[Physical activity and pulmonary rehabilitation in adults with asthma]. / Apports de l'activité physique et de la réadaptation respiratoire dans l'asthme de l'adulte.

Physical activity is reduced in people with asthma compared to the general population, especially in situations where patients have uncontrolled asthma symptoms, persistent airflow obstruction and other long-term medical problems, in particular obesity and anxiety. Exertional dyspnea, which is of multifactorial origin, is the main cause of reduced physical activity reduction and draws patients into a vicious circle further impairing quality of life and asthma control. Both the resumption of a regular physical activity, integrated into daily life, adapted to patients' needs and wishes as well as physical and environmental possibilities for mild to moderate asthmatics, and pulmonary rehabilitation (PR) for severe and/or uncontrolled asthmatics, improve control of asthma, dyspnea, exercise tolerance, quality of life, anxiety, depression and reduce exacerbations. A motivational interview to promote a regular programme of physical activity in mild to moderate asthma (steps 1 to 3) should be offered by all health professionals in the patient care pathway, within the more general framework of therapeutic education. The medical prescription of physical activities, listed in the Public Health Code for patients with long-term diseases, and pulmonary rehabilitation should be performed more often by specialists or the attending physician. Pulmonary rehabilitation addresses the needs of severe asthma patients (steps 4 and 5), and of any asthmatic patient with poorly controlled disease and/or requiring hospitalized for acute exacerbations, regardless of the level of airflow obstruction, and/or with associated comorbidities, and before prescribing biological therapies.

Influence of DISC behavioral profile on the short- and long-term outcomes of home-based pulmonary rehabilitation in patients with chronic obstructive pulmonary disease.

INTRODUCTION: Pulmonary rehabilitation (PR) programs are commonly prescribed for patients with severe respiratory disorders, but little is known about how the patient's personality traits influence PR outcomes. We analyzed the response of patients with chronic obstructive pulmonary disease (COPD) to a home-based PR program according to their predominant behavioral profiles using the Dominance - Influence - Steadiness - Conscientiousness (DISC) tool. METHODS: This was a retrospective observational study of 335 COPD patients referred by their pulmonologists between January 2010 and December 2015. The DISC behavioral profile was determined at the beginning of the program. Patients received individual supervised sessions at home once a week for 8 weeks, which consisted of exercise training and psychosocial, motivational, and educational support, all tailored to the participant's DISC profile. Exercise tolerance (6-minute stepper test, 6MST), anxiety and depression (Hospital anxiety and depression scale, HADS), and quality of life (Visual simplified respiratory questionnaire, VSRQ) were evaluated immediately before and after the PR program (T0 and T2, respectively) and then 6 and 12 months later (T8 and T14, respectively). Responders were defined as patients who exhibited at least minimal clinically important differences (improvements) from baseline. RESULTS: Of the 335 COPD patients, 102 (30.4%), 98 (29.3%), 82 (24.5%), and 53 (15.8%) were classified as having predominant D, I, S, and C behavioral traits, respectively. All four patient groups showed significantly (P<0.01) improved performance in the 6MST, HADS, and VSRQ evaluations at T2 (n=300), T8 (n=262), and T14 (n=231) compared with T0, and the proportion of responders in all groups at T8 and T14 was high (∼60%). The percentage of responders differed significantly between groups only at T2, when the S group contained fewer responders on the HADS anxiety subscale. Most patients who did not complete the study were classified as D type (42/102, 41.2%), followed by I (28/98, 28.6%), S (22/82, 26.8%), and C (12/53, 22.6%) types. CONCLUSION: The personality profile of COPD patients influenced their adherence to, but not their benefit from, a home-based PR program. The high proportion of patients in all personality groups showing significant improvements in outcomes supports a personalized approach to the design of PR programs.

[Cardiopulmonary exercise testing for the diagnosis of unexplained dyspnea: a review of 194 cases]. / Épreuve fonctionnelle à l'exercice et dyspnée inexpliquée : à propos de 194 cas.

