[Characteristics of mild asthma: descriptive epidemiology and nature of bronchial inflammation. Position of the Mild Asthma Working Group]. / Caractéristiques de l'asthme léger: épidémiologie descriptive et nature de l'inflammation bronchique.

INTRODUCTION: Update on the state of knowledge in the mild asthma (intermittent and persistent mild asthma, according to the GINA classification) literature, and position of a French Mild Asthma Working Group. STATE OF THE ART: The French Mild Asthma Working Group (11 lung specialists, 4 paediatricians, 1 pharmacologist, and 1 general practitioner) selected, analysed, and summarised the literature on the epidemiology, physiopathology, clinical signs, and management of mild asthma. The present article shows the position of the working group on mild asthma descriptive epidemiology (causal factors excluded) and the nature of the bronchial inflammation. Clinical signs and medicinal treatments will be presented in a second article. PERSPECTIVES: Between 50% and 75% of asthma patients, depending on the study, present mild asthma. Childhood-to-adulthood cohort monitoring found severity to be unchanged over developmental time. Its generally benign evolution may in some (<10%) cases be complicated by severe episodes. Inflammation and airway-wall remodelling were always found, although of variable intensity, and non-specific (except for absence of infiltration by polymorphonuclear neutrophils). Corticosteroid therapy by inhalation reduces bronchial inflammation, but with little impact on airway-wall remodelling. CONCLUSION: The present findings should help clinicians in identifying and understanding mild asthma.

[Characteristics of mild asthma: clinical signs and medication use. Position statement of the Mild Asthma Working Group (174)]. / Caractéristiques de l'asthme léger: signes cliniques et traitements médicamenteux. Le point de vue du Groupe de Travail sur l'Asthme Léger.

OBJECTIVE: To update on the state of knowledge in mild asthma (intermittent and persistent mild asthma, according to the GINA classification) review the literature, and the position statement of the French Mild Asthma Working Group. METHODS: The French Mild Asthma Working Group (11 lung specialists, 4 paediatricians, 1 pharmacologist, and 1 general practitioner) selected, analysed, and summarised the literature on the descriptive epidemiology, physiopathology, clinical signs, and management of mild asthma. The position of the working group on the descriptive epidemiology (causal factors excluded) and the nature of the bronchial inflammation has been presented in a previous article. The present article focuses on the clinical features of mild asthma and the use of medication for it. RESULTS: Mild asthma was more frequent, more symptomatic, and less well controlled in children than in adults. Its generally benign evolution may in some (<10%) cases be complicated by severe episodes. Patients with mild persistent asthma require controller medication every day: permanent low-dose inhaled corticosteroid monotherapy is the reference foundation treatment for persistent mild asthma. CONCLUSIONS: The present findings should help clinicians and guide them in their approach to managing this condition.

[Purulent pleurisy revealing an esophageal diverticulum]. / Pleurésie purulente révélatrice d'un diverticule de l'oesophage.

We report a very rare case of a purulent pleurisy which was revealed to be caused by an oesophageal diverticulum. The pleuro-pulmonary infection probably followed the inhalation of septic material which refluxed from an oesophageal diverticulum into the trachea. This was suggested by a barium swallow which showed the transit of the barium into the trachea during swallowing movements.

[Thoracoscopic study of 6 cases of catamenial pneumothorax]. / Etude thoracoscopique de 6 cas de pneumothorax cataménial.

Six new cases seen personally, and 72 cases of catamenial pneumothorax found in the literature have had thoracoscopic talcage. We shall discuss several peculiarities of this syndrome: its relative rarity, symptoms linked to periods, the specific and unique endopleural aspects, confirming certain pathogenetic theories, the first among which is pleural endometriosis. Therapeutic methods are also discussed, stressing the sharing of the association between pleural symphysis surgically and above all by thoracoscopy with antigonadotrophic hormone therapy an association which alone gives good results in 95% of cases.

[Development over 3 years of asthma recently diagnosed in a cohort of children (ASMA study). Factors related to improvement in clinical status]. / Evolution sur 3 ans de l'asthme récemment diagnostiqué dans une cohorte d'enfants (étude ASMA). Facteurs liés à l'amélioration de l'état clinique.

