[Aerosol therapy: help in selecting an adapted inhaler for COPD patients]. / Aérosolthérapie : aide à la sélection d'un inhalateur adapté chez les patients souffrant de BPCO.

Inhaled medication is the cornerstone of medical treatment of COPD. The efficacy of these treatments depends on the optimal use of inhalation devices. This requires not only an impeccable inhalation technique, but above all the selection of an inhaler adapted to the patient. In this article, we describe the specificities of the different inhalation devices and some of the patient's characteristics to be taken into account when selecting an inhaler, in particular the presence of cognitive disorders, impaired dexterity or insufficient inspiratory force.

La thérapie par aérosols est la pierre angulaire du traitement médicamenteux de la BPCO. L'efficacité de ces traitements repose sur une utilisation optimale du dispositif d'inhalation. Cela nécessite non seulement une technique d'inhalation irréprochable mais surtout la sélection d'un inhalateur adapté au patient. Dans cet article, nous décrivons les spécificités des différents dispositifs d'inhalation et certaines caractéristiques du patient à prendre en compte lors de la sélection d'un inhalateur, notamment la présence de troubles cognitifs, d'atteinte de la dextérité ou de force inspiratoire insuffisante.

[Pulmonary Aspergillosis in immunocompetent patient]. / Aspergillose pulmonaire chez le patient immunocompétent.

Aspergillus is a group of molds which is found everywhere worldwide, exposition of human being is common. Most of immunocompetent people do not develop disease caused by Aspergillus. However, diseases in different forms may occur in certain conditions in immunocompetent patient. These diseases include hypersensitivity reactions, like allergic broncho-pulmonary aspergillosis, or infectious process like chronic pulmonary aspergillosis or invasive pulmonary aspergillosis. This article reviewed the clinical features of these diseases and the current available diagnostic techniques.

Aspergillus englobe un groupe de champignons ubiquitaires auquels l'être humain est quotidiennement exposé. Il est rarement pathogène chez le patient immunocompétent, cependant il peut être responsable de différentes formes de maladies dans certaines conditions. Ces pathologies comprennent des réactions d'hypersensibilité, comme l'aspergillose bronchopulmonaire allergique, ou des processus infectieux comme l'aspergillose pulmonaire chronique et l'aspergillose pulmonaire invasive aiguë. Cet article aborde les situations cliniques lors desquelles ces pathologies doivent être suspectées, tout en décrivant les caractéristiques de ces dernières et les moyens diagnostiques à disposition.

An in-hospital intervention to reduce the proportion of misused inhalers at hospital discharge among patients with COPD: a non-randomised intervention study.

AIMS OF THE STUDY: Misuse of inhalers during chronic obstructive pulmonary disease (COPD) treatment is common and may result from errors in inhalation technique or insufficient peak inspiratory flow (PIF). We aimed to evaluate the impact of an in-hospital intervention to reduce inhaler misuse at hospital discharge among patients with COPD. METHODS: We conducted a monocentric, non-randomised intervention study to compare the proportion of misused inhalers at hospital discharge by patients with COPD between a group with standard care and a group receiving an in-hospital intervention. The control group successively included all patients hospitalised between March and June 2022, and the intervention group included patients hospitalised between August and December 2022. The intervention consisted of (a) an evaluation of inhalation technique and PIF at admission, (b) the provision of a written guide to assist in the selection of an inhaler, and (c) therapeutic education. The primary outcome was the proportion of misused inhalers, defined as an inhaler used with a critical error and/or insufficient PIF, at hospital discharge. The primary outcome was assessed by observing inhalation technique and measuring PIF using the In-Check DIAL G16® . RESULTS: The study included 93 patients: 46 in the control group and 47 in the intervention group. Mean age was 70.5 years (SD 10.9 years), 56 patients (60.2%) were men, and 57 patients (62%) were hospitalised for a COPD exacerbation. Patients used an average of 1.9 inhalers at hospital discharge; 98 inhalers were assessed in the control group and 81 in the intervention group. The proportion of misused inhalers at discharge was 61.2% in the control group and 21.0% in the intervention group (absolute risk reduction 40.2% [95% CI 25.5-55.0]; p <0.01). In the intervention group, the proportion of inhalers used with at least one critical error was reduced by 38.6% (95% CI 24.3-52.3%) and that of inhalers used with insufficient PIF by 13.9% (95% CI 4.2-23.6%). CONCLUSIONS: An in-hospital intervention was associated with a reduction in the proportion of misused inhalers at hospital discharge. This intervention should be considered for hospitalised patients with COPD. The trial was registered with ClinicalTrials.gov (NCT05207631).

