[Social and housing conditions of patients with chronic respiratory failure treated in the ANTADIR Federation]. / La vie quotidienne et sociale des patients insuffisants respiratoires chroniques sévères pris en charge dans le réseau ANTADIR.

INTRODUCTION: Chronic respiratory failure (CRF) has an impact on quality of life because of respiratory handicap. METHODS: The purpose of this study was to analyse the daily life and social activities of patients with CRF. A questionnaire was addressed to over 9000 patients being cared for in the ANTADIR homecare network, with over a 60% response rate. RESULTS: The data showed that patients were old, and frequently had comorbidity. The predominant diagnosis was chronic obstructive airways disease (COPD) and the number of women in this population continues to increase. Respiratory handicap led to a loss of autonomy, a reduction in social activity and mobility of patients, but the impact differed markedly according to the cause of the respiratory failure, as well as age and social class. A typological study of behavioural characteristics revealed three groups of patients with contrasting profiles. CONCLUSION: These results lead to recommendation for better management of social aspects of patient care in the ANTADIR network.

Pulmonary blood volume and haemodynamic changes with legs raised in chronic lung disease patients.

STUDY OBJECTIVE: The aim was determine the early effect of a posture change from supine (S) to legs raised 30 degrees above the table plane (LR) on haemodynamics in patients with chronic lung disease. STUDY DESIGN: Right heart catheterization was performed as part of a routine evaluation. Pulmonary arterial, pulmonary wedge, right atrial, and systemic arterial pressure were monitored at rest supine and during 8 min (steady values) after LR. Pulmonary blood volume was measured by double dye dilution, at rest S and after 1 and 8 minutes LR, in 14 patients; cardiac output was measured by thermodilution in the remaining 15 subjects, during S and 1, 4, and 8 minutes LR. SUBJECTS: 29 patients with chronic pulmonary disease of various types, mainly chronic bronchitis and emphysema, were studied when in a stable clinical condition, with no signs of heart failure. MEASUREMENTS AND MAIN RESULTS: Raising the legs produced a sharp increase in all the pressures measured, with a subsequent decline towards a steady value slightly higher than during S. Pulmonary blood volume increased in all patients initially, but stayed elevated only in the normocapnic patients; in the patients with hypercapnia it decreased from 1 to 8 min LR. The pulmonary blood volume change showed a significant correlation with PaCO2 (p less than 0.01), and with the VD/VT ratio (p less than 0.01). The relation between the pulmonary blood volume and the distending pressure changes from S to 1 and 8 min LR was linear in the normocapnic group, but not in the hypercapnic group, where it showed a hysteresis. CONCLUSION: In patients with chronic lung disease who are hypercapnic, the volume/pressure relation following leg raising cannot be expressed by a single distensibility coefficient.

Predictors of survival in patients receiving domiciliary oxygen therapy or mechanical ventilation. A 10-year analysis of ANTADIR Observatory.

STUDY OBJECTIVE: To analyze predictors of survival for patients receiving home long-term oxygen therapy (LTOT) or prolonged mechanical ventilation (PMV) according to the cause of chronic respiratory insufficiency (CRI) and the patients physiologic data. DESIGN: Analysis of a nationwide database (ANTADIR Observatory). SETTING: The national nonprofit network for home treatment of patients with CRI Association Nationale pour le Traitement a Domicile de lInsuffisance Respiratoire Chronique (ANTADIR); founded in France in the 1980s. PATIENTS: There were 26,140 patients receiving LTOT or PMV (noninvasive or via tracheostomy) between January 1, 1984 and January 1, 1993 (chronic bronchitis, 12,043; asthma, 1,755; bronchiectasis, 1,556; emphysema, 551; tuberculosis sequelae, 4,147; kyphoscoliosis, 1,574; neuromuscular diseases, 1,097; pneumoconiosis, 919; and fibrosis, 2,498. MEASUREMENTS AND RESULTS: Survival analysis was performed using the actuarial and the Cox's semiparametric model. The mean survival for patients with chronic bronchitis is 3 years. Survival is slightly better for patients with bronchiectasis and asthma and worse for those with emphysema. Patients with kyphoscoliosis and a neuromuscular disease have the longest survival (8 and 6.5 years, respectively). Patients with CRI due to tuberculosis sequelae experience the same survival as COPD patients (3 years). Prognosis is the worst in patients with pneumoconiosis or fibrosis: 50% of these patients die during the year following the beginning of home treatment. The association of an obstructive lung disease worsens the prognosis of patients with kyphoscoliosis or neuromuscular disease and tends to bring the survival rate of the patients with pneumoconiosis or fibrosis closer to that of COPD patients. In COPD, male sex, older age, lower body mass index (BMI),FEV1 percent predicted,PaO2,and PaCO2 are independent negative prognostic factors. For tuberculous sequelae and kyphoscoliosis, female sex, younger age, a high BMI, PaO2 and PaCO2 (and for kyphoscoliosis a higher FEV1/vital capacity [VC] ratio) are all independent favorable prognostic factors. In pulmonary fibrosis, a lower PaO2 and PaCO2 values, a lower VC percent predicted, and a higher FEV1/VC ratio are negative prognostic factors. CONCLUSIONS: The ANTADIR Observatory allows a unique opportunity to analyze long-term survival of a large population with CRI treated at home.

