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Traitement par bronchoscopie rigide de l’obstruction maligne des voies aériennes centrales

Introduction La désobstruction endobronchique par bronchoscopie rigide interventionnelle constitue le traitement de référence des sténoses néoplasiques des voies aériennes. L’amélioration clinique et fonctionnelle respiratoire de cette procédure a déjà été évaluée mais dans des populations très hétérogènes.

Méthodes Entre février 2009 et février 2011, nous avons mené une étude prospective monocentrique au centre hospitalier universitaire de Lille. Vingt-cinq patients atteints de sténoses tumorales malignes trachéo-bronchiques ont bénéficié d’une évaluation clinique et fonctionnelle respiratoire avant et après une procédure de désobstruction par bronchoscopie rigide avec éventuelle pose d’endoprothèse bronchique.

Résultats Treize patients (52 %) présentaient un cancer bronchique primitif, 12 un cancer d’une autre origine. Dix-neuf patients (76 %) bénéficiaient de la pose d’une endoprothèse bronchique après désobstruction. Sur le plan clinique, la totalité des malades ressentaient soit une amélioration, soit une non-dégradation de leur dyspnée estimée par le score de Borg avec une médiane de −2 points [−1 ; −4] après procédure (p <0,001) et 96 % avaient une EVA de dyspnée qui s’améliorait de 40mm [27 ; 67] (p <0,0001). Le VEMS augmentait après la désobstruction de 9 % [−3,5 ; 28,5] (p <0,05). Les Rint diminuaient significativement de −0,19kPa/L par seconde [−0,06 ; −0,23] (p =0,001). Les corrélations entre échelles de dyspnée et valeurs spirométriques étaient non significatives (p >0,05). Le taux de survie à un an était de 29 %.

Conclusion La bronchoscopie interventionnelle diminue la dyspnée ressentie par les malades. Elle améliore modestement la fonction respiratoire et diminue les résistances des voies aériennes. Cependant, fonction respiratoire et échelles de dyspnée ne sont pas corrélées. Aucun facteur spirométrique ne permet de prédire la réponse clinique en termes de dyspnée. Un score élevé de dyspnée de Borg initial pourrait être un bon argument décisionnel.

Introduction Endobronchial resection is now the standard treatment for tracheobronchial narrowing due to malignancy. The clinical and functional respiratory improvement has been evaluated previously but only in heterogeneous population.

 

Methods Between February 2009 and February 2011, we conducted a prospective single centre study at the University Hospital of Lille. Twenty-five patients with malignant tracheobronchial stenosis received a clinical and functional respiratory evaluation before and after a rigid bronchoscopy procedure to reduce the obstruction followed where appropriate by placement of an endobronchial stent.

Results Thirteen patients (52%) had primary lung cancer and in 12 the tumor had another origin. Nineteen patients (76%) received a stent after bronchial unblocking. Clinically, all patients felt an improvement in their dyspnea estimated by the Borg score with a median improvement of −2 points [−1; −4] following the procedure (P <0.001). In 96% the dyspnea visual analogic scale improved by 40mm [27; 67] (P <0.0001). The FEV1 increased significantly after unblocking by 9% [−3.5; 28.5] (P <0.05). The Rint decreased significantly by −0.19kPa/L per second [−0.06; −0.023] (P =0.001). Correlations between scales of dyspnea and spirometric values were not significant (P >0.05). The survival rate at 1year was 29%.

Conclusion Interventional bronchoscopy decreases dyspnea. It modestly improves respiratory function and decreases the Rint. However, lung function and dyspnea scales are not correlated. No spirometry factor can predict clinical dyspnea response but an elevated Borg dyspnea scale might be a good indicator.

 

Linezolid for XDR-TB

This randomised phase 2a trial in South Korea recruited 41 patients with sputum culture-positive pulmonary extensively drug-resistant tuberculosis (XDR-TB), who had failed to respond to 6 months of available treatment. Daily dosage of 600 mg linezolid was added either immediately or after a delay of two months. After four months of linezolid, or two consecutive negative sputum smears, patients continued either 300 mg or 600 mg daily for another 18 months. After 4 months, the primary outcome of sputum culture conversion was achieved in 15 of the 19 immediately treated patients, and in 7 of 20 in the delayed treatment group. Eighty-seven per cent of all linezolid-treated patients had negative sputum cultures after 6 months. Significant adverse events including m...

Regulatory T cells and COPD

While the innate immune system has long been implicated in the pathogenesis of COPD, a role for the acquired immune system is less well studied. The increasing recognition that COPD shares features with autoimmune disease has led to interest in a potential role for regulatory T cells, which are intimately involved in the control of autoimmunity. The suggestion that regulatory T cell numbers are increased in patients with COPD may indicate their dysfunction or resistance to suppression by target cells. Investigation of regulatory T cells may therefore be of importance in understanding the inflammation and tissue damage that occurs in patients with COPD who cease smoking. (Source: Thorax)

Tuberculosis vaccines: time to reset the paradigm?

The recent publication of a Phase IIb efficacy trial of the tuberculosis vaccine candidate MVA85A represents the long awaited outcome of the hopes and investment of a global research endeavour seeking a giant leap in tuberculosis control. MVA85A, a modified vaccinia virus expressing the Mycobacterium tuberculosis (Mtb) 85A antigen, is designed to improve on the currently available vaccine Bacillus Calmette-Guerin (BCG) and is the first among a number of novel vaccine candidates to enter a Phase IIb efficacy trial in infants. Given that the immunological rationale underpinning the development of MVA85A is shared by 9 out of 14 vaccines in clinical trials, the lack of efficacy in this recent pivotal trial is a significant setback to the tuberculosis vaccine community.1 The results of this tr...

Use of inhaled corticosteroids and the risk of tuberculosis

Conclusions ICS use increases the risk of TB in an intermediate-TB-burden country. Clinicians should be aware of the possibility of TB development among patients who are long-term high-dose ICS users. (Source: Thorax)

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