[Is stairclimbing a maximal exercise test for COPD patients?]. / La montée des escaliers est-elle une épreuve d'effort maximale pour des patients BPCO ?

INTRODUCTION: Variable tests evaluate the cardio-respiratory working capacity of COPD patients. Stairclimbing testing has been less studied. Our hypothesis is that this functional exercise test represents a submaximal effort for these patients. METHOD: We compared in 10 COPD patients the main metabolic and ventilatory parameters at the end of an effort between stairclimbing and cycle ergometer test. RESULTS: The following parameters studied (RER, V'CO2, lactates, V'E) are significantly lower for stair climbing. Nevertheless, in 8 patients, the V'O2 at the end of the stairclimbing testing is equal to the cycle ergometer test and in two patients superior. Concerning the evolution of some parameters during stairclimbing, 2 distinct profiles were observed: stabilization of the V'O2, HR, V'E and Vt (6/10 patients) or a constant increase of those parameters (4/10 patients). CONCLUSION: Stairclimbing represents a submaximal effort for the majority of COPD patients combined with a high metabolic cost. However, some COPD patients execute a maximal effort like in the cycle ergometer test when climbing stairs. These two groups could not be differentiated with the rest lung function data. The hypothesis of different mechanical constraints and/or motivation is suggested.

[Determining factors of walking distance during 6-minutes walk test in COPD patients]. / Déterminants de la distance parcourue et de la dyspnée lors du test de marche de six minutes chez les patients atteints de BPCO.

INTRODUCTION: In stable COPD, we studied the factors determining six-minute walking distance and dyspnea at the end of the test. METHODS: Patients were evaluated by tests of lung function, St Georges' respiratory questionnaire (SGRQ) and 6MWT with inspiratory capacity measurements (IC) and continuous oxymetry. RESULTS: Eighty-two patients (mean FEV(1): 56+19% predicted) were studied. Mean 6-minute walking distance was 477+89m, (72+14% PV). Walking distance during 6MWT (m) was correlated with FEV(1), IC/TLC ratio, TLC, pre-test IC and DLco/VA. When expressed as a percent of predicted values, walking distance was correlated with FRC, pre-test IC and SGRQ activity score. End-test dyspnea was correlated with FRC, pre-test dyspnea and SGRQ activity and total scores. CONCLUSION: The factors determining 6-minute walking distance and end-test dyspnea are complex and include both functional and non-functional factors. In COPD, 6MWT is thus an investigation that has additional integrative value.

Clinical use of the meropenem-clavulanate combination for extensively drug-resistant tuberculosis.

Mycobacterium tuberculosis strains resistant to almost all available anti-tuberculosis drugs are an increasing threat to public health worldwide. Among existing drugs with potential antimycobacterial effects, the combination of meropenem with clavulanate has been shown to have potent in vitro bactericidal activity against extensively drug-resistant tuberculosis (XDR-TB). To explore its potential clinical efficacy, a meropenem-clavulanate-containing salvage regimen was started in six patients with severe pulmonary XDR-TB, in association with the only one or two remaining active second-line drugs. Encouraging preliminary data are detailed and discussed.

[Chest physiotherapy techniques - can they reduce hyperinflation]. / Les techniques de médecine physique peuvent-elles pallier la distension?

The authors review the literature concerning the possibilities of modifying the mechanical characteristics of the respiratory system with breathing retraining and other chest physiotherapy intervention. Breathing retraining techniques with prolonged and active expiration induce increased work of breathing and do not help diaphragmatic function. Only pursed lips breathing seems to produce some mechanical advantages. The seated and forward position with fixed arms may reduce dyspnea but this does not appear to be caused by a decrease in operating lung volumes. By contrast, the dorsal decubitus position may reduce hyperinflation, giving some mechanical advantage to the diaphragm but does not reduce dyspnea and is not a position spontaneously adopted by patients. General muscular training may reduce ventilatory demand, and by reducing respiratory frequency lead to a decrease in the end expiratory lung volume; therefore inducing improvement in exercise tolerance.

