Dyspnoea in acutely ill mechanically ventilated adult patients: an ERS/ESICM statement.

This statement outlines a review of the literature and current practice concerning the prevalence, clinical significance, diagnosis and management of dyspnoea in critically ill, mechanically ventilated adult patients. It covers the definition, pathophysiology, epidemiology, short- and middle-term impact, detection and quantification, and prevention and treatment of dyspnoea. It represents a collaboration of the European Respiratory Society and the European Society of Intensive Care Medicine. Dyspnoea ranks among the most distressing experiences that human beings can endure. Approximately 40% of patients undergoing invasive mechanical ventilation in the intensive care unit (ICU) report dyspnoea, with an average intensity of 45 mm on a visual analogue scale from 0 to 100 mm. Although it shares many similarities with pain, dyspnoea can be far worse than pain in that it summons a primal fear response. As such, it merits universal and specific consideration. Dyspnoea must be identified, prevented and relieved in every patient. In the ICU, mechanically ventilated patients are at high risk of experiencing breathing difficulties because of their physiological status and, in some instances, because of mechanical ventilation itself. At the same time, mechanically ventilated patients have barriers to signalling their distress. Addressing this major clinical challenge mandates teaching and training, and involves ICU caregivers and patients. This is even more important because, as opposed to pain which has become a universal healthcare concern, very little attention has been paid to the identification and management of respiratory suffering in mechanically ventilated ICU patients.

Brain functional connectivity alterations associated with neuropsychological performance 6-9 months following SARS-CoV-2 infection.

Neuropsychological deficits and brain damage following SARS-CoV-2 infection are not well understood. Then, 116 patients, with either severe, moderate, or mild disease in the acute phase underwent neuropsychological and olfactory tests, as well as completed psychiatric and respiratory questionnaires at 223 ± 42 days postinfection. Additionally, a subgroup of 50 patients underwent functional magnetic resonance imaging. Patients in the severe group displayed poorer verbal episodic memory performances, and moderate patients had reduced mental flexibility. Neuroimaging revealed patterns of hypofunctional and hyperfunctional connectivities in severe patients, while only hyperconnectivity patterns were observed for moderate. The default mode, somatosensory, dorsal attention, subcortical, and cerebellar networks were implicated. Partial least squares correlations analysis confirmed specific association between memory, executive functions performances and brain functional connectivity. The severity of the infection in the acute phase is a predictor of neuropsychological performance 6-9 months following SARS-CoV-2 infection. SARS-CoV-2 infection causes long-term memory and executive dysfunctions, related to large-scale functional brain connectivity alterations.

Obstructive sleep apnea: a major risk factor for COVID-19 encephalopathy?

BACKGROUND: This study evaluates the impact of high risk of obstructive sleep apnea (OSA) on coronavirus disease 2019 (COVID-19) acute encephalopathy (AE). METHODS: Between 3/1/2020 and 11/1/2021, 97 consecutive patients were evaluated at the Geneva University Hospitals with a neurological diagnosis of COVID-19 AE. They were divided in two groups depending on the presence or absence of high risk for OSA based on the modified NOSAS score (mNOSAS, respectively ≥ 8 and < 8). We compared patients' characteristics (clinical, biological, brain MRI, EEG, pulmonary CT). The severity of COVID-19 AE relied on the RASS and CAM scores. RESULTS: Most COVID-19 AE patients presented with a high mNOSAS, suggesting high risk of OSA (> 80%). Patients with a high mNOSAS had a more severe form of COVID-19 AE (84.8% versus 27.8%), longer mean duration of COVID-19 AE (27.9 versus 16.9 days), higher mRS at discharge (≥ 3 in 58.2% versus 16.7%), and increased prevalence of brain vessels enhancement (98.1% versus 20.0%). High risk of OSA was associated with a 14 fold increased risk of developing a severe COVID-19 AE (OR = 14.52). DISCUSSION: These observations suggest an association between high risk of OSA and COVID-19 AE severity. High risk of OSA could be a predisposing factor leading to severe COVID-19 AE and consecutive long-term sequalae.

Bronchiectasis: an update for the general practitioner.

