Introduction Asthma is the most common chronic disease in children. Advances in knowledge of asthma pathophysiology have led to the description of endotypes including: allergic eosinophilic asthma, non-allergic eosinophilic asthma (grouped under the term T2-high) and neutrophilic asthma (T2-low). Eosinophilic asthma is poorly described in children, and clinical practice suggests an increase in its prevalence over time. The aim of our study was to evaluate the evolution of the proportion of hyper-eosinophilic asthma in the pediatric population over time, and to characterize this population. Patients and methods We conducted a single-center retrospective study at the University Hospital of Rouen, France, between 1995 and 2021: 1041 children aged 0-17 years, followed for asthma in our tertiary center, in which eosinophil blood count was prescribed, were included. Results Between 1995 and 2021, we found no change in hyper-eosinophilia levels in asthmatic children. We found that blood eosinophilia > 400 cells/μL was associated with allergy, male gender and the 6-11 age group. Biologic therapies were significantly associated with hyper-eosinophilia (p<0.001). Discussion Our results suggest that we repeat more eosinophilia assays during follow-up of an asthmatic patient, giving the clinical impression of higher hyper-eosinophilia. The three biologic therapies currently approved for young children target T2-high asthma. A new monoclonal antibody targeting TSLP is available in children over 12 years old; it is effective in T2-low asthma, according to initial studies. This would be an interesting prospect for young children with severe T2-low, for whom no biotherapy is currently available.
Introduction In studies evaluating the efficacy of anti-programmed cell death (ligand)1 (anti-PD-(L)1) in patients with non-small-cell lung cancer (NSCLC), smokers tend to have better clinical outcomes than non-smokers. However, whether co-existing emphysema is associated with differences in clinical outcomes, regardless of smoking status remains unclear. Methods In a single-arm, prospective, multicenter, phase II trial, patients aged 18-75 years with metastatic NSCLC, PD-L1≥25% and a performance status (PS) of 2-3 received durvalumab until progression or toxicity. Pre-planned analyses classified emphysema visually as follows: <10% (no/mild emphysema), 10 to 25% (moderate emphysema) and >25% (severe emphysema). We also quantified emphysema (%LAV-950HU), along with bronchial (wall thickness) and small pulmonary vessels (cross-sectional area<5 mm²). Results Fifty patients were enrolled with 49 analyzable CT scans, of whom 43 (87.8%) had emphysema. Twenty-eight patients (57%) had an emphysema extent >10%, with a median %LAV-950 HU of 0.97 [IQR: 0.25-3.12]. In univariate analyses, compared to mild emphysema, patients with moderate emphysema had a significantly poorer overall survival (OS (HR 2.73, 95%CI [1.25-5.98]), whereas severe emphysema had not. Objective response rate and progression free survival were similar in all groups. In multivariate analyses, OS remained lower in patients with moderate emphysema (HR: 2.53, 95%CI [1.12-5.71]), after adjustment for smoking, age and PS. There was no difference according to bronchial and vascular involvement. Conclusion In a single-arm cohort of PS2-3 patients with advanced NSCLC treated with 1st-line durvalumab, the presence of moderate emphysema was associated with worse overall survival.
Background The efficacy of endobronchial valve (EBV) treatment has been demonstrated in randomized controlled trials. However, real-life nationwide data from more heterogeneous patient populations remains limited. Therefore, this study aims to evaluate the one-year outcome of EBV treatment in a nationwide cohort study. Method In this nationwide cohort study, Danish patients treated with endobronchial valves from 2017-2024 were included. Outcomes, such as lung function, exercise capacity, and dyspnea, were assessed at 3 and 12 months, together with data on complications and mortality. Data was obtained from electronic medical records. Results A total of 232 patients were included in the study. Follow-up visits at 3 (1-5) and 12 (9-18) months were available for 189 and 165 patients, respectively. Nine patients died within the first year, and 37 patients underwent valve removal. Significant improvements from baseline were observed at both follow-up points in lung function (forced expiratory volume in 1 second +4.75%points & +3.43 %points, residual volume -30.5%points & -27.7 %points, total lung capacity -7.0%points & -5.7%points), physical ability (6-minute walk distance +30.6 m & +20.8 m), and dyspnea (Medical Research Council dyspnea scale -0.73 & -0.47). Responder rates declined over time, but 40-50% of patients maintained a clinically meaningful benefit at the 12-month visit. Revision bronchoscopies were performed in 44% of the patients. Conclusions Endobronchial valve treatment is associated with statistically significant improvements in lung function, exercise capacity, and dyspnea at both 3 and 12 months, with considerable inter-individual variability.