Survival and long-term follow-up of tracheostomized patients with COPD treated by home mechanical ventilation. A multicenter French study in 259 patients. French Cooperative Study Group.

To define more clearly the value of home mechanical ventilation by tracheostomy (HMVT) in patients with advanced COPD, a retrospective French multicenter study group analyzed the prognostic factors and long-term survival of 259 patients with severe COPD, who were tracheostomized for at least 1 year. Seventy-eight percent of the patients died by the end of the observation period. The actuarial survival rate for the overall study population was, therefore, 70 percent at 2 years, 44 percent at 5 years, and 20 percent at 10 years. These results appear to be better than those of the major published series and compare to the prognosis of COPD patients treated by long-term oxygen therapy (LTO) 15 hr/24 hr. The parameters most closely correlated with a survival for more than 5 years were age < 65 years, use of an uncuffed cannula, and a PaO2 > 55 mm Hg in room air during the 3 months after tracheostomy (p < 0.01). This study, therefore, confirmed the feasibility of HMVT in COPD and should lead to a review of the place of permanent tracheostomy in the long-term prognosis of severe COPD patients.

Reliability of six pulse oximeters in chronic obstructive pulmonary disease.

Six pulse oximeters with finger probes were studied in three groups of 17 hypoxemic patients with COPD aged 50 to 75 years. Transcutaneous arterial oxygen saturation (SpO2) was measured with the Nellcor N101 (oximeter 1a), the Ohmeda Biox III (oximeter lb), the Nellcor N200 (oximeter 2a), the Critikon Oxyshuttle (oximeter 2b), the Radiometer Oxi100 (oximeter 3a), and the Ohmeda Biox 3700 (oximeter 3b). The SpO2 was compared with SaO2 measured in simultaneously withdrawn samples of arterial blood (Radiometer OSM2) at three 20-minute steady-state levels of FIO2 ranging from 0.21 to 0.40 (SaO2, 62 to 100 percent). The bias (mean SpO2-SaO2 difference) and the error in precision (SD of the differences) were both below 4 percent for instruments 1a and 1b and remained below 1.2 and 3 percent, respectively, for the others. A good agreement between SpO2 and SaO2, as reflected by the Bartko intraclass correlation coefficient, was observed in instruments 2a, 3a, and 3b. The individual relationships between SpO2-SaO2 differences and SaO2 appeared to be linear and parallel. With four instruments (1a, 1b, 2a, and 2b), the mean slope of this relationship was negative, showing a systematic instrumental error: the lower the SaO2, the larger the overestimation of SaO2. The scattering of the data (precision) principally reflects a subject source of error. In most instruments a technical adjustment could greatly improve instrumental errors and accuracy. The correction of the errors due to between-subject variation would require a system of calibration adjustable by the users to each individual.

Effect of acute hypercapnia on alpha atrial natriuretic peptide, renin, angiotensin II, aldosterone, and vasopressin plasma levels in patients with COPD.