Bronchiectasis is a heterogeneous lung condition characterized by irreversible bronchial dilatation, chronic inflammation and frequent exacerbations. Diagnosis is based on the presence of a productive cough most of the days, a history of exacerbations and the presence of bronchial dilatation on chest CT scan. Etiologic and microbiologic workup should be performed to determine the underlying cause. A personalized treatment approach is mandatory and includes patient education, improvement of mucociliary clearance, prevention and treatment of exacerbations, in order to preserve lung function and improve quality of life.

Les bronchiectasies sont un ensemble hétérogène de pathologies pulmonaires caractérisées par une dilatation irréversible des bronches, une inflammation chronique et des exacerbations fréquentes. Le diagnostic repose sur la présence d'une toux productive, des antécédents d'exacerbations, ainsi qu'un scanner thoracique avec des dilatations bronchiques. Le bilan étiologique et microbiologique doit être réalisé pour déterminer la cause sous-jacente. La prise en charge nécessite une approche personnalisée incluant l'éducation du patient, l'amélioration de la clairance mucociliaire et la prévention et le traitement des infections bronchiques pour préserver la fonction pulmonaire et améliorer la qualité de vie.

Long-Term Noninvasive Ventilation in Chronic Obstructive Pulmonary Disease: Association between Clinical Phenotypes and Survival.

BACKGROUND: Long-term noninvasive ventilation (LTNIV) is widely used in patients with chronic hypercapnic respiratory failure (CHRF) related to COPD. Prognosis of these patients is however poor and heterogenous. RESEARCH QUESTION: In COPD patients under LTNIV for CHRF, is it possible to identify specific phenotypes which are predictive of probability of pursuing NIV and survival? STUDY DESIGN AND METHODS: A latent class analysis was performed in a COPD population under LTNIV included in a comprehensive database of patients in the Geneva Lake area, to determine clinically relevant phenotypes. The observation period of this subgroup of COPD was extended to allow assessment of survival and/or pursuit of NIV for at least 2 years after inclusion. A logistic regression was conducted to generate an equation accurately attributing an individual patient to a defined phenotype. The identified phenotypes were compared on a series of relevant variables, as well as for probability of pursuing NIV or survival. A competitive risk analysis allowed to distinguish death from other causes of cessation of NIV. RESULTS: Two phenotypes were identified: a "respiratory COPD" profile with very severe airway obstruction, a low or normal body mass index, and a low prevalence of comorbidities and a "systemic COPD" profile of obese COPDs with moderate airway obstruction and a high rate of cardiovascular and metabolic comorbidities. The logistic regression correctly classified 95.7% of patients studied. Probability of pursuing NIV and survival were significantly related to these phenotypes, with a poorer prognosis for "respiratory COPD." Probability of death 5 years after implementing NIV was 22.3% (95% CI: 15.4-32.2) for "systemic COPD" versus 47.2% (37.4-59.6) for "respiratory COPD" (p = 0.001). CONCLUSION: The two distinct phenotypes of COPD under LTNIV for CHRF identified appear to be strongly related to prognosis and require further validation in other cohort studies.

[Pulmonology 2021: year in review]. / Pneumologie.

Among the new therapeutic developments in pulmonology during 2021, we have identified three topics of interest. A new biotherapy is now available for the management of severe uncontrolled non-Th2 asthma. In the field of pulmonary arterial hypertension, upfront triple therapy at the time of diagnosis is associated with a survival benefit in high-risk patients. Riociguat is a therapeutic option for patients that remain at intermediate risk despite treatment with iPDE5. Sotatercept, a promising new class of drug for treatment of group 1 PAH will soon be available. Finally, the use of transbronchial cryobiopsies as a valid alternative to surgical lung biopsy for the diagnosis of diffuse interstitial lung diseases will also be discussed in this review.

Parmi les nouveautés thérapeutiques en pneumologie au cours de l'année 2021, nous aborderons trois sujets. Une nouvelle biothérapie est désormais disponible pour la prise en charge de l'asthme sévère non contrôlé non T-Helper 2. Concernant l'hypertension artérielle pulmonaire (HTAP), une triple thérapie d'emblée au moment du diagnostic est associée à un bénéfice sur la survie chez les patients à haut risque. Le riociguat est une option thérapeutique lors d'HTAP restant à risque intermédiaire malgré un traitement par inhibiteur de la phosphodiestérase de type 5, et le sotatercept vise une nouvelle cible thérapeutique prometteuse pour l'HTAP du groupe 1. Enfin, la place des cryobiopsies transbronchiques comme alternative valable à la biopsie chirurgicale pour le diagnostic des pneumopathies interstitielles diffuses selon des recommandations récentes se précise.