OBJECTIVE: The objective of the ASMA study was to describe the evolution of light to moderate asthma, newly or recently (12 Pounds months) diagnosed in private pneumology centers, and to search for the predictive factors. METHODS: In 1995, 251 private pneumologists, throughout Metropolitan France, recruited 396 asthmatic children, 6 to 12 years old (64% boys). The 334 patients eligible for the study were examined every 4 months during 3 years (a mean of 6 controls were conducted out of the expected 9). The data were collected on standardized questionnaires completed by the physicians and notebooks filled-in by the patients the week before each control. This questionnaire comprised two asthma 'control' criteria: "control" of the clinical state, defined as asthma attacks < 1 per week AND nocturnal awakening < 1 per week AND absence of asthma symptoms between attacks on every control visit; "control" of the need for b2 mimetics on request, defined as the non-use throughout the week preceding the control visit. RESULTS: The global clinical state of the cohort rapidly improved once care was initiated: the proportion of children exhibiting at least one attack of asthma per week rapidly dropped to 43% on inclusion and to 13% on the first control visit (4 months), 10% on the second control visit, and then fluctuated at around 8% up until the last control visit. A similar evolution was noted regarding nocturnal asthma attacks. The proportion of patients with prescriptions for inhaled corticosteroids and long-lasting b2-mimetics increased over the three years of follow-up. Analysis of the factors related to the individual 'control' of the clinical state showed a negative effect in family histories of asthma (father) and the presence of smokers in the home, but above all a positive effect of compliance to treatment and particularly its understanding (OR = 2.5; p = 0.03) and respect of the doses (OR = 2.7; p < 0.01). The positive effect of compliance was confirmed by analysis of the factors related to the use of b2 mimetics on request. CONCLUSION: Smoking should be avoided in the home. Compliance to treatment could be improved by making sure that the patients and their parents fully understand the disease and its treatment, and by persuading them to strictly follow the treatments prescribed.

[Factors predicting the severity and the degree of symptom control of asthma in a recently diagnosed cohort of adult patients (A.S.M.A study)]. / Facteurs liés à la sévérité et au contrôle de l'asthme récemment diagnostiqué dans une cohorte de patients adultes.

INTRODUCTION: The aim of this cohort study was to describe the evolution of recently diagnosed (<12 months) asthma, and to identify outcome predictive factors. This paper describes the evolution of an adult cohort and the factors related to asthma severity and control. METHODS: In 1995, 251 chest specialists from throughout France, recruited 347 asthmatic adults (subjects with severe asthma were excluded). 220 eligible patients were examined every four months over a three year period. Data (socio-demographic characteristics, asthma history, results of atopy testing and lung function tests, treatment, drug compliance, respiratory infections, changes in lifestyle and environment, and major life events) were collected by means of detailed standardised questionnaires completed by physicians. Asthma severity, recorded one year after study inclusion, and asthma control, assessed at each follow-up visit in the second and third year, were defined according to the international guidelines. RESULTS: The clinical status of these adult patients generally improved rapidly. Asthma severity correlated closely with allergy, with a history of childhood asthma and with sensitisation to indoor allergens. After adjusting for severity, poor asthma control was associated with poor compliance, with respiratory infections, and, to a lesser extent, with animals inside the home. CONCLUSIONS: This cohort study highlights the association of asthma severity with allergy, and of poor asthma control with poor compliance and respiratory infections.

[Asthma in private pneumology practice]. / Asthme en pneumologie libérale.

We assessed asthma severity in patients attending private practice chest specialists, studied the factors related to classification by physicians, and described medications prescribed. 545 chest specialists scattered throughout France, included the patients examined from 3 to 28 May 1993 (N = 14,865). Besides a classification of asthma severity in four classes (mild, moderate, moderately severe, and severe), questionnaires included 20 questions on the history and characteristics of asthma, lung function level and medications prescribed. The proportion of mild asthmatics was 55% among the 3,620 children (aged 6 to 15 years), 42% among the 6,479 young adults (aged 16 to 45 years), and 18% among the 4,766 older adults (aged 46 to 75 years). Followed-up patients were considered more severe than new patients among adults, but not among children. The factors related to asthma severity were impaired FEV1, history of hospitalization, critical care and emergency visits for asthma, limitation of physical activities, and, to a latter extent, symptoms between exacerbations, frequent asthma attacks and daily use of beta 2-agonists. Anti-inflammatory drugs were prescribed to practically all patients from grade 2 (moderate): steroids increased whereas sodium cromoglycate and nedocromil decreased with increasing severity. This study provides a valuable estimate of the classification and medications prescribed to asthmatic patients examined by 50% of private practice chest specialists in France.