Microbial communities in the respiratory tract of patients with interstitial lung disease.

BACKGROUND: Molecular methods based on phylogenetic differences in the 16S rRNA gene are able to characterise the microbiota of the respiratory tract in health and disease. OBJECTIVES: Our goals were (1) to characterise bacterial communities in lower and upper airways of patients with interstitial lung disease (ILD) and (2) to compare the results with the microbiota of patients with Pneumocystis pneumonia (PCP) and normal controls. METHODS: We examined the upper and lower respiratory tract of 18 patients with ILD of whom 5, 6, and 7 had idiopathic interstitial pneumonia (IIP), non-IIP and sarcoidosis, respectively. In addition, six immune-compromised patients with PCP and nine healthy subjects were included as controls. Exclusion criteria were recent bacterial/viral respiratory tract infection, HIV-positivity and subjects receiving antibiotic therapy. Bronchoalveolar lavage fluid and oropharyngeal swabs were simultaneously collected, and microbiota was characterised by ultra-deep 16S rRNA gene sequencing. RESULTS: The microbiota in lower airways of the majority of patients (30; 90%) primarily consisted of Prevotellaceae, Streptococcaceae and Acidaminococcaceae. α and ß diversity measurements revealed no significant differences in airway microbiota composition between the five different groups of patients. Comparison of bacterial populations in upper and lower respiratory tract showed significant topographical discontinuities for 7 (23%) individuals. CONCLUSIONS: IIP, non-IIP and sarcoidosis are not associated with disordered airway microbiota and a pathogenic role of commensals in the disease process is therefore unlikely. Nevertheless, molecular analysis of the topographical microbiota continuity along the respiratory tract may provide additional information to assist management of individual patients.

Combination of endobronchial bronchoscopic debulking and bronchoplastic segmentectomy of an obstructive neuroendocrine tumour: probably the least invasive approach.

We report the case of a female patient with an obstructing well-differentiated neuroendocrine tumour in the apical segment of the completely atelectatic right lower lobe. Bronchoscopic debulking of the tumour lead to re-ventilation of the remaining lobe, allowing to perform a lung-sparing bronchoplastic resection of the affected segment by uniportal video-assisted thoracic surgery.

Off-Patent Transgenic Events: Challenges and Opportunities for New Actors and Markets in Agriculture.

More than 20 years ago, the first genetically modified (GM) plants entered the seed market. The patents covering the first GM plants have begun to expire and these can now be considered as Off-Patent Events. Here we describe the challenges that will be faced by a Secondary Party by further use and development of these Off-Patent Events. Indeed, the conditions for Off-Patent Events are not available yet to form the basis for a new viable industry similar to the generic manufacturers of agrochemicals or pharmaceutical products, primarily because of (i) unharmonized global regulatory requirements for GM organisms, (ii) inaccessibility of regulatory submissions and data, and (iii) potential difficulties to obtain seeds and genetic material of the unique genotypes used to generate regulatory data. We propose certain adaptations by comparing what has been done in the agrochemical and pharmaceutical markets to facilitate the development of generics. Finally, we present opportunities that still exist for further development of Off-Patent Events in collaboration with Proprietary Regulatory Property Holders in emerging markets, provided (i) various countries approve these events without additional regulatory burdens (i.e., acceptance of the concept of data transportability), and (ii) local breeders agree to meet product stewardship requirements.