BACKGROUND:The most common complication preventing outpatient management after percutaneous CT-guided lung biopsy (PTLB) is the occurrence of pneumothorax requiring drainage. We previously developed a pragmatic score to predict the risk of clinically relevant pneumothorax after PTLB (hereafter called the CAPAD score), to guide patient management. OBJECTIVES:To externally validate the CAPAD score in an independent cohort, with a specific focus on its ability to rule out pneumothorax requiring drainage after PTLB. METHOD:We retrospectively analysed a pre-existing institutional database of consecutive adult patients undergoing CT-guided PTLB at Bichat-Claude-Bernard University Hospital (Paris, France) between 1 January 2015 and 31 December 2017. The CAPAD score combines five variables: COPD, Anterior PTLB approach, more than one Pleural crossing, pneumothorax ≥10 mm on the end-of-procedure CT (post-procedural immediate pneumothorax), and skin-pleura Distance ≤30 mm, with a pre-specified cut-off of 73 points. The primary endpoint was the diagnostic performance of the score for post-PTLB pneumothorax on the 4-6 h control CXR and secondary endpoint was its performance for pneumothorax requiring drainage. RESULTS:The CAPAD score was computable in 313 of 474 patients. Pneumothorax occurred in 95 patients (30.4%), and 23 patients (7.3%) required drainage. At the pre-specified cut-off of 73, the score had a C-index of 0.77, a sensitivity of 75%, a specificity of 56%, a negative predictive value (NPV) of 84% and a positive predictive value of 43% for any post-PTLB pneumothorax. For pneumothorax requiring drainage, a score < 73 was associated with a 2.0% risk (3/147), corresponding to a NPV of 98%. CONCLUSION:Our pragmatic CAPAD score demonstrated a good prognostic performance for predicting the risk of post-procedural pneumothorax, achieve a NPV of 98% for pneumothorax requiring drainage.
INTRODUCTION:Current guidelines recommend risk-guided treatment escalation in pulmonary arterial hypertension (PAH) and selected chronic thromboembolic pulmonary hypertension (CTEPH). However, the extent to which these recommendations are implemented in routine practice and the reasons for non-adherence remain unclear. METHODS:We conducted a single-center, retrospective cohort study including consecutive patients with PAH (WHO group 1) and/or inoperable CTEPH (WHO group 4), including combined pulmonary hypertension, treated between September 2022 and September 2023. Risk stratification was performed using the three-strata model at baseline and the four-strata model at follow-up, in combination echocardiographic assessment. An indication for escalation of pH-specific therapy was defined as an intermediate-high or high risk score. Non-adherence was defined as absence of therapy escalation despite this increased risk score. RESULTS:A total of 119 patients were included, (median age 67 years [IQR 54-75], 66% female; 80% PAH, 20% CTEPH). Combined pH was present in 43%. Non-adherence was identified in 32 patients (27%). In nine patients, non-escalation was considered appropriate, owing to medication intolerance (n = 5), patient preference (n = 3), or ongoing dose titration (n = 1). Potentially inappropriate non-escalation occurred in 12 patients and was mainly related to comorbidities affecting risk assessment (n = 10) or undocumented physician decision-making (n = 2). Non-adherence was more frequent among older patients and those with combined pulmonary hypertension. CONCLUSION:Although risk scores often indicated treatment escalation, real-world decision-making was frequently guided by clinical complexity. In many cases, apparent non-adherence reflected appropriate individualized care, as comorbidities and limited guidance for CTEPH reduced the applicability of guideline-based strategies.
