Titrated mandibular advancement versus positive airway pressure for sleep apnoea.

The aim of this study was to compare mandibular advancement device (MAd) therapy and continuous positive airway pressure (CPAP) for obstructive sleep apnoea/hypopnoea syndrome (OSAHS) after one-night polysomnographic (PSG) titration of both treatments. 59 OSAHS patients (apnoea/hypopnoea index (AHI): 34+/-13 events x h(-1); Epworth scale: 10.6+/-4.5) were included in a crossover trial of 8 weeks of MAd and 8 weeks of CPAP after effective titration. Outcome measurements included home sleep study, sleepiness, health-related quality of life (HRQoL), cognitive tests, side-effects, compliance and preference. The median (interquartile range) AHI was 2 (1-8) events x h(-1) with CPAP and 6 (3-14) events x h(-1) with MAd (p<0.001). Positive and negative predictive values of MAd titration PSG for treatment success were 85% and 45%, respectively. Both treatments significantly improved subjective and objective sleepiness, cognitive tests and HRQoL. The reported compliance was higher for MAd (p<0.001) with >70% of patients preferring this treatment. These results support titrated MAd as an effective therapy in moderately sleepy and overweight OSAHS patients. Although less effective than CPAP, successfully titrated MAd was very effective at reducing the AHI and was associated with a higher reported compliance. Both treatments improved functional outcomes to a similar degree. One-night titration of MAd had a low negative predictive value for treatment success.

Prevalence of residual excessive sleepiness in CPAP-treated sleep apnoea patients: the French multicentre study.

The percentage of compliant continuous positive airway pressure (CPAP)-treated apnoeic patients that continue to experience residual excessive sleepiness (RES) is unknown. RES was defined by an Epworth Sleepiness Scale (ESS) score of >or=11. In total, 502 patients from 37 French sleep centres using CPAP >3 h night(-1) attending their 1-yr follow-up visit were eligible. ESS and polysomnographic data as well as symptoms, quality of life, depression scores and objective CPAP compliance at 1 yr were collected. Overall, 60 patients remained sleepy on CPAP (ESS 14.3+/-2.5) leading to a prevalence rate of RES of 12.0% (95% confidence interval (CI) 9.1-14.8). After having excluded associated restless leg syndrome, major depressive disorder and narcolepsy as confounding causes, the final prevalence rate of RES was 6.0% (95% CI 3.9-8.01). Patients with RES were younger and more sleepy at diagnosis. The relative risk of having RES was 5.3 (95% CI 1.6-22.1), when ESS before treatment was >or=11. Scores of emotional and energy Nottingham Health Profile domains were two times worse in patients with RES. As 230,000 obstructive sleep apnoea patients are currently treated in France by continuous positive airway pressure, more than 13,800 of them might suffer from residual excessive sleepiness.

[Practical aspects of the management of patients treated by continuous positive airway pressure]. / Le suivi pratique des patients sous pression positive continue.

The therapeutic follow-up is a decisive factor of the success of a long course treatment by continuous positive airway pressure (CPAP). The effectiveness of this treatment on both symptoms and complications must be regularly verified. Polysomnography with CPAP could be necessary in order to check out the efficacy of this treatment and/or to find an associated diagnosis when symptoms persist, particularly a diurnal drowsiness, which is the main therapeutic target in obstructive sleep apnea syndrome (OSAS). The secondary effects that are likely to compromise the compliance of CPAP treatment must be resolved, particularly the nasal intolerance, which are enhanced by mask leakages and often corrected by using heated humidity with CPAP delivery systems. The efficacy of CPAP on both diurnal drowsiness and hypertension is related to the compliance of this treatment which must be regularly verified, at the same time that the clinical evaluation. The data obtained from the device's memory give information concerning the number of hours day to day, in which the CPAP device was running at the prescribed pressure. The first months with CPAP are decisive to avoid a failure of the treatment at long term. This period must be closely monitored by both the physician and the home care provider. Patients should use the CPAP at least 3-4 h by night and all possible means should be used to obtain a maximal compliance. Therapeutic educational programs could help to reach this goal.

[Drug-induced pneumonitis in a patient treated with venlafaxine and propanolol]. / Pneumopathie médicamenteuse sous traitement par venlafaxine et propranolol.

