Prevalence and management of chronic breathlessness in COPD in a tertiary care center.

BACKGROUND: Breathlessness is the prominent symptom of chronic obstructive pulmonary disease (COPD). Despite optimal therapeutic management including pharmacological and non-pharmacological interventions, many COPD patients exhibit significant breathlessness. Chronic breathlessness is defined as breathlessness that persists despite optimal treatment of the underlying disease. Because of the major disability related to chronic breathlessness, symptomatic treatments including opioids have been recommended by several authors. The prevalence of chronic breathlessness in COPD and its management in routine clinical practice have been poorly investigated. Our aim was to examine prevalence, associated characteristics and management of chronic breathlessness in patients with COPD recruited in a real-life tertiary hospital-based cohort. METHODS: A prospective study was conducted among 120 consecutive COPD patients recruited, in stable condition, at Nancy University Hospital, France. In parallel, 88 pulmonologists of the same geographical region were asked to respond to an on-line questionnaire on breathlessness management. RESULTS: Sixty four (53%) patients had severe breathlessness (modified Medical Research Council scale≥3), despite optimal inhaled medications for 94% of them; 40% had undergone pulmonary rehabilitation within the past 2 years. The severity of breathlessness increased with increasing airflow limitation. Breathlessness was associated with increased symptoms of anxiety, depression and with osteoporosis. No relation was found with other symptoms, exacerbation rate, or cardiovascular comorbidities. Among the patients with chronic breathlessness and Hospitalized Anxiety and/or Depression score > 10, only 25% were treated with antidepressant or anxiolytic. Among the pulmonologists 46 (52%) answered to the questionnaire and expressed a high willingness to prescribe opioids forchronic breathlessness, which contrasted with the finding that none of these patients received such treatments against breathlessness. CONCLUSION: Treatment approaches to breathlessness and associated psychological distress are insufficient in COPD. This study highlights underuse of pulmonary rehabilitation and symptomatic treatment for breathlessness.

Emergence of Aspergillus fumigatus azole resistance in azole-naïve patients with chronic obstructive pulmonary disease and their homes.

Azole-resistant Aspergillus fumigatus (ARAF) has been reported in patients with chronic obstructive pulmonary disease (COPD) but has not been specifically assessed so far. Here, we evaluated ARAF prevalence in azole-naïve COPD patients and their homes, and assessed whether CYP51A mutations were similar in clinical and environmental reservoirs. Sixty respiratory samples from 41 COPD patients with acute exacerbation and environmental samples from 36 of these patient's homes were prospectively collected. A. fumigatus was detected in respiratory samples from 11 of 41 patients (27%) and in 15 of 36 domiciles (42%). Cyp51A sequencing and selection on itraconazole medium of clinical (n = 68) and environmental (n = 48) isolates yielded ARAF detection in 1 of 11 A. fumigatus colonized patients with COPD (9%) and 2 of 15 A. fumigatus-positive patient's homes (13%). The clinical isolate had no CYP51A mutation. Two environmental isolates from two patients harbored TR34 /L98H mutation, and one had an H285Y mutation. Coexistence of different cyp51A genotypes and/or azole resistance profiles was detected in 3 of 8 respiratory and 2 of 10 environmental samples with more than one isolate, confirming the need for a systematic screening of all clinically relevant isolates. The high prevalence of ARAF in patients with COPD and their homes supports the need for further studies to assess the prevalence of azole resistance in patients with Aspergillus diseases in Northern France.

[Take-home messages from the 2nd COPD 2023 Biennial of the French Society of Respiratory Diseases. Placing the patient at the center of the care pathway]. / Principaux messages de la deuxième Biennale BPCO 2023 de la SPLF. Le patient au cœur du parcours de soins.

INTRODUCTION: The second COPD Biennial organized by the COPD working group of the French Society of Respiratory Diseases took place in Paris (Cochin) on 13th December 2023. STATE OF THE ART: Major trends in 2023 were discussed; they encompassed concepts, definitions, biologics, care pathways, pulmonary rehabilitation and complex situations entailed by respiratory infections, cardiovascular comorbidities and pulmonary hypertension, and modalities of oxygen therapy and ventilation. PERSPECTIVES: The different talks underlined major changes in COPD including the concepts of pre-COPD, etiotypes, health trajectories and new definitions of exacerbation. Recent results in biologics for COPD open the door to new pharmacological options. Assessment of current care pathways in France highlighted some causes for concern. For example, pulmonary rehabilitation is a key but insufficiently practiced element. Respiratory infections require careful assessment and treatments. Diagnosis and treatment of cardiovascular comorbidities and pulmonary hypertension are of paramount importance. As of late, oxygen therapy and ventilation modalities have evolved, and are beginning to afford more personalized options. CONCLUSIONS: As regards COPD, a personalized approach is crucial, placing the patient at the center of the care pathway and facilitating coordination between healthcare providers.