Multidrug-resistant tuberculosis: a review of the 23 cases treated by the Saint-Pierre University Hospital (Brussels).

For about fifteen years, Belgium, as other developed countries, has been confronted with multidrug-resistant tuberculosis (MDR-TB). The treatment of MDR-TB is complex, associating several antibiotics and causing multiple adverse effects. The aim of this study is to report our experience with MDR-TB at the Saint-Pierre University Hospital in Brussels.

[Manual abdominal compression for the detection of expiratory flow limitation]. / La compression abdominale manuelle dans la détection de la limitation du débit expiratoire.

INTRODUCTION: Expiratory flow limitation (EFL) is a characteristic feature of chronic obstructive pulmonary disease (COPD) and leads to dynamic hyperinflation (DH) which is a major source of dyspnoea, particularly during exercise. STATE OF THE ART: A new technique for the detection of EFL, based on manual compression of the abdomen (MCA), was assessed both in normal subjects and patients with COPD. MCA was always associated with a moderate increase in pleural pressure and allowed the detection of EFL in a reproducible manner, in both the seated and supine postures. The technique was well tolerated. It was also a reliable method for the detection of EFL during exercise since EFL detection was effectively associated with the development of DH. Finally, MCA was also compared to NEP in patients with obstructive sleep apnoea syndrome (OSAS) and in these patients, MCA invariably increased expiratory flow whereas the NEP method produced flow limitation in some cases because of upper airway collapse. PERSPECTIVES: EFL detection with MCA may be clinically useful since EFL is a determinant of dyspnoea, affects ventilatory response to exercise as well as maximum exercise capacity. CONCLUSIONS: MCA is a reliable technique for the detection of EFL in different positions, during resting breathing or exercise, requiring neither special equipment nor patient cooperation.

P0.1 during exercise in normal subjects breathing mixtures of gas with varying densities.

BACKGROUND AND AIM: The aim of the study was to re-examine the occlusion pressure measured simultaneously in the mouth (P0.1) and the oesophagus (Poes.1) during exercise in normal subjects submitted to different gas mixtures. METHODS: 7 healthy men breathing random gas mixtures containing 21% oxygen with either by 79% helium (He-O2) or sulphur hexafluoride (SF6-O2) and room-air, were studied during a steady-state 90w exercise performed on a cyclo-ergometer. Ventilatory parameters were derived from the flow signal recorded by a pneumotachograph calibrated with the different gas mixtures. Three pressure transducers (mouth, eosophageal and gastric) were checked to have iso-time identical responses up to 4Hz. P0.1, Poes.1, deltaPoes (difference in oesophageal pressure between end-inspiratory and end-expiratory levels) and deltaPdi (variation of transdiaphragmatic pressure between end-inspiratory and end-expiratory levels) were measured. RESULTS: Hyperventilation associated with a similar deltaPoes/deltaPdi but a lower P0.1/deltaPdi ratio was observed in He-O2 breathing compared to SF6-O2 and air. Variable time delays between oesophageal and mouth pressures were observed during air and SF6-O2. Whatever the condition involved, no change was detected in the shape of the inspiratory pressure during the occlusion manoeuvres. CONCLUSIONS: He-O2 breathing probably induced a change in the shape of the pressure wave later on in the inspiratory phase, making P0.1 not representing the total inspiratory drive. On the contrary in air and SF6-O2 conditions, P0.1 seemed to remain a useful tool for looking at the output of the respiratory controller.

[Respiratory physiotherapy in lung diseases]. / La kinésithérapie respiratoire dans les pathologies pulmonaires.

