Le diagnostic étiologique des infections bronchopulmonaires ne peut se faire sur les seules données cliniques, radiologiques et épidémiologiques. La part importante des infections virales chez l’adulte et chez l’enfant est démontrée.Le diagnostic des infections bronchopulmonaires virales repose sur l’analyse d’un prélèvement respiratoire, de préférence profond, par des techniques qui détectent soit les virus grippaux et le virus respiratoire syncytial, soit un large panel d’agents susceptibles d’être responsables de la pathologie. Ces dernières, appelées techniques de PCR multiplex, permettent une approche syndromique de l’infection respiratoire. Leur coût élevé pour le laboratoire pose la question de leur place dans la prise en charge des patients en termes d’épargne antibiotique et d’isolement. Devant l’absence de recommandation, la stratégie et l’équipement sont très hétérogènes.La place de ces tests dans la prise en charge des patients doit être évaluée par des études médicoéconomiques. Le rôle des différents virus, souvent détectés en coinfection, en particulier chez les enfants, mérite également l’attention des virologues et des cliniciens.Les nouvelles technologies de diagnostic, l’émergence du coronavirus SARS-CoV-2 et la mise sur le marché de nouveaux antiviraux vont impacter les recommandations de la prise en charge de ces infections.The etiological diagnosis of bronchopulmonary infections cannot be assessed with clinical, radiological and epidemiological data alone. Viruses have been demonstrated to cause a large proportion of these infections, both in children and adults.The diagnosis of viral bronchopulmonary infections is based on the analysis of secretions, collected from the lower respiratory tract when possible, by techniques that detect either influenza and respiratory syncytial viruses, or a large panel of viruses that can be responsible for respiratory disease. The latter, called multiplex PCR assays, allow a syndromic approach to respiratory infection. Their high cost for the laboratory raises the question of their place in the management of patients in terms of antibiotic economy and isolation. In the absence of clear recommendations, the strategy and equipment are very unevenly distributed in France.Medico-economic analyses need to be performed in France to evaluate the place of these tests in the management of patients. The evaluation of the role of the different viruses often detected in co-infection, especially in children, also deserves the attention of virologists and clinicians.The availability of new diagnostic technologies, the recent emergence of SARS-CoV-2, together with the availability of new antiviral drugs are likely to impact future recommendations for the management of viral bronchopulmonary infections.

The predictive factors for long-term dependency (LTD) on noninvasive ventilation (NIV) immediately after acute hypercapnic respiratory failure (AHRF) have not been identified. The present authors studied 42 patients with chronic obstructive pulmonary disease (COPD) and 58 non-COPD patients successfully treated by NIV for an AHRF episode. Parameters at stable state, at admission for AHRF and during a 1-yr follow-up were compared in patients with or without LTD-NIV at discharge. The incidence of LTD-NIV was 39% in non-COPD patients and 19% in COPD patients. Based on multivariate analysis with stepwise logistic regression, lower baseline pH values and noninfectious causes of AHRF were independently associated with LTD-NIV. Mutually adjusted odds ratios were found to be 1.316 (95% confidence interval (CI) = 1.127-1.536) for a 0.01 decrease of baseline pH value and 5.1 (95% CI = 1.8-14.0) for a noninfectious cause of AHRF. Outcome after 1 yr was poor in COPD patients. Long-term dependency on noninvasive ventilation is not an uncommon situation after resolution of an acute hypercapnic respiratory failure episode, especially in patients with non-chronic obstructive pulmonary disease causes of respiratory failure. The present study raises the need for prospective validation of a weaning protocol in patients managed by noninvasive ventilation for an acute hypercapnic respiratory failure episode.

The aim of this study was to evaluate the clinical efficacy of telithromycin administered for 5 days at a dosage of 800 mg/day, in patients with acute exacerbation of chronic obstructive pulmonary disease (AECOPD) presenting with at least 2 of Anthonisen's criteria including the increase of purulence.Methodology. - During this multicenter (211 private lung specialists), prospective, non-comparative, open-labeled French study, 365 patients were included between April 2002 and March 2003. Clinical efficacy was assessed on D12-D19 by the rate of clinical success as defined by recovery or clinical improvement (main endpoint) according to the number of exacerbation episodes during the previous year.Results. - On D12-D19 clinical success rate in the per protocol global population was 88.0% and respectively 87.9% in patients with <= 3 episodes in the previous year and 88.6% in patients with >= 4 episodes in the previous year. These success rates were similar to those in the intent-to-treat population. Safety, assessed on 359 patients, was satisfactory, with mainly digestive disorders related to the treatment in 3.9% of the patients. No treatment-related serious adverse events were observed.Conclusion. - This study, conducted among private practitioners in France according to COPD classification as defined by official recommendations, validates the results obtained in previous studies. Our results confirm the place attributed to telithromycin in the treatment of patients presenting with AECOPD without chronic respiratory failure, according to ongoing official recommendations. (c) 2005 Elsevier SAS. Tous droits reserves.