BACKGROUND:The COVID-19 pandemic caused a surge of admissions to intensive care unit (ICU) of patients with severe hypoxemic acute respiratory failure (ARF). Due to the specificities of COVID-19 ARF and a risk of viral aerosolization, the different oxygenation strategies were widely debated, including high-flow nasal oxygen therapy (HFNO). Few studies have compared ICU populations between the different waves of the pandemic and the impact of the oxygenation strategy on patient outcomes. PATIENTS AND METHODS:We conducted a retrospective study to compare the clinical characteristics, ventilatory management and the outcomes of patients with COVID-19 ARF during the first three waves of the pandemic in France. We also assessed patient outcomes according to the time to intubation, i.e., the duration of HFNO before intubation (HFNO late failure: > 48 h, FiO2 ≥ 80% and flow rate ≥ 60 L./min). RESULTS:Between March 2020 and April 2021, 198 patients were included in the study 56, 85 and 57 patients, respectively in the three waves. Despite similar clinical characteristics at admission, the use of HFNO increased significantly between the three waves (62.5%, 96.5%, 98.2% respectively; p < 0.001) with a trend for HFNO success (46.4%, 65.9%, 63.2%; p = 0.057). When HFNO failed, the time from ICU admission to intubation was longer (p < 0.001), the duration of HFNO before intubation was longer (1.8, 3.0, 5.2 days, respectively; p = 0.015, and with more severe underlying hypoxemia (PaO2/FiO2 ratio; p = 0.012). ICU length of stay and mortality were similar between the three waves. Finally, all waves combined, the time to intubation (early n = 20 intermediate n = 24, late n = 31) had no effect on patient outcomes. CONCLUSION:Our study confirms that HFNO was an effective oxygenation strategy for the management of patients with severe COVID-19 ARF, and was used increasingly over the first three waves. HFNO is a non-invasive treatment that should be preferred to intubation as a first-line respiratory support of patients with acute respiratory failure.
INTRODUCTION:Diagnostic yields of sampling techniques for the diagnosis of mediastinal lymphadenopathy, mainly rely on transbronchial needle aspiration (EBUS-TBNA) and intranodal forceps biopsy (EBUS-IFB), vary depending on the underlying pathology. The respective roles of these two sampling techniques remain to be clearly defined. OBJECTIVES:To compare the diagnostic yields of EBUS-TBNA and EBUS-IFB for the cytological and/or histological diagnosis of mediastinal and hilar lymphadenopathy. STUDY DESIGN AND METHODS:A single-centre, retrospective, paired study was conducted at Hôpital Nord, Marseille (Assistance Publique-Hôpitaux de Marseille, AP-HM, Marseille, France) in patients who underwent EBUS-TBNA and EBUS-IFB performed during the same procedure on the same target lymph node for the diagnosis of mediastinal lymphadenopathy. Diagnostic yields of both sampling techniques were compared in patients for whom a definitive diagnosis was established after completion of the diagnostic work-up. RESULTS:A total of 131 patient records were analysed. A definitive diagnosis was obtained in 101 patients after endoscopic sampling and additional investigations, predominantly malignancies (41 patients) and granulomatous diseases (54 patients). Endoscopic samples were considered adequate for interpretation in 103 patients (78%) with EBUS-IFB and in 114 patients (87%) with EBUS-TBNA. In 70 patients (69%), bronchoscopy alone provided a definitive diagnosis without the need for further investigations, 61 diagnoses were obtained by EBUS-IFB and 28 by EBUS-TBNA (p = 10⁻⁷). Among the 41 malignant cases, diagnoses were established in 22 patients using EBUS-IFB and in 25 patients using EBUS-TBNA. EBUS-IFB enabled the diagnosis of granulomatous disease in 39 patients, compared with only 3 patients using EBUS-TBNA (p = 10⁻⁵). Two procedures were complicated by minor bleeding. CONCLUSION:In this retrospective, single-centre study, EBUS-IFB was associated with a higher diagnostic yield for mediastinal lymphadenopathy, with a significant benefit observed in selected patients with granulomatous diseases. No additional diagnostic benefit of EBUS-IFB over EBUS-TBNA was observed in malignant conditions. These findings should be interpreted in the context of the study's selection bias, as EBUS-IFB was preferentially performed in patients with suspected benign or granulomatous disease.
Non-malignant airway stenoses remain major challenges in interventional pulmonology, particularly when long-term stenting is required. Although conventional silicone airway stents effectively restore patency, their standardized geometry often fails to accommodate patient-specific airway anatomy, leading to migration, granulation tissue formation, mucus plugging, and repeated bronchoscopic interventions that limit long-term tolerance and efficacy. Advances in high-resolution imaging and modeling, and additive manufacturing have enabled the emergence of patient-specific, 3D-engineered silicone airway stents, predominantly produced using mold-based approaches. Early clinical experience suggests that personalization improves anatomical congruence and mechanical stability, particularly in anatomically complex non-malignant disease. The strongest evidence supports their use in post-surgical and post-lung transplant anastomotic complications, where distorted anatomy and prolonged stenting magnify the limitations of conventional devices. Additional emerging indications include complex inflammatory or post-infectious bronchial stenoses, selected benign tracheal stenoses with anatomical distortion, and refractory airway fistulas requiring customized occlusion. This narrative review summarizes current design principles, workflow, and patient selection for patient-specific airway stents. While evidence remains limited, ongoing trials and technological advances may broaden clinical indications, contingent on standardized reporting, biomechanical validation, regulatory clarity, and comparative studies establishing long-term clinical and economic value.
