[Swallowing disorders, pneumonia and respiratory tract infectious disease in the elderly]. / Troubles de la déglutition du sujet âgé et pneumopathies en 14 questions/réponses.

Swallowing disorders (or dysphagia) are common in the elderly and their prevalence is often underestimated. They may result in serious complications including dehydration, malnutrition, airway obstruction, aspiration pneumonia (infectious process) or pneumonitis (chemical injury caused by the inhalation of sterile gastric contents). Moreover the repercussions of dysphagia are not only physical but also emotional and social, leading to depression, altered quality of life, and social isolation. While some changes in swallowing may be a natural result of aging, dysphagia in the elderly is mainly due to central nervous system diseases such as stroke, parkinsonism, dementia, medications, local oral and oesophageal factors. To be effective, management requires a multidisciplinary team approach and a careful assessment of the patient's oropharyngeal anatomy and physiology, medical and nutritional status, cognition, language and behaviour. Clinical evaluation can be completed by a videofluoroscopic study which enables observation of bolus movement and movements of the oral cavity, pharynx and larynx throughout the swallow. The treatment depends on the underlying cause, extent of dysphagia and prognosis. Various categories of treatment are available, including compensatory strategies (postural changes and dietary modification), direct or indirect therapy techniques (swallow manoeuvres, medication and surgical procedures).

[Lung cancer in the elderly subject]. / Cancer bronchique du sujet âgé.

INTRODUCTION: In France, the average age for the diagnosis of bronchial carcinoma is 64. It is 76 in the population of over 70. In fact, its incidence increases with age linked intrinsic risk of developing a cancer and with general ageing of the population. Diagnosis tools are the same for elderlies than for younger patients, and positive diagnosis mainly depends on fibreoptic bronchoscopy, complications of which being comparable to those observed in younger patients. STATE OF THE ART: The assessment of dissemination has been modified in recent years by the availability of PET scanning which is increasingly becoming the examination of choice for preventing unnecessary surgical intervention, a fortiori in elderly subjects. Cerebral imaging by tomodensitometry and nuclear magnetic resonance should systematically be obtained before proposing chirurgical treatment. An assessment of the general state of health of the elderly subject is an essential step before the therapeutic decision is made. This depends on the concept of geriatric evaluation: Geriatric Multidimensional Assessment, and the Comprehensive Geriatric Assessment which concerns overall competence of the elderly. PERSPECTIVES: This is a global approach that allows precise definition and ranking of the patient's problems and their impact on daily life and social environment. Certain geriatric variables (IADL, BADL, MMSE, IMC etc) may be predictive of survival rates after chemotherapy or the incidence of complications following thoracic surgery. The main therapeutic principles for the management of bronchial carcinoma are applicable to the elderly subject; long term survival without relapse after surgical resection is independent of age. Whether the oncological strategy is curative or palliative, the elderly patient with bronchial carcinoma should receive supportive treatments. They should be integrated into a palliative programme if such is the case. In fact, age alone is not a factor that should detract from optimal oncological management. CONCLUSIONS: The development of an individual management programme for an elderly patient suffering from bronchial carcinoma should be based on the combination of oncological investigation and comprehensive geriatric assessment.

[Evaluation of pulmonary function in the elderly. Intergroupe Pneumo Gériatrie SPLF-SFGG]. / Evaluation de la fonction respiratoire chez le sujet âgé. Intergroupe Pneumo Gériatrie SPLF-SFGG.

Aging is associated with a progressive decrease in lung function. As a consequence of aging, individual's reserve is diminished, but this decrease is heterogeneous between individual subjects. Many factors are involved in the overall decline in lung function. The prevalence of asthma in the elderly is estimated between 6 and 10%. Mortality due to COPD is increasing, especially among older subjects. Older subjects are at an increased risk of developing chronic diseases such as Parkinson's disease, which can have consequences for lung function. Under-nutrition is also common in the elderly and can produce sarcopenia and skeletal muscle dysfunction. The presentation of respiratory disorders may differ in the elderly, especially because of a lack of perception of symptoms such as dyspnea. The impact of bronchodilatators or corticosteroids on respiratory function has not been studied in the elderly. Drugs usually used for the treatment of hypertension or arrhythmias, which are often observed with aging, can have pulmonary toxicity. There is no difference between functional evaluation in younger and older subjects but it is more difficult to find predicted values for older patients. Performing pulmonary function tests in older patients is often difficult because of a higher prevalence of cognitive impairment and/or poor coordination. When assessing pulmonary function in the elderly, the choice of tests will be depend on the circumstances, with the use of voluntary manoeuvres dependent on the condition of the patient.