[Take-home messages from the COPD 2021 biennial of the French Society of Respiratory Diseases. Understanding to so as to better innovate]. / Principaux messages de la première Biennale BPCO 2021 de la SPLF. Mieux comprendre pour innover.

INTRODUCTION: The first COPD biennial organized by the French Society of Respiratory Diseases (SPLF) took place on 17 December 2021. STATE OF THE ART: The objective of the biennial was to discuss current knowledge regarding COPD pathophysiology, current treatments, research development, and future therapeutic approaches. PERSPECTIVES: The different lecturers laid emphasis on the complexity of pathophysiologic mechanisms including bronchial, bronchiolar and parenchymal alterations, and also dwelt on the role of microbiota composition in COPD pathenogenesis. They pointed out that addition to inhaled treatments, ventilatory support and endoscopic approaches have been increasingly optimized. The development of new therapeutic pathways such as biotherapy and cell therapy (stem cells…) call for further exploration. CONCLUSIONS: The dynamism of COPD research was repeatedly underlined, and needs to be further reinforced, the objective being to "understand so as to better innovate" so as to develop effective new strategies for treatment and management of COPD.

Dramatic impact of morbid obesity on child lung development.

OBJECTIVE: To assess the respiratory function and sleep characteristics of obese adults and children. METHODS: All patients with non-syndromic, severe obesity (BMI ≥3 z-scores for children and ≥40.00kg/m2 for adults), referred for pulmonary function tests at Lille University Hospital, were retrospectively included. RESULTS: A total of 69 children (mean±SD BMI 36.8±6.7 and mean BMI z-score 4.7±1.0) and 70 adults were included (mean BMI 45.7±6.2). Metabolic syndrome was diagnosed in 13 children (26%) and 40 adults (80%). Reduced lung volumes were observed in 34 children (50.0%) and 16 adults (24.0%) and both the mean functional residual capacity (FRC) and the mean residual volume (RV) were lower in children than in adults (FRC: -1.7±2.1 z-score in children vs. -1.0±1.1 in adults, P=0.026; and RV: -0.8±1.2 z-score in children vs. -0.1±1.1 in adults, P=0.002). The prevalence of severe obstructive sleep apnea syndrome was greater in adults (40.7% vs. 18.8%, P=0.007). Children had a higher average oxygen saturation (median of 96.0% [91.0-98.0] vs. 93.0% [76.0-97.0] in adults, P<0.0001). CONCLUSION: Obesity has consequences for lung volumes in children; however, a longitudinal study is needed to determine the impact on pulmonary expansion and growth.

Influence of DISC behavioral profile on the short- and long-term outcomes of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease.

INTRODUCTION: Pulmonary rehabilitation (PR) programs are commonly prescribed for patients with severe respiratory disorders, but little is known about how the patient's personality traits influence PR outcomes. We analyzed the response of patients with chronic obstructive pulmonary disease (COPD) to a home-based PR program according to their predominant behavioral profiles using the Dominance - Influence - Steadiness - Conscientiousness (DISC) tool. METHODS: This was a retrospective observational study of 335 COPD patients referred by their pulmonologists between January 2010 and December 2015. The DISC behavioral profile was determined at the beginning of the program. Patients received individual supervised sessions at home once a week for 8 weeks, which consisted of exercise training and psychosocial, motivational, and educational support, all tailored to the participant's DISC profile. Exercise tolerance (6-minute stepper test, 6MST), anxiety and depression (Hospital anxiety and depression scale, HADS), and quality of life (Visual simplified respiratory questionnaire, VSRQ) were evaluated immediately before and after the PR program (T0 and T2, respectively) and then 6 and 12 months later (T8 and T14, respectively). Responders were defined as patients who exhibited at least minimal clinically important differences (improvements) from baseline. RESULTS: Of the 335 COPD patients, 102 (30.4%), 98 (29.3%), 82 (24.5%), and 53 (15.8%) were classified as having predominant D, I, S, and C behavioral traits, respectively. All four patient groups showed significantly (P<0.01) improved performance in the 6MST, HADS, and VSRQ evaluations at T2 (n=300), T8 (n=262), and T14 (n=231) compared with T0, and the proportion of responders in all groups at T8 and T14 was high (∼60%). The percentage of responders differed significantly between groups only at T2, when the S group contained fewer responders on the HADS anxiety subscale. Most patients who did not complete the study were classified as D type (42/102, 41.2%), followed by I (28/98, 28.6%), S (22/82, 26.8%), and C (12/53, 22.6%) types. CONCLUSION: The personality profile of COPD patients influenced their adherence to, but not their benefit from, a home-based PR program. The high proportion of patients in all personality groups showing significant improvements in outcomes supports a personalized approach to the design of PR programs.