True prevalence of COPD and its association with peripheral arterial disease in the internal medicine ward of a tertiary care hospital.

OBJECTIVES: The primary objective was to determine the prevalence of confirmed chronic obstructive pulmonary disease (COPD) in patients aged 45 years or more who were admitted to the internal medicine ward of our tertiary care hospital (HFR Fribourg, Switzerland), and were either "tagged" as having COPD or at risk for COPD. The secondary objective was to determine the prevalence of the association of COPD with peripheral artery disease (PAD) in this population. METHODOLOGY: We evaluated all consecutive patients aged 45 years, admitted to our internal medicine ward between November 2013 and March 2014. All patients with a diagnosis of COPD, chronic bronchitis and/or lung emphysema in their electronic medical record ("tagged" as COPD) were evaluated for inclusion, as well as patients with at least one classic symptom and one classic risk factor for COPD identified by them on a check-list (patients at risk for COPD). Spirometry, and measurement of ankle-brachial index (ABI) and toe-brachial index when necessary, were performed in each patient once they were clinically stable. RESULTS: One hundred and seventy-two of 888 consecutive patients were included. COPD was found in 81 patients. Amongst the 75 patients tagged as COPD, 65 (87%) were actually suffering from COPD and 10 (13%) carried a false diagnosis. COPD was diagnosed in 16 (16%) of the 97 at-risk patients. PAD was identified in 35 (43%) of patients suffering from confirmed COPD and in 22 (24%) of patients without COPD. There was a significant association between COPD and PAD (p <0.01). CONCLUSION: COPD was identified in 9% of the 888 patients evaluated. The majority of patients tagged as COPD were accurately diagnosed and a substantial proportion of at-risk patients were underdiagnosed. A significant association between COPD and PAD was found. In smokers, spirometry showing COPD is a useful test to detect patients at higher cardiovascular risk. Thus, we suggest that screening for PAD using an ABI should be proposed to every smoker with confirmed COPD.

Pulmonary arteriovenous malformation treated with embolotherapy: systemic collateral supply at multidetector CT angiography after 2-20-year follow-up.

PURPOSE: To retrospectively evaluate frequency of systemic arterial collateral supply to treated pulmonary arteriovenous malformations (PAVMs) in long-term follow-up with multi-detector row helical computed tomography (CT). MATERIALS AND METHODS: Institutional review board approval was obtained, with waiver of informed consent. Thirty-two patients (19 male, 13 female; mean age, 43 years) underwent follow-up multi-detector row helical CT angiography of the chest (collimation, 16x0.75 mm) 2 or more years after embolotherapy of PAVMs. The study group had a history of successful embolotherapy of 53 PAVMs and a mean of 9 years of follow-up (range, 2-20 years). A search for abnormal systemic arteries was based on analysis of thin-collimated contiguous transverse CT scans and two- and three-dimensional images including maximum intensity projections and volume-rendered images. Statistical comparison was performed with the Fisher exact test (categoric variables) and Wilcoxon rank sum test (continuous variables). RESULTS: At CT, 13 patients (group 1) had abnormally enlarged systemic arteries and 19 patients (group 2) had no abnormal arteries. In group 1, 32 abnormally enlarged arteries were seen-five bronchial and 27 nonbronchial arteries (14 inferior phrenic, six musculophrenic, five internal mammary, two intercostal). The degree of enlargement was moderate for 26 arteries and marked for six. There were no significant differences between groups for (a) clinical characteristics of patients, including history of surgery before or after embolotherapy (P=.7); (b) anatomic structures of treated PAVMs; and (c) embolization procedures and their effectiveness. The number of patients with features suggestive of lung infarction in the days or months after embolotherapy was significantly higher in group 1 (P=.04). On CT angiograms, the number of patients with features suggestive of sequelae of lung infarction was significantly higher in group 1 (P=.02). There were no symptomatic differences attributable to systemic collateral supply between groups; in particular, there was no hemoptysis in group 1. CONCLUSION: Abnormally enlarged systemic arteries were present in 13 of 32 patients, in whom there was a significantly higher frequency of clinical and/or radiographic features suggestive of lung infarction after embolotherapy.

