Inflammatory bowel diseases, chronic liver diseases and the lung.

This review is devoted to the distinct associations of inflammatory bowel diseases (IBD) and chronic liver disorders with chronic airway diseases, namely chronic obstructive pulmonary disease and bronchial asthma, and other chronic respiratory disorders in the adult population. While there is strong evidence for the association of chronic airway diseases with IBD, the data are much weaker for the interplay between lung and liver multimorbidities. The association of IBD, encompassing Crohn's disease and ulcerative colitis, with pulmonary disorders is underlined by their heterogeneous respiratory manifestations and impact on chronic airway diseases. The potential relationship between the two most prevalent liver-induced pulmonary vascular entities, i.e. portopulmonary hypertension and hepatopulmonary syndrome, and also between liver disease and other chronic respiratory diseases is also approached. Abnormal lung function tests in liver diseases are described and the role of increased serum bilirubin levels on chronic respiratory problems are considered.

Early postoperative prophylactic noninvasive ventilation after major lung resection in COPD patients: a randomized controlled trial.

OBJECTIVES: To investigate whether prophylactic postoperative NIV prevents respiratory complications following lung resection surgery in COPD patients. METHODS: In seven thoracic surgery departments, 360 COPD patients undergoing lung resection surgery were randomly assigned to two groups: conventional postoperative treatment without (n = 179) or with (n = 181) prophylactic NIV, applied intermittently during 6 h per day for 48 h following surgery. The primary endpoint was the rate of acute respiratory events (ARE) at 30 days postoperatively (ITT analysis). Secondary endpoints were acute respiratory failure (ARF), intubation rate, mortality rate, infectious and non-infectious complications, and duration of ICU and hospital stay. MEASUREMENTS AND MAIN RESULTS: ARE rates did not differ between the prophylactic NIV and control groups (57/181, 31.5 vs. 55/179, 30.7%, p = 0.93). ARF rate was 18.8% in the prophylactic NIV group and 24.5% in controls (p = 0.20). Re-intubation rates were similar in the prophylactic NIV and control group [10/181 (5.5%) and 13/179 (7.2%), respectively, p = 0.53]. Mortality rates were 5 and 2.2% in the control and prophylactic NIV groups, respectively (p = 0.16). Infectious and non-infectious complication rates, and duration of ICU and hospital stays were similar between groups. CONCLUSIONS: Prophylactic postoperative NIV did not reduce the rate of ARE in COPD patients undergoing lung resection surgery and did not influence other postoperative complications rates, mortality rates, and duration of ICU and hospital stay.

Influence of ICU case-volume on the management and hospital outcomes of acute exacerbations of chronic obstructive pulmonary disease*.

OBJECTIVES: To study the relationship between case-volume and the use of noninvasive ventilation during acute exacerbations of chronic obstructive pulmonary disease in ICUs. DESIGN: A 13-year multicenter retrospective cohort study of prospectively collected data. SETTING: Medical ICUs. PATIENTS: From 1998 to 2010, patients with acute exacerbations of chronic obstructive pulmonary disease were identified through a regional database. INTERVENTIONS: The characteristics of hospitalization (including the type of mechanical ventilation) and demographic data of the patients were analyzed. ICUs were categorized into tertiles of the running mean annual volume of admissions. A logistic model performed a conditional multivariate analysis of prognostic factors after matching on a propensity score of being admitted to a high-volume unit and on the year of admission. MEASUREMENTS AND MAIN RESULTS: Fourteen thousand four hundred forty acute exacerbations of chronic obstructive pulmonary disease were identified. The Simplified Acute Physiology Score II and ICU mortality increased during the study period (36 to 41 and 12% to 14%, respectively). The proportion of patients receiving any mechanical ventilation support also increased during the study period (from 64% to 86%), with a marked increase in the use of noninvasive ventilation (from 18% to 49%) and a decrease in the use of invasive ventilation (from 34% to 19%). Participating units were distributed into low-volume (< 25 patients per year), medium-volume (26-47 patients per year), and high-volume (> 47 patients per year) tertiles. There was a significant association between case-volume and 1) the proportion of patients receiving noninvasive ventilation (highest vs lowest case-volume tertiles: odds ratio, 1.43 [95% CI, 1.23-1.66]) and 2) lower mortality. CONCLUSIONS: Between 1998 and 2010, severity and mortality of acute exacerbations of chronic obstructive pulmonary disease admitted to Collège des Utilisateurs de Données en Réanimation ICUs increased. There was an increasing use of noninvasive ventilation and a decreasing use of invasive ventilation. Use of noninvasive ventilation was related to case-volume, suggesting that increasing experience favors the use of noninvasive ventilation and was associated with a strong trend toward decreased mortality.