INTRODUCTION: Venlafaxine and propranolol have rarely been identified as causes of pulmonary pathology. We describe a case of drug-induced pneumonitis occurring in a patient treated with these two medications. CASE REPORT: A 55 years old woman with liver cirrhosis treated with venlafaxine for 1 year and propranolol for 1 month was admitted to the intensive care unit because of acute respiratory failure. A Mycoplasma pneumoniae pneumonitis was diagnosed. After initial improvement under antibiotics, a new deterioration of respiratory status was observed 4 days after the reintroduction of venlafaxine and propranolol. Spontaneous recovery occurred after these treatments were withheld. Co administration of venlafaxine and propranolol, 2 drugs with affinity for the same cytochrome P450 isoenzyme (CYP2D6), may have contributed to drug accumulation and pulmonary toxicity. The liver cirrhosis of our patient may also have contributed to decreased cytochrome P450 enzymatic activity. CONCLUSIONS: Venlafaxine and propranolol share the same metabolic pathway and their co-administration may be complicated by drug induced pneumonitis.

[Prevalence of symptoms of sleep apnea syndrome. Study of a French middle-aged population]. / Prévalence des symptômes du syndrome d'apnées du sommeil. Etude dans une population française d'âge moyen.

OBJECTIVE: To study the prevalence of symptoms of sleep apnoea syndrome (SAS) in a large French middle-aged population and to establish what proportion have symptoms that justify further investigation with a sleep study. METHODS: We performed a cross-sectional study of 2,195 men and 2,247 women, 33 to 69 year old (DESIR. cohort) recording responses to a self-administered "sleep" questionnaire and a general questionnaire including socio-economic characteristics and lifestyle factors. RESULTS: The prevalence of symptoms in men and women were respectively: snoring frequently (28%, 14%), frequent daytime sleepiness (14%, 18%) and frequent apnoeas (5%, 2%). Overall, 8.5% of men and 6.3% of women reported a pattern of symptoms suggestive of OSA, as they snored and had daytime sleepiness and/or apnoeas. This pattern was associated, for both sexes, with age, body mass index and after adjustment on these two factors, to a mediocre self-reported health status and treatment with benzodiazepines or other sedatives. For men only, the OSA pattern of symptoms was also associated with, hypertension, alcohol consumption and smoking. CONCLUSION: Snoring, daytime hypersomnolence and witnessed apnoeas are symptoms frequently observed in the general population. Subjects with a combination of these abnormalities suggesting a high probability of sleep apnoea syndrome and in whom a sleep study is warranted represent 7.5% of the adult population.

[Central apnea developing during treatment with a mandibular advancement device]. / Apnées centrales induites sous traitement par orthèse d'avancée mandibulaire.

INTRODUCTION: Mandibular advancement (MA) has emerged over the last decade as an alternative solution to nasal continuous airway pressure (nCPAP) for the treatment of obstructive sleep apnea syndrome (OSAS). OBSERVATION: We report the case of a patient with history of chronic atrial fibrillation and moderate supine-dependent OSAS in whom central sleep apneas developed during treatment by a bi-bloc MA device. Central apneas increased with the level of MA and preferentially occurred in the supine position. We hypothesized that mouth opening under excessive mandibular advancement in supine position may have led to pharyngeal narrowing at the base of the tongue and potentially unstable ventilation. Sleep fragmentation that enhanced during progressive MA may also have compromised ventilatory control stability in our patient. Finally, chronic atrial fibrillation may have predisposed to central sleep apneas. CONCLUSION: Our case report highlights the importance of follow-up nocturnal recordings during progressive MA.

[An unusual cause of pulmonary cysts]. / Une cause inhabituelle de kystes pulmonaires.

INTRODUCTION: Multiple pathologies may be associated with cystic appearances in the lungs. Lymphangioleiomyomatosis, Langerhans cell histiocytosis and lymphocytic interstitial pneumonia are the principal causes of thin walled pulmonary cysts. CASE REPORT: We report the case of a non-smoking woman of 71 years, a retired farmer, who was admitted on account of cough, increasing dyspnoea, fever and loss of weight that developed following exposure to hay. The thoracic CT scan revealed diffuse ground glass opacities and centrilobular nodules. Multiple thin walled cystic shadows were distributed homogeneously throughout both lung fields. Broncho-alveolar lavage revealed a marked lymphocytosis (63%) and precipitins for Microsporum Faeni were strongly positive (6 arcs). The respiratory symptoms resolved spontaneously during the stay in hospital, allowing the patient to be discharged after 3 weeks with the advice to avoid all contact with hay. One month later she remained symptom free, the repeat CT scan showed a diminution ofthe ground glass opacities and the nodules but persistence of the pulmonary cysts. CONCLUSION: The diagnosis of hypersensitivity pneumonitis should be considered in the presence of a diffuse pulmonary infiltrate with multiple thin walled cysts in a patient with a suggestive history and clinical picture.