Cardiac Output Determination in Precapillary Pulmonary Hypertension: A Systematic Review.

BACKGROUND: Cardiac output determination is essential in precapillary pulmonary hypertension. While direct Fick is the gold standard, thermodilution is commonly used as the reference method. Moving to noninvasive methods would be highly beneficial for patients, avoiding repetitive invasive assessments. This systematic review followed 3 objectives: (1) assessing the validity of indirect Fick and thermodilution in precapillary pulmonary hypertension, (2) assessing the interchangeability of noninvasive cardiac output measurement methods against reference methods in precapillary pulmonary hypertension, and (3) detecting methodological heterogeneity in the included studies. METHODS: We systematically reviewed the literature using medical databases and following PRISMA guidelines. We included articles comparing an invasive or noninvasive cardiac output measurement method with thermodilution or direct Fick in precapillary pulmonary hypertension patients. Cutoffs of limits of agreement and percentage error derived from the Bland and Altman graph were used to accept interchangeability. To study methodological heterogeneity, we extracted 9 quality criteria from all studies. RESULTS: Eleven studies were included. None reached the suggested interchangeability criteria. The median number of the 9 assessed quality criteria was 2 with interquartile range (0-4). CONCLUSIONS: Further studies evaluating the reliability of thermodilution and the consequences of its use in precapillary pulmonary hypertension patients are necessary. No evidence supports the use of indirect Fick in precapillary pulmonary hypertension. The studied noninvasive methods could not be considered interchangeable with invasive methods. A robust methodology should be used to draw sensible conclusions.

Impact of Confinement in Patients under Long-Term Noninvasive Ventilation during the First Wave of the SARS-CoV-2 Pandemic: A Remarkable Resilience.

BACKGROUND: During the first wave of the SARS-CoV-2 pandemic in Switzerland, confinement was imposed to limit transmission and protect vulnerable persons. These measures may have had a negative impact on perceived quality of care and symptoms in patients with chronic disorders. OBJECTIVES: To determine whether patients under long-term home noninvasive ventilation (LTHNIV) for chronic respiratory failure (CRF) were negatively affected by the 56-day confinement (March-April 2020). METHODS: A questionnaire-based survey exploring mood disturbances (HAD), symptom scores related to NIV (S3-NIV), and perception of health-care providers during confinement was sent to all patients under LTHNIV followed up by our center. Symptom scores and data obtained by ventilator software were compared between confinement and the 56 days prior to confinement. RESULTS: Of a total of 100 eligible patients, 66 were included (median age: 66 years [IQR: 53-74]): 35 (53%) with restrictive lung disorders, 20 (30%) with OHS or SRBD, and 11 (17%) with COPD or overlap syndrome. Prevalence of anxiety (n = 7; 11%) and depressive (n = 2; 3%) disorders was remarkably low. Symptom scores were slightly higher during confinement although this difference was not clinically relevant. Technical data regarding ventilation, including compliance, did not change. Patients complained of isolation and lack of social contact. They felt supported by their relatives and caregivers but complained of the lack of regular contact and information by health-care professionals. CONCLUSIONS: Patients under LTHNIV for CRF showed a remarkable resilience during the SARS-CoV-2 confinement period. Comments provided may be helpful for managing similar future health-care crises.

Role of Intermediate Care Unit Admission and Noninvasive Respiratory Support during the COVID-19 Pandemic: A Retrospective Cohort Study.