Chronic bronchitis in the general population: influence of age, gender and socio-economic conditions.

Chronic bronchitis (CB) is an indicator of an increased risk of developing COPD, but its symptoms are often underestimated. Demographic and socio-economic conditions might influence its prevalence, reporting and impact. Data from a large epidemiological survey of the French general population were analyzed to determine the burden of CB, the magnitude of under-diagnosis and the influence of age, gender and socio-economic conditions. Altogether, 9050 participants aged 45 years or more provided complete data. The prevalence of symptoms and diagnosis of CB was 3.5% and 3.4%, respectively. CB was associated with impaired health status and activity and, in women, work loss. Among subjects with symptoms of CB, only 28.6% declared a known diagnosis of respiratory disease. Factors associated with symptoms of CB in multivariate analysis were male gender, active smoking, lower income and occupational category: the highest prevalence was observed in manual workers (5.6%) and self-employed subjects (5.2%). The under-diagnosis of CB was more marked in men and subjects of higher socio-economic categories. These results confirm that CB is markedly under-diagnosed in the general population. Socio-economic conditions influence both its prevalence (higher in low categories) and rate of diagnosis (lower in high categories), which should be considered when elaborating prevention and detection campaigns.

[Treatment of COPD]. / Traitement de la BPCO.

COPD treatment begins with smoking cessation and influenza and pneumococcal vaccines. Bronchodilators are indicated when dyspnea on exertion is reported (usually, FEV1 < 80% predicted). On-demand short-acting agents are chosen when dyspnea is intermittent, daily long-acting agents are administered once dyspnea occurs in daily life activities. In all cases, anticholinergics and beta2 agonists can be associated when one class is not sufficiently effective. In patients with FEV1 < 50% predicted (budesonide-formoterol) or 60% predicted (fluticasone-salmeterol), repeated exacerbations and symptoms despite maintenance bronchodilators, fixed associations are indicated. When a handicap persists on pharmacological treatment, respiratory rehabilitation centered on education and exercise training has to be proposed. Care for COPD has to integrate treatment of comorbidities such as cardio-vascular diseases, anxiety-depression, malnutrition, muscle dysfunction, osteoporosis, anemia ... Ongoing research aims at identifying new therapeutic targets, focusing on inflammation, remodeling, protease-antiprotease balance, oxidative stress, lung regeneration/repair and mucus production.

Chronic obstructive pulmonary disease exacerbations in emergency departments: predictors of outcome.

PURPOSE OF REVIEW: Exacerbations have a major short-term and long-term impact on patients with chronic obstructive pulmonary disease (COPD). Risk stratification of patients presenting to the emergency department for an exacerbation of COPD is of utmost importance to help in deciding patients' orientation and treatment and in improving outcomes. RECENT FINDINGS: Studies on predictors of outcomes of COPD exacerbations are markedly heterogeneous in terms of assessed variables, outcomes of interest and timeframe (short-term vs. long-term outcomes). Age, severity of underlying disease, clinical signs of immediate severity, and comorbidities are among the most frequently identified prognostic factors of in-hospital outcome. In the most severe patients, ICU scores such as the Acute Physiology and Chronic Health Evaluation II (APACHE II) also have a prognostic value. Several biomarkers have also been studied, but their additional value for risk stratification is not clarified. SUMMARY: Scores predicting the risk of poor outcome could prove useful in the management of COPD exacerbations. Some have been suggested but remain to be further validated before their use can be generalized.

[Difficulties in the assessment of dyspnea and respiratory function in general practice]. / Difficultés de l'évaluation de la dyspnée et de la fonction respiratoire en médecine générale.

BACKGROUND: Dyspnea is one of the principal signs of chronic respiratory diseases. OBJECTIVE AND METHODS: To determine the appropriate questions and tests for recognizing dyspnea, 295 general practitioners questioned 1991 patients with or at risk of COPD in this cross-sectional study. After a brief training session, the physicians were asked to assess respiratory function with a small electronic spirometer. RESULTS: A questionnaire with a six-point semi-quantitative scale of dyspnea detected more dyspneic patients (78.1%) than the single question "Are you usually short of breath?" (68.6%), which in turn detected this symptom more often than simply listening for spontaneous complaints (33.7%). Even when dyspnea was reported only for substantial exertion, it was associated with impairment of all domains of quality of life. Only half the spirometry results met the minimal criteria of validity and reproducibility. DISCUSSION AND CONCLUSIONS: These results underline the importance of a specific, systematic assessment of dyspnea in patients at risk, and the need for sufficient training and practice before the use of electronic spirometers in general practice.

[Pharmacological treatment of stable chronic obstructive pulmonary disease]. / Traitement médicamenteux de la bronchopneumopathie chronique obstructive en état stable.