Frequency and correlates of the saw-tooth pattern of flow-volume curves in an epidemiological survey.

The object of this report was to assess the possibility of identifying saw-tooth patterns on flow-volume curves in men aged 28 to 58 years. We studied the frequency of these patterns and their relationships with two indirect signs of UAO increase in FEV1/PEF and FEF50%/FIF50% ratios--as well as with clinical and functional data. Twenty-six of the 360 subjects surveyed, ie, 7.2 percent, had flow oscillations in the inspiratory and/or expiratory part of flow-volume curves, corresponding to the definition of the saw-tooth pattern. We observed significant relationships between the saw-tooth pattern and the mean FEV1/PEF ratio. In 97 subjects, the proportion of those with saw-tooth patterns was 13.4 percent, and the mean FEF50%/FIF50% ratio was 1.53 in those with the pattern vs 1.07 in those without it. These results show that the saw-tooth pattern was not rare in these men.

Total circulating IgE and FEV1 in adult men. An epidemiologic longitudinal study.

Epidemiologic data relating total circulating immunoglobulin E (IgE), an objective marker of allergy, to cross-sectional and longitudinal FEV1 as well as to methacholine bronchial hyperresponsiveness were obtained from 310 French adult men surveyed five years apart. Skin prick test responses to common aeroallergens, IgE level, and bronchial hyperresponsiveness were assessed at the end of the follow-up. IgE level was not associated with PD20 to methacholine. Cross-sectionally, age and height-adjusted FEV1 score was inversely related to total IgE level (regression coefficient of FEV1 score on Log[IgE] beta = -.20; p = 0.02). Stratified analysis showed that IgE level was associated with FEV1 score only in nonsmokers (beta = -0.52; p less than 0.001), an association that remained after exclusion of asthmatics. Longitudinally, five-year FEV1 decline was related to IgE in nonsmokers (regression coefficient of FEV1 decline on Log[IgE] beta = 19.9; p = 0.03) and exsmokers (beta = 18.9; p = 0.06) but not in current smokers. The relationship persisted, even if with lesser significance, among exsmokers after exclusion of asthmatics (beta = 17.2) and further exclusion of skin prick test-positive men (beta = 18.8). Whether IgE production also reflects factors other than allergy, possibly nonallergic inflammation, needs further investigations.

Nutritional status of patients with chronic obstructive pulmonary disease and acute respiratory failure.

The prevalence and features of malnutrition in COPD patients have been studied extensively in stable conditions but are poorly defined in the presence of acute respiratory failure (ARF). Nutritional status was prospectively assessed, on hospital admission, in 50 consecutive COPD patients presenting with ARF, 27 of them requiring mechanical ventilation (MV). Malnutrition, defined on a multiparameter nutritional index, was observed in 60 percent (30/50) of all patients, and in 39 percent (13/33) of those whose body weight was equal to or above 90 percent ideal body weight (IBW). Malnutrition was more frequent in those patients who required MV than in those who did not (74 percent vs 43 percent, p < 0.05). Subcutaneous fat stores were decreased (triceps skinfold thickness [TSF] < 80 percent pred) in 68 percent of patients, and markedly depleted (TSF < 60 percent pred) in 52 percent of them. The indices of lean body mass, ie, mid-arm muscle circumference (MAMC) and creatinine height index (CHI) were decreased in, respectively, 42 percent and 71 percent of patients, but MAMC was severely depressed (< 60 percent pred) in only 6 percent of them. A severe decrease of prealbumin (< 100 mg/L), retinol-binding-protein (< 20 mg/L), and albumin (< 20 g/L) serum concentrations was observed in, respectively, 22 percent, 28 percent, and 4 percent of patients. These results suggest that an assessment of nutritional status using a multiparameter approach should be systematically performed in COPD patients with ARF, especially in those requiring MV, as malnutrition may have deleterious effects on weaning off MV.

Bronchial hyperresponsiveness following acute severe asthma.