[Treatment of a compressive bronchogenic cyst by computed tomography-guided needle aspiration]. / Traitement d'un kyste bronchogénique compressif par ponction sous tomodensitométrie.

INTRODUCTION: Bronchogenic cysts are benign tumours of the posterior or middle mediastinum. Treatment usually consists of complete surgical resection. We report the case of an elderly woman presenting with an inoperable bronchogenic cyst causing tracheal compression which was treated successfully using computed-tomography (CT)-guided needle aspiration. CASE REPORT: A 92 years old woman was admitted for inspiratory dyspnoea associated with stridor. She reported the incidental discovery of a right paratracheal mass, 2 years previously. Thoracic CT scan and bronchoscopy revealed a large mediastinal bronchogenic cyst causing tracheal compression. Surgery was contraindicated because of the patient's age and cardiac disease. CT-guided needle aspiration of 250 ml of viscous fluid was performed, followed by rapid clinical improvement. The patient remained symptom free for several months. The procedure was repeated successfully one year later because of a recurrence of compression. CONCLUSION: This observation supports the potential use of CT guided transthoracic needle aspiration as an alternative to surgical treatment in cases of inoperable symptomatic bronchogenic cyst.

[Long term use of nCPAP therapy in sleep apnoea patients]. / Acceptation a long terme du traitement par pression positive continue.

INTRODUCTION: Although obstructive sleep apnoea syndrome (OSAS) is usually a lifelong condition, little is known about compliance with nasal continuous positive airway pressure (nCPAP) over longer periods of follow up. METHODS: Long term acceptance of nCPAP was evaluated retrospectively using a survival analysis in 137 consecutive patients who started nCPAP therapy for OSAS between 1985 and 1993. RESULTS: During a mean follow-up of 9.2 +/- 4.7 years, 30 patients died, 5 were lost of follow-up and 30 patients stopped their treatment most of them during the first 5 years. In compliant patients, the median value of daily nCPAP use was 7.5 hours. Kaplan Meier analysis showed that 82% of patients were still using nCPAP at 5 years, 77% at 10 years and 61% at 15 years. Multivariate analysis showed that OSAS severity was an independent predictor of long-term nCPAP use. The rate of nCPAP acceptance at 10 years was 82% in patients with an apnoea-hypopnoea index (AHI) > or = 30 compared to 58% in patients with AHI < 30. CONCLUSION: nCPAP is a suitable long-term therapy for OSAS, particularly in patients with more severe disease, with more than 80% of patients continuing to be compliant with treatment at 10 years.

[Invasive pulmonary aspergillosis complicating septic shock]. / Aspergillose pulmonaire invasive compliquant un choc septique.

INTRODUCTION: Invasive pulmonary aspergillosis (IPA) is an opportunistic infection with a poor prognosis, occurring primarily in patients who are severely immunocompromised. CASE REPORT: We report a case of IPA that occurred in a 37-year-old woman with no history of previous immunosuppression or significant co-morbidity. She was admitted to our intensive care unit (ICU) with septic shock and multi-organ failure complicating a bacterial pneumonia. After an initial improvement, her condition deteriorated on the 10th day after admission with fever and lesions consistent with IPA seen on high-resolution computed tomography (HRCT). IPA was confirmed by isolating Aspergillus fumigatus from bronchoalveolar lavage and by a positive circulating galactomannan test (sandwich ELISA). First line therapy with voriconazole had to be stopped after 12 days due to hepatic toxicity. The patient was successfully treated with caspofungine for 2 months then itraconazole for 4 months with progressive improvement of HRCT abnormalities. Her galactomannan test became negative at 6 months. CONCLUSION: The diagnosis of IPA must be considered in critically ill patients even in the absence of underlying immunosupression where suggestive HRCT abnormalities occur in the context of septic shock and multiple organ failure.

Altered trabecular architecture induced by corticosteroids: a bone histomorphometric study.