Disturbances in hormonal systems involved in sodium and water homeostasis are common during respiratory insufficiency. To investigate the role of hypercapnia, we designed a study to examine the hormonal response to acute hypercapnia induced at constant cardiac filling pressures and without hypoxemia. Seven sedated patients with COPD receiving mechanical ventilation were studied during five successive periods. Hemodynamics, arterial blood gases, and plasma hormone levels (atrial natriuretic peptide, renin, angiotensin II, aldosterone, vasopressin) were measured three times during 60 min of acute hypercapnia (52 +/- 5 mm Hg) and at control periods, before (36 +/- 4 mm Hg) and after (42 +/- 3 mm Hg) acute hypercapnia. During acute hypercapnia, mean pulmonary arterial pressure and cardiac output were increased without variation of other measured cardiorespiratory data and hormonal levels when compared with control values. After acute hypercapnia, cardiorespiratory variables returned to control values without variations of hormonal levels. Our results show that moderate acute hypercapnia does not significantly influence the hormonal levels when cardiac filling pressures and sympathetic tone remain stable. We suggest that changes in those plasma hormones involved in salt and water homeostasis during acute hypercapnia are secondary to hemodynamic changes induced by acute respiratory failure and not to acute hypercapnia per se.

Hemodynamic effects of intravenous diltiazem in hypoxic pulmonary hypertension.

The short-term effects of intravenously administered diltiazem on pulmonary and systemic hemodynamics were evaluated in patients with hypoxic pulmonary hypertension. Twelve patients were randomly assigned to two groups in a double-blind fashion. One group (eight patients) received diltiazem, and the other group (four patients) received a placebo. Three increasing doses of diltiazem (0.2, 0.3, and 0.4 mg/kg of body weight) were injected into each patient, followed each time by an infusion (2 micrograms/kg/min, 3 micrograms/kg/min, and 4 micrograms/kg/min). The effects of the drug were also compared with those of oxygen, and the combined effect of high oxygen and diltiazem was tested. The mean plasma concentrations of diltiazem were, successively, 64 +/- 4, 158 +/- 19, and 267 +/- 40 ng/ml with the three increasing doses. There was no significant effect of diltiazem on the pulmonary vascular resistance even when given with oxygen. Diltiazem was well tolerated even at high doses. The arterial oxygen pressure, systemic oxygen supply, and oxygen consumption were unchanged. We conclude that diltiazem does not seem to decrease acutely hypoxic pulmonary vasoconstriction in patients with chronic hypoxia; however, diltiazem may be given safely to these patients for other indications, such as angina pectoris.

Computed tomography in the etiologic assessment of idiopathic spontaneous pneumothorax.

In an attempt to elucidate the origin of the so-called idiopathic spontaneous pneumothorax (ISP), clinical examination, pulmonary function tests, and computed tomography (CT) with visual quantification and density analysis were performed in 20 young patients two months after an ISP episode. Twenty controls were recruited for CT. The chest roentgenograms were normal in the two groups. The results indicated the presence of various types of emphysematous lesions (EL) in the ISP group located predominantly in the apical fields with subpleural location in 16 patients. Interestingly, diffuse but moderate centrilobular emphysema was noted in 12 of 20 patients. The EL visual quantification was always less than 5 percent of the CT slices' total areas. The lung mean density shifted significantly toward the air density in the patient group (patients: -743 +/- 57.5 HU vs controls -713 +/- 59.5 HU, p less than 0.01). These findings suggest that CT may be useful for early assessment of EL in patients with ISP.

Effect of terbutaline on mucociliary transport and sputum properties in chronic bronchitis.

A double-blind study with placebo control was carried out in 20 patients with chronic bronchitis to analyze the effect of oral terbutaline on mucociliary transport and sputum properties. Terbutaline (2.5 mg tablets) was given 3 times a day for 1 week. The clinical score, forced vital capacity (FVC) and forced expiratory volume in 1 second (FEV1) significantly improved after treatment with terbutaline and confirmed the bronchodilating action of this drug. The mucociliary clearance measured with a radioactive aerosol tracer did not significantly differ after treatment with terbutaline and placebo although the initial site of aerosol deposition was similar in the two groups before and after treatment. The viscoelastic properties of sputum and their in vitro transport rate on the frog palate were not modified by terbutaline. The decrease in sputum volume and serum albumin concentration suggests a bronchial anti-inflammatory effect of this medication.

