Indacaterol and glycopyrronium versus indacaterol on body plethysmography measurements in COPD-a randomised controlled study.

BACKGROUND: Dual bronchodilator therapy is recommended for symptomatic patients with chronic obstructive pulmonary disease (COPD). There are limited data on effects of a combination of two long-acting bronchodilators on lung function including body plethysmography. METHODS: This multicentre, randomised, double-blind, single-dose, cross-over, placebo-controlled study evaluated efficacy and safety of the free combination of indacaterol maleate (IND) and glycopyrronium bromide (GLY) versus IND alone on spirometric and body plethysmography parameters, including inspiratory capacity (IC), forced expiratory volume in 1 s (FEV1), forced vital capacity (FVC), total lung capacity (TLC) and airway resistance (Raw) in moderate-to-severe COPD patients. RESULTS: Seventy-eight patients with FEV1 % pred. (mean ± SD) 56 ± 13% were randomised. The combination of IND + GLY versus IND presented a numerically higher peak-IC (Δ = 0.076 L, 95% confidence interval [CI]: -0.010 - 0.161 L; p = 0.083), with a statistically significant difference in mean IC over 4 h (Δ = 0.054 L, 95%CI 0.022 - 0.086 L; p = 0.001). FEV1, FVC and Raw, but not TLC, were consistently significantly improved by IND + GLY compared to IND alone. Safety profiles of both treatments were comparable. CONCLUSION: The free combination of IND + GLY improved lung function parameters as evaluated by spirometry and body plethysmography, with a similar safety profile compared to IND alone. TRIAL REGISTRATION: NCT01699685.

Titrated sedation with propofol for medical thoracoscopy: a feasibility and safety study.

BACKGROUND: Bispectral index (BIS) is a valuable tool for assessing the depth of sedation and guiding the administration of sedative drugs. We previously demonstrated the benefits of BIS-guided propofol sedation in patients undergoing flexible bronchoscopy. OBJECTIVE: To examine the feasibility and safety profile of propofol sedation in patients undergoing medical thoracoscopy (MT). METHODS: Patients undergoing MT for diagnostic evaluation or treatment of pleuropulmonary diseases were enrolled over a 2-year period. Nurses and chest physicians were trained by anesthetists to provide analgosedation, to detect and correct cardiopulmonary disturbances. The level of sedation was optimized individually by titrating the propofol infusion according to the BIS and clinical evaluation. Patients' clinical data, procedure time, medications and any adverse events were recorded. RESULTS: Fifty-three patients (60% male) with a median age of 62 years (range 19-84 years) underwent MT. The operative procedure lasted a median time of 28 min (range 9-112 min). The median doses of anesthetic drugs were 145 mg of propofol (range 20-410 mg) and 84 µg of fentanyl (range 0-225 µg). Hemodynamic disturbances occurred in 39 patients (bradycardia n = 4, tachycardia n = 12, hypotension n = 34) and required drug administration in only 4 cases. Hypoxemic events (n = 4) resolved upon gentle patient stimulation (verbal command, chin lift, oral cannula). All patients could be discharged from the recovery unit within 105 min after the procedure. CONCLUSIONS: BIS-guided propofol sedation is a safe method that might replace midazolam sedation in MT and can be managed by well-trained nonanesthesiologist personnel.

[Pulmonary fibrosis and emphysema]. / Fibrose pulmonaire et emphysème.

We report a case of combined pulmonary fibrosis and emphysema. This syndrome, including upper-lobe emphysema and pulmonary fibrosis of the lower lung was recently described in smokers or ex-smokers (mean age: 65 years). Exertional dyspnea is always present. Pulmonary functions are subnormal while carbon monoxyde transfer is reduced and exercise hypoxemia is present. High resolution CT-scan is key of diagnosis with upper lobes emphysema with diffuse infiltrating fibrosing disease at the bases. Pulmonary hypertension is present is almost 50% of patients, representing the principal negative pronostic factor. Five years survival is 54.6% (median survival 6, 1 years).

[Endobronchic palliative brachytherapy]. / Brachythérapie endobronchique palliative.