Prolonged corticosteroid (CS) therapy induces osteoporosis and fractures. Osteoporosis is characterized at the histomorphometric level by reduced bone volume (BV/TV) and disruption of the three-dimensional (3D) trabecular architecture. Several stereological methods have been proposed to characterize these alterations: measurements of trabecular thickness and trabecular number, star volumes, interconnectivity index (ICI) of the bone marrow spaces, and trabecular bone pattern factor (TBP(f)). These methods were computerized with a single program running on an image analyzer to evaluate the bone changes in a series of iliac biopsies performed on 31 male patients. All of them were asthmatic and had received CS for a long period of time. BV/TV was reduced when compared with age-matched controls. In the CS-treated population, exponential relationships were obtained between bone volume and the different connectivity parameters. The various methods used to measure connectivity were well correlated. When the population was divided into two groups (BV/TV greater or less than an 11% threshold), the architectural disturbances were found to imply two mechanisms. A progressive decline in trabecular thickness was noted in both groups versus controls. Trabecular perforations were not established in the group with BV/TV> 11% with the star volume or ICI, although some alterations were detected by trabecular bone pattern factor measurement. However, perforations were revealed in the group with BV/TV < 11% by all the different methods. Perforations seemed to occur when the trabecular thickness was below 70 mu m. This strongly suggests that bone histomorphometry should take into consideration bone volume in combination with detailed 3D descriptors of the trabecular architecture. Several histological methods need to be used in combination to appreciate the 3D architecture of trabecular bone.

Forced expirations in normal subjects. Is the shape of the flow rate curve related to existence of a wheeze?

The flow rate curve takes different shapes during forced expirations performed by normal subjects. In some cases a wheeze may exist. In this study, we examine the conditions for appearance of a wheeze, before and after the peak flow, and the relationship between the wheeze and the shape of the flow rate curve. We analyzed ten parameters in 83 forced expirations produced by 32 normal subjects (16 men and 16 women) using multidimensional scaling techniques. Among these expirations, 53 presented a wheeze. The first two axes of the analysis define a plane on which forced expirations are divided into four quadrants. Two opposite quadrants (upper right and bottom left) contain the wheezing expirations, while the two others only have the ones with no wheezing. This distribution corresponds to specific shapes of the flow rate curve. We found that wheezes are associated with two main shapes. One of them consists of a short onset until a sharp peak, followed by a fast exponential decay. The other is about triangular, with a late appearance of the wheeze, and is only produced by women.

Accidents in obstructive sleep apnea patients treated with nasal continuous positive airway pressure: a prospective study. The Working Group ANTADIR, Paris and CRESGE, Lille, France. Association Nationale de Traitement à Domicile des Insuffisants Respiratoires.

Many studies have shown a relationship between obstructive sleep apnea (OSA) and accidents, but to our knowledge, none have investigated prospectively the effects of treatment with nasal continuous positive airway pressure (CPAP). CPAP was proposed to 973 patients, of whom 893 patients actually underwent CPAP. These patients were consecutively invited to enter a prospective follow-up study including a questionnaire before treatment and after 6 and 12 months of treatment; 547 patients completed the study (153 left the study, and only partial data were available for 193). The baseline questionnaire included questions concerning accidents in the previous 12 months, asking whether patients had had an accident and, if so, whether they felt that the accident(s) were related to sleepiness, and whether the patients felt that they had had near-miss accidents due to sleepiness. The questionnaires at 6 and 12 months included the same questions referring to the previous 6 months; the accidents reported on each follow-up questionnaire were cumulated and compared with the accidents during the 1-year period before treatment. The number of patients having an accident decreased with treatment for real accidents (from 60 to 36; p<0.01), as well as for near-miss accidents (from 151 to 32; p<0.01). The average number of accidents per patient also decreased, for real accidents (from 1.6+/-1.3 to 1.1+/-0.3; p<0.01) and for near-miss accidents (from 4.5+/-6.5 to 1.8+/-1.4; p<0.01). The cost, in terms of days in hospital related to accidents, decreased from 885 to 84 days. With caution due to the absence of a control group, it is suggested that treatment with CPAP decreases the number of accidents occurring in OSA patients. This result may have important implications in the evaluation of the cost/benefit ratio when treating OSA patients.

[Epidemiological definition of obstructive sleep apnea syndrome]. / Définition épidémiologique du syndrome d'apnées obstructives du sommeil.