BACKGROUND: The COVID-19 pandemic has led to shortage of intensive care unit (ICU) capacity. We developed a triage strategy including noninvasive respiratory support and admission to the intermediate care unit (IMCU). ICU admission was restricted to patients requiring invasive ventilation. OBJECTIVES: The aim of this study is to describe the characteristics and outcomes of patients admitted to the IMCU. METHOD: Retrospective cohort including consecutive patients admitted between March 28 and April 27, 2020. The primary outcome was the proportion of patients with severe hypoxemic respiratory failure avoiding ICU admission. Secondary outcomes included the rate of emergency intubation, 28-day mortality, and predictors of ICU admission. RESULTS: One hundred fifty-seven patients with COVID-19-associated pneumonia were admitted to the IMCU. Among the 85 patients admitted for worsening respiratory failure, 52/85 (61%) avoided ICU admission. In multivariate analysis, PaO2/FiO2 (OR 0.98; 95% CI: 0.96-0.99) and BMI (OR 0.88; 95% CI: 0.78-0.98) were significantly associated with ICU admission. No death or emergency intubation occurred in the IMCU. CONCLUSIONS: IMCU admission including standardized triage criteria, self-proning, and noninvasive respiratory support prevents ICU admission for a large proportion of patients with COVID-19 hypoxemic respiratory failure. In the context of the COVID-19 pandemic, IMCUs may play an important role in preserving ICU capacity by avoiding ICU admission for patients with worsening respiratory failure and allowing early discharge of ICU patients.

[Pathophysiology of COVID-19 related happy hypoxemia]. / Physiopathologie de l'hypoxémie silencieuse dans le Covid-19.

A significative proportion of patients with pulmonary-related COVID-19 initially present with « silent ¼ or « happy ¼ hypoxemia, a term denoting an absence of dyspnea or other respiratory distress symptoms in face of profound hypoxemia. COVID-19 is a multisystemic disease characterized by the diffusion of SARS-COV-2 through the blood and a widespread secondary immune response. Most of the organs are involved, including the brain and this translates into the development of acute encephalopathy and other complications. Silent hypoxemia and the consequent "vanishing dyspnea" represent a loss of warning signal and may be associated with a rapid clinical worsening and a fatal outcome. In this article, we will describe the physiological basis of ventilation and we will elucidate the different pathophysiological mechanisms underlying the phenomenon of silent hypoxemia in COVID-19.

Une proportion significative de patients atteints de pneumopathie Covid-19 présente initialement une « hypoxémie silencieuse ¼, désignant une absence de dyspnée et de signe de détresse respiratoire en présence d'une hypoxémie profonde. Le Covid-19 est multisystémique, le virus et la réaction immunitaire secondaire à l'infection se répandant par voie hématogène. Le cerveau n'est pas épargné par le Covid-19 avec le développement d'encéphalopathie ou d'autres complications. L'hypoxémie silencieuse représente une perte d'un signal d'alarme pour l'organisme, précédant parfois une rapide aggravation clinique avec issue fatale. Dans cet article, nous reprenons les bases physiologiques du contrôle de la ventilation et tentons d'élucider les différents mécanismes physiopathologiques qui sous-tendent le phénomène d'hypoxémie silencieuse.

[Novel therapies in respiratory management]. / Pneumologie.

In this review of the recent medical literature, we have identified 4 topics of interest for the readers of Revue Médicale Suisse. Use of antifibrotic drugs in interstitial lung diseases will soon be extended to a phenotype labeled « progressive fibrosing interstitial lung disease ¼ (PF-ILD). While awaiting for evidence-based treatment, consensual recommendations for a treatment algorithm in pulmonary sarcoidosis has been published. New guidance for non-invasive ventilation in COPD and obesity-hypoventilation syndrome are available in Switzerland and are in line with international recommendations. New treatments targeting CFTR protein activity have become available and could become a therapeutic option for up to 85% of cystic fibrosis patients in Switzerland.

Dans cette revue de la littérature médicale récente, nous avons identifié quatre sujets d'intérêts pour les lecteurs de la Revue Médicale Suisse. L'utilisation de médicaments antifibrotiques dans les maladies pulmonaires interstitielles sera bientôt étendue à un phénotype étiqueté « maladie pulmonaire interstitielle fibrosante progressive ¼. Des recommandations consensuelles pour un algorithme de traitement dans la sarcoïdose pulmonaire ont été publiées. De nouvelles directives pour la ventilation non invasive dans la BPCO et le syndrome d'obésité-hypoventilation sont disponibles en Suisse et sont conformes aux recommandations internationales. De nouveaux traitements ciblant l'activité protéique CFTR (Cystic Fibrosic Transmembrane Conductance Regulator) sont disponibles et pourraient devenir une option thérapeutique pour 85 % des patients atteints de mucoviscidose en Suisse.

