Imagerie des BPCO [Imaging of COPD].

Standard chest radiographs have been shown to be insensitive for the diagnosis of morphologic abnormalities of airways. Computed tomography is the most sensitive and specific investigation to diagnose emphysema. However, as emphysema may be missed on computed tomography, this investigation cannot be used to definitely rule out the diagnosis. Computed tomography may contribute to the investigation of bronchiolitis, and it is now considered as the gold standard for establishing the diagnosis of bronchiectasis. Imaging may contribute to identify complications such as bronchopulmonary infection, pulmonary hypertension, pneumothorax, cancer of the lung, compressive bullae, and pulmonary embolism.

Nouvelles pistes pour la réhabilitation respiratoire dons la bronchopneumopathie chronique obstructive (BPCO) [New perspectives for respiratory rehabilitation in COPD].

COPD is associated with some skeletal muscle dysfunction which contributes to a poor exercise tolerance. This dysfunction results from multiple factors: physical inactivity, corticosteroids, smoking, malnutrition, anabolic deficiency, systemic inflammation, hypoxia, oxidative stress. Respiratory rehabilitation is based on exercise training and allows patients with COPD to experience less dyspnoea, and to improve their exercise tolerance and quality of life. Not all patients, however, benefit from rehabilitation. Acknowledging the different factors leading to muscular dysfunction allows one to foresee new avenues to improve efficacy of exercise training in COPD.

Pulmonary biomarkers in COPD exacerbations: a systematic review.

Exacerbations of COPD (ECOPD) represent a major burden for patients and health care systems. Innovative sampling techniques have led to the identification of several pulmonary biomarkers. Although some molecules are promising, their usefulness in clinical practice is not yet established. Medline and Highwire databases were used to identify studies evaluating pulmonary sampled biomarkers in ECOPD. We combined 3 terms for ECOPD, 3 for biomarkers and 6 for the sampling method. Seventy-nine studies were considered eligible for inclusion in the review and were analyzed further. Pulmonary biomarkers sampled with non-invasive, semi-invasive and invasive methods were evaluated for their potential to illustrate the disease's clinical course, to correlate to clinical variables and to predict clinical outcomes, ECOPD etiology and response to treatment. According to published data several pulmonary biomarkers assessed in ECOPD have the potential to illustrate the natural history of disease through the modification of their levels. Among the clinically relevant molecules, those that have been studied the most and appear to be promising are spontaneous and induced sputum biomarkers for reflecting clinical severity and symptomatic recovery, as well as for directing towards an etiological diagnosis. Current evidence on the clinical usefulness of exhaled breath condensate and bronchoalveolar lavage biomarkers in ECOPD is limited. In conclusion, pulmonary biomarkers have the potential to provide information on the mechanisms underlying ECOPD, and several correlate with clinical variables and outcomes. However, on the basis of published evidence, no single molecule is adequately validated for wide clinical use. Clinical trials that incorporate biomarkers in decisional algorithms are required.

Prise en charge du patient avec bronchopneumopathie obstructive: ambulatoire ou hospitalière [Management of the patient with COPD: home case or hospitalization].

Acute exacerbation of COPD is one of the most common causes of hospital admission in patients affected with this disease. In most cases, consideration of differential diagnoses and assessment of important comorbidities will allow to make the decision whether or not the patient needs to be hospitalized. A decision to hospitalize will be based on specific symptoms and signs, as well on the patient's history. Contrary to bronchial asthma, a systematic action plan strategy is lacking for COPD. However, a disease management plan involving all the health care providers may have the potential to improve the patient's well being and to decrease costs related to these exacerbations.

Lung transplantation for COPD - evidence-based?

Lung transplantation has now been performed for more than 30 years in patients with end-stage chronic obstructive pulmonary disease (COPD). This disease is the major indication for lung transplantation, involving more than one third of the procedures worldwide. Although lung transplantation in COPD patients has clearly shown a positive impact on lung function, exercise capacity and quality of life, the survival benefit remains difficult to ascertain. Several methodological difficulties, particularly the absence of classical randomised studies, make the analysis especially challenging. There is however indirect but convincing evidence that lung transplantation can, when appropriate selection criteria are applied, provide not only an active post-transplant lifestyle but also a survival benefit for patients with COPD.

Survival impact of lung transplantation for COPD.