Obstructive sleep apnea syndrome (OSAS) is currently a clinically defined syndrome associating somnolence and on or two of the following symptoms: severe snoring, nocturnal respiratory arrest, repeated nocturnal awakening, non-recuperative sleep, diurnal fatigue, and altered concentration. The polysomnographic criterion is a more than 5 apnea-hypopnea episodes plus micro-awakenings related to respiratory efforts per hour of sleep. The epidemiological definition of OSAS is different because the prevalence of OSAS is estimated from the prevalence of the apnea-hyponea index (AHI) per hour of sleep and the prevalence of somnolence in the population. Epidemiological studies have produced different estimates of the prevalence of OSAS. The differences are less pronounced but still persist when comparing studies with a similar methodology, an identical sample, and sleep laboratory polysomnography recordings. These differences are related to the populations studied and also to the recording methods with different sensitivity and specificity. The difference between the prevalence P, which is the ratio between the number of patients in the study population, and the number Q, which is the ratio of the number of positive tests in the population, depends on the sensitivity and the specificity of the test used. The prevalence is also equal to the number of positive tests only if the sensitivity and specificity are both 1. The most widely used method, the thermistance method, has poor sensitivity and specificity. Prevalence is probably underestimated with this test. A rigorous consensual definition of this OSAS and abnormal ventilatory events as well as standardized diagnostic tests adapted for epidemiology studies are indispensable.

[Obstructive sleep apnea syndrome and cardiovascular risk]. / Syndrome d'apnées obstructives du sommeil et risque cardio-vasculaire.

Numerous studies have shown that obstructive sleep apnea syndrome (OSAS) is associated with an increased cardiovascular morbidity and mortality. Obstructive sleep apnea syndrome and cardiovascular disorders are frequent diseases. They share several risk factors such as age, gender, obesity, smoking, and alcohol. Therefore it is difficult to demonstrate that OSAS is a cardiovascular risk factor, independent of previously known factors. Recent epidemiological studies and trials, consistent with the results of previous studies, have demonstrated a strong association between OSAS and systemic hypertension. They also suggest that there is a possible cause-effect relation between OSAS and coronary artery disease or cardiac arrhythmias. Studies demonstrating that early recognition and treatment of OSAS may be effective in reducing these cardiovascular complications are still needed.

[The analysis of bronchial obstruction and its reversibility after bronchodilators using a study of "density-effect" on maximum flow]. / Analyse de l'obstruction bronchique et de sa réversibilité après bronchodilatateurs par l'étude de l' "effet-densité" sur les débits maximaux.

The change in maximal expiratory flows after inhalation of gases of various physical properties is studied since 1963. The Montreal team proposed in 1972 the helium-to-air difference in maximal expiratory flows at low lung volumes (delta He) and the volume at which the flows breathing air and the helium-oxygen mixture (the "volume isoflow" - Viso V) as "sensitive tests" for the detection of peripheral airway obstruction. "Density-dependence" (DD) has been widely used subsequently in the study of the site of bronchial obstruction in asthmatics in smokers, in subjects with early chronic bronchitis, subjects with occupational exposures to respiratory irritants, etc. The site of action of bronchodilators according to their nature or route of administration (atropine derivates acting on "central airways", "global" bronchodilation obtained by parenteral administration) was studied using DD. However, the interpretation of these studies was always based on Mead's "equal pressure point" concept minimizing the role played by bronchial wall compliance as put forward by Pride and coll. (1967). The results of certain experimental or clinical studies was found not to agree with the original explanations. Finally, the model of flow limitation recently described by Dawson and Elliott (1977) takes into account gas density and bronchial wall elasticity which determine the speed of waves propagating against flow in elastic tubes, the site of "choke points" and the cross-sectional airway area at this level. Besides methodological problems, the complex nature of mechanisms controlling bronchial flow with gases of different densities and the unavoidable influence of bronchodilators or bronchial wall compliance are major limiting factors for the use of DD in the study of the site of airflow obstruction, and effect of bronchodilator action.

[Bronchial hyperreactivity in 1994, a cheerful quinquagenarian. Conclusions]. / Hyperréactivité bronchique en 1994, une quinquagénaire allègre. Conclusions.

A review is made of the principal themes that are discussed in this supplement of the Revue des Maladies Respiratoires. Three important questions on bronchial hyperresponsiveness, a key feature of asthma, are raised: 1) the clinical usefulness of its assessment, mostly in the atypical forms of asthma and in occupational asthma and, less so, to estimate the severity of asthma; data derived from the Bayesian analysis lead to the conclusion that it is a test which is better for excluding rather than for confirming asthma; in an epidemiological setting, the assessment of bronchial responsiveness should be carried out to assess both host factors and the effect of environmental exposure; 2) the method of assessment which should take into account the stimulus, be it pharmacological or not, the physiological index used to assess the response and the mode of expression of results; 3) finally, the mechanisms of bronchial responsiveness are probably multiple as examined in different chapters of this supplement.

