[Endoscopic lung volume reduction for emphysema]. / Réduction de volume pulmonaire endoscopique dans l'emphysème.

Lung hyperinflation which is a hallmark of advanced emphysema plays a major role in the exertional dyspnoea experienced by patients. This has led to the development of surgical lung volume reduction which, though effective, is also associated with significant morbidity and mortality. The goal of endoscopic lung volume reduction which has developed over several years is to decrease hyperinflation without exposing patients to the risks of surgery. Several endoscopic techniques have been assessed by high quality controlled studies: airway by-pass, instillation of glue, insertion of coils or unidirectional valves, vapour ablation. The aim of this review is to present the results of these studies in terms of functional benefit and side effects. Based on these studies, an algorithm for the endoscopic management of advanced forms of emphysema is proposed.

[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.

[Sirolimus-associated interstitial pneumonitis in a renal transplant patient]. / Pneumopathie organisée au sirolimus: un diagnostic à évoquer chez le patient transplanté d'organe.

INTRODUCTION: Sirolimus is a new immunosuppressive drug used in organ transplantation, particularly in renal transplantation. In the future, it could replace calcineurin inhibitors such as cyclosporine. It is currently associated with side effects, such as thrombocytopenia and hyperlipidemia. Several interstitial pneumonitis associated with sirolimus has been previously described in renal transplant recipients associated with marked general symptoms. EXEGESIS: We report on a 65-year-old renal recipient presenting with a non typical case of sirolimus interstitial pneumonitis. He presented with fever and marked general symptoms for several months. CT scan showed a unilateral interstitial pneumonitis. After infectious, inflammatory and tumoral diseases were ruled out, sirolimus associated interstitial pneumonitis was evoked. The patient improved quickly after discontinuation of sirolimus. CONCLUSION: It is important to evoke, after eliminating other aetiologies, sirolimus induced pneumonitis in face of an organ transplant recipient presenting with marked general symptoms even if the pulmonary symptoms are not predominant.

Somatostatin receptor scintigraphy and gallium scintigraphy in patients with sarcoidosis.

UNLABELLED: Somatostatin receptor scintigraphy (SRS) has been shown to reveal sarcoidosis sites. The aim of this study was to prospectively compare SRS and gallium scintigraphy in the evaluation of pulmonary and extrapulmonary involvement in patients with proven sarcoidosis. METHODS: Eighteen patients with biopsy-proven sarcoidosis were included. Nine were or recently had been receiving steroid therapy at the time of the examination. Planar gallium scintigraphy (head, chest, abdomen, and pelvis) and thoracic SPECT were performed at 48-72 h after injection of a mean dose of 138 +/- 21 MBq 67Ga. Planar SRS and thoracic SPECT were performed at 4 and 24 h after injection of a mean dose of 148 +/- 17 MBq 111n-pentetreotide. RESULTS: Gallium scintigraphy found abnormalities in 16 of 18 patients (89%) and detected 64 of 99 clinically involved sites (65%). SRS found abnormalities in 18 of 18 patients and detected 82 of 99 clinically involved sites (83%). Of the 9 treated patients, gallium scintigraphy found abnormalities in 7 (78%), detecting 23 of 39 clinically involved sites (59%), whereas SRS found abnormalities in 9, detecting 32 of 39 clinically involved sites (82%). CONCLUSION: This study suggests that, compared with gallium scintigraphy, SRS appears to be accurate and contributes to a better evaluation of organ involvement in sarcoidosis patients, especially those treated with corticosteroids.

Cardiopulmonary effects of bronchoalveolar lavage in critically ill patients.

Bronchoalveolar lavage (BAL) has been proposed as a useful procedure for bacteriologic diagnosis of lower respiratory tract infection in mechanically ventilated patients. To determine the cardiopulmonary effects of this procedure and to identify the patients at risk of poor tolerance, 30 critically ill ventilated patients suspected of having pneumonia were studied. Hemodynamic and gas exchange parameters were continuously recorded using an arterial catheter, a Swan-Ganz catheter with SvO2 display, and a pulse oximeter. In addition to the basal sedation required by these patients, midazolam, 0.1 mg/kg intravenously, was administered 5 min prior to bronchoscopy. A moderate increase (10 percent from basal values) in heart rate, mean arterial pressure, and cardiac index was recorded at each measurement during the procedure. A marked decrease in PaO2 was observed during bronchoscopy associated with an increase in oxygen consumption. Maximal changes in SaO2 and SvO2 were recorded at the end of BAL. Two hours after the end of BAL, PaO2 values were still 20 percent lower than pre-BAL values in 40 percent of the patients. We conclude that BAL can be performed safely in most critically ill ventilated patients who have stable hemodynamic and ventilatory parameters. However, none of the recorded parameters allows identification of the patients at risk of poor tolerance of the procedure.