The pharmacological treatment of chronic obstructive pulmonary disease (COPD) can significantly improve quality of life by reducing exacerbations, dyspnea and exercise intolerance, thereby limiting the degree of handicap and improving daily activities. Recently, large randomised trials showed that some treatments can alter the decline in FEV1, which was previously only accessible to smoking cessation, and maybe reduce mortality. Bronchodilators are the first-line pharmacological treatment of COPD. Their clinical efficacy cannot be predicted by the inconstant changes in FEV(1.) Their main mechanism of action is the reduction in lung hyperinflation. Theophylline has a lower efficacy/tolerance ratio than inhaled bronchodilators. In symptomatic patients with FEV1 <50/60% predicted and repeated exacerbations despite bronchodilators, inhaled corticosteroids combined with long acting beta-agonists can be used. Several other approaches targeting inflammation and oxidative stress, remodelling and lung regeneration are also being studied. Medications must be associated with non-pharmacological measures (including help towards smoking cessation, education, exercise training...). Systemic manifestations of COPD must also be taken into account.

Noninvasive ventilation for acute respiratory failure after lung resection: an observational study.

BACKGROUND: A single prospective randomized study found that, in selected patients with acute respiratory failure (ARF) following lung resection, noninvasive ventilation (NIV) decreases the need for endotracheal mechanical ventilation and improves clinical outcome. METHOD: We prospectively evaluated early NIV use for ARF after lung resection during a 4-year period in the setting of a medical and a surgical ICU of a university hospital. We documented demographics, initial clinical characteristics and clinical outcomes. NIV failure was defined as the need for tracheal intubation. RESULTS: Among 690 patients at risk of severe complications following lung resection, 113 (16.3%) experienced ARF, which was initially supported by NIV in 89 (78.7%), including 59 with hypoxemic ARF (66.3%) and 30 with hypercapnic ARF (33.7%). The overall success rate of NIV was 85.3% (76/89). In-ICU mortality was 6.7% (6/89). The mortality rate following NIV failure was 46.1%. Predictive factors of NIV failure in univariate analysis were age (P = 0.046), previous cardiac comorbidities (P = 0.0075), postoperative pneumonia (P = 0.0016), admission in the surgical ICU (P = 0.034), no initial response to NIV (P < 0.0001) and occurrence of noninfectious complications (P = 0.037). Only two independent factors were significantly associated with NIV failure in multivariate analysis: cardiac comorbidities (odds ratio, 11.5; 95% confidence interval, 1.9-68.3; P = 0.007) and no initial response to NIV (odds ratio, 117.6; 95% confidence interval, 10.6-1305.8; P = 0.0001). CONCLUSION: This prospective survey confirms the feasibility and efficacy of NIV in ARF following lung resection.

FEV1/FVC and FEV1 for the assessment of chronic airflow obstruction in prevalence studies: do prediction equations need revision?

Little is known on the long-term validity of reference equations used in the calculation of FEV(1) and FEV(1)/FVC predicted values. This survey assessed the prevalence of chronic airflow obstruction in a population-based sample and how it is influenced by: (i) the definition of airflow obstruction; and (ii) equations used to calculate predicted values. Subjects aged 45 or more were recruited in health prevention centers, performed spirometry and fulfilled a standardized ECRHS-derived questionnaire. Previously diagnosed cases and risk factors were identified. Prevalence of airflow obstruction was calculated using: (i) ATS-GOLD definition (FEV(1)/FVC<0.70); and (ii) ERS definition (FEV(1)/FVC

The effect of an information leaflet upon knowledge and awareness of COPD in potential sufferers. A randomized controlled study.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is markedly under-diagnosed, which may be related to the under-reporting of symptoms and poor awareness of the disease. We hypothesized that written information on COPD may help increase awareness of the disease in people at risk of developing it. OBJECTIVES: To evaluate the impact of an information leaflet sent by postal mail on the level of knowledge of COPD in subjects with or at risk of COPD. METHODS: A total of 860 subjects with or at risk of COPD were selected by using a phone questionnaire. All subjects who reported a known diagnosis of COPD, a chronic cough and sputum production, or a smoking history of at least 15 pack-years were eligible for selection. Their knowledge of COPD was assessed during a telephone interview (baseline). They were randomized into 2 groups, with only 1 group receiving the information leaflet, and were then contacted 3 months later for a second interview. The changes in the knowledge of COPD from baseline were compared between subjects who reported receiving and reading the leaflet (true sensitized group) and subjects to whom the leaflet was not sent (control group). RESULTS: At the follow-up interview, the proportion of patients who spontaneously mentioned 'respiratory difficulties', when asked about the meaning of COPD, significantly increased in the true sensitized group (+11.9%) compared with the control group (+2.6%, p < 0.05). In addition, the frequency of patients who cited lung function test as the primary diagnostic tool for COPD increased by +14.4% in the true sensitized group versus+2.0% in the control group (p < 0.05). However, there was no short-term leaflet-dependent improvement in smoking behaviour or utilization of health-care resources. CONCLUSIONS: This study shows that an information leaflet sent by postal mail to subjects with or at risk of COPD can significantly improve their knowledge of COPD; however, it has no significant impact on their behaviour.