The distinction between idiopathic pulmonary arterial hypertension (iPAH) and pulmonary hypertension associated with lung disease remains increasingly challenging, particularly in patients with overlapping clinical features. In a timely study, Valentin and colleagues investigated whether cardiac magnetic resonance (CMR) native T1 mapping could improve phenotypic characterization in patients with classical iPAH, iPAH with a lung phenotype, and group 3 pulmonary hypertension (PH). While conventional CMR measures of right ventricular (RV) structure and function showed no significant differences between groups, native T1 values were significantly higher in classical iPAH, particularly at the interventricular septum and RV insertion points, suggesting more pronounced myocardial fibrosis and RV remodeling. Patients with lung phenotype iPAH exhibited T1 profiles closer to group 3 PH, supporting the concept of distinct underlying pathophysiology. Although the observed differences were modest and require validation across larger cohorts and 1.5 Tesla MRI platforms, these findings highlight the potential of myocardial tissue characterization as a complementary tool for integrated PH phenotyping. Beyond diagnostic classification, advanced CMR techniques may provide valuable biomarkers of RV adaptation, disease progression, and treatment response, contributing to a more personalized and mechanistically informed approach to pulmonary vascular disease.
INTRODUCTION:Pulmonary hypertension (PH) is a frequent and serious complication of chronic obstructive pulmonary disease (COPD) with limited therapeutic options. The aim was to evaluate the effectiveness and tolerance of respiratory rehabilitation (RR) in COPD according to the echocardiographic probability of PH. METHODS:This was a retrospective, comparative observational study conducted between 2013 and 2023 in the University Hospital of Poitiers (France) and its associated rehabilitation center. All adult COPD patients with an echocardiographic assessment of the probability of PH and having undergone RR for at least 3 weeks were included. Patients with intermediate or high echocardiographic probability of PH, considered as suspected PHCOPD (s-PHCOPD) were compared with COPD patients with low probability of PH. The effectiveness of RR was assessed by the difference in the 6-minute walking distance (6MWD) between the beginning and the end of the RR course. Other criteria of RR effectiveness and tolerance were assessed. RESULTS:Fifty-nine patients were included (11 s-PHCOPD, 48 COPD without PH). The population was predominantly male with a median age of 65 [58-70] y.o, and all were smokers or ex-smokers. Both groups demonstrated significant improvement in 6MWD: 75 m [-24 to 121, p = 0.04] in the s-PHCOPD group and 33 m [6 to 63, p = 0.0001] in the COPD-without PH group with no significant difference in 6MWD improvement between groups (p = 0.3). There was no significant difference in the other criteria of effectiveness and tolerance between the two groups. CONCLUSION:RR was effective and well-tolerated in both s-PHCOPD and COPD-without PH patients. Prospective studies are needed to confirm these findings.
Endoscopic lung volume reduction with endobronchial valves (LVRV) is an established treatment option for patients with severe emphysema and little to no collateral ventilation (CV). However, approximately 10% of patients fail to achieve meaningful target lobe volume reduction (TLVR) despite appropriate CV assessment and repeated revision bronchoscopies, suggesting alternative mechanisms such as pleuroparenchymal constraints or limitations of the Chartis® evaluation. We report a stepwise surgical salvage strategy in a patient with severe emphysema treated with valves in the right upper lobe (RUL), who showed no TLVR despite two revision bronchoscopies. A sequential robot-assisted thoracoscopic approach combining complete adhesiolysis, repeated intraoperative reventilation testing, and surgical interruption of the fissure resulted in a partial atelectasis of the RUL. At 3 months, although the intended volume reduction target was not fully achieved, TLVR reached 50.6%, with clinically meaningful functional improvement. This sequential strategy could therefore constitute a future therapeutic solution in this setting.