Usefulness of quantitative cultures of BAL fluid for diagnosing nosocomial pneumonia in ventilated patients.

STUDY OBJECTIVE: To evaluate the role of quantitative cultures of BAL for diagnosing nosocomial pneumonia in mechanically ventilated patients. DESIGN: Cohort study. SETTING: Medical ICU, Hôpital Bichat, Paris, France, an academic tertiary care center. PATIENTS: A total of 141 episodes of suspected lung infection in 84 consecutive patients mechanically ventilated for 48 h or more. MEASUREMENTS AND RESULTS: Microbiologic findings obtained using BAL were compared with those obtained with protected specimen brush (PSB) samples and their operating characteristics were determined. The level of qualitative agreement between BAL and PSB specimen cultures was high, with 83% of the organisms isolated in PSB specimens being recovered simultaneously from BAL fluid. In addition, the results of quantitative BAL and PSB cultures were significantly correlated (rho = 0.46, p < 0.0001). Fifty-seven cases of pneumonia were diagnosed based on the following criteria: PSB sample yielding > or = 10(3) cfu/mL of at least one microorganism and/or > or = 5% of cells containing intracellular bacteria on direct examination of BAL. The operating characteristics of BAL fluid cultures were determined using different ways to report the results and over a range of values. The discriminative value of 10(4) cfu/mL was found to be an optimal threshold, with a sensitivity of 82% (95% confidence interval [CI], 76 to 88) and a specificity of 84.5% (95% CI, 79 to 90). CONCLUSIONS: These results indicate that BAL fluid cultures can offer a sensitive and specific means to diagnose pneumonia in ventilated patients and may provide relevant information about the causative pathogens.

[Pneumococci with diminished sensitivity to penicillin in pneumopathies. Clinical consequences]. / Pneumocoques à sensibilité diminuée à la pénicilline au cours des pneumopathies. Conséquences cliniques.

INCREASING PREVALENCE: Since 1988, French clinicians have been faced with an increasing prevalence of penicillin-resistant pneumococcal pneumonia. In 1996, the percentage of strains with reduced susceptibility to penicillin reached more than 40% and the number of multiresistant strains has increased steadily. CLINICAL IMPACT: Despite this apparently alarming situation, the clinical impact is not obvious. Different clinical studies have demonstrated that mortality due to pneumococcal pneumonia has not been affected by the development of resistant strains, eventually because the strains involved belong to less invasive serotypes than penicillin susceptible pneumococci. HYPOTHESIS: The preferential distribution of penicillin resistance among less invasive serotypes might explain the development of resistance in carriage strains more often exposed to antibiotic selection and the greater risk for immunodepressed subjects to acquire these strains. PRACTICAL CONSEQUENCES: To date, first-line antibiotic therapy with amoxicillin at the dose of 3g/24 h remains valid for the great majority of cases. Use of much higher dosages or other antibiotics for pneumococcal pneumonia would only be rational when penicillin minimum inhibitory concentrations are above 2 mg/l.

[The risks of bronchoscopy in coronary patients]. / Risques de l'endoscopie bronchique chez le coronarien.

In order to study the electrical changes that may occur during bronchoscopy in coronary patients we have carried out continuous electrocardiographic recordings during the course of endoscopy in 36 patients. We have been able to compare two groups: Group 1 consisting of 18 patients with coronary disease, and Group 2 with 18 non-coronary patients. There was no difference for sex, age or blood gases at the time of the examination in either group. Continuous electrocardiographic recording was started one hour before the examination and went on until two hours after, and was analysed as a function of the different durations of the endoscopy and any possible incidents. The blood potassium and the lidocaine blood levels at the end of the examination did not differ between the two groups. We observed no disorders of rhythm or of conduction. The only common change in the two groups was a frequent elevation of heart rate. There was no difference between the two groups. We have on the other hand been able to show in 3 coronary patients problems of repolarisation, which looked like current ischaemia occurring during the bronchoscopy and disappearing after the examination. We had no clinical upsets and do not have to regret having done any of the examinations, but these observations suggest we should be particularly careful in considering the indications for bronchoscopy, and the surveillance of patients during bronchoscopy where there is coronary disease.