A review of guidelines for antibacterial use in acute exacerbations of chronic bronchitis.

Acute exacerbations of chronic bronchitis (AECB) affect a significant proportion of the adult population worldwide and are associated with a substantial socioeconomic burden. The majority of episodes of AECB are bacterial in aetiology and patients are generally treated empirically with orally administered antibacterial agents. Guidelines for the management of AECB have been developed by a number of national health authorities and international organisations, with the aim of promoting rational selection of antibacterial therapy to minimise the risk of treatment failure and subsequent hospitalisation while containing the development and spread of antibacterial resistance. This paper reviews a number of recently published or updated AECB treatment guidelines, focusing on patient stratification strategies, antibacterial treatment recommendations, and newer antibacterial treatment options, including respiratory fluoroquinolones and the ketolide telithromycin, which have recently been added to a number of national treatment guidelines.

Prognosis of cocaine body-packers.

OBJECTIVE: To study the prognosis and complications of cocaine body-packing (concealment of cocaine in the body for transportation between countries). DESIGN: We retrospectively reviewed the files of all cocaine body-packers hospitalized during a 4-year period in a medico-judiciary emergency unit. Subjects included in the survey were identified from the hospital databases using ICD-10 codes. SETTING: The Medico-Judiciary Emergency Unit of Hôtel-Dieu university hospital in Paris is a unique medical and surgical emergency unit receiving all patients in legal custody arrested at the two Paris international airports and suspected of body-packing. PATIENTS: All the cases of cocaine body-packers (n=581) hospitalized between January 1999 and December 2002 were studied. They had been arrested at Paris airports while arriving from drug-producing countries. RESULTS: The mean number of carried packets was 70.0+/-20.4 (range 18-150). The mean duration of hospitalization was 5.0+/-1.6 days (range 1-18). No complication occurred in 573 body-packers cases. Eight subjects developed a complication requiring admission to an intensive care unit: six acute cocaine intoxications due to packet rupture and two intestinal occlusions. No one died. Surgical treatment was necessary in six cases. CONCLUSIONS: Good prognosis observed in these body-packers cases is due to the careful monitoring of asymptomatic patients, allowing early detection and treatment of complications. Surgical removal of the packets when complication occurs is warranted.

Prognosis of patients with acute myeloid leukaemia admitted to intensive care.

This retrospective study assessed the prognostic factors associated with early and long-term outcome in consecutive patients with acute myeloid leukaemia (AML) admitted to the intensive care unit (ICU) over a 9-year period. A total of 83 patients were studied (age 48 +/- 16 years), among whom 60% were neutropenic on admission. For 68%, admission occurred within the first month following diagnosis of AML. The main reason for ICU admission was an acute respiratory disease in 82% of cases. Mechanical ventilation (MV) was required in 57% of patients. In-ICU mortality was 34%. Among patients discharged alive from ICU, 49% died within a year after discharge. Factors significantly associated with in-ICU death in multivariate analysis were simplified acute physiology score II and need for invasive MV (IMV). Age, performance status, AML3 subtype and complete remission were significantly associated with 1-year survival. Patients with acute respiratory failure initially supported with non-invasive MV had significantly better ICU outcome than patients initially supported with IMV. In conclusion, ICU admission is justified for selected patients with AML. The ICU mortality rate is highly predictable by the acute illness severity score. A 1-year survival is predicted by haematological prognostic factors.

[Epidemiology of chronic obstructive pulmonary disease]. / Epidémiologie de la bronchopneumopathie chronique obstructive.

Prevalence of COPD is 4 to 10% in developed countries according to spirometric studies. COPD is markedly under-diagnosed, only 1/3 of patients being recognised. COPD is the only disease whose rank among causes of death increases, placing it at the third place in 2020. In France, COPD-related annual mortality rate is 25 per 100 000, which corresponds to 15 000 deaths. Between 1990 and 2020, it will rise from the 12th to the 5th rank among causes of handicap in the world. The main risk factor is tobacco smoking. Other factors with proven responsibility in the occurrence of COPD include some occupational exposures and inherited alpha 1-antitrypsine deficiency. Other genetic factors, prematurity, bronchial hyper-responsiveness and respiratory infections may also be involved.