Evaluation of patients with chronic obstructive pulmonary disease (COPD) often includes the use of post-bronchodilator reversibility testing to guide treatment decisions. Recommendations for reversibility testing differ and there is no universally accepted method or outcome criterion. A survey of recent clinical trials with beta2-agonists in COPD illustrates the diversity of methods used to assess reversibility and highlights the difficulty of comparing data from such trials. Two recent studies demonstrated the benefits of treatment with the long-acting beta2-agonist bronchodilator formoterol (Foradil Aerolizer) in patients with COPD. When patients were classified according to their degree of reversibility as partially or poorly reversible, improvements were observed in both groups irrespective of the definition applied. These results suggest that bronchodilator reversibility testing should not be used as a rigid basis for treatment decisions with beta2-agonists in COPD patients. There is a pressing need for the role of reversibility testing to be clearly defined.

A l'occasion d'une insuffisance respiratoire aiguë (IRA), un nombre croissant de patients âgés est aujourd'hui admis en secteur de Réanimation afin d'y bénéficier d'une assistance ventilatoire mécanique, par exemple dans le cadre d'une décompensation de BPCO ou d'un œdème pulmonaire cardiogénique. La VNI a fait la preuve de son efficacité au cours des IRA de nombreuses étiologies en réduisant le recours à l'intubation endotrachéale, les complications durant l'hospitalisation et la durée de séjour hospitalier. En ce qui concerne les patients insuffisants respiratoires chroniques en décompensation, la VNI constitue désormais la modalité ventilatoire de première intention, en l'absence des critères de gravité requérant une intubation endotrachéale. Dans tous les cas, l'efficacité de la VNI dépend en partie du degré d'expertise de l'équipe médicale et paramédicale (incluant les kinésithérapeutes) et nécessite un cadre approprié à la pathologie et à la sévérité du patient. S'il existe peu de données concernant la VNI chez les personnes âgées, les études incluant des patients de plus de 75 ans ne font pas état de résultats particuliers concernant cette population. Les prochains travaux concernant la VNI devraient nous permettre de mieux sélectionner les malades susceptibles de bénéficier de cette technique. Quelques situations plus fréquentes chez la personne âgée sont en cours d'évaluation par exemple la VNI dans le contexte des soins palliatifs ou lorsqu'une décision de « non intubation » a été prononcée par le patient, son entourage proche et l'équipe soignante. En raison de son efficacité clinique et d'une bonne tolérance permise par une approche non invasive, la VNI est devenue une technique incontournable dans la prise en charge des IRA et tout particulièrement chez les personnes âgées. An increasing number of elderly patients, with acute respiratory failure (ARF) due to e.g. COPD exacerbation or cardiac failure, are being referred to intensive care units for mechanical ventilation. NIV can be an effective ventilatory technique in ARF due to a variety of aetiologies. NIV has been shown to decrease endotracheal intubation rates, complication rates and median hospital length of stay. When managing acute-on-chronic respiratory failure, NIV is a first-line ventilatory technique, in the absence of criteria for immediate endotracheal intubation. The efficacy of NIV depends on the expertise of the medical and nursing staff (including physiotherapists) and should always be performed in an appropriate setting. There are very few data about NIV in the elderly but studies, which included patients over 75 years, did not identify different outcomes for this age group. Future clinical studies on NIV should allow us to better understand which patients will benefit the most from the technique. Certain specific settings in elderly populations, such as in palliative care or when an "non intubation order" has been given by the patient, his family or the medical/nursing staff, are under evaluation. NIV is effective and well tolerated and it has become a key ventilatory technique in the management of ARF, particularly for elderly patients.

INTRODUCTION:An increasing number of elderly patients, with acute respiratory failure (ARF) due to e.g. COPD exacerbation or cardiac failure, are being referred to intensive care units for mechanical ventilation.STATE OF ART:NIV can be an effective ventilatory technique in ARF due to a variety of aetiologies. NIV has been shown to decrease endotracheal intubation rates, complication rates and median hospital length of stay. When managing acute-on-chronic respiratory failure, NIV is a first-line ventilatory technique, in the absence of criteria for immediate endotracheal intubation. The efficacy of NIV depends on the expertise of the medical and nursing staff (including physiotherapists) and should always be performed in an appropriate setting. There are very few data about NIV in the elderly but studies, which included patients over 75 years, did not identify different outcomes for this age group.PERSPECTIVES:Future clinical studies on NIV should allow us to better understand which patients will benefit the most from the technique. Certain specific settings in elderly populations, such as in palliative care or when an "non intubation order" has been given by the patient, his family or the medical/nursing staff, are under evaluation.CONCLUSIONS:NIV is effective and well tolerated and it has become a key ventilatory technique in the management of ARF, particularly for elderly patients.