Functionally COPD is characterized by a reduction in airflow and an increase in dead space. Physical therapy and breathing training is designed to increase tidal volume, decrease respiratory rate and sense of dysponea. The respiratory exercises include controlled breathing, diaphragmatic and pursed-lip breathing. Postural drainage has, in most parts of the world, been replaced by airway clearance regimens that include forced expiratory manoeuvres or technique of breathing at different airflow and lung volume. Percussions and external or internal vibrations are seldom justified in adults. About instrumental chest physiotherapy with positive expiratory pressure support, the literature is confusing except for non invasive ventilation in acute stages. Dyspnoea, impaired exercise tolerance and reduced quality of life are common complaints in patients with chronic obstructive pulmonary disease. The efficacy of pulmonary rehabilitation has been strongly established by randomized controlled trials as reported by recent meta-analysis. The training intensity is of key importance. High-intensity training is feasible even in patients with more advanced COPD. There is substantial evidence that lower extremity endurance training should be included in the rehabilitation programs. There are beneficial effects of upper extremity endurance and strength training. Ventilatory muscle training may be considered in individual patients. Pulmonary rehabilitation programs must also be comprehensive and flexible to address each patients' need and include smoking cessation, optimal medical treatment, nutritional intervention, psychosocial support and health education. The maintenance of benefits after pulmonary rehabilitation is possible with minimal maintenance of activity.

Expiratory flow limitation during exercise in COPD: detection by manual compression of the abdominal wall.

Manual compression of the abdomen (MCA) during spontaneous expiration is a simple method for the detection of flow limitation in the chronic obstructive pulmonary disease (COPD) patients during resting breathing, based on comparison of flow/volume curves obtained during MCA with that of the preceding control breath. It was assessed whether this nonstandardized technique is also feasible during exercise. MCA was performed during resting breathing and constant-exercise work at one- and two-thirds maximal mechanical power output (W'max) in six normal subjects and 12 COPD patients. Changes in end-expiratory lung volume (EELV) were also studied. With the aid of inspection, abdominal palpation and lung auscultation, MCA could always be applied during expiration. Flow limitation was never detected in the six normal subjects, whereas four of the COPD patients were flow limited at rest, seven during exercise at one-third W'max and nine during exercise at two-thirds W'max. Expiratory flow limitation detected by MCA was always associated with an increase in EELV during exercise, indicating dynamic hyperinflation occurrence or increase. It is concluded that manual compression of the abdomen is a very simple and reliable method for the detection of flow limitation during exercise.

Detection of expiratory flow limitation by manual compression of the abdominal wall.

We have assessed a new method, manual compression of the abdominal wall (MCA) during expiration, in the detection of expiratory flow limitation. Twelve stable patients with chronic obstructive pulmonary disease (COPD) and five normal subjects were studied during spontaneous breathing in the supine and seated posture. MCA was performed during expiration with one hand at the umbilical level and we measured flow, volume, pleural (Ppl) and gastric (Pga) pressures and abdominal anteroposterior (AP) diameter at the umbilical level with magnetometers. No increase in expiratory flow during MCA relative to the preceding breath despite associated increases in pressures was considered as indicating expiratory flow limitation. In seven additional patients with increased upper airway collapsibility (obstructive sleep apnea syndrome [OSAS]), MCA was compared with negative expiratory pressure (NEP). In normal seated subjects, MCA was associated with a decrease in abdominal AP dimension (mean +/- SD: -27 +/- 6%), an increase in Pga (14.7 +/- 7.4 cm H(2)O) and Ppl (6.2 +/- 2.2 cm H(2)O), and an increase in expiratory flow. MCA caused similar changes in abdominal AP dimension and pressures in seated patients with COPD but six of them (50%), including four patients with FEV(1) less than 1 L, had no increase in expiratory flow. In the supine posture, MCA always increased expiratory flow in normal subjects but four additional patients with COPD showed evidence of flow limitation. MCA invariably increased expiratory flow in patients with OSAS whereas the NEP method suggested flow limitation in some cases. We conclude that MCA is a very simple method that allows detection of flow limitation in different positions.

Effect of anti-asthmatic drugs on the response to inhaled endotoxin.