INTRODUCTION: Chronic dyspnoea that remains unexplained after resting pulmonary function and cardiovascular testing is a common problem in clinical practice. The aim of this study was to determine the utility of cardiopulmonary exercise testing (CPET) in the diagnosis of unexplained dyspnoea. METHODS: This retrospective single-centre study included consecutive patients with dyspnoea who had normal resting cardiopulmonary examinations (including chest X-ray, electrocardiography, pulmonary function tests [PFTs], and cardiac ultrasound). CPET was performed using a cycle ergometer with analysis of blood gases. The results were interpreted as being most likely due to one of the six pathophysiological mechanisms shown below. Consensus required agreement between at least three of the authors. RESULTS: Of the 194 patients included (median age 53 years, sex-ratio (M:F) 0.83, mean body mass index 27.3±5.36kg/m2), 32% of the test profiles were compatible with deconditioning, 20% with inappropriate hyperventilation (without gas exchange abnormalities), 18% with disorders of gas exchange, 13% with sub-maximal CPET, 9% with cardiovascular anomalies, and 8% with normal CPET. Of the patients with gas exchange abnormalities, the most common causes were bronchiectasis (6), emphysema (6), recent pneumonia (2), and diffuse interstitial pneumonitis (2). Ten of the patients with cardiovascular abnormalities had chronotropic insufficiencies, 5 had excessive tension responses, and 3 had disorders of rhythm or repolarisation. CONCLUSIONS: CPET may greatly facilitate the diagnosis of unexplained dyspnoea. More than 50% of the dyspnoea cases examined here were due to deconditioning or hyperventilation syndrome and would benefit from a simple pulmonary rehabilitation program.

[Cardiopulmonary exercise testing and unexpected dyspnea]. / Exploration fonctionnelle à l'exercice (EFX) et dyspnée inattendue.

Cardiopulmonary exercise testing (CPET) is the examination of choice to understand mechanisms responsible for dyspnea in patients without significant medical history. The three observations illustrate the major interest of the CPET in this frequent situation in clinical practice. A 68-year-old man who has severe dyspnea in her leisure time hiking in the mountains, a 25-year cyclist presenting disabling dyspnea follow competitors racing neo-professional cyclists, and a 37-year woman who developed a persistent dyspnea, 6 months after delivery. In these three situations, CPET determined the disorder responsible for the symptoms without increasing the diagnostic tests.

[Unusual pneumonia by Pasteurella multocida]. / Pneumopathie d'étiologie inhabituelle à Pasteurella multocida.

Pasteurellosis is an infection caused by inoculation usually through bites or scratches. Pasteurella multocida is involved in 50 to 60% of cases. Cats are the main vectors of the pathogen. Immunodepression increases the risk of systemic disease. We report a case of Pasteurella multocida pneumonia in an 81-year-old patient who had no cutaneous portal of entry. The patient had a past medical history of rectal neoplasia and prostate neoplasia treated with brachytherapy and hormonal therapy respectively. He had an environmental risk factor (the presence of a cat at home). The diagnosis was confirmed by repeated blood cultures. Antimicrobial therapy resulted in clinical, biological and radiological improvement. This case report raises the question of a possible pathogenesis different from the commonly described "inoculation".

[Diagnostic performance of EBUS-TBNA in patients with mediastinal lymphadenopathy and extrathoracic malignancy]. / Performance diagnostique de l'EBUS-PTBA chez des patients aux antécédents néoplasiques extrapulmonaires adressés pour adénopathies médiastinales.

INTRODUCTION: There is limited data about the diagnostic performance of EBUS-TBNA in patients with mediastinal lymphadenopathy and extrathoracic malignancy. METHODS: From January 2007 to July 2011, EBUS-TBNA was performed in 68 patients with a history of extrathoracic malignancy (current or past) and suspected mediastinal lymph node metastases. RESULTS: Thirty-one patients had a final diagnosis of cancer. In nineteen patients, the same histology was identified in the mediastinal nodes as in their prior extrathoracic cancer (colorectal cancer, esophageal cancer and lymphoma). In 12, the diagnosis was not "as expected" (ten lung cancers, one colorectal cancer, one unidentified cancer). Among 37 patients without diagnosis, biopsies in 27 showed normal lymphoid material, two had non-specific inflammation and eight had no contributory results. It was noted that procedures were reported to have been more difficult in these patients. CONCLUSIONS: Diagnostic performance of EBUS-TBNA in the context of extrathoracic malignancy is very variable depending on the origin of the cancer. Nevertheless, a diagnosis is concluded in almost 50% of the cases. These results underline the necessity to select carefully the indications of EBUS-TBNA in extrathoracic cancer.

[Effects of thromboendarterectomy for post-embolic pulmonary hypertension on physiological dead space on exercise]. / Effets de la thromboendartériectomie pour hypertension pulmonaire post-embolique sur l'espace mort physiologique à l'exercice.

The effect of therapy on the modification of a functional parameter is an elegant method for assessing the causal relationship between functional abnormalities and symptoms. We report an analysis of the effects of thromboendarterectomy for post-embolic pulmonary arterial hypertension on exercise functional parameters. A patient (62 years) had post-embolic pulmonary hypertension documented by pulmonary angiography and right heart catheterization (PAP mean: 48 mmHg). Cardiopulmonary exercise testing demonstrated a decreased aerobic capacity (59% predicted), significant hyperventilation (VE/VO(2) at peak 82) and a dead space to tidal volume ratio (VD/Vt) increased at rest (0.55) and remaining high at peak exercise (0.48). Thromboendarterectomy was performed and led to a dramatic improvement in dyspnoea (NYHA class II to I), a gradual improvement in aerobic capacity, and a significant decrease of VD/Vt (0.26) and hyperventilation (VE/VO(2) at peak: 38) on exercise. This observation illustrates the fact that an increase in the physiological dead space on exercise is associated with significant hyperventilation and consequently dyspnoea of effort.