STUDY OBJECTIVES:To compare, in clinical conditions, the efficacy of refilled oxygen cylinders (O2-HFs) in improving oxygenation and exercise capacity of patients with COPD during a 6-min walking test.DESIGN:Prospective randomized study with a cross-over design.SETTING:A university teaching hospital.PATIENTS:Ten patients with COPD, in a stable state and previously treated with long-term domiciliary oxygen therapy. Baseline characteristics were as follows: age, 65 +/- 7 years; PaO2 on room air, 55.4 +/- 6.3 mm Hg; PaCO2 on room air, 46.2 +/- 7.4 mm Hg; FEV1/vital capacity, 47 +/- 7%; and FEV1, 30 +/- 7% of predicted value (mean +/- SD).DESIGN:All patients performed three successive 6-min walking tests, the first test in room air and the other tests in a randomized order with either a conventional oxygen cylinder (O2-C) or an O2-HF.MEASUREMENTS AND RESULTS:The fraction of inspired oxygen (FIO2) delivered by O2-HFs was significantly lower than the FIO2 delivered by O2-Cs (94.2 +/- 2.6% vs 98.8 +/- 4.9%, p = 0.02). Mean O2-HF and O2-C weights before the walking tests were similar (3,510 +/- 251 g and 3,770 +/- 142 g, respectively; p = 0.09). Mean transcutaneous oxygen saturation was similarly improved with both oxygen delivery systems. Mean distances with O2-C (373.5 +/- 81 m) and O2-HF (375 +/- 97 m) were not different but significantly improved, as compared with room air (334.5 +/- 90 m; p = 0.03 and 0.02, respectively). Dyspnea sensations were similar for the three tests.CONCLUSION:O2-HFs are as efficient as O2-Cs for performing short-term exercises. Because of a lower cost, pressurizing units may be worthwhile for improving ambulatory oxygen therapy and pulmonary rehabilitation programs.

Nasal mask ventilation (NMV) has been used successfully in chronic restrictive respiratory failure and more recently in acute exacerbations of chronic obstructive pulmonary disease (COPD). This study aimed to evaluate the possible role of NMV in acute respiratory failure (ARF) episodes when mechanical ventilation with endotracheal intubation is questionable. Thirty patients (age, 76 +/- 8.1 years) were treated by NMV during ARF episodes (COPD, 20; other chronic respiratory failure [CRF], 5; chronic heart failure [CHF], 4). All patients were hypoxemic (PaO2, 5.85 +/- 1.62 kPa) and hypercapnic (PaCO2, 8.63 +/- 1.89 kPa) with respiratory acidosis (pH, 7.29 +/- 0.08). In all cases, clinical or physiologic parameters indicated the need for mechanical ventilation, but endotracheal intubation was either not applied because of the age and the physiologic condition of the patients (17 cases) or was postponed (13 cases). NMV was performed using a volume-cycled ventilator and a customized nasal mask. Ventilation was continuous during the first 12 hours and the following nights and was then intermittent during the day. Twenty-one patients improved clinically, within a few hours. Progressive correction of arterial blood gases was observed: PaO2 increased during the first hour, but PaCO2 decreased more slowly. Eighteen patients were able to be successfully weaned from NMV. Twelve patients failed to improve despite NMV: eight of them died and four required endotracheal intubation. There was no difference in the success rate between patients in whom endotracheal ventilation was contraindicated or postponed. Clinical tolerance was satisfactory in 23 patients and poor in seven patients. A return to the respiratory condition was observed in the surviving patients with subsequent discharge from hospital. NMV therefore successfully treated respiratory distress initially in 60 percent of the 30 patients. These results suggest that NMV could be a possible alternative in the treatment of ARF, even in very ill patients, when endotracheal ventilation is controversial or not immediately required.

The exploration of a stenosis of an intermediate bronchus in a 50 year-old woman showed it to be severe, limited, and non-malignant. Pre-operative angiography showed hypovascularization of the right lower and middle pulmonary lobes. A short resection of the stenosis, with termino-terminal bronchial anastomosis was performed. Post-operative evaluation showed normal bronchography and angiography. This suggests that bronchial stenosis plays a role in the hypovascularization observed before its surgical correction, the most likely hypothesis being vasoconstriction.