Pulmonary arteriovenous malformations treated with embolotherapy: helical CT evaluation of long-term effectiveness after 2-21-year follow-up.

PURPOSE: To retrospectively evaluate the long-term results of transcatheter embolotherapy of pulmonary arteriovenous malformations (PAVMs) with helical computed tomography (CT). MATERIALS AND METHODS: Neither institutional review board approval nor patient consent was required for this retrospective study. Thirty-eight patients underwent follow-up helical chest CT 2-21 years after successful embolotherapy of 64 PAVMs. Four outcome categories were analyzed on the basis of the PAVM morphologic changes and perfusion findings seen on CT angiograms: successful treatment (marked reduction or disappearance of the aneurysmal sac), partially successful treatment (reduced size of the aneurysmal sac and pulmonary vessels, with feeding artery[ies] less than 3 mm in diameter, deemed too small to be occluded), partially failed treatment (reduced size of the aneurysmal sac and pulmonary vessels, with feeding artery[ies] larger than 3 mm and additional embolotherapy required), and failed treatment (similar size of or interim growth in the aneurysmal sac, with unchanged or enlarged pulmonary vessels). chi(2) or Fisher exact tests were used to analyze categorical variables; Mann-Whitney rank tests were used to analyze continuous variables. P < .05 was considered to indicate statistical significance. RESULTS: Long-term follow-up of the 64 occluded PAVMs revealed successful treatment of 30 (47%), partially successful treatment of 18 (28%), partially failed treatment of two (3%), and failed treatment of 14 (22%) PAVMs. The overall treatment success rate was 75% (47% plus 28%). Delayed recanalization requiring repeat embolotherapy occurred in 12 (19%) cases. No relationship between failed treatment and number of coils deposited in the feeding arteries was found. The frequency of gastrointestinal tract and/or hepatic arteriovenous fistulas at initial diagnosis (P = .01) and/or the interim development of pulmonary hypertension with or without heart failure (P = .01) was significantly higher in patients with at least one PAVM for which embolotherapy failed (n = 9) than in patients who underwent successful or partially successful embolotherapy of all PAVMs (n = 29). CONCLUSION: Long-term CT follow-up of initially successfully treated PAVMs revealed successful embolotherapy of 75% and partially or completely failed embolotherapy of 25% of PAVMs.

Systemic collateral supply in patients with chronic thromboembolic and primary pulmonary hypertension: assessment with multi-detector row helical CT angiography.

