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Methacholine challenge in young children as evaluated by spirometry and impulse oscillometry.

In young children, it is difficult to obtain a reproducible flow-volume curve throughout all stages of bronchial challenge. The forced oscillation technique (FOT) is especially established in paediatrics because this method does not require forced or maximal manoeuvres and is less cooperation-dependent than conventional spirometry.

OBJECTIVES: To evaluate the association of spirometric and impulse oscillometric (IOS) indices in a short protocol for methacholine provocation.

METHODS: The primary endpoint was the methacholine dose that caused a 20% decrease in FEV(1) (PD(-20)FEV(1)) compared to baseline. Changes in respiratory resistance (Rrs5) and reactance (Xrs5) acquired by IOS were compared with FEV(1).

RESULTS: Forty-eight children (5.3 ± 0.9 years) were challenged. The mean maximal reduction in FEV(1) was 29.8% ± 14.7 (p < 0.0001), the mean increase in Rsr5 was 55.3% ± 31.7, and the mean decrease in Xrs5 was 0.37 kPa s L(-1) ± 0.23 (p < 0.001). An increase in Rrs5 of 45.2% and a decrease in Xrs5 of 0.69 kPa s L(-1) showed the optimal combination of sensitivity and specificity to detect a 20% reduction in FEV(1) (0.72 and 0.73; 0.80 and 0.76, respectively), and the area under the ROC curve was 0.76 and 0.81, respectively (p < 0.005). In 28 patients with significant changes in FEV(1) and Rsr5, the PD(-20)FEV(1) was 0.48 mg methacholine ±0.59 and the PD(+40)Rrs5 was 0.28 mg methacholine ±0.45 (p = 0.03).

CONCLUSIONS: A short protocol for methacholine challenge testing is feasible in young children. IOS detected 70-80% of patients who responded in spirometry. During the challenge, the Rrs5 response preceded the FEV(1) response.

Dose effect of once-daily fluticasone furoate in persistent asthma: a randomized trial.

BACKGROUND: This randomized, double-blind, multicenter study was designed to evaluate the efficacy of inhaled once-daily fluticasone furoate (FF) administered in the evening in patients with persistent asthma not controlled by short-acting beta(2) agonists, and to determine the dose(s) suitable for further development.

METHODS: Of 1459 patients screened, 598 received one of six treatments: placebo, FF (25 μg, 50 μg, 100 μg or 200 μg) once daily each evening, or fluticasone propionate (FP) 100 μg twice daily for 8 weeks. The primary endpoint was change from baseline in pre-dose evening forced expiratory volume in 1 s (FEV(1)).

RESULTS: A dose-response effect was observed for once-daily FF 25-200 μg including (p < 0.001) and excluding placebo (p = 0.03). FF 50-200 μg once daily significantly increased FEV(1) from baseline (p < 0.05 vs placebo), by >200 mL for FF 100 μg and 200 μg. Significant improvements were also achieved for peak expiratory flow, and percentage symptom-free and rescue-free 24 h periods. The magnitude of effect was at least as good as twice-daily FP. Overall, once-daily FF was well tolerated with no systemic corticosteroid effects.

CONCLUSION: FF 50-200 μg/day once daily in the evening demonstrated dose-related efficacy in asthma with 100-200 μg appearing to be the optimal doses for further evaluation. ClinicalTrials.gov: NCT00603382.

Scheduled asthma management in general practice generally improve asthma control in those who attend.

Successful asthma management involves guideline-based treatment and regular follow-up. We aimed to study the level of disease control in asthmatic individuals managed by their GP and a dedicated nurse when using a systematic asthma consultation guide based on Global Initiative of Asthma guidelines (GINA guidelines).

METHODS: Patients aged 18-79 years with doctor-diagnosed asthma were included. When managing the patients, the clinics were instructed to follow a consultation guide based on the principles of the GINA guidelines. This included evaluation of symptoms, treatment, compliance, lung function, and a scheduled follow-up appointment based on the level of asthma control:

RESULTS: At the initial visit (baseline), 684 patients (36.8%) were classified as well-controlled, 740 (39.8%) as partly controlled and 434 (23.4%) as uncontrolled. 1784 patients had been offered a follow-up visit and 623 (35%) had attended. A response analysis was performed, and those participating were older (46 versus 45 years, p < 0.01), whereas other variables were similar. A higher level of asthma control was found at the follow-up visit compared to the baseline visit (uncontrolled asthma 29.7% and 16.5%, respectively, p < 0.001). At the time of the follow-up visit, changes in treatment strategies were found (p < 0.01), and furthermore, level of lung function improved at the follow-up visit.

CONCLUSION: Although most asthmatic individuals received asthma treatment, a substantial number still were partly or poorly controlled. The overall asthma control improved significantly when a systematic asthma management approach was introduced and applied by dedicated health care staff.

