INTRODUCTION:Chronic obstructive pulmonary disease (COPD) is underdiagnosed because of limited disease awareness with trivialization of the symptoms in the general population.METHODS:A survey was conducted in a representative sample (n=2758) of individuals older than 40 years of age in the general population of France. Respiratory symptoms and knowledge about COPD were assessed in individuals with or at risk for COPD (n=860, 31% of the sample).RESULTS:In the overall sample, 40% of individuals had a Medical Research Council dyspnea grade of 1 or more but only 9% spontaneously reported shortness of breath. Of these 9%, 72% reported limitations to their daily activities but only 14% believed they had severe lung disease. In the overall sample, only 220 (8%) individuals knew the term COPD and only 66% associated the term COPD with respiratory disease.CONCLUSIONS:Despite a large proportion of individuals at risk for COPD or having COPD and a high prevalence of breathlessness, awareness of respiratory symptoms and knowledge of COPD were limited. These findings indicate a need for educating the general population about COPD.

Rationale: Both obesity and obstructive sleep apnea (OSA) are risk factors for hypertension (HT) and chronic heart failure (CHF). The association between OSA and COPD (overlap syndrome) and the obesity hypoventilation syndrome (OHS) have been proposed as leading to enhanced cardiovascular risk. Methods: 3093 obese subjects (IMC>30kg/m2) referred for suspicion of OSA were prospectively assessed by sleep studies, lung function tests and blood gazes. For the whole group, mean age was 57±13 years with 66% of men, mean BMI: 36.8±6.2 kg/m2, 52.8% of the subjects being hypertensive and 3.23% suffering from CHF. 926 of the 3093 did not exhibit OSA or COPD. Results: In multivariate analysis, prevalent hypertension was associated with OSA (Odd ratio (OR): 1.23 (confidence intervals (CI): 1.04-1.45), p=0.015), ≥2 nocturia episodes per night (OR: 1.295 (CI: 1.10-1.52), p<0.01), type 2 diabetes (OR: 2.12 (CI: 1.56-2.88), p<0.01), hypercholesterolemia (OR: 1.94 (CI: 1.6-2.34), p<0.01), reduced physical activity (OR: 1.25 (CI: 1.04-1.49), p<0.01), each one unit increase in BMI increase (OR: 1.025 (CI: 1.01-1.04), p<0.01), each one unit increase in age (OR: 1.06 (CI: 1.04-1.07), p<0.01). In multivariate analysis, cardiac failure was explained by diurnal hypoventilation (OR: 2.64 (CI: 1.67-4.29), p<0.01), reduced physical activity (OR: 3.73 (CI: 2.44-5.7), p<0.01), former smoking (OR: 1.63 (CI: 1.06-2.51), p=0.025), and each one unit increase in age (OR: 1.07 (CI: 1.03-1.11), p<0.01). Conclusions: Sleep apnea was linked with HT independently of other classical cardiovascular risk factors. Diurnal hypoventilation was highly predictive of cardiac failure.

Tobacco smoking is the leading cause of COPD worldwide but other risk factors have been recognized. Air pollution is one of them, but its exact role in the development of COPD is hard to demonstrate. Its physiological effects on lung function have only been studied since the nineties by long and tedious cohort studies. Difficulties arise from the heterogeneity of air pollution (gas and particles); thus, its respiratory effects have to be examined for every component separately, and in different populations. It is also necessary to analyse the effects of atmospheric pollution in the short and the long term, considering both its physiological, clinical and toxicological effects, from childhood to adulthood. These factors make it difficult to obtain statistically significant results. Nevertheless, most studies seem to point to a role of air pollution in the development of COPD via oxydative stress but further studies are needed to confirm the exact effect of each component of air pollution on the respiratory tract. These studies could lead to improved public health policies and results are awaited that would identify at-risk populations, decide appropriate preventive measures and propose documented thresholds in pollution exposure. . . thereby limiting the spread of COPD. (C) 2010 Elsevier Masson SAS. All rights reserved.

This document is an update of Guidelines published in 2005 and now includes scientific publications through to May 2010. It provides evidence-based recommendations for the most common management questions occurring in routine clinical practice in the management of adult patients with LRTI. Topics include management outside hospital, management inside hospital (including community-acquired pneumonia (CAP), acute exacerbations of COPD (AECOPD), acute exacerbations of bronchiectasis) and prevention. The target audience for the Guideline is thus all those whose routine practice includes the management of adult LRTI.