[Frequency and severity of hypoxemia during sleep in COPD. Clinical and therapeutic impact]. / Fréquence et sévérité des hypoxémies pendant le sommeil des BPCO. Incidences cliniques et thérapeutiques.

The occurrence of episodes of desaturation during sleep in patients suffering from chronic airflow obstruction is well known. The severity of nocturnal hypoxaemia depends, in part, on the level of the diurnal PaO2. Hypoventilation linked to sleep is the principle mechanism responsible for the decrease in PaO2 and the desaturation which results and depends on the level of oxyhaemoglobin saturation (SaO2) during wakefulness. However, it is not possible to predict the severity of nocturnal desaturation solely on the basis of diurnal oxyhaemoglobin saturation. Numerous factors may contribute to a worsening of nocturnal desaturation. In some patients it may be associated with hypoventilation and a worsening of the ventilation perfusion inequalities. A fall in the ventilatory response to hypoxaemia and hypercapnea contributes equally to the severity of desaturation. The awake response to hypoxia is variable according to the stage of their respiratory failure but may play a role in worsening nocturnal hypoxia. Snoring and obstructive apnoea are responsible for severe desaturation in chronic airflow obstruction presenting as hypoxaemia which may be moderated during the day. At present the value of systematic nocturnal polygraphic recordings in the "work-up" of chronic airflow obstruction has not been demonstrated. Its principle practical interest is in research into the associated sleep apnoea syndrome. It should be recognised in a patient with chronic airflow obstruction who snores and is somnolent with hypoxaemia and/or poorly explained hypercapnea. The therapeutic approach in respiratory failure should take account of nocturnal desaturation and the oxygen flow at night should be superior to the one to two litres which are required to correct the diurnal hypoxaemia.

[Treatment of the sleep apnea syndrome by continuous positive pressure]. / Traitement du syndrome d'apnées du sommeil par pression positive continue.

Six patients with severe sleep apnoea syndrome (SAS) were treated for one night by continuous positive pressure by the nasal route (PPC). The six patients tolerated the treatment well. During the course of the night, while receiving PPC, we noticed that in five patients there was a normalisation of the indices of apnoea, a disappearance of the episodes of desaturation and a re-organisation of sleep pattern. In one patient PPC was effective on obstructive apnoea, but did not make all mixed and central apnoea disappear. After a 4 or 5 day trial in hospital, 4 patients have now been treated at home for at least 6 months. PPC remains effective and well tolerated in the long term. As it is well tolerated and effective, PPC may be used to treat patients with SAS at an earlier stage than that at which tracheotomy is proposed.

[Educational diagnosis in asthma. Descriptive results of a questionnaire survey]. / Diagnostic éducatif de l'asthme. Résultats descriptifs d'une enquête par questionnaire.

The object of this work was to carry out an audit on an asthmatic's knowledge of their disease and of the risk factors, their usual therapy and of therapy for acute exacerbations as well as their need for information and education. The study was carried out by a survey of 327 adult asthmatics who were in consultation with specialist physicians in thoracic medicine. The information was gathered using an anonymous questionnaire completed by a nurse. The doctors looking after these patients had given their opinion on the severity of their asthma and the educational needs of their patients. The population studied had an average of 47 +/- 17 years. Forty seven per cent of the subjects were masculine. The general level of education was high. Seventy five per cent of the patients were from an urban environment. The duration of the asthma was on an average of 19 years. Half of these patients had already been in hospital for a serious attack. One third of the patients were considered by their doctors as having severe asthma. The patients were good at distinguishing the level of severity of their acute exacerbations and adapted their therapy on their own initiative in appropriate fashion based on the degree of severity of their disease. The enquiry revealed that patients take some liberties around the basic treatment that they had been prescribed. It also showed some defects or errors in their knowledge of the disease and the appropriate approach vis-à-vis the disease. One noted for example that one third of the asthmatics had already stopped the treatment before the date fixed by their doctor. In a general, patients who were surveyed were interested in their health problems with their health and hoped to be better informed both on asthma and its treatment. This study was biased towards an interest in the understanding of the education in order to manage the asthmatic population better.