[Fixed-dose fluticasone-salmeterol combination: at least effective and better tolerated than open-dose combinations]. / Association fixe fluticasone-salmétérol. Au moins aussi efficace et mieux acceptée par les patients asthmatiques que les associations libres.

BACKGROUND: Asthma guidelines recommend combining inhaled corticosteroids and long-acting inhaled B2-agonists when inhaled corticosteroids alone are insufficient to achieve good control of the disease. OBJECTIVES: To determine in routine practice whether the fixed-dose fluticasone-salmeterol combination (FP/s) is as least as effective as inhaled corticosteroids combined with long-acting B2-agonists administered separately and to study patient perception. METHODOLOGY: An open multicentric randomized study was conducted in two matched populations stratified by the prior treatment. Patients insufficiently controlled by moderate-dose inhaled corticosteroids +/- long-acting B2-agonists or high-dose inhaled corticosteroids alone were treated for 3 months using one inhalation of FP/S twice daily or inhaled corticosteroids and long-acting B2-agonists given separately (TC). RESULTS: Mean improvement in morning PEFR at 3 months was 39.2 +/- 4.1 l/min with FP/S and 30.7 +/- 4.0 l/min with TC. The difference (FP/S-TC: 8.5 l/min, CI95: -0.7 - 17.7 l/min) did not reach significance. There was no difference between the two groups for criteria other than TC. Tolerance was good in both groups. CONCLUSION: The fixed-dose fluticasone-salmeterol combination is as least as effective as open combinations of inhaled corticosteroids and long-acting B2-agonists and is appreciated by patients (easier dosing, easier administration).

[Bullous dystrophy and bronchopulmonary cancer in young patients]. / Dystrophie bulleuse et cancers broncho-pulmonaires chez des sujets jeunes.

It is classically admitted that young subjects with bullous dystrophy may develop lung cancer, but this rarely occurs. We report the case of 2 patients under 40 years of age who were found to have bronchial carcinoma. In such cases the clinical signs are not different from those of ordinary bronchial cancer, but the lesions are very often located in the upper lobes, adenocarcinoma is rare in contrast with the usual cancers on scars, the histological diagnosis is difficult and the prognosis usually poor owing to frequent extension to the chest wall. The problem of cancer on bullous dystrophy is essentially that of management of the dystrophy in young subjects: systematic surgery or wait-and-see attitude?

[Resection of bronchial carcinoid tumor with the YAG-Nd laser under local anesthesia]. / Résection d'une tumeur carcinoïde bronchique au laser YAG-Nd sous anesthésie locale.

The YAG-Nd laser has been used for several years in tracheobronchial pathology. The authors report the case of an inoperable female patient with a carcinoid tumour of the left main bronchus. The laser resulted in complete removal of obstruction with an excellent clinical, radiological and isotope scan result.

[Use of the YAG laser in tracheobronchial pathology. Apropos of 154 cases]. / Utilisation du laser YAG en pathologie trachéo-bronchique. A propos de 154 cas.

The laser has been used for several years in a number of medical disciplines and more recently in pneumology. The authors report their personal experience and define two principal types of indication for this technique: iatrogenic tracheal stenoses, in which the laser is able to effectively treat granulomas and to a lesser extent stenoses, and malignant tracheo-bronchial tumours, in which the laser is usually only a palliative form of treatment which improves the quality of the patient's survival. The other indications and their results are also briefly reviewed.

[Transparietal pulmonary puncture in the diagnosis of excavated pulmonary masses. Apropos of 18 cases]. / Apport de la ponction pulmonaire transpariétale au diagnostic des masses pulmonaires excavées. A propos de 18 cas.

