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[Indications for intrapulmonary percussive ventilation (IPV): A review of the literature].

Intrapulmonary Percussive Ventilation (IPV) is used to treat peripheral airway obstruction as well as disorders of ventilation.

STATE OF THE ART: The medical literature shows that IPV can be deployed for both symptomatic and prophylactic purposes. When conventional techniques of chest physiotherapy have been ineffective, IPV may be delivered in a variety of severe respiratory diseases via both invasive and non-invasive interfaces. Diseases such as advanced neuromuscular disorders with severe bronchial congestion, stable or decompensated cystic fibrosis and chronic obstructive pulmonary disease whether in the stable condition, during exacerbations or after extubation as well as atelectasis or other severe respiratory complications may all benefit from therapeutic effects of IPV. Very few contra-indications are reported in the literature.

PERSPECTIVES: The precise physiological effects of IPV are not yet well demonstrated. Despite significant progresses, the level of evidence for the clinical effectiveness of IPV remains insufficient.

CONCLUSIONS: IPV can be considered as a technique that may offer valuable assistance in the treatment of severe respiratory diseases that are refractory to conventional techniques of respiratory therapy.

[Inhalation devices: Characteristics, modeling, regulation and use in routine practice. GAT Aerosolstorming, Paris 2011].

Aerosoltherapy is a first-line treatment for chronic obstructive respiratory diseases such as asthma and COPD. Treatment modalities and devices are varied and the choice of the device must be adapted to and optimized for every patient. Spacers can be used for some categories of patients for whom the use of other devices turns out to be complicated.

The improvement of these treatments requires the optimization of the lung deposition of inhaled particles; lung modeling plays an essential role in the understanding of the mechanisms of flow in the airways. Regulations must frame prescription of inhaled treatments to optimize its quality and, thus, the care for these chronic diseases. Many generally-accepted ideas concerning these treatments turn out to be false.

Inhaled treatments are constantly evolving, both pharmacologically and technologically.

[COPD and erythropoiesis: Interactions and consequences].

Erythropoiesis is modified in chronic obstructive pulmonary disease (COPD). Tobacco smoke, hypoxaemia, systemic inflammation, and infectious exacerbations are the main factors involved. Polymorphisms in genes involved in the regulation of erythropoiesis probably explain the individual susceptibility and variability in the response.

The roles of comorbidities related to COPD and the impact of treatment on erythropoiesis are important confounding factors. While polycythaemia is often related to tobacco smoke and hypoxaemia, it has become less common due to the improvement of COPD follow-up and especially the initiation of long-term oxygen therapy. The control of the main causes is often sufficient, but in cases of severe polycythaemia an erythrapheresis is indicated. Anaemia has recently been reported as a more common and serious complication. It increases dyspnoea and reduces physical activity and quality of life. Its impact on survival and the requirements for healthcare has recently been confirmed.

The main approach to the management of anaemia remains exclusion of any curable causes, reducing exacerbations and systemic inflammation, and controlling the comorbidities. Though erythropoietin has some benefits in the so-called "anaemia of chronic disease", this still remains to be confirmed in patients with COPD.

Transition of patients with COPD across different care settings: challenges and opportunities for hospitalists.

Hospitalists play an important role in treating current and preventing future acute exacerbations of chronic obstructive pulmonary disease (AECOPD), which are associated with high rates of medical resource use and morbidity.

Comprehensive admission screening and diagnostic tests are important in enabling hospitalists to reliably identify patients with AECOPD, the severity of the episode, and related issues that may prolong patients' hospital length of stay. Recurring exacerbations, especially those that require repeated acute care, can reduce physical activity and accelerate pulmonary decline and risk of death. Recommended pharmacotherapies for AECOPD should include short-acting bronchodilators, systemic corticosteroids, and appropriate antibiotics in cases of suspected bacterial infection. Patients with demonstrable hypoxemia or respiratory failure may benefit from oxygen and/or ventilatory support.

Long-term disease management with the goal of preventing future exacerbations should include ongoing emphasis toward smoking cessation and up-to-date vaccination, in addition to prescribing maintenance pharmacotherapies in accordance with respiratory treatment guidelines. Additional benefits may be derived from nonpharmacologic therapies, such as pulmonary rehabilitation, weight-loss recommendations, and treatment of obstructive sleep dyspnea when present. Effective communication among members of the inpatient and outpatient health care teams, the patient, and his or her caregivers is an important aspect of care transitions. Hospital discharge summaries should be transmitted to the patient's primary care physician and be readily available at the first follow-up visit. Discharge coaches and other allied health care providers can aid hospitalists in reinforcing self-management skills and patient education, and in emphasizing the importance of follow-up visits. Recent findings suggest that health and cost benefits are associated with improved COPD management.

This article focuses on the pivotal role of the hospitalist in promoting and facilitating the steps toward improving quality outcomes and transitions of care for patients with COPD.

[Functional measurements of the peripheral airways in COPD].

INTRODUCTION: COPD is characterized by airflow limitation that is not fully reversible. Changes in the structure and function of the small airways (less than 2mm diameter) are now recognized to play a major pathophysiological and mechanical role in airflow limitation in COPD. There is, therefore, a need for technology to quantify small airways disease.

BACKGROUND: For the diagnosis and assessment of COPD, spirometry is the gold standard (postbronchodilator FEV(1)/FVC less than 70%). The ATS/ERS definition of an obstructive pulmonary defect contrasts with the definitions suggested by clinical guidelines, in that FEV(1) is related to VC rather than FVC and the cut-off value of this ratio is set at the 5(th) percentile of the normal distribution rather than at a fixed value of 0.7. There is also a significant association between the severity of the disease and the degree of inflammation in the small airways. Therefore, a variety of physiological tests have been proposed as non-invasive surrogate measurements of distal lung function, such as a reduction in the forced expiratory flow at 25% to 75% of forced vital capacity (FEF(25-75)). However, the reproducibility and comparability of the FEF(25-75) is limited if not adjusted for lung volume, and the relationship between FEF(25-75) and histology is unknown. It is difficult to quantify the narrowing of the small airways and physiological measurements are difficult to interpret because there is abnormal airflow in the larger airways. Therefore, it will be difficult to assess the effects of new treatments on small airway function, and it is important to develop new techniques in order to do so.

VIEWPOINT: The single breath nitrogen washout, with calculation of the slope (dN(2)) of the N(2) alveolar plateau, the closing volume and the closing capacity, is a more sensitive test of early lung damage in smokers than the FEV(1). The Forced Oscillation Technique (FOT) is a method for assessing respiratory mechanics non-invasively during spontaneous breathing. The more sophisticated multiple breath washout test (MBW) has the potential to locate the affected small airways anatomically in acinar and conductive lung zones through increased phase III slope indices, Sacin and Scond. In more advanced stages of smoking-induced lung disease, differential patterns of Sacin and Scond are characteristics of parenchymal destruction in addition to peripheral airways changes.

CONCLUSION: These functional tests are promising solutions for small airways assessment. FOT has the advantage of being a simple method, requiring only the passive cooperation of the subject.

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