Brachytherapy, the placement of an encapsuled radioactive source (Iridium) in or near a tumor, is a palliative therapeutic modality available for patients suffering of a bronchogenic cancer, especially if they present invalidating symptoms such an incoercible cough, haemoptysis, dyspnea. The treatment modality is indicated if chemotherapy or external irradiation are not possible. It is typically a team work.

[Referring to an unusual case: pulmonary affection and rheumatoid arthritis]. / Atteinte pulmonaire et polyarthrite rhumatoïde.

We report the case of a 60 year female patient suffering from rheumatoid arthritis for the last 25 years, under TNF-blocker and leflunomide, affected by a recurrent pneumothorax with several subpleural nodules, basal bronchiectasis and apical bullous emphysema. The patient was administered several treatments: aspiration, talc pleurodesis, surgical pleurodesis, pleurodesis induced by tetracycline and autologous blood. To allow the pleural inflammatory reaction necessary to the success of the pleurodesis, we had to interrupt the treatment by TNF-blocker and leflunomide. We then witnessed a partial pleurodesis with persistence of a pneumothorax. The medical situation is improving with disappearance of dyspnea.

Aerosolized salbutamol accelerates the resolution of pulmonary edema after lung resection.

BACKGROUND: Ischemia-reperfusion injuries, fluid overload, and cardiac insufficiency may all contribute to alveolar and interstitial lung edema. We hypothesized that aerosolized salbutamol would reduce extravascular lung water and improve oxygenation after lung resection by stimulating epithelial fluid clearance and cardiovascular function. DESIGN: Blinded, randomized, cross-over trial. METHODS: We selected 24 patients with risk factors for lung edema. Aerosolized drugs (salbutamol, 5 mg; vs ipratropium, 0.5 mg) were administered on two consecutive trials, with a 6-h washout period, on the day of surgery (postoperative day [POD]-0) as well as on POD-1. Before and 50 min after the end of drug administration, we determined the oxygenation index (Pao(2)/fraction of inspired oxygen [Fio(2)] ratio), the extravascular lung water index (EVLWI), the pulmonary vascular permeability index (PVPI), and the cardiac index (CI) using the single-indicator thermal dilution technique. RESULTS: Complete data were obtained in 21 patients. On POD-0, the EVLWI was increased compared with preoperative values (13.0 +/- 3.8 vs 9.1 +/- 4.4, p < 0.001); salbutamol treatment induced significant increases in Pao(2)/Fio(2) ratio (+ 25 +/- 13%) that were associated with decreases in EVLWI (- 18 +/- 10%, p < 0.05) and in PVPI (- 19 +/- 10%, p < 0.05) along with increased CI (+ 23 +/- 11%, p < 0.05). On POD-1, repeated nebulization of salbutamol induced significant increases in Pao(2)/Fio(2) ratio and CI (+ 22 +/- 10% and 19 +/- 11%, respectively), whereas both EVLWI and PVPI remained unchanged. Nebulization of ipratropium bromide did not produce significant hemodynamic and respiratory changes on POD-0 and POD-1. CONCLUSIONS: Aerosolized salbutamol accelerates the resolution of lung edema, improves blood oxygenation, and stimulated cardiovascular function after lung resection in high-risk patients. TRIAL REGISTRATION: This protocol trial (CER03-160) has been registered at (Clinicaltrials.gov) under NCT00498251.

Sleep apnea syndrome: improved detection of respiratory events and cortical arousals using oxymetry pulse wave amplitude during polysomnography.

Respiratory events (RE) during sleep induce cortical arousals (A) and marked changes in autonomic markers in sleep apnea syndrome (SAS). The aims of the study were double. First, we assessed whether pulse wave amplitude (PWA) added to polysomnography (PSG) could improve RE and A detection; second, we wanted to know whether the quality of detection of these two parameters could be improved using PWA. Respiratory disturbance index (RDI) and A were randomly scored twice by the same observer in 12 male patients with SAS. The first scoring was done using conventional PSG signals, the second scoring adding PWA to PSG. We also measured interobserver agreement by randomly selecting and reading 100 PSG sequences of 5 min with and without PWA by two observers. Adding PWA to PSG parameters allowed to detect significantly more RDI (53.9 +/- 21.6 h(-1) versus 48.3 +/- 22.3 h(-1), p < 0.001) and more A (68.0 +/- 14.4 versus 59.4 +/- 16.5, p < 0.001). Moreover, after using PWA, there was no significant disagreement between two observers for detecting RE, showing better quality of RE detection. PWA is a simple and cheap parameter that improves the diagnostic value of conventional PSG in sleep apnea syndrome by better detecting respiratory events and A.