La bronchopneumopathie chronique obstructive (BPCO) est causée à plus de 90 % par le tabagisme, mais plusieurs autres facteurs de risque ont été clairement identifiés ; la pollution extérieure (atmosphérique) en fait partie, mais son implication dans la constitution de la maladie est très difficile à démontrer. Ses effets sur la fonction respiratoire ne sont réellement étudiés que depuis une vingtaine d’années grâce à des études de cohortes, longues et fastidieuses, ce qui explique les controverses concernant leurs conclusions et les difficultés à mettre en évidence des résultats statistiquement significatifs. Ces difficultés sont d’autant plus grandes que la pollution est faite d’un ensemble de molécules (gaz, particules…), et qu’il faut rechercher l’effet respiratoire de chaque constituant au sein d’une population donnée. Par ailleurs, mettre en évidence un lien de causalité entre pollution atmosphérique et BPCO nécessite d’analyser ses effets à court terme, à long terme, ses effets physiologiques, toxicologiques et cliniques, depuis l’enfance jusqu’à l’âge adulte. Il semble qu’à l’heure actuelle, de nombreux travaux soient concordants et stigmatisent certains polluants extérieurs comme responsables d’altération de la fonction respiratoire, notamment via le stress oxydatif. Néanmoins, d’autres résultats sont attendus pour confirmer l’implication exacte de chaque composant, ce qui va probablement devenir un enjeu majeur de santé publique. Le but de ces analyses est d’identifier les populations à risque, afin de proposer des actions préventives, des seuils de tolérance, pour éviter la constitution d’une BPCO invalidante.