Interleukin-6, interferon-gamma, and phospholipid levels in the alveolar lining fluid of human lungs. Profiles in coal worker's pneumoconiosis and idiopathic pulmonary fibrosis.

Cytokines are widely involved in physiologic as well as immunoinflammatory and fibrosing processes of the lung. The aim of this work was to study, by bronchoalveolar lavage, two groups of human interstitial lung diseases (ILD) with fibrosing propensity (ie, idiopathic pulmonary fibrosis [IPF], n = 10; and coal worker's pneumoconiosis [CWP], n = 15). Patients were compared with nonsmoker control subjects (n = 20). Cellularity, proteins, and phospholipids were determined in the alveolar fluids. In addition, two cytokines (interleukin-6 [IL-6] and interferon-gamma [IFN-gamma]), which are presumed to possess respective antifibrotic and profibrotic activities, were measured in the respiratory tract. Compared with control subjects, IPF and simple CWP showed alveolar hypercellularity (p < 0.05) and relative lymphocytosis (p < 0.05). Both exhibited increased alveolar permeability (ie, increased albumin/urea ratio, p < 0.05), with enhanced IL-6 and decreased IFN-gamma in the alveolar spaces (p < 0.05). On the other hand, IPF displayed an associated polymorphonuclear alveolitis, enhanced alveolar epithelial lining fluid (AELF) volume and low surfactant phospholipid levels (p < 0.05 vs control), whereas simple CWP shared an exclusive lymphocytosis, normal AELF volume, and a surfactant lipid overflow (p < 0.05 vs control). Relationships among all of these parameters were found only between alveolar cellularity, neutrophils and IL-6 levels in the AELF of IPF (respectively, r = 0.85, p = 0.0009, and r = 0.89, p = 0.0006). In summary, common alterations of cellular and cytokine turnover were observed in IPF and simple CWP and may reflect activity of the antifibrotic fight in these diseased lungs. Surfactant phospholipid levels are likely to represent a specific disturbance among IPF and CWP, but no clear relationship with respect to the other parameters could be established for explaining the difference in time course outcome.

Implications of lower- and upper-limb training procedures in patients with chronic airway obstruction.

In assessing the effectiveness of lower-limb and upper-limb nonspecific physical training, we have considered 3 objectives in this study: (1) determination of clinical and functional actual state in patients with chronic airway obstruction (CAO), before and after training; (2) determination of the tests, level of work, and duration of the session training as well as how to increase the training load throughout the training program; and (3) the "particular" upper-limb exercise training in patients with CAO. Many personal factors such as psychologic (personality, degree of patient motivation), alcohol and smoking habits, physical activity, malnutrition, as well as routine tests, at rest and maximal exercise, including the control of metabolic acidosis (lactate) and arterial blood gases (or at least of SaO2), should be considered. Exercise training has the potential to improve exercise tolerance in those who develop metabolic acidosis. The pattern of lactates during exercise represents a good criterion on the selection of patient's training. Two ergospirometric strategies, at high intensity exercise, established from the anaerobic threshold (AT) are described: (a) the above AT 45 min constant exercise (high work rate), at 60% of the difference between AT and maximum VO2 or 80% of the maximal tolerated power (MTP), and (b) the "45 min square-wave endurance exercise test" (SWEET), simulating an interval training session, established from the MTP and the AT. To the SWEET's base (% MTP from AT or aerobic training), a peak of 60 s at MTP (anaerobic training) is added every 5 min. While those 2 protocols, after 6 to 8 weeks of training, lactate and ventilation were lower for identical work rate. In addition, endurance (time in "a" and total physical work in "b") increased up to 60%. Further, maximal exercise ventilation and maximum VO2 increased after SWEET training. Roughly every 7 training sessions, a 10% to 15% reduction in heart rate (HR), during the training program, allows the patient to increase the work rate of the sessions. Evaluation of training the upper limb in patients with CAO requires measurements of MTP and maximum VO2. With the upper limb (wheelchair ergometer), Wmax, maximum VO2, and HR represent 30%, 65%, and 95%, respectively, of the lower limb (ergometer). Further, some expiratory and inspiratory accessory muscles show electromyographic fatigue at the MTP upper-limb level. This may contribute to the rationale for training respiratory muscles.(ABSTRACT TRUNCATED AT 400 WORDS)

Two-dimensional echocardiographic assessment of the right ventricle in patients with chronic obstructive lung disease.