Chronic obstructive pulmonary disease (COPD) is the primary indication for lung transplantation (LTx), but survival benefit is still under debate. We analysed the survival impact of LTx in COPD with a new approach, using the BODE (body mass index, airway obstruction, dyspnoea, exercise capacity) index. We retrospectively reviewed 54 consecutive lung transplants performed for COPD. The pre-transplant BODE score was calculated for each patient and a predicted survival was derived from the survival functions of the original BODE index validation cohort. Predicted and observed post-transplant survival was then compared. In the subgroups with a BODE score >or=7 and <7, a majority of patients (66% and 69%, respectively) lived for longer after LTx than predicted by their individual BODE index. The median survival was significantly improved in the entire cohort and in the subgroup with a BODE score >or=7. 4 yrs after LTx a survival benefit was only apparent in patients with a pre-transplant BODE score of >or=7. In conclusion, while a majority of COPD patients had an individual survival benefit from LTx regardless of their pre-transplant BODE score, a global survival benefit was seen only in patients with more severe disease. This supports the use of the BODE index as a selection criteria for LTx candidates.

Mortality of patients with COPD participating in chronic disease management programmes: a happy end?

BACKGROUND: Concerns about increased mortality could question the role of COPD chronic disease management (CDM) programmes. We aimed at extending a recent Cochrane review to assess the effects of CDM on mortality in patients with COPD. METHODS: Mortality data were available for 25 out of 29 trials identified in a COPD integrated care systematic review. Meta-analysis using random-effects models was performed, followed by subgroup analyses according to study length (3-12 months vs >12 months), main intervention component (exercise, self-management, structured follow-up) and use of an action plan. RESULTS: The meta-analysis showed no impact of CDM on mortality (pooled OR: 1.00, 95% CI 0.79 to 1.28). CONCLUSIONS: These results do not suggest that CDM programmes expose patients with COPD to excessive mortality risk.

Survival impact of lung transplantation for COPD

La bronchopneumopathie chronique obstructive (BPCO) est l'indication la plus fréquente de la transplantation pulmonaire. Néanmoins, le bénéfice de survie dans cette indication est toujours débattu. Le but de cette étude était d'analyser l'impact de la transplantation pulmonaire sur la survie de patients BPCO à l'aide d'une nouvelle méthode utilisant l'index de BODE, un indice validé dans la prédiction de la survie de patients BPCO. L'index de BODE est composé de 4 variables (indice de masse corporelle, obstruction bronchique, dyspnée, capacité d'effort) et son score s'échelonne de 0 à 10, une valeur élevée signifiant une maladie plus sévère et donc une probabilité de survie moindre.Cette étude rétrospective a porté sur 54 patients BPCO ayant consécutivement bénéficié d'une transplantation pulmonaire (unilatérale ou bilatérale) au Centre Hospitalier Universitaire Vaudois et aux Hôpitaux Universitaires de Genève entre 1994 et 2007, avec un suivi jusqu'au 30 juin 2009. Le score de BODE avant transplantation a été calculé pour chaque patient, à partir duquel une survie prédite a été dérivée. Cette survie prédite a été comparée à la survie réelle des patients transplantés.Une majorité de patient (67%) a présenté un bénéfice individuel de survie suite à la transplantation pulmonaire. Ceci s'est vérifié aussi bien dans le sous-groupe de patients avec un score de BODE > 7 que dans celui avec un score de BODE < 7. La survie médiane était significativement améliorée par la transplantation pulmonaire dans la cohorte totale et dans le sous-groupe avec un score de BODE > 7, mais pas dans celui avec un score de BODE < 7. De plus, 4 ans après la transplantation, un bénéfice de survie ne peut être escompté que chez les patients présentant un score de BODE > 7.Dans notre cohorte, la transplantation pulmonaire a donc conduit à un bénéfice individuel de survie chez la majorité des patients, quel que soit leur score de BODE avant l'intervention. Toutefois, un bénéfice global de survie n'a pu être démontré que dans le groupe de patients ayant la maladie la plus sévère. Chez les patients moins sévèrement atteints, les risques liés à l'intervention sont plus importants que le bénéfice de survie escompté à long terme. Ces résultats confortent l'utilisation de l'index de BODE comme critère de sélection pour la transplantation pulmonaire chez les patients BPCO.