Background and Objectives The national French Registry to evaluate sleep breathing disorders (OSFP Registry: Observatoire sommeil de la Fédération de Pneumologie) is intended to collect updated information about current practices of respiratory physicians managing sleep apnoea patients. Methods, Program Description and Follow-up The main goal of the Internet-based registry (www.osfp.fr) is to improve clinical management quality by offering respiratory physicians a complete and systematically organised online evaluation of patients referred for sleep disorders. The content of the registry addresses four goals: (1) to improve physician's knowledge not only of sleep apnoea but also of alternative diagnosis by the systematic use of validated clinical scales for sleepiness, fatigue, depression and restless legs syndrome, (2) to increase awareness of comorbidities and cardio-metabolic risk associated with sleep apnoea, by suggesting measurements of waist circumference, blood pressure, fasting lipids and fasting glucose, (3) to identify subgroups of at-risk patients (ie obesity hypoventilation and a combination of chronic obstructive pulmonary disease and sleep apnoea, the so-called overlap syndrome), and (4) to suggest appropriate follow-up and treatments for these specific subgroups of patients according to national guidelines. Information from the database is available at anytime and data can be extracted for statistical analysis. Participating physicians can compare their practices with others’ in the registry and with the guidelines established with the French High Health authority (HAS: Haute Autorité de Santé). Results in terms of clinical impact More than 560 centres were involved and between January 2007 and November 2009, more than 22 000 suspected sleep apnoea patients were enrolled. These centres included varied clinical practices, reflecting real life sleep apnoea clinical management in France. The majority of centres were private practices (74% of the patients) whilst others were public hospital practices, either teaching university hospitals (4% of the patients) or district hospitals (22% of the patients). Patients from all regions of France were included and constitute a representative sample in terms of places of residence, rural/urban ratio and socio-professional groups. Sleep apnoea was diagnosed in 80% of referred patients and CPAP prescribed in 70% of them, with a mean CPAP usage of 5.7 h/night which is higher than the usually reported compliance in clinical studies (Cochrane 2009: 5.5 h/night). Significant improvement occurred with reduction in the sleepiness, fatigue and depression scales (from 12 to 8, 14 to 9 and 6 to 4.5, respectively). Appropriate characterisation of the patients at baseline allowed the identification of cardiovascular comorbidities in 45% of the patients. A significant percentage of patients (11%) were referred to cardiologist or other specialists after associated or alternative diagnosis had been appropriately recognised. To date, 50% of obese patients underwent blood gases and pulmonary function testing. Obesity hypoventilation syndrome was then diagnosed in 11.8 % of these obese subjects, leading to a prescription of CPAP or noninvasive ventilation in the most severe cases. Abnormal pulmonary function tests during the baseline evaluation led to implement bronchodilator medications in 2.8% of the investigated patients. Discussion and Conclusion This quality control program using an Internet-based registry allows the description of key demographic characteristics of patients referred for sleep disorders as well as an evaluation of current practices and treatment management of sleep apnea patients by respiratory physicians in France. This system aims to prompt respiratory physicians to use wide-ranging diagnostic tools when evaluating and following sleep disorder patients. Caregivers can compare their own practices and current guidelines. For the patients, comorbidities, both respiratory and nonrespiratory, are more systematically identified and appropriately addressed. Finally, the registry is an appropriate tool to assess the usefulness of guidelines across the country and improve patient care. Contexte Et Objectifs L'Observatoire sommeil de la Fédération de Pneumologie (OSFP) collecte, à partir d'une saisie internet, des informations sur les pratiques des pneumologues en termes de diagnostic et de gestion thérapeutique du syndrome d'apnées du sommeil. Programme Description, mise En oeuvre, suivi L'objectif principal de ce registre via internet (www.osfp.fr) est d'améliorer la qualité de la prise en charge des patients en proposant aux pneumologues participants de réaliser une évaluation plus complète et systématiquement organisée de leurs patients. L'observatoire poursuit quatre objectifs permettant une amélioration de la qualité : (i) Augmenter la connaissance des praticiens non seulement concernant le syndrome d'apnées du sommeil mais aussi concernant les diagnostics différentiels ou associés. Pour cela il leur est proposé une utilisation systématique d’échelles cliniques validées de somnolence, de fatigue, de dépression et de sévérité du syndrome des jambes sans repos. (ii) Elargir le bilan à la recherche de co-morbidités de la maladie et documenter le risque cardiovasculaire en réalisant une mesure de la pression artérielle, du périmètre ombilical et un bilan biologique. (iii) Inciter à l'identification des sous groupes de patients à risque élevé de complications et de mortalité (Obèses hypoventilateurs ou association entre une BPCO et un syndrome d'apnées du sommeil) , (iv) proposer et organiser un suivi et un traitement approprié pour ces différents sous-groupes de patients en accord avec les recommandations nationales. A partir d'analyses statistiques disponibles en permanence, les praticiens participants à l'observatoire peuvent à tout moment comparer leurs pratiques avec celles des autres centres et avec les recommandations de pratique clinique en cours d’élaboration avec la Haute Autorité de Santé. Resultats En Termes D'impact clinique Plus de 560 centres participent à l'observatoire et entre 01/2007 et 11/2009 plus de 22 000 patients suspects d’être porteurs d'un syndrome d'apnées du sommeil ont été inclus dans le registre. Les centres participants correspondent à des modes d'exercice variés reflétant la « vrai vie » de la prise en charge du syndrome d'apnées du sommeil en France (Pratique libérale, hôpitaux généraux et universitaires pour respectivement 74, 22 et 4% des patients). Les patients proviennent de toutes les régions françaises et constituent un échantillon représentatif en terme de lieu de résidence, habitat rural/urbain et répartition des catégories socioprofessionnelles. Un syndrome d'apnées du sommeil a été diagnostiqué chez 80% des patients et une pression positive continue proposée à 70% d'entre eux avec une utilisation moyenne de 5,7 heures/nuit ce qui est supérieur à l'observance rapportée dans les études cliniques (Cochrane 2009: 5,5 heures/nuit). Des améliorations cliniques étaient constatées avec une réduction significative des scores de somnolence, fatigue et dépression (de 12 à 8, 14 à 9 et 6 à 4,5 respectivement). Caractériser précisément les patients lors de l’évaluation initiale a permis de retrouver des comorbidités cardiovasculaires dans 45% des cas. 11% des patients ont été adressés au cardiologue ou à un autre spécialiste car le bilan initial avait permis d'identifier des diagnostics associés. Un syndrome obésité hypoventilation a été diagnostiqué chez 11,8 %, ceci permettant dans les cas les plus sévères d'orienter les patients vers une ventilation non-invasive. Les tests fonctionnels respiratoires ont conduit à débuter un traitement bronchodilatateur chez 2,8% des patients. Discussion-conclusions Ce programme d’évaluation des pratiques reposant sur un registre internet permet d'améliorer la qualité de gestion du syndrome d'apnées du sommeil directement profitable au malade tout en disposant de données épidémiologiques. Ce mode de fonctionnement invite les praticiens à utiliser des outils diagnostiques et d’évaluation au-delà de leur propre spécialité. L'impact pour les patients est une meilleure reconnaissance des co-morbidités, des pathologies associées ceci permettant une prise en charge plus efficiente.