The aetiological diagnosis of excavated pulmonary opacities is sometimes uneasy, hovering between squamous cell carcinoma and abscess. Normal results at bronchoscopy and two weeks of antibiotic therapy do not always provide a definite answer. The authors report 18 cases of such excavated masses and conclude that transparietal needle aspiration can establish the diagnosis provided some technical procedures are followed and the samples obtained are examined by skilled cytologists.

[Management of COPD according to severity by respiratory specialists in France]. / Prise en charge de la BPCO en pneumologie selon le stade de sévérité.

INTRODUCTION: The diagnosis and treatment of chronic obstructive pulmonary disease (COPD) is suboptimal in many patients, which may impact on morbidity, mortality, use of healthcare resources and patients' overall quality of life. OBJECTIVES: To describe the management of COPD by respiratory physicians from the French mainland according to severity. METHODS: Observational cross-sectional survey performed in France in 2006-2007. 515 pulmonologists located throughout the national territory were involved and each of them had to recruit 5 patients with stable COPD. RESULTS: The study included 2494 patients (mean age 67 years, 78% males), of whom nearly 50% had severe to very severe COPD (GOLD stage III-IV). At inclusion, 93.2% of patients were receiving pharmacological treatment, most often non-nebulised bronchodilators (91.2%) and/or inhaled corticosteroids (73.7%). Pulmonary rehabilitation was scheduled or had been performed within the last 2 years in 26.9% of patients. Investigations and treatments were more frequent when the disease was more severe, but there was considerable overlap between severity grades. CONCLUSIONS: Differences in decisions about the investigation and treatment of COPD by pulmonologists can not be explained only by the severity of disease. Efforts must be made to identify other patient characteristics associated with these decisions, in order to help developing future recommendations.

Mild asthma: an expert review on epidemiology, clinical characteristics and treatment recommendations.

This review is the synthesis of a working group on mild asthma. Mild asthma includes intermittent and persistent mild asthma according to the Global Initiative for Asthma (GINA) classification, and affects between 50% and 75% of asthmatic patients. Mild asthma is more frequent, more symptomatic, and less well controlled in children than in adults. Cohort studies from childhood to adulthood show that asthma severity usually remains stable over time. Nevertheless, mild asthma can lead to severe exacerbations, with a frequency ranging from 0.12 to 0.77 per patient-year. Severe exacerbations in mild asthma represent 30-40% of asthma exacerbations requiring emergency consultation. In mild asthma, inflammation and structural remodelling are constant, of varying intensity, but nonspecific. Therapy with inhaled corticosteroids (ICS) decreases bronchial inflammation, but has only a slight effect on structural remodelling, and, when stopped, inflammation immediately recurs. Permanent low-dose ICS therapy is the reference treatment for persistent mild asthma. Effectiveness is to be reassessed at 3 months, and if it is insufficient the patient is no longer considered mildly asthmatic, and treatment has to be stepped up. As mild asthma is the most frequent form of the disease, diagnosis and management require physicians' particular attention.

Treatment of asthma by the inhaled corticosteroid ciclesonide given either in the morning or evening.

The study addressed the question whether the novel inhaled prodrug corticosteroid ciclesonide is equally effective when inhaled in the morning compared to the evening. For this purpose a double-blind, randomized, parallel group study was initiated in which 209 asthmatic patients (forced expiratory volume in one second = 50-90% predicted) inhaled either 200 microg ciclesonide in the morning or in the evening, for 8 weeks. Efficacy was assessed by means of spirometry as well as daily recordings of morning and evening peak expiratory flow (PEF), symptoms and use of rescue medication. The 24-h urinary cortisol excretion was measured to evaluate any effect on hypothalamic-pituitary-adrenol axis. Ciclesonide significantly improved asthma control. Morning and evening administration was shown to be equally effective for the different spirometry variables, evening PEF, symptoms, use of rescue medication and number of asthma exacerbations. Regarding morning PEF, the improvements after evening dosing were more prominent and equivalence of morning and evening administration could not be demonstrated. No relevant influence on cortisol excretion was found. Overall, the study indicates that ciclesonide can be given either in the morning or in the evening to meet the patients' preference and individual medical needs, although evening administration may lead to a more pronounced improvement in morning peak expiratory flow.