OBJECTIVE: To evaluate bronchial hyperresponsiveness (BHR) early after recovery from acute severe asthma (ASA). DESIGN: Prospective study including all patients admitted to the intensive care unit (ICU) for ASA over a 12-month period. SETTING: University teaching ICU and pneumonology department. PATIENTS: 41 consecutive patients admitted to the ICU for ASA. Results were compared with those of a control group with stable asthma and no history of ASA or steroid therapy, matched for sex and age. MEASUREMENT AND RESULTS: Of the 41 patients, 40 completed respiratory function tests 10 days after ICU admission, and the minimal dose of acetylcholine inducing a fall in forced expiratory volume in 1 s (FEV1) of 20% or more (PD AC) could be determined safely by a novel method in 26 patients with an FEV1 above 60% predicted. PD AC (micrograms) was found to be significantly lower in ASA than in control patients. Very severe BHR (PD AC < or = 100 micrograms) was found in 18 ASA patients, but not in the control patients; 5 ASA versus 12 control patients had marked BHR (100 > PD AC < or = 500 micrograms); and 3 ASA versus 14 control patients had moderate BHR (> 500 micrograms). A similar level of BHR was found in ASA patients with progressive or acute worsening. No correlation was found between PD AC and admission PaCO2 value, admission peak expiratory flow (PEF) value, delay in improvement of PEF, delay in PD AC determination, or prechallenge FEV1 value. CONCLUSION: BHR measurement is safe soon after an episode of ASA if done with caution. At this time, patients who are free of clinical symptoms and have no significant objective bronchial obstruction appear to have severe bronchial hyper-responsiveness.

[Nocturnal oxymetry in patients with amyotrophic lateral sclerosis: role in predicting survival]. / Oxymétrie nocturne chez les patients atteints de sclérose latérale amyotrophique: analyse de son rôle prédictif sur la survie.

Death is the most important end point along the course of amyotrophic lateral sclerosis (ALS). It is commonly attributed to a respiratory failure in relation with a restrictive respiratory disorder. However, in clinical practice, it is frequent to observe that death has not direct relation with the values of the respiratory function, at least measured with vital capacity. It is also frequent that relatives report sudden death during nocturnal sleep. All these features raised the question of the possible relation between death and nocturnal oxymetry in ALS patients. In a prospective study, we studied 69 ALS patients. We recorded demographic data, clinical parameters as manual muscle testing and functional scales, various parameters of oxymetry measured by pulse oxymetry recorded during night, slow vital capacity and survival time. There is a strong correlation between survival time measured by Kaplan Meier curves and log rank and the mean nocturnal saturation. We determined 93 mmHg as a threshold value. Below this threshold, mean survival time was 7.5+/-1.6 months and above it was equal to 18.5+/-1.5; relative risk was 3.31. These data confirm the importance of nocturnal oxymetry on survival in ALS patients both in clinical practice and in view of therapeutic trials.

[Effect of a single dose of nifedipine on the CO transfer capacity in patients with scleroderma]. / Effet d'une prise unique de nifédipine sur la capacité de transfert du CO de patients sclérodermiques.

The calcium antagonists are currently used in the treatment of Raynaud's syndrome for patients with scleroderma. The effect on the pulmonary vasculature in these patients is little understood. The study reported here is based on 15 patients with scleroderma. In each patient lung volumes, expiratory flow and transfer factor (DLCO) were carried out in a basal state and one hour after the administration of sub lingual nifedipine. Nine patients showed a diminution in the DLCO before taking the product but the mean variation after nifedipine was not significant. Different mechanisms may explain the absence of any effect: irreversible vascular disease or the absence of pulmonary arterial hypertension or hypoxic constriction, the latter conditions were previously associated with the efficacy of nifedipine. Thus it does not seem that nifedipine, in acute tests, has an effect on the pulmonary localisation of scleroderma, at least in the absence of pulmonary arterial hypertension.

[Respiratory function abnormalities and pneumonia in HIV-positive patients. A prospective study of 112 patients]. / Anomalies fonctionnelles respiratoires et pneumopathies des patients VIH+. Etude prospective de 112 patients.