Experimental dyspnoea interferes with locomotion and cognition: a randomised trial.

BACKGROUND: Chronic respiratory diseases are associated with cognitive dysfunction, but whether dyspnoea by itself negatively impacts on cognition has not been demonstrated. Cortical networks engaged in subjects experiencing dyspnoea are also activated during other tasks that require cognitive input and this may provoke a negative impact through interference with each other. METHODS: This randomised, crossover trial investigated whether experimentally-induced dyspnoea would negatively impact on locomotion and cognitive function among 40 healthy adults. Crossover conditions were unloaded breathing or loaded breathing using an inspiratory threshold load. To evaluate locomotion, participants were assessed by the Timed Up and Go (TUG) test. Cognitive function was assessed by categorical and phonemic verbal fluency tests, the Trail Making Tests (TMTs) A and B (executive function), the CODE test from the Wechsler Adult Intelligence Scale (WAIS)-IV (processing speed) and by direct and indirect digit span (working memory). RESULTS: The mean time difference to perform the TUG test between unloaded and loaded breathing was -0.752 s (95% CI -1.012 to -0.492 s) (p<0.001). Executive function, processing speed and working memory performed better during unloaded breathing, particularly for subjects starting first with the loaded breathing condition. CONCLUSION: Our data suggest that respiratory threshold loading to elicit dyspnoea had a major impact on locomotion and cognitive function in healthy adults.

Comorbidities and Readmissions in Survivors of Acute Hypercapnic Respiratory Failure.

Chronic obstructive pulmonary disease (COPD) is defined by chronic airflow obstruction, but is presently considered as a complex, heterogeneous, and multicomponent disease in which comorbidities and extrapulmonary manifestations make important contributions to disease expression. COPD-related hospital readmission. In particular frequent intensive care unit (ICU) readmissions for exacerbations represent a major challenge and place a high burden on patient outcomes and health-related quality of life, as well as on the healthcare system.In this narrative review, we first address major and often undiagnosed comorbidities associated with COPD that could have an impact on hospital readmission after an index ICU admission for acute hypercapnic respiratory failure. Some guidance for treatment is discussed. Second, we present predictors of hospital and ICU readmission and discuss various strategies to reduce such events.There is a strong rationale to detect and treat major comorbidities early after index ICU admission for acute hypercapnic respiratory failure. It still remains unclear, however, if a comprehensive and holistic approach to comorbidities in frail patients surviving hypercapnic respiratory failure can efficiently reduce the readmission rate.

Long-Term Mechanical Ventilation: Recommendations of the Swiss Society of Pulmonology.

Long-term mechanical ventilation is a well-established treatment for chronic hypercapnic respiratory failure (CHRF). It is aimed at improving CHRF-related symptoms, health-related quality of life, survival, and decreasing hospital admissions. In Switzerland, long-term mechanical ventilation has been increasingly used since the 1980s in hospital and home care settings. Over the years, its application has considerably expanded with accumulating evidence of beneficial effects in a broad range of conditions associated with CHRF. Most frequent indications for long-term mechanical ventilation are chronic obstructive pulmonary disease, obesity hypoventilation syndrome, neuromuscular and chest wall diseases. In the current consensus document, the Special Interest Group of the Swiss Society of Pulmonology reviews the most recent scientific literature on long-term mechanical ventilation and provides recommendations adapted to the particular setting of the Swiss healthcare system with a focus on the practice of non-invasive and invasive home ventilation in adults.

[Diagnostic approach to chronic dyspnea in adults]. / Approche diagnostique de la dyspnée chronique chez l'adulte.

Dyspnea is a symptom resulting from a complex interaction between multiple mechanisms that are not fully understood to this day. Chronic dyspnea is defined as dyspnea lasting more than one month and this symptom is commonly seen in primary care. Cardio-respiratory pathologies account for approximately 85 % of all cases of dyspnea. Dyspnea significantly impacts the quality of life of the affected patients and is a good predictor of morbidity and mortality. Chronic dyspnea is challenging, especially when the etiology is unclear. Performing pulmonary function tests (PFTs) and a cardiopulmonary exercise test (CPET) allows to better understand the pathophysiology of the dyspnea in order to guide the diagnosis.