A consecutive series of 40 patients (39 men, one woman; mean age 54.1 +/- 8.2 years) with chronic obstructive lung disease (COLD) underwent right heart catheterization and 2-D echocardiographic examination within 72 hr. An adequate 2-D echocardiographic study was obtained in 32 patients (80 percent) using the apical and/or subcostal views. Mean pulmonary artery pressure at rest and during exercise were correlated with right ventricular diameters and areas in end-systole and end-diastole (r = 0.63 to 0.73). Correlations between right ventricular free wall thickness and pulmonary artery pressure were weak (r = 0.51 and 0.57). Right ventricular end-diastolic pressure was also weakly correlated with right ventricular dimensions (r = 0.45 to 0.51), whereas right ventricular area fractional shortening was not correlated with hemodynamic parameters. Patients with previous episode of right heart failure had larger right ventricles than those without such episodes. Thus, 2-D echocardiography appears useful to study the right heart chambers in patients with COLD.

Nasal intermittent positive pressure ventilation. Long-term follow-up in patients with severe chronic respiratory insufficiency.

Prior studies have shown that nasal intermittent positive pressure ventilation (NIPPV) can improve arterial blood gas values, prevent symptoms resulting from alveolar hypoventilation, and decrease hospitalization in patients with chronic respiratory failure. Most studies have involved small samples of patients followed up for a limited time. This study reviews our experience during 5 years use of NIPPV in 276 patients with kyphoscoliosis, posttuberculosis sequelae, Duchenne-type muscular dystrophy, COPD, and bronchiectasis followed up for > or = 3 years while receiving NIPPV. Outcomes were compared for patients who survived short term eg, died or converted to management with a tracheostomy and intermittent positive ventilation (TIPPV) during year 1 or year 2 on a regimen of NIPPV and long term, eg, survived more > or = 2 years on a regimen of NIPPV. The most favorable outcome was achieved by patients with kyphoscoliosis and posttuberculosis sequelae with improvement in PaO2 and PaCO2 (p < 0.0001) and a reduction in days of hospitalization for respiratory illness (p < 0.0001) for > or = 2 years while receiving NIPPV. Patients with Duchenne-type muscular dystrophy also had fewer hospital days during NIPPV (p < 0.003) but only 9 of 16 patients (56 percent) continued using NIPPV for the duration of followup. Benefit was also more short term for patients with COPD and bronchiectasis. NIPPV can sustain improvement in gas exchange, while reducing hospitalization for substantial periods of time. NIPPV can be an attractive and effective alternative to other methods of assisted ventilation such as TIPPV.

Theophylline disposition in patients with COLD with and without hypoxemia.

This study aimed to assess the effect of hypoxemia on theophylline disposition. Ten patients with a mean (+/- SEM) of 58 +/- 3 years with COLD (PaO2 55 +/- 1 mm Hg, PaCO2 46 +/- 2 mm Hg, and pH of 7.39 +/- 0.01) were hospitalized to have oxygen therapy. Before starting O2, they received intravenously, 4 mg/kg of theophylline over a 20-minute period; blood samples and urine were collected for six hours. The results suggested that hypoxia does not influence the disposition of theophylline or its metabolites.

The continuous monitoring of CO2 ductances in pulmonary intensive care.