Place de la chirurgie dans les maladies aspergillaires et autres mycoses pulmonaires

Publication year: 2012
Source:Revue de Pneumologie Clinique, Volume 68, Issue 2

P.-B. Pagès, H. Abou Hanna, D. Caillot, A. Bernard

La chirurgie fait partie de la stratégie thérapeutique des infections aspergillaires et des mucormycoses. L’aspergillome se définit comme une masse arrondie pseudotumorale de développement intracavitaire due à la prolifération des spores d’Aspergillus. La complication la plus fréquente est l’hémoptysie rapportée dans 50 à 95 % des cas. Les lésions pleuropulmonaires favorisantes sont : les cavernes tuberculeuses, les poches pleurales résiduelles, les bulles d’emphysème et le poumon détruit après radiothérapie ou fibrose ou bronchectasies. Les indications de la chirurgie dépendent des symptômes, de la fonction respiratoire du patient, de l’état du poumon sous-jacent et du type d’aspergillome (simple ou complexe). Chez un patient porteur d’un aspergillome intrapulmonaire, si les fonctions respiratoires le permettent, une résection pulmonaire sera proposée éventuellement précédée d’une embolisation. Pour les aspergillomes intrapleuraux, la thoracoplastie sera préconisée si l’état général du patient le permet. L’aspergillose pulmonaire invasive (API) se caractérise par une invasion des tissus bronchiques et des vaisseaux par les filaments mycéliens chez des patients ayant une immunosuppression profonde et prolongée. Le taux de décès des patients ayant fait une API après traitement pour une leucémie ou lymphome était de 30 à 40 %, après une greffe de moelle de 60 %, après transplantation de 50 à 60 % et après toute autre cause d’immunosuppression de 70 à 85 %. La principale cause de ces décès est l’hémoptysie massive. La chirurgie (une lobectomie) est indiquée pour la prévention des hémoptysies lorsque la masse aspergillaire se situe au contact de l’artère pulmonaire ou l’une de ses branches et si elle augmente de taille avec la disparition du liseré de sécurité entre la masse et la paroi du vaisseau. Le patient sera opéré en urgence avant que les globules blancs n’atteignent le seuil de 1000éléments/mm3. Une masse résiduelle persistante après un traitement antifongique peut justifier d’une résection pulmonaire (wedge ou lobectomie) avant la reprise d’une nouvelle thérapeutique agressive. Les mucormycoses surviennent chez des patients immunodéprimés (maladie hématologique, diabètes, transplantation, brûlures, dénutrition). Le traitement d’une mucormycose pulmonaire associe les antifongiques et la résection pulmonaire. Surgery is part of the therapeutic strategy of aspergillosis and mucormycosis. The aspergilloma is defined as a rounded mass, developing in a cavity by the proliferation of spores of Aspergillus. The most common complication was haemoptysis reported in 50–95% of cases. The pleuropulmonary lesions predisposing are: tuberculosis, residual pleural space, emphysema and lung destroyed by fibrosis or radiotherapy or bronchiectasis. The indications for surgery depend on symptoms, respiratory function, the parenchyma and the type of aspergilloma (simple or complex). In a patient with an intrapulmonary aspergilloma, lung resection preceded by embolization is recommended based on respiratory function. For intrapleural aspergilloma, thoracoplasty is recommended according to the patient's general condition. The invasive pulmonary aspergillosis (IPA) is characterized by an invasion of lung tissue and blood vessels by hyphae in immunocompromised patients. The death rate of patients who have an API after treatment for leukemia or lymphoma was 30 to 40%, after bone marrow transplantation 60%, after solid organ transplantation from 50 to 60% and after any other cause of immunocompromising from 70 to 85%. The main cause of these deaths is massive hemoptysis. Surgery (lobectomy) is indicated for the prevention of hemoptysis when the mass is in contact with the pulmonary artery or one of its branches, and if it increases in size with the disappearance of border security between the mass and the vessel wall. The patient will be operated in an emergency before the white blood cells do not exceed the threshold of 1000cells/μl. A persistent residual mass after antifungal treatment may justify a lung resection (lobectomy or wedge) before a new aggressive therapy. Mucormycosis affects patients following immunocompromising states — haematologic malignancy, diabetes mellitus, transplantation, burns and malnutrition. The treatment of pulmonary mucormycosis combines surgical and medical approach.




Biopsie pulmonaire chirurgicale : indications et incidences thérapeutiques

Publication year: 2012
Source:Revue de Pneumologie Clinique, Volume 68, Issue 2

D.M. Radu, J. Macey, D. Bouvry, A. Seguin, D. Valeyre, E. Martinod

La biopsie pulmonaire chirurgicale a sa place dans le diagnostic étiologique des pneumopathies infiltrantes diffuses aiguës et chroniques. Cet article résume les indications actuelles, les incidences thérapeutiques, les différentes techniques opératoires et les risques per- et postopératoires de cette méthode diagnostique. Les différentes controverses et problèmes liés à la procédure sont également présentés. Surgical biopsy of lung parenchyma can be used to establish a diagnosis in interstitial lung disease both of acute and chronic presentation. The present article summarizes the current indications, the therapeutic implications, the different surgical techniques and postoperative complications of the procedure. Common controversies and problems related to surgical lung biopsy are also presented.




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