC analysis confirmed a cut-off level for eosinophils count at 0.04g/L as discriminant to predict bacterial infection. In a multivariate analysis, the eosinophil/neutrophil ratio, a history of COPD, the C reactive protein concentration, patient age and initial temperature were the most significant variables. They were used to build the CIBLE score. For a score higher than or equal to 87, the probability of a bacterial infection is at least 70 %. CONCLUSION: The CIBLE score appears to be a relevant and inexpensive tool to establish a probability for bacterial infection.
Subject(s)
Bacterial Infections/diagnosis , Biomarkers/blood , Eosinophils/pathology , Adult , Aged , Aged, 80 and over , Bacterial Infections/blood , Female , Humans , Leukocyte Count , Male , Middle Aged , Predictive Value of Tests , Prognosis , Research Design , Young AdultABSTRACT
Chronic obstructive pulmonary disease (COPD) most often results from the inhalation of toxic agents. Cigarette smoking still remains the principal cause but the pertinence of occupational COPD is now clearly established. After a brief overview of the epidemiology of this "other COPD", the clinical and functional characteristics are summarized, taking into account recent advances in this field. The combined effects of occupational exposure and tobacco are also considered, providing evidence of the need to continuously reinforce campaigns of education and prevention in occupational COPD.
Subject(s)
Occupational Diseases/etiology , Occupational Exposure/adverse effects , Pulmonary Disease, Chronic Obstructive/classification , Pulmonary Disease, Chronic Obstructive/etiology , Smoking/adverse effects , Tobacco Smoke Pollution/adverse effects , Cardiovascular Diseases/etiology , Humans , Occupational Diseases/classification , Occupational Diseases/diagnosis , Occupational Diseases/epidemiology , Occupational Exposure/statistics & numerical data , Pulmonary Disease, Chronic Obstructive/diagnosis , Pulmonary Disease, Chronic Obstructive/epidemiology , Radiography, Thoracic , Respiratory Function Tests , Risk Factors , Smoking/epidemiology , Nicotiana/adverse effects , Tobacco Smoke Pollution/statistics & numerical dataABSTRACT
INTRODUCTION: Farmer's lung (FL) is the most common type of hypersensitivity pneumonitis (HP), with an estimated prevalence of between 0.5 and 1.5% in dairy farmers. In chronic FL, fibrotic sequelae are widely described in the literature although our experience and occasional epidemiological studies emphasize an increased risk of developing emphysema in these patients. CASE REPORT: We report a case of FL in a 37-year-old patient with typical clinical features (exertional dyspnoea, lymphocytic alveolitis and computed tomography appearances) together with proven allergen exposure. This patient developed early pulmonary emphysema probably due to intermittent massive exposure to antigens and to bacterial and fungal micro-organisms. CONCLUSION: The current classification of HP differentiates acute, subacute and chronic forms but does not take account of the role of the mode of exposure and the evolution of the disease. The prognosis and evolution of HP seem to be dependent on the type and pattern of exposure. A new classification with two clusters has been suggested: in type 1, massive and intermittent exposure, as in FL, may lead to emphysema with chronic airflow obstruction and, in type 2, chronic exposure to a low level, as in bird fanciers, may lead to fibrosis with a restrictive pattern.