Impact of a Dedicated Noninvasive Ventilation Team on Intubation and Mortality Rates in Severe COPD Exacerbations.

BACKGROUND: Compared with usual care, noninvasive ventilation (NIV) lowers the risk of intubation and death for subjects with respiratory failure secondary to COPD exacerbations, but whether administration of NIV by a specialized, dedicated team improves its efficiency remains uncertain. Our aim was to test whether a dedicated team of respiratory therapists applying all acute NIV treatments would reduce the risk of intubation or death for subjects with COPD admitted for respiratory failure. METHODS: We carried out a retrospective study comparing subjects with COPD admitted to the ICU before (2001-2003) and after (2010-2012) the creation of a dedicated NIV team in a regional acute care hospital. The primary outcome was the risk of intubation or death. The secondary outcomes were the individual components of the primary outcome and ICU/hospital stay. RESULTS: A total of 126 subjects were included: 53 in the first cohort and 73 in the second. There was no significant difference in the demographic characteristics and severity of respiratory failure. Fifteen subjects (28.3%) died or had to undergo tracheal intubation in the first cohort, and only 10 subjects (13.7%) in the second cohort (odds ratio 0.40, 95% CI 0.16-0.99, P = .04). In-hospital mortality (15.1% vs 4.1%, P = .03) and median stay (ICU: 3.1 vs 1.9 d, P = .04; hospital: 11.5 vs 9.6 d, P = .04) were significantly lower in the second cohort, and a trend for a lower intubation risk was observed (20.8% vs 11% P = .13). CONCLUSIONS: The delivery of NIV by a dedicated team was associated with a lower risk of death or intubation in subjects with respiratory failure secondary to COPD exacerbations. Therefore, the implementation of a team administering all NIV treatments on a 24-h basis should be considered in institutions admitting subjects with COPD exacerbations.

Research needs in allergy: an EAACI position paper, in collaboration with EFA.

In less than half a century, allergy, originally perceived as a rare disease, has become a major public health threat, today affecting the lives of more than 60 million people in Europe, and probably close to one billion worldwide, thereby heavily impacting the budgets of public health systems. More disturbingly, its prevalence and impact are on the rise, a development that has been associated with environmental and lifestyle changes accompanying the continuous process of urbanization and globalization. Therefore, there is an urgent need to prioritize and concert research efforts in the field of allergy, in order to achieve sustainable results on prevention, diagnosis and treatment of this most prevalent chronic disease of the 21st century.The European Academy of Allergy and Clinical Immunology (EAACI) is the leading professional organization in the field of allergy, promoting excellence in clinical care, education, training and basic and translational research, all with the ultimate goal of improving the health of allergic patients. The European Federation of Allergy and Airways Diseases Patients' Associations (EFA) is a non-profit network of allergy, asthma and Chronic Obstructive Pulmonary Disorder (COPD) patients' organizations. In support of their missions, the present EAACI Position Paper, in collaboration with EFA, highlights the most important research needs in the field of allergy to serve as key recommendations for future research funding at the national and European levels.Although allergies may involve almost every organ of the body and an array of diverse external factors act as triggers, there are several common themes that need to be prioritized in research efforts. As in many other chronic diseases, effective prevention, curative treatment and accurate, rapid diagnosis represent major unmet needs. Detailed phenotyping/endotyping stands out as widely required in order to arrange or re-categorize clinical syndromes into more coherent, uniform and treatment-responsive groups. Research efforts to unveil the basic pathophysiologic pathways and mechanisms, thus leading to the comprehension and resolution of the pathophysiologic complexity of allergies will allow for the design of novel patient-oriented diagnostic and treatment protocols. Several allergic diseases require well-controlled epidemiological description and surveillance, using disease registries, pharmacoeconomic evaluation, as well as large biobanks. Additionally, there is a need for extensive studies to bring promising new biotechnological innovations, such as biological agents, vaccines of modified allergen molecules and engineered components for allergy diagnosis, closer to clinical practice. Finally, particular attention should be paid to the difficult-to-manage, precarious and costly severe disease forms and/or exacerbations. Nonetheless, currently arising treatments, mainly in the fields of immunotherapy and biologicals, hold great promise for targeted and causal management of allergic conditions. Active involvement of all stakeholders, including Patient Organizations and policy makers are necessary to achieve the aims emphasized herein.