La dyspnée est un symptôme qui résulte d'une interaction complexe entre de multiples mécanismes incomplètement élucidés à l'heure actuelle. Elle est fréquemment rencontrée en médecine de premier recours et elle est considérée comme chronique si elle dure plus d'un mois. Dans 85 % des cas, la cause est une pathologie cardiorespiratoire. Elle est à elle seule un prédicteur de morbidité et de mortalité important, impactant sensiblement la qualité de vie du patient. Les étiologies sont multiples. En cas de dyspnée chronique d'étiologie indéterminée, les explorations fonctionnelles respiratoires et un test d'effort cardiopulmonaire aident à une meilleure compréhension de la physiopathologie de la dyspnée et permettent ainsi d'affiner le diagnostic.

[Pulmonary medicine: asthma, chronic obstructive pulmonary disease and idiopathic pulmonary fibrosis]. / Pneumologie: asthme, bronchopneumopathie chronique obstructive et fibrose pulmonaire idiopathique.

Important changes have been proposed by expert groups for the management of mild asthma and chronic obstructive pulmonary disease (COPD): for safety reasons, short-acting beta-2 agonists (SABA) are no longer recommended as «â€…reliever therapy ¼ in mild asthma, and should be replaced by symptom-driven inhaled corticosteroids, alone or combined with a beta-2 agonist ; for COPD patients recommendations as to use of inhaled corticosteroids have been redefined. New therapeutic options for idiopathic pulmonary fibrosis are being evaluated: recombinant human pentraxin 2 may become a new therapeutic option among the existing specific treatments (pirfenidone, nintedanib). These novelties are discussed in this review of the recent medical literature.

D'importantes modifications ont été proposées par les sociétés savantes dans la prise en charge des sujets asthmatiques légers et des sujets souffrant de bronchopneumopathie chronique obstructive (BPCO) : abandon des bêta-2 agonistes à action courte (BAAC) en traitement de secours pour l'asthme pour des raisons de sécurité, en privilégiant le rôle des corticostéroïdes inhalés seuls ou associés à un bêta-2 mimétique chez des sujets symptomatiques, et redéfinition de la place des corticostéroïdes inhalés lors de BPCO. Dans la fibrose pulmonaire idiopathique, la pentraxine-2 humaine recombinante se profile comme une nouvelle option thérapeutique possible, venant compléter la gamme des traitements spécifiques (pirfénidone, nintédanib). Ces nouveautés sont discutées dans cette revue de la littérature récente.

The Pathophysiology of Respiratory Failure: Control of Breathing, Respiratory Load, and Muscle Capacity.

The purpose of this review is to provide an overview on how interactions between control of breathing, respiratory load, and muscle function may lead to respiratory failure. The mechanisms involved vary according to the underlying pathology, but respiratory failure is most often the result of an imbalance between the muscular pump and the mechanical load placed upon it. Changes in respiratory drive and response to CO2 seem to be important contributors to the pathophysiology of respiratory failure. Inspiratory muscle dysfunction is also frequent but is not a mandatory prerequisite to respiratory failure since increased load may also be sufficient to precipitate it. It is crucial to recognize these interactions to be able to timeously establish patients on mechanical ventilation and adapt the ventilator settings to their respiratory system physiology.

Assessing Inspiratory Muscle Strength for Early Detection of Respiratory Failure in Motor Neuron Disease: Should We Use MIP, SNIP, or Both?