A cardiorespiratory monitoring system allows the measurement of FAECO2 and FECO2 in the expired air of the patient at the mouth (endtidal CO2) and in a mixing box. From these parameters, combined with the measured PACO2, the alveolo-expired (DuA = PECO2/PAECO2) and alveolar-arterial (Dua = PAECO2/PACO2) ductances which assimilate the respiratory system to a two-stage exchanger have brought about a lot of valuable information 1. DuA improves by 20% in 20 patients after removal of bronchial obstruction (p < 0.001) and by 9% in 7 intubated patients after tracheotomy (p < 0.02). DuA falls by 15% (p < 0.001) in 10 patients with hypocapnia (PaCO2 = 28 mmHg) after a dead space adjunction with the aim of normalizing PaCO2 (paCO2 = 35 mmHg). 2. Dua falls by 33% in six patients after pulmonary embolism, proved by angiography (p 0.001) by 9% in 34 patients after 30 min of pure oxygen breathing (p 0.001). On the other hand, inthe absence of clinical or radiological pulmonary edema, in increases by 19% in 38 patients with hypervolemia after diuresis (furosemide) (p < 0.001). Thus since DuACO2 varies with anatomical dead space and the air distribution disorder, DuaCO2 evolves according to the disorders of the blood distribution and arterial-alveolar diffusion. The determination of these coefficients, in the absence of significant changes in the arterial blood gases, helps the diagnosis, guides the early treatment and allows for the monitoring of its efficiency.

Evaluation of efficacy and safety of erdosteine in patients affected by chronic bronchitis during an infective exacerbation phase and receiving amoxycillin as basic treatment (ECOBES, European Chronic Obstructive Bronchitis Erdosteine Study).

An international multicentric study was conducted with the aim of demonstrating that erdosteine improves the efficacy of amoxycillin in the treatment of infective exacerbation of chronic bronchitis mainly on the clinical symptomatology (primary objective), on spirometric tests and body temperature, without negatively influencing the tolerance (secondary objectives). The study was conducted as a prospective evaluation, with 2 comparative groups treated with erdosteine (300 mg x 2/day) or placebo in association with amoxycillin (1500 mg/day) for a maximum of 10 days. The design of the trial was double-blind and parallel group with 2 subgroups. The treatments have been assigned randomly to a population of chronic bronchitic patients in exacerbation phase of n = 237 subjects. The study was conducted according to the principles of the Declaration of Helsinki and its amendments (Hong Kong, September 1989). The primary end-point used to determine effectiveness in this study was the global clinical assessment (GCA) which was choosen as a general indication of activity with objective/subjective evaluation of the clinical picture. Secondary endpoints of efficacy are sputum parameters, functional signs of chronic obstructive bronchitis, spirometric tests and overall judgement of efficacy. Safety was evaluated with adverse drug reactions reporting, arterial blood pressure, heart rate and laboratory tests monitoring. The obtained values have been analyzed with two-way and factorial ANOVA, Least Squares Catmod-SAS, Wilcoxon and Chi-square tests. The number of patients included in the effectiveness analysis is of n = 226 subjects, due to the fact that 11 patients were lost due to different reasons. In term of results as far as the primary objective of the study was concerned, erdosteine resulted more active than placebo. The analysis evidenced a very significant difference for treatment, time and interaction time x treatment. No difference on the contrary was observed for center and the interaction center x treatment. Sputum volume, body temperature and spirometric parameters were not significantly influenced by both treatments. Viscosity, appearance as well as functional signs evidenced a modification over time in favour of erdosteine. As safety is concerned the majority of adverse events, both in the erdosteine and in the placebo group, were related to the gastrointestinal area. For erdosteine, of 9/17 side-effects, 3 were epigastralgias, 3 nauseas, 1 diarrhoea, 1 taste loss, 1 hemorrhoids. For placebo of 13/17 related events 3 were epigastralgias, 4 nauseas, 4 diarrhoeas, 1 pyrosis, 1 dry mouth. In terms of severity they have been all defined as mild or moderate degree. Also from a qualitative perspective it is clear that there are no relevant differences between the 2 treatments under evaluation, concerning safety. In conclusion of particular interest is the datum arising from the efficacy/safety evaluation, which indicates that the clinical picture is modified earlier and at deeper degree by the synergistic activity of erdosteine and of the antibiotic without the risk of an augmentation of side-effects incidence.

[Methotrexate pneumonitis arising during the treatment of non-Hodgkin's lymphomas with the m-BACOD protocol]. / Pneumopathies du méthotrexate survenant dans le cadre du traitement des lymphomes non hodgkiniens par le protocole m-BACOD.