[Induced expectoration: its role in the diagnosis of pneumocystis carinii pneumonia]. / Expectorations induites: intérêt pour le diagnostic des pneumocystoses pulmonaires.

OBJECTIVES: The purpose of this retrospective study was to describe the changes and the effect of Pneumocystis carinii pneumonia (PCP) prophylaxis on induced sputum sensitivity during these five last years METHODS: An induced sputum examination was performed in 80 cases of PCP over a 5-year period. RESULTS: The induced sputum were positive in 30 cases (sensitivity = 37.5%). This sensitivity changed very little during these five years. Thirty of these 80 patients (37.5%) received PCP prophylaxis at least for four weeks before PCP diagnosis. Induced sputum sensitivity was 50% in the group with prophylaxis versus 30% in the group without prophylaxis (p = 0.073). CONCLUSION: In our institution, the induced sputum examination remains an interesting diagnostic procedure for PCP. PCP prophylaxis does not seem to have effects on induced sputum sensitivity.

[Pneumocystis pneumonia in a patient treated with pemetrexed for non small cell lung cancer]. / Pneumocystose chez un patient traité par pemetrexed pour adénocarcinome pulmonaire.

INTRODUCTION: Pneumocystis pneumonia is a life-threatening infection in patients undergoing chemotherapy for solid malignancies. CASE REPORT: A 49-year-old man developed gradually increasing dyspnoea while receiving pemetrexed as a third line treatment for an adenocarcinoma of the lung. The diagnosis of pneumocystis pneumonia was based on ground-glass opacities on the thoracic CT scan and alveolar lavage revealing occasional cysts of Pneumocystis jiroveci in the context of recent lymphopenia developing during chemotherapy. Treatment with cotrimoxazole for three weeks was only partially successful due to progression of the tumour. CONCLUSIONS: Pneumocystis pneumonia should be considered in cancer patients receiving antifolate drugs and presenting with increasing dyspnoea. It is important to identify a high-risk population among patients undergoing chemotherapy because of the significant morbidity and mortality and in order to administer effective prophylactic agents.

Pulmonary alveolar proteinosis.

Pulmonary alveolar proteinosis (PAP) is a rare pulmonary disease characterised by alveolar accumulation of surfactant. It may result from mutations in surfactant proteins or granulocyte macrophage-colony stimulating factor (GM-CSF) receptor genes, it may be secondary to toxic inhalation or haematological disorders, or it may be auto-immune, with anti-GM-CSF antibodies blocking activation of alveolar macrophages. Auto-immune alveolar proteinosis is the most frequent form of PAP, representing 90% of cases. Although not specific, high-resolution computed tomography shows a characteristic "crazy paving" pattern. In most cases, bronchoalveolar lavage findings establish the diagnosis. Whole lung lavage is the most effective therapy, especially for auto-immune disease. Novel therapies targeting alveolar macrophages (recombinant GM-CSF therapy) or anti-GM-CSF antibodies (rituximab and plasmapheresis) are being investigated. Our knowledge of the pathophysiology of PAP has improved in the past 20 yrs, but therapy for PAP still needs improvement.

[Use of moxifloxacin in tuberculosis regimen in a French teaching hospital]. / Bilan de l'utilisation de la moxifloxacine dans le traitement de la tuberculose dans un hôpital universitaire.

OBJECTIVE: To evaluate retrospectively indications of moxifloxacin prescriptions in inpatients with tuberculosis in a referent teaching hospital. DESIGN: All patients hospitalized at Bichat-Claude Bernard hospital and who had an active tuberculosis disease with a tuberculosis regimen including moxifloxacin were included. Medical charts were retrospectively reviewed for all these patients over 21 months. Data collected were reasons for introduction of moxifloxacin in regimen. RESULTS: Out of the 23 patients included in the study, 13 of them had a recurrence of tuberculosis. Several reasons for introduction of moxifloxacin were recorded and one prescription can be associated with one or more reasons: an extra pulmonary tuberculosis or disseminated tuberculosis (16 cases), an intolerance to other anti-tuberculosis drugs (13 cases), a medical history of therapeutic failure or a proved or suspected drug-resistant Mycobacterium tuberculosis (12 cases) or to avoid drug interactions (two cases). CONCLUSIONS: This retrospective study in our hospital highlights that drug-resistance was not the first reason for introduction of moxifloxacin in anti-tuberculosis regimen. One major indication was bad tolerance to other first-line regimen drugs. A better supervision of the moxifloxacin prescription in tuberculosis regimen is needed in order to limit its ecological impact.