PURPOSE: To compare retrospectively the frequency of systemic collateral supply in patients who have chronic thromboembolic pulmonary hypertension with the frequency of systemic collateral supply in patients who have primary pulmonary hypertension by using multi-detector row helical computed tomographic (CT) angiography. MATERIALS AND METHODS: For this review, neither institutional board approval nor informed consent was required. Thirty-six consecutive patients, including 22 patients (four men, 18 women; mean age, 46.0 years) with chronic thromboembolic pulmonary hypertension (group 1) and 14 patients (five men, nine women; mean age, 63.0 years) with primary pulmonary hypertension (group 2), underwent multisection spiral CT angiography of the pulmonary and systemic circulations with a four- (n = 17) or 16- (n = 19) detector row scanner. CT angiograms were assessed for the presence of abnormal bronchial and/or nonbronchial systemic arteries, CT features of pulmonary hypertension, and right ventricular dysfunction. Vascular and parenchymal signs of chronic pulmonary embolism were specifically analyzed on CT angiograms of group 1 patients. Comparative analyses were performed by using the chi(2) or the Fisher exact test for categoric data. An unpaired bilateral Wilcoxon rank sum test was used for continuous data. A chi(2) goodness-of-fit test was used to compare observed proportions with equal proportions. RESULTS: The degree of pulmonary hypertension was comparable in groups 1 and 2. Abnormally enlarged systemic arteries were identified in 16 (73%) of 22 patients from group 1 and in two (14%) of 14 patients from group 2 (P = .002). The systemic collateral supply in group 1 comprised enlargement of both bronchial and nonbronchial systemic arteries in nine (56%) of the 16 patients; the remaining seven patients had an exclusive enlargement of bronchial systemic arteries (n = 6, 38%) or nonbronchial (n = 1, 6%) systemic arteries. A total of 31 enlarged nonbronchial systemic arteries were depicted, including 13 inferior phrenic arteries, 10 intercostal arteries, seven internal mammary arteries, and one lateral thoracic artery. The mean +/- standard deviation of abnormal nonbronchial systemic arteries per patient was 1.4 +/- 1.9. No relationship was found between the mean number of abnormally enlarged nonbronchial systemic arteries and the CT angiographic features of chronic pulmonary embolism. CONCLUSION: These results demonstrate the higher frequency of abnormally enlarged bronchial and nonbronchial systemic arteries in patients who have chronic thromboembolic pulmonary hypertension compared with patients who have primary pulmonary hypertension; this finding could help distinguish these two entities on CT angiograms.

High-resolution computed tomography techniques in diffuse parenchymal lung disease and their application to clinical practice.

The remarkable ability of high-resolution computed tomography (HRCT) to provide sufficient detail of both normal and abnormal pulmonary anatomy requires high-quality examinations with considerable attention paid to the technique. Despite the use of optimal scanning protocols, there are well-known limitations of sequential scanning that explain the recent interest in the use of multislice spiral CT for diagnosing lung diseases in routine clinical practice. A basic knowledge of the most recent developments in spiral CT technology appears a necessary prerequisite for those clinicians, pulmonologists, internists, or thoracic surgeons who are involved in the management of diffuse infiltrative lung diseases. This chapter reviews the various aspects of multislice spiral CT technology applied to routine clinical evaluation of diffuse infiltrative lung diseases.

Bronchial and nonbronchial systemic arteries at multi-detector row CT angiography: comparison with conventional angiography.

PURPOSE: To retrospectively evaluate bronchial and nonbronchial systemic arteries at multi-detector row helical computed tomography (CT) compared with conventional angiography in patients undergoing endovascular treatment of hemoptysis. MATERIALS AND METHODS: Neither institutional board approval nor informed consent was required. Forty-eight consecutive patients (39 men, nine women; mean age, 55.7 years; range, 20-82 years) with hemoptysis of bronchial and nonbronchial systemic artery origin underwent multi-detector row helical CT angiography of the thorax with use of a four-detector row (n = 31) or 16-detector row (n = 17) scanner prior to embolization. Findings on CT angiograms, including CT scans, maximum intensity projections, and three-dimensional volume-rendered images, were used to evaluate the depiction of bronchial and nonbronchial systemic arteries. Retrospective analysis of the ostium and the course of bronchial and/or nonbronchial systemic arteries on CT angiograms enabled evaluation of the accuracy of this technique in identification of the relevant vasculature. RESULTS: Among the 46 patients initially treated with bronchial artery embolization, 58 bronchial arteries were identified at CT and/or angiography. In 50 (86%) cases, concordant findings were observed with both modalities. In five (9%) cases, CT could not be used to identify the ostia of bronchial arteries. In three (5%) cases, CT depicted bronchial arteries that could not be selectively catheterized. Three-dimensional images were found to be superior to transverse CT scans in depicting the ectopic origin of the bronchial arteries, which enabled the interventional radiologists to perform successful embolization after direct catherization of the ectopic vessel in every case. In five (11%) patients, the nonbronchial systemic origin of bronchial bleeding was identified on CT angiograms. CONCLUSION: Multi-detector row helical CT angiography provides more precise depiction of bronchial and nonbronchial systemic arteries than does conventional angiography.