[Bronchiectasis: a reemerging disease]. / Bronchiectasies: une pathologie qui réémerge.

Bronchiectasis has a barely studied and under-estimated prevalence. Diagnosis is based on clinical history and CT scan. It is necessary to make some tests to clarify its etiology. Microbiology of expectoration, physiotherapy, prolonged and repeated antibiotherapy play the key role in treatment. We lack studies to recommend other therapies. Surgery is reserved for localized lesions. Ten years mortality is 30%, but in ICU it is very high. An early and aggressive treatment seems justified.

[Narcolepsy: current view]. / Narcolepsie: le point actuel.

Narcolepsy is a primary sleep disorder which may or may not arise associated with catalepsy. It is a relatively frequent disease with 2 peaks of appearance in childhood and in young adulthood. It has genetic components which do not seem sufficient for its demonstration. It often depends on the environment and its clinical picture can be very variable, particularly in children. It is thus under-diagnosed and often confused with other diseases. In this short review of the literature we discuss: narcolepsy's history, clinical evaluation, diagnoses criteria, patient's history, clinical status and complementary examinations, clinical picture in the child and in the teenager, epidemiology, neurobiology, differential diagnoses, symptomatic narcolepsy, current treatments and internet sites of reference.

[Pulmonary blastoma in adults]. / Le pneumoblastome pulmonaire chez l'adulte.

Pneumoblastoma (PB) is a rare, malignant, primary, pulmonary tumour, of young adults. Its discovery is fortuitous in asymptomatic patients. It is a well-delimited, homogeneous lesion in the lung periphery. Histologically, its structure looks like a normal fetal lung. The surgical resection is the treatment of choice. The radiotherapy is an empirical palliative treatment to relieve dyspnea when other treatments failed. The prognosis is bad: 16% survive 5 years and 8% beyond 10 years, all treatments included. Metastases could appear in the liver, the brain and the bone.

Risk factors for early mortality and major complications following pneumonectomy for non-small cell carcinoma of the lung.

STUDY OBJECTIVES: To assess the mortality rate and the incidence of cardiopulmonary complications after pneumonectomy for non-small cell lung carcinoma (NSCLC) and to identify possible associated risk factors. DESIGN: Observational study of patients who underwent pneumonectomy. Potential risk factors were analyzed from a local database including all thoracic surgical cases. SETTING: A university hospital and a chest medical center. PATIENTS AND METHODS: From January 1, 1990, to April 30, 2000, 193 consecutive pneumonectomies were performed for NSCLC in two affiliated institutions. The following information was recorded: demographic, clinical, functional, and surgical variables; as well as intraoperative and postoperative events. The risk of mortality and cardiopulmonary complications was evaluated using multiple logistic regression analysis to estimate odds ratios (ORs) and 95% confidence intervals (CIs). RESULTS: After undergoing pneumonectomy, all patients were successfully extubated in the operating room and then transferred to a postanesthesia care unit (126 patients) or ICU (67 patients). The 30-day mortality rate was 9.3%, and cardiovascular and/or pulmonary complications occurred in 47% of cases. Coronary artery disease (CAD) was a predictor of 30-day mortality (OR, 2.9; 95% CI, 1.1 to 8.9). Cardiac morbidity (mainly arrhythmias) was significantly related to advanced age (OR, 3.7; 95% CI, 1.6 to 8.6) and pathologic stages III/IV (OR, 1.4; 95% CI, 1.1 to 4.7), whereas continuous epidural analgesia was associated with a reduced incidence of respiratory complications (OR, 0.2; 95% CI, 0.1 to 0.6). CONCLUSIONS: Pneumonectomy for lung cancer is a high-risk procedure, the risk for which is significantly related to the presence of CAD and advanced pathologic stages. Importantly, the provision of epidural analgesia contributes to lower the risk of respiratory complications.