[The DISC tool improves communication and results in pulmonary rehabilitation]. / L'outil DISC améliore la communication et les résultats de la réhabilitation respiratoire : une approche comportementale adaptée.

INTRODUCTION: Competence in personal relationships is essential for a caregiver, especially in pulmonary rehabilitation (PR). Considering the behavioral profile of patients might help to optimize their management and the results of PR. METHODS: We evaluated eight hundred and thirty-two consecutive patients with chronic respiratory disease who received eight weeks of home-based PR. Their exercise tolerance (six-minute stepper test, 6MST), mood (HAD), and quality of life (VSRQ, MRF28) were evaluated at the beginning and end of PR. For six hundred and ninety patients, a behavioral approach was implemented at the beginning of PR by using the DISC tool to identify four behavioral profiles: dominance, influence, steadiness, conscientiousness. The remaining 142 patients served as the control group. RESULTS: Subjectively, the therapeutic alliance was more easily established with the behavioral approach. Compared with the control group, patients with the "steadiness" profile were younger (60.7±12 years) and mostly female (52.8%), whereas patients with the "conscientiousness" profile were older (67.5±10.6 years) and mostly male (85.5%). The four behaviorally profiled groups showed no differences in exercise tolerance, mood, or quality of life scores at baseline. Globally, all patients improved their exercise tolerance, mood and quality of life. The percentage of responders to 6MST and VSRQ (>MCID) was 7.5% and 5.3% higher with the behavioral approach. For non-responders to 6MST and VSRQ (

Improvement in body composition following a supervised exercise-training program of adult patients with cystic fibrosis.

OBJECTIVES: Maintenance of optimal nutritional status is a crucial issue for cystic fibrosis (CF) patients. Here, we evaluate the effects of an 8-week exercise training (ET) program on body composition in CF patients. METHODS: This prospective pilot observational study was conducted in adult CF subjects in stable condition following their annual check-up. The ET program consisted of three sessions per week and included aerobic training (≥30min), muscle strengthening, circuit training, and relaxation. Exercise tolerance (6-minute walk test, 6MWT), pulmonary function, quadriceps isometric strength, and body composition (bioelectrical impedance analysis of fat-free mass [FFM], fat mass, and body cell mass) were analyzed before and immediately after the ET program. A control group of CF patients who preferred not to participate in the ET program received the same evaluations. RESULTS: A total of 43 CF patients were enrolled and offered the ET program; 28 accepted (aged 28±5 years, forced expiratory volume in 1s [FEV1] 48.8±19% predicted) and 15 declined the ET program but agreed to be part of the control group (matched for age and CF severity: 30.8±9 years, FEV1 51.8±16.5%). Pulmonary function was unchanged at the end of the ET program, but significant improvements were observed in 6MWT distance (from 520±96m to 562±105m, P<0.001) and muscle strength (331±141N to 379±168N, P<0.001). Although mean body mass index did not change, the ET group showed significantly increased FFM (43.85±8kg to 44.5±9.2kg, P=0.03) and a trend towards increased body cell mass (21.4±6 to 22.1±6.6kg, P=0.06). All other parameters were unchanged by ET. There were no significant correlations between the increase in FFM and the improvements in either 6MWT distance or muscle strength. The CF control group exhibited no significant changes in any parameters between evaluations. CONCLUSIONS: ET significantly improved FFM, but not body mass index, in CF patients. The results illustrate the superiority of bioimpedancemetry for assessing changes in body composition and reveal the importance of ET for improving not only exercise tolerance but also nutritional status in these patients.

Oxidative stress-mediated iNKT-cell activation is involved in COPD pathogenesis.