Pulmonary function studies are often limited to the alone measurement of transfer lung factor for CO (TLCO) in screening for pneumonia in patients with Human Immunodeficiency Virus (HIV) infection. We prospectively measured pulmonary function tests (PFT) in 112 HIV seropositive patients. The population consisted of two groups: on one hand, a group free of clinical and radiological abnormalities, on the other hand, one with respiratory symptoms and/or abnormal chest X-Ray, with or without overt pneumonitis. For this latter group, a fiberoptic bronchoscopy with bronchoalveolar lavage was routinely performed in addition to PFT. In case of pneumonitis, PFT showed a restrictive disease and a reduced TLCO. The specificity of this functional pattern was however weaker in the subgroup of drug abusers than in the non-drug addicts. This difference was above all linked to a low TLCO value in the subgroup of drug addicts without pulmonary complications. Multivariate statistical analysis, including discriminant analysis, maintained the same sensibility and improved specificity of PFT in diagnosis of pneumonia, especially if the analysis takes the existence of drug abuse into account. Moreover, initial PFT, performed before any lung disease, improved the sensibility of the screening. The results are discussed in relation to new tests proposed for the screening of pneumonitis in HIV positive patients. At the present time, PFT seems to be useful and enables one to understand natural functional evolution.

[Body composition in chronic obstructive lung patients. Comparison of bioelectric impedance and anthropometry]. / Composition corporelle des patients ayant une bronchopneumopathie chronique obstructive. Comparaison de l'impédancemétrie bioélectrique et de l'anthropométrie.

Malnutrition is associated with poor prognosis in patients with chronic obstructive pulmonary disease (COPD). Body weight is not a reliable evaluation criterium. Body composition which is more useful can be determined routinely using 2 techniques: skinfold thickness anthropometry (Ant) and bioelectrical impedance analysis (BIA). The validity of this last technique has not been demonstrated in patients with COPD. Fat-free mass (FFM) in 58 patients (51 men, 7 women) with stable COPD (FEV1 < 50% of predicted value) was assessed using the 4-skinfold-thickness method (Ant) and BIA (Imp). Statistical analysis included correlation analysis, intraclass correlation coefficient, and the Bland and Altman analysis. Imp-FFM and Ant-FFM correlated well (r = 0.920; p < 0.0001). Intraclass correlation coefficient was high (rI = 0.9065). However, the values were scattered and there was a systematic bias (significant linear regression between the difference in estimates obtained by the 2 methods and the means). As anthropometric measurements are not reliable in the elderly patients, our results suggest that BIA could be a useful tool to determine FFM in patients with COPD. Its validity still has to be tested against a reference method.

[Value of Holter ECG in the diagnosis of sleep apnea syndrome in patients with massive obesity]. / Intérêt du Holter ECG dans le dépistage du syndrome d'apnées du sommeil chez des patients atteints d'obésité massive.

OBJECTIVE: Assess the diagnostic contribution of cyclic nocturnal variations in heart rate in sleep apnea syndrome. PATIENTS AND METHODS: Holter recordings performed in a population of 30 patients with massive obesity defined as a body mass index greater than 40 kg/m2 and sleep apnea syndrome defined by an apnea index greater than 5 apneas per hour were analyzed retrospectively. The control group was composed of 15 patients with massive obesity but without sleep apnea syndrome. High variability in nocturnal heart rate was assessed using a visual criterion defined as repeated episodes of progressive reduction in heart rate followed by a sudden acceleration reaching a difference of 30 bpm between the highest and lowest heart rate and occurring at least 5 times during one consecutive hour of recording. RESULTS: Increased nocturnal variability in heart rate was evidenced in all the patients with sleep apnea syndrome (30/30) but was not observed in any of the control subjects (0/15). CONCLUSION: These results suggest that Holter recordings can be a useful tool for the diagnosis of sleep apnea syndrome.

[Forced expiration. Various current concepts, 50 years after Robert Tiffeneau]. / Expiration forcée. Quelques concepts actuels, 50 ans après Robert Tiffeneau.

One hundred and fifty years after the original description of spirometry by Hutchinson and 50 years after the definition of his famous ratio by Tiffeneau, a certain number of physiological advances have enabled a better understanding of the determinants of the forced expired manoeuvre and to mitigate some of its inconveniences. This review focuses on three of these advances. The first is the influence of an inspiratory manoeuvre which precedes a forced expiration, on the expiratory flow. This influence is probably a consequence of viscoelastic phenomena and impose some strains on standardisation in current practice. The second is the possibility of detecting in a reproducible and simple fashion, without the need for co-operation on the part of the subject, a limitation in expiratory flow by the application of a negative expiratory pressure at the opening of the airways (NEP for negative expiratory pressure). The third is the possibility to verify in a simple fashion the quality of the expiratory performance achieved by the patient and thus to detect an insufficient effort in the force of a falling expiratory flow.