Concentration of meropenem in serum and in bronchial secretions in patients undergoing fibreoptic bronchoscopy.

The objective of the study was to evaluate the ability of meropenem to reach the bronchial lumen. 24 patients undergoing fibreoptic bronchoscopy for exploratory purposes were given a single dose of meropenem 1 g as an (i.v., infusion over 30 min. Plasma (P) sampling times were: 0, 0.5, 1, 2 and 3 h. Bronchial secretions (BS) were collected by fibreoptic bronchoscopy at the same sampling times (except for 0 and 0.5 h) in three groups of 8 patients. Meropenem was measured by bioassay using E. coli ATCC 39118 as the test-organism. The results showed that meropenem had reached a high plasma concentration at the first sampling time (59.8 mg.l-1) and then the plasma level decreased rapidly to 10.6 mg.l-1 and 2.7 mg.l-1 at 2 and 3 h respectively. The highest concentration achieved in bronchial secretion was 0.53 mg.l-1 in the third hour, ie 20% of the serum level. The data indicate significant penetration of meropenem into bronchial secretions and achievement of a local level sufficiently high to eradicate most respiratory pathogens.

Acute lysis pneumopathy after chemotherapy for acute myelomonocytic leukemia with abnormal marrow eosinophils.

Acute respiratory failure developed in two patients with hyperleukocytic acute myelomonocytic leukemia with abnormal marrow eosinophils within 1 to 3 days after the beginning of high-dose induction chemotherapy. The presence of moderate pulmonary leukostasis before chemotherapy initiation, the simultaneous occurrence of an acute tumor lysis syndrome, the lack of evidence of any other cause of respiratory distress, and the clinical evolution lead the authors to attribute pulmonary injury to lysis of resident leukemic cells. The responsibility of eosinophilic cellular constituents for the diffuse alveolar damage is discussed.

Follow-up protected specimen brushes to assess treatment in nosocomial pneumonia.

To prospectively determine the bacteriologic and clinical efficacy of antimicrobial therapy for nosocomial bacterial pneumonia selected based upon information provided by cultures of protected specimen brush (PSB) samples obtained during bronchoscopy, 76 consecutive patients with ventilator-associated pneumonia were studied using follow-up quantitative PSB cultures obtained after 3 days of treatment. Of the 173 microorganisms initially present in the PSB samples, only 11 (6%) were not eradicated by antimicrobial therapy, including three recovered at high (> or = 10(3) cfu/ml) concentrations. Thirty-two emerging pathogens, including nine at high concentrations, were also detected; 26 of them (81%) were resistant to the initial antibiotics administered. Of the 76 patients included in the study, cultures of follow-up PSB samples identified 51 in whom the infection site in the lung was completely sterilized, 16 with low-grade infection, and only nine with persistent high-grade infection. Analysis of clinical outcome within the 15 days after the initiation of antimicrobial therapy demonstrated clinical improvement in 62 of 67 (93%) patients in whom the site of infection was contained by treatment as compared with four of 9 (44%) patients with persistent high-grade infection (p < 0.01). These data suggest that appropriate antimicrobial therapy for ventilator-associated pneumonia results in the control of the initial infection in 88% of the patients. However, an early superinfection caused by multiresistant pathogens can occur in a small subset of these patients. When follow-up PSB cultures were negative, an improved outcome was noted.

Pulmonary Kaposi's sarcoma revealed by a solitary nodule in a patient with acquired immunodeficiency syndrome.

Kaposi's sarcoma is very common in patients with AIDS. Usually, skin lesions are associated with various visceral involvements. A homosexual patient with AIDS presented with cough and dyspnea, which were followed months later by hemoptysis. He had no skin lesions or endobronchial Kaposi's sarcoma at any time. His chest radiograph showed only an irregular solitary nodule. It exhibited very slow development over time. Surgery was performed, and this solitary nodule proved to be pulmonary Kaposi's sarcoma. Pulmonary Kaposi was the sole manifestation of this associated AIDS sarcoma. This very unusual case report of pulmonary Kaposi sarcoma indicates that this diagnosis should be considered in patients with AIDS presenting with a solitary pulmonary nodule.