[Prognostic value of clinical exercise testing in idiopathic pulmonary fibrosis]. / Intérêt pronostique de l'exploration fonctionnelle à l'exercice (EFX) au cours de la fibrose pulmonaire idiopathique.

Current guidelines for referring patients with idiopathic pulmonary fibrosis (IPF) for lung transplantation, based on resting parameters, are insufficient to predict 3-year mortality. The aim of this study was to determine the prognostic value of cardio-pulmonary exercise testing (CPET) in patients with IPF. A multicentre retrospective study of 3-year outcome was made on 63 adult patients with IPF who underwent CPET with blood gas analysis. Demographic data, resting pulmonary function and CPET parameters were collected to perform a univariate survival analysis. To estimate prognosis at 3 years, a multivariate logistic regression analysis by Kaplan-Meier curves and log-rank tests was performed. Forty-four patients (70%) were alive without lung transplant at the end of the 3-year follow-up: 19 patients (30%) were dead (n=14) or transplanted (n=5). Univariate analysis indicated that: at rest lower TLC, FVC, DLCO and PaCO(2), higher alveolo-arterial gradient for oxygen [P(A-a)O(2)] and pH; at ventilatory threshold (VT) higher VE/VO(2) and VE/VCO(2) and at peak exercise higher VE/VO(2) and VE/VCO(2), higher pH and ΔP(A-a)O(2)/ΔVO(2) (mmHg/L), lower VO(2) peak, PaO(2) and VO(2)/FC were associated with a significantly lower survival at 3 years. The multivariate logistic regression analysis showed that CPT (<65%) and VE/VO(2) at VT (>45) were independently associated with a lower survival at 3 years. Restriction and hyperventilation at ventilatory threshold are major prognostic factors in the course of IPF. CPET with blood gas analysis may have a prognostic value in these patients and initial evaluation of these parameters can help to predict disease progression.

[Hepatopulmonary syndrome and diffuse interstitial lung disease]. / Syndrome hépatopulmonaire et pneumopathie interstitielle diffuse idiopathique.

INTRODUCTION: The association between interstitial pneumonia and hepatopulmonary syndrome (HPS) has rarely been described. OBSERVATION: We report the cases of two patients, 62 and 64 years old, who presented with idiopathic interstitial pneumonia (IIP) and severe, disproportionate hypoxemia, PaO(2) 42 and 47 mmHg, respectively. This hypoxemia lead to search for associated disease. The diagnosis of right-to-left shunt was established by the 99mTc-MAA perfusion lung imaging. A contrast cardiac echography confirmed the intrapulmonary shunt. Both patients were found to have hepatic cirrhosis, classed as Child Grade A6 and C10. In this context of chronic hepatopathy, the diagnosis of SHP associated with IIP was established. Liver transplantation, the only way to cure the lung consequences of the HPS, was planned. CONCLUSION: These two cases highlight the importance of searching for right-to-left shunt in patients who have lung disease with severe disproportionate hypoxemia. Liver transplantation is the only way to cure the lung consequences of the hepathopathy. The rare association between ILD and HPS raises problems when deciding to go forward to transplantation in the absence of a histological diagnosis of the lung disease and where the prognosis of the lung disease is unclear.

[Pulmonary embolism diagnosed during an endobronchial ultrasound procedure]. / Embolie pulmonaire diagnostiquée au cours d'une échoendoscopie bronchique.

INTRODUCTION: Pulmonary embolism occurs frequently in lung cancer. The clinical features are non-specific and the diagnosis is often missed. CASE REPORT: A 60-year old man presented with a right upper lobe mass associated with right hilar adenopathy. Both had activity on positron emission tomography. As bronchoscopy was normal, an endobronchial, ultrasound guided, transbronchial needle aspiration (EBUS-TBNA) was performed to obtain a diagnosis. During the procedure, a hypoechogenic image was seen in the right pulmonary artery. A CT pulmonary angiogram confirmed the diagnosis of right pulmonary embolism. The transbronchial needle aspiration confirmed the neoplastic nature of the adenopathy. To our knowledge, this is the first description of a pulmonary embolism diagnosed by EBUS. This observation confirms the results of a recently published study showing that known pulmonary embolism can be detected by EBUS. CONCLUSION: Although EBUS is not the classic tool for the diagnosis of pulmonary embolism, it seems advisable to undertake a careful examination of the proximal pulmonary artery during an EBUS procedure.