BACKGROUND: Motor neuron disease (MND) invariably impacts on inspiratory muscle strength leading to respiratory failure. Regular assessment of sniff nasal inspiratory pressure (SNIP) and/or maximal mouth inspiratory pressure (MIP) contributes to early detection of a requirement for ventilatory support. OBJECTIVES: The aim of this study was to compare the feasibility, agreement, and performance of both tests in MND. METHODS: Patients with MND followed by a multidisciplinary consultation were prospectively included. Pulmonary follow-up included forced expiratory volumes, vital capacity (VC) seated and supine, MIP, SNIP, pulse oximetry, and daytime arterial blood gases. RESULTS: A total of 61 patients were included. SNIP and MIP could not be performed in 14 (21%) subjects; 74% of the subjects showed a decrease in MIP or SNIP at inclusion versus 31% for VC. Correlation between MIP and SNIP (Pearson's rho: 0.68, p < 0.001) was moderate, with a non-significant bias in favor of SNIP (3.6 cm H2O) and wide limits of agreement (-34 to 41 cm H2O). Results were similar in "bulbar" versus "non-bulbar" patients. At different proposed cut-off values for identifying patients at risk of respiratory failure, the agreement between MIP and SNIP (64-79%) and kappa values (0.29-0.53) was moderate. CONCLUSIONS: MIP and SNIP were equally feasible. There was no significant bias in favor of either test, but a considerable disparity in results between tests, suggesting that use of both tests is warranted to screen for early detection of patients at risk of respiratory failure and avoid over diagnoses. SNIP, MIP, and VC all follow a relatively linear downhill course with a steeper slope for "bulbar" versus "non-bulbar" patients.

[Overlap syndrome in chronic obstructive pulmonary disease patient]. / Le syndrome d'overlap chez le patient BPCO.

Overlap syndrome (OVS) is defined by the co-existence of chronic obstructive pulmonary disease (COPD) and obstructive sleep apnea (OSA) in a same patient. This condition is associated with increased mortality and a higher risk of respiratory exacerbation, compared to patients with COPD or OSA alone. Nocturnal positive PAP treatment is effective to mitigate the additional risk related to OSA. Identification of OVS is a major challenge for clinicians because of the many phenotypes of OVS patients, with atypical OSA presentation, whose sleep quality is already impacted by COPD itself. Dedicated prospective studies are mandatory to improve our understanding of OVS patients and to optimize their medical care.

Le syndrome d'overlap (SOV) est défini par l'association d'une bronchopneumopathie chronique obstructive (BPCO) et d'un syndrome d'apnées obstructives du sommeil (SAOS). Il est associé à une mortalité et un risque d'exacerbation respiratoire augmentés, comparé à la BPCO ou au SAOS seuls. Un traitement par pression positive nocturne est efficace pour corriger le risque lié aux apnées du sommeil. L'identification du SOV est un défi pour le clinicien, en raison d'une importante hétérogénéité clinique, d'une présentation souvent frustre du SAOS chez le patient BPCO, dont la qualité du sommeil est déjà dégradée par la maladie elle-même. Des études prospectives dédiées sont nécessaires afin de préciser les phénotypes du SOV ainsi que la prise en charge diagnostique et thérapeutique de ces patients.

Development and validation of a simple tool for the assessment of home noninvasive ventilation: the S3-NIV questionnaire.

Patient-centred outcomes are significantly modified by long-term home noninvasive ventilation (NIV), but a short, self-administered, specific tool for routine clinical assessment is lacking. The aim of this study was to develop and validate the S3-NIV questionnaire, a short questionnaire to measure respiratory symptoms, sleep quality and NIV-related side effects.Patients with stable disease who were under long-term home NIV were recruited from three outpatient NIV services. Questionnaire development consisted of a selection of core items for analysis, followed by item reduction, validation and test-retest reliability.338 patients completed a 22-item questionnaire. 11 items were removed because of non-scalability (n=2), redundancy (n=8) and lack of fit (n=1). The final version of the S3-NIV questionnaire consisted of 11 items covering two dimensions: "respiratory symptoms" (Cronbach's α=0.84) and "sleep & NIV-related side effects" (Cronbach's α=0.77). Convergent validity was high between the "respiratory symptoms" subscale of the S3-NIV questionnaire and the St George's Respiratory Questionnaire (rho= -0.76, p<0.001), and between the "sleep & NIV-related side effects" subscale and the Quebec Sleep Questionnaire (rho=0.51, p<0.001). The S3-NIV questionnaire had good test--retest reliability after 4 weeks (intraclass correlation coefficient=0.72).The S3-NIV questionnaire is a short, valid and repeatable self-completed tool for the routine clinical assessment of patients undergoing home NIV.