BACKGROUND: Endotoxin is a pro-inflammatory agent contaminating the dust that has been associated with the risk to develop pulmonary diseases. There is no data on the protective efficacy of anti-asthmatic drugs on the response induced by inhaled endotoxin in human. METHODS: Twelve mildly asthmatic subjects were submitted weekly to bronchial challenge tests with 20 microg endotoxin. The response was evaluated by the changes in FEV1, blood cells count, neutrophils activation (measured with the luminol-enhanced chemiluminescence) and blood concentration in the acute phase proteins, C-reactive protein (CRP) and haptoglobin. In a double-blind randomized cross-over placebo-controlled design, a single dose each of 500 microg beclomethasone dipropionate, 200 microg salbutamol, and 50 microg salmeterol were administered 30 minutes before the endotoxin challenge test. RESULTS: The 20-microg endotoxin challenge test induced a significant decrease in FEV1 and luminol-enhanced chemiluminescence (P < .001 and <.05, respectively). There was an increase in the blood neutrophils count (P < .05), in CRP (P < .02) and in haptoglobin (P < .03) concentrations. Pretreatment with beclomethasone dipropionate did not have any significant effect on the response to inhaled endotoxin. Salbutamol and salmeterol completely prevent the FEV1 decline due to their potent bronchodilatation activity. Salmeterol and salbutamol did not have any significant effect on the blood inflammation induced by endotoxin inhalation. CONCLUSION: The bronchodilating properties of beta2-agonists prevent the lung function response to inhaled endotoxin. When given in a single dose, an inhaled corticosteroid does not have protective activity on the endotoxin-induced blood inflammation.

Prognostic factors for patients with small cell lung carcinoma: analysis of a series of 763 patients included in 4 consecutive prospective trials with a minimum follow-up of 5 years.

BACKGROUND: The purposes of this study were to identify prognostic factors for response to chemotherapy, overall survival, and long term survival of patients with small cell lung carcinoma and to construct a classification of patients on the basis of their expected overall survival. METHODS: In the 763 patients registered in 4 consecutive clinical trials conducted by the European Lung Cancer Working Party from 1982 to 1993, the impact of 21 pretreatment variables assessable in a routine practice was analyzed for the various outcomes with a minimum follow-up of 5 years. RESULTS: The key prognostic role of disease extent was confirmed for all the outcomes. Additional independent prognostic factors for response to chemotherapy were gender, neutrophil count, and hemoglobin level; for overall survival, these factors were Karnofsky performance status, gender, and neutrophil count. Recursive partitioning and amalgamation algorithms (RECPAM) analysis classified patients into 4 groups, taking into consideration disease extent, Karnofsky performance status, age, gender, and neutrophil count. Median survival times for the 4 groups were 60, 47, 36, and 28 weeks, respectively. For long term survival, defined as a minimum survival of 2 years (9% of the patients), Karnofsky performance status was the only independent predictive factor, along with the achievement of a complete response (if this was taken into consideration). Small cell lung carcinoma remained the main cause of death among these patients. Cure was infrequent, with only 14 patients alive and disease free at 5 years (1.8%). CONCLUSIONS: In this study the long term prognosis associated with small cell lung carcinoma was poor. The well-known prognostic values of disease extent and Karnofsky performance status were confirmed, but the authors also identified age and gender (which are more controversial) as independent characteristics, in addition to citing the role of complete response in the attainment of long term survival. The independent role of neutrophils observed by the authors. must be validated by further studies.

[Treatment of chronic obstructive bronchopneumopathies]. / Traitement des bronchopneumopathies chroniques obstructives (BPCO).

Guidelines and statements from ERS, ATS, BTS and SPLF are now available for adequate treatment of COPD. The recommendations are summarised but the author emphasizes what has changed, what remains unchanged or was adapted and what is new and promising. The therapeutic approach tends also to improve symptoms, especially dyspnea, and quality of life. This is mainly obtained with a multidisciplinary team offering the patient a program of rehabilitation.