[Mechanisms of diurnal hypercapnia in sleep apnea syndromes associated with morbid obesity]. / Mécanismes de l'hypercapnie diurne dans le syndrome d'apnées du sommeil associé à une obésité massive.

OBJECTIVES: The prevalence and mechanisms of diurnal hypercapnia in subjects with sleep apnea syndrome are not well known, particularly in the morbidly obese. METHODS: We studied a group of 24 subjects with sleep apnea syndrome and morbid obesity defined as a body mass index greater than 40 kg/m2 and free of chronic respiratory disease. RESULTS: Hypercapnia (PaCO2 > 42 mmHg) was found in 50% of the subjects. Age, body mass index, waist/hip ratio, apnea index, ratio of maximum forced expiratory volume in one second (FEV1) to vital capacity and expiratory reserve volume were not significantly different between hypercapnic and normocapnic subjects. Total pulmonary capacity, vital capacity and FEV1 were significantly lower in hypercapnic subjects than in normocapnic subjects. CONCLUSION: These findings suggest that ventilatory restriction plays an important role in the development of diurnal alveolar hypoventilation in subjects with sleep apnea syndrome and morbid obesity.

[Cardio-respiratory complications of sleep apnea in obese patients]. / Les complications cardio-respiratoires des apnées du sommeil chez l'obèse.

The cardio-respiratory complications of sleep apnea syndrome have been prospectively assessed in 60 patients with massive obesity and free of chronic obstructive lung disease while the associated cardiovascular diseases and the alterations of pulmonary function were taken into account. These cardio-respiratory complications were observed only in patients with a number of apneas per hour of sleep greater than 20. The sleep apneas induced nocturnal hypoxemia that is frequently severe and independently correlated to the apnea index, diurnal hypoxemia and hypercapnia that are usually moderate, and presumably left ventricular hypertrophy that is not related to the development of daytime hypertension. However the nocturnal apneas were not associated with the development of an impairment of right or left ventricular function, or with the occurrence of cardiac arrhythmias or conduction disturbances. The absence of severe cardiac complications in this study may be related to the fact that the patients were relatively young and that the sleep apnea syndrome was diagnosed at an early stage of evolution. The findings of this study could help to define a more rationale approach in several therapeutic indications of sleep apnea syndrome.

[The forced expiration test from the pulmonary capacity usable in effort to the transit time]. / L'épreuve d'expiration forcée de la capacité pulmonaire utilisable à l'effort (CPUE) aux temps de transit.

Since Tiffeneau's days the forced expiration test used qualitatively and quantitatively has undergone numerous changes. FEV1 remains useful to diagnose bronchial obstruction, but other, more sensitive parameters have been introduced for epidemiological purposes. Following a review of the data provided by flow-volume curves, the authors discuss the pros and cons of its statistical analysis by the moment method, as expressed in the literature.

[Functional follow-up of pulmonary localization of scleroderma]. / Le suivi fonctionnel des localisations pulmonaires de la sclérodermie.

Pulmonary lesions of scleroderma are frequent, but little is known of their course, especially where lung function is concerned. We report the results of a longitudinal study performed in 32 patients with generalized scleroderma (ARA criteria) explored on at least 2 occasions with an interval of at least 24 months between the two examinations. Functional alterations seemed to be more pronounced in patients with severe Raynaud's syndrome, but in view of major individual variations no pathognomonic functional profile could be described.

[Respiratory complications of massive obesity]. / Les complications respiratoires des obésités massives.

Massive obesity may lead to serious, and sometimes fatal, respiratory complications. Alterations of ventilatory mechanics and function are well known; they include a decrease in respiratory compliance, an increase in ventilatory work and a restrictive pulmonary disease. Hypoxemia is rather due to an impaired ventilation/perfusion ratio than to alveolar hypoventilation. Sleep Apnea Syndrome (SAS) is very frequent in excessively obese patients. These subjects with daytime hypersomnolence should be systematically screened for SAS before the occurrence of life-threatening complications. Continuous positive airway pressure ventilation through a nasal mask is the treatment of choice of SAS especially since the results of body weight reduction and ENT surgery are inconstant and variable in these patients.