We retrospectively studied 32 patients treated with the m-BACOD regimen in a single institution between January 1988 and December 1991. After four to seven courses, four patients presented severe acute pneumonitis (PaO2 < 55 mmHg in room air), with diffuse bilateral interstitial syndrome. Broncho-alveolar lavage displayed increased lymphocyte count (> 45%) with inversion of CD4/CD8 in two cases and no evidence of parasitic, bacterial or viral infection. All patients received methyl-prednisolone (0.5 to 1 mg/kg/d x 1 week) with both complete clinical and radiological recovery within a week. The m-BACOD regimen was continued without bleomycine for four patients and without bleomycine plus methotrexate for two patients, until the completion of eight courses, without recurrence of pneumonitis. Drug-exclusion decisions were made empirically because the exact nature of the pneumonitis was not recognized at the time of diagnostic. Because of the regular administration in the m-BACOD regimen, methotrexate leads to an increased risk of pneumonitis. We concluded that the use of the m-BACOD regimen should henceforth be discontinued.

[Anomalies of mucus and bronchial pathology in adults]. / Anomalies du mucus et pathologie bronchique de l'adulte.

Recent studies have shown that normal bronchial secretion composed of proteoglycans, atypical glycoproteins and neutral lipids neither includes mucins nor glycolipids, nor phospholipids. The rheological characteristics of bronchial mucus thus depend on mucociliary clearance and clearance of bronchial secretions by cough, which in turn depend on the properties of the glycoprotein acids secreted and on the degree of their entanglement which is linked to their water content and on the chemical bonds with other protein or lipid components which are present in the secretions. Chronic bronchitis, asthma and bronchorrhoea allow for changes in the biochemical composition and the physical and rheological characteristics of the bronchial mucus which alter the clearance. In certain conditions mucus plugs can form. An understanding of the pathology of bronchial mucus in the adult enables one to choose the best therapeutic prescriptions but the efficacy of measurements available remains imperfect.

[Home ventilation after intensive care]. / La ventilation à domicile après un séjour en réanimation.

In the course of chronic respiratory insufficiency, acute episodes often require the use of mechanical ventilation. Failure of weaning, or worsening of alveolar hypoventilation, results in long term ventilatory assistance with the need of overall care of the patient. The pneumologist has a key role in the choice of indications, devices and mode of home mechanical ventilation. Thanks to the non-invasive ventilation with a facial or nasal mask, tracheostomy is less often needed. Respiratory failure due to lung restriction is the best indication of mechanical ventilation. The results in COPD are questionable. Whatever to the technique of ventilation and the underlying disease, the pneumologist has to ascertain the steady state of the medical condition, patient and family education, and social situation, all factors to be taken into account before the patient can be discharged. Knowing the specific needs in these patients'care, the pneumologist plays a key role at each stage of home return and follow-up. He co-ordinates the different aspects of pneumological care, like rehabilitation and acute episodes treatment. The overall care of the patients should be improved by the development of health networks in the field of chronic respiratory insufficiency.

[Evaluation of smoking in chronic severe respiratory insufficiency patients treated with long-term oxygen at home]. / Evaluation du tabagisme chez les insuffisants respiratoires chroniques graves traités par oxygène de longue durée à domicile.

Two hundred and fifty patients with chronic respiratory insufficiency (202 men and 48 women), being treated by oxygen therapy at home were included in a study, which aim was to estimate the proportion of patients who were either smokers or exposed to passive smoking, by the use of a questionnaire and measurement of cotininuria. Urinary sample and autoquestionnaire collection was carried out by the nurses of the Lorraine's association of home respiratory assistance. Urinary continine was measured by radio immuno assay. Twenty one smokers, 186 ex-smokers and 43 non-smokers were identified through the questionnaire. Of the 21 self confessed smokers 20 had a urinary cotinine level over 250 ng/ml, 1 smoker lower than 250 ng/ml; among the professed non-smokers, 42 had a level lower than 100 ng/ml and 1 over 250 ng/ml but the contininuria creatinuria ratio classified this latter in the non-smokers non exposed to passive smoking group. Among the 186 declared ex-smokers, 20 over 250 ng/ml were probably smokers, 160 lower than 100 ng/ml could be considered as non-smokers, and finally 100 in between could be assessed as non-smokers exposed to passive smoking. The results enabled 43 smokers (17%) and 5 (2%) exposed to passive smoking to be identified. They confirm the unreliability of smoking habits questionnaires and the importance of cotininuria in the detection of nicotine poisoning.