Chronic obstructive pulmonary disease (COPD) is a major clinical challenge mostly due to cigarette smoke (CS) exposure. Invariant natural killer T (iNKT) cells are potent immunoregulatory cells that have a crucial role in inflammation. In the current study, we investigate the role of iNKT cells in COPD pathogenesis. The frequency of activated NKT cells was found to be increased in peripheral blood of COPD patients relative to controls. In mice chronically exposed to CS, activated iNKT cells accumulated in the lungs and strongly contributed to the pathogenesis. The detrimental role of iNKT cells was confirmed in an acute model of oxidative stress, an effect that depended on interleukin (IL)-17. CS extracts directly activated mouse and human dendritic cells (DC) and airway epithelial cells (AECs) to trigger interferonγ and/or IL-17 production by iNKT cells, an effect ablated by the anti-oxidant N-acetylcystein. In mice, this treatment abrogates iNKT-cell accumulation in the lung and abolished the development of COPD. Together, activation of iNKT cells by oxidative stress in DC and AECs participates in the development of experimental COPD, a finding that might be exploited at a therapeutic level.

[Comparison of home-based and outpatient, hospital-based, pulmonary rehabilitation in patients with chronic respiratory diseases]. / La réhabilitation respiratoire : évaluation de deux types de prise en charge, ambulatoire versus domicile.

INTRODUCTION: The comprehensive care and personalized pulmonary rehabilitation (PR) of patients with chronic respiratory disease is effective regardless of the place of performance. The objective of this prospective observational study was to compare two types of care in an outpatient rehabilitation center, versus a home-based PR. METHODS: Two hundred and eighty-six patients were supported : 137 patients were included in outpatients (age : 61.2±10.8years, BMI: 28.7±7.1), 149 in home-based PR (age: 62.9±12years, BMI: 26.1±6.6). The choice between outpatient and home was a function of distance from the center and the patient's wishes. The outpatient care was done in groups of six, four times a week for 6weeks. At home she was single, once a week for 8weeks with continued physical activity independently of the other days a week depending on individual action plan. The therapeutic education programs and psycho-social support were identical in both structures. The assessment included assessment of exercise tolerance test in 6minutes stepper (TS6), anxiety and depression and quality of life. RESULTS: There were no incidents or accidents during the PR in the two structures. The exercise intolerance was significantly higher in patients TS6 home (332.9±154.8 versus 460.2±137.9 counts, P<0.01). All the parameters studied, except for HAD score in the center, were improved significantly (P<0.001) after the course. The evolution of the different scores was not significantly different between the ambulatory versus home. CONCLUSION: The PR of chronic respiratory unselected patients is as safe and effective at home or in outpatient center on exercise tolerance and quality of life. Home-based PR is an alternative to outpatient care as long as all activities, physical training, therapeutic education and psychosocial support, are achieved.

[Benign trachobronchial schwannoma treated by complete endoscopic resection followed by cryotherapy]. / Schwannome trachéal bénin traité par exérèse endoscopique et cryocoagulation.

INTRODUCTION: Tracheobronchial schwannoma is a rare benign airway tumour. There is no evidence to guide treatment for this condition. CASE REPORT: A 76-year-old woman with a history of ischemic cardiomyopathy was hospitalized for dyspnoea with bronchial symptoms. Incidentally, the CT scan of the chest identified a tracheal mass. The bronchoscopy revealed a multilobar and regular whitish tumour with moderate vascularisation that was not causing obstruction. The patient was treated by complete resection with a rigid bronchoscope followed by cryotherapy. The histopathologic diagnosis was of a benign schwannoma without malignant elements. There was no recurrence during the follow-up period. CONCLUSIONS: There is no consensus as to the optimal management of tracheal schwannoma because of the rarity of this tumour. Our observation supports the use of endoscopic resection with the additional of local cryotherapy which may reduce the risk of recurrence.

[Pulmonary embolism diagnosed during an endobronchial ultrasound procedure]. / Embolie pulmonaire diagnostiquée au cours d'une échoendoscopie bronchique.

INTRODUCTION: Pulmonary embolism occurs frequently in lung cancer. The clinical features are non-specific and the diagnosis is often missed. CASE REPORT: A 60-year old man presented with a right upper lobe mass associated with right hilar adenopathy. Both had activity on positron emission tomography. As bronchoscopy was normal, an endobronchial, ultrasound guided, transbronchial needle aspiration (EBUS-TBNA) was performed to obtain a diagnosis. During the procedure, a hypoechogenic image was seen in the right pulmonary artery. A CT pulmonary angiogram confirmed the diagnosis of right pulmonary embolism. The transbronchial needle aspiration confirmed the neoplastic nature of the adenopathy. To our knowledge, this is the first description of a pulmonary embolism diagnosed by EBUS. This observation confirms the results of a recently published study showing that known pulmonary embolism can be detected by EBUS. CONCLUSION: Although EBUS is not the classic tool for the diagnosis of pulmonary embolism, it seems advisable to undertake a careful examination of the proximal pulmonary artery during an EBUS procedure.