Exacerbations of COPD are common and cause a considerable burden to the patient and the healthcare system. To optimize the hospital care of patients with exacerbations of COPD, clinicians should be aware of some key points: management of exacerbations is broadly based on clinical features and severity. Initial clinical evaluation is crucial to define those patients requiring hospital admission and those who could be managed as outpatients. In hospitalized patients, the appropriate level of care should be determined by the initial severity and response to initial medical treatment. Medical treatment should follow recent recommendations, including rest, titrated oxygen therapy, inhaled or nebulized short-acting bronchodilators (Beta2-agonists and anticholinergic agents), DVT prevention with LMWH, steroids in most severely ill patients, unless there are contraindications and antibiotics in the case of a clear bacterial infectious aetiology. Severe exacerbations may lead to acute hypercapnic respiratory failure. Unless contraindicated, non-invasive ventilation (NIV) should be the first line ventilatory support for these patients. NIV should be commenced early, before severe acidosis ensues, to avoid the need for endotracheal intubation and to reduce mortality and treatment failures. Several randomised controlled clinical trials support the use of NIV in the management of acute exacerbations of COPD, demonstrating a decreased need for mechanical ventilation and an improved survival. In most severe cases, NIV should be provided in ICU. Although it has been shown that for less severe patients (with pH values > 7.30), NIV can be administered safely and effectively on general medical wards, a lead respiratory consultant and trained nurses are mandatory. Mechanical ventilation through an endotracheal tube should be considered when patients have contraindications to the use of NIV or fail to improve on NIV. The duration of mechanical ventilation should be shortened as much as possible by an early weaning process, including preventive post-extubation NIV in hypercapnic patients. hospital stay could be shortened by non-invasive treatments. Future exacerbations should be avoided by respiratory specialist management of the patients, including education, optimization of long-term medical treatment, vaccinations, nutritional support, and pulmonary rehabilitation. (C) 2010 SPLF. Published by Elsevier Masson SAS. All rights reserved.

A 60 year old male patient was admitted to hospital with pulmonary and cerebral abscesses. A percutaneous lung biopsy under CT scanning showed actinomycosis. After 4 weeks antibiotic therapy with ceftriaxone and metronidazole there was an improvement in the pulmonary lesion but new cerebral lesions appeared. A neurosurgical cerebral biopsy showed evidence of metastatic squamous carcinoma, probably of pulmonary origin. The diagnosis had been delayed by the presence of the actinomycosis. His general condition did not permit anti-tumour treatment and the patient soon afterwards. In the presence of pulmonary actinomycosis an associated malignancy should be excluded.

Introduction Chronic obstructive pulmonary disease (COPD) is markedly under-diagnosed, which may relate to under-reporting of symptoms and poor awareness of the disease.Methods A survey was conducted in a sample of the French general population aged 40-75 years (n=2758) to assess respiratory symptoms and level of knowledge of the disease in subjects with or at-risk of COPD (n=860, 31%).Results The high frequency of dyspnoea (MRC dyspnoea grade >= 1: 40%) contrasted with that of subjects spontaneously reporting respiratory problems (9%). Among these, 72% reported limitations in daily-life activities but only 14% considered that they were severely affected by their respiratory status. A very low proportion of subjects knew the term COPD (8%) and only 66% of these associated COPD with a respiratory disease.Conclusions There is a wide gap between the high number of subjects at risk of COPD in the general population and the frequency of breathlessness in these subjects on one hand, and the poor knowledge of the disease, poor perception of symptoms, and under-diagnosis and under-use of spirometry on the other. Increasing awareness of COPD in the population is needed.

We report the case of a 61-year old man in whom a deep venous thrombosis was the presenting feature of disseminated lung carcinoma. A few days later, an arterial thrombosis occurred necessitating amputation. Within a few weeks, the lung cancer progressed dramatically and the patient died. While the association between venous thrombosis and cancer is well known, the relationship between cancer and arterial thrombosis has been less explored. This observation allows discussion of the pathophysiological and clinical aspects of this association, as well as the implications for patient care.

We report the case of a 61-year old man in whom a deep venous thrombosis was the presenting feature of disseminated lung carcinoma. A few days later, an arterial thrombosis occurred necessitating amputation. Within a few weeks, the lung cancer progressed dramatically and the patient died. While the association between venous thrombosis and cancer is well known, the relationship between cancer and arterial thrombosis has been less explored. This observation allows discussion of the pathophysiological and clinical aspects of this association, as well as the implications for patient care.

INTRODUCTION:Chronic obstructive pulmonary disease (COPD) is markedly under-diagnosed, which may relate to under-reporting of symptoms and poor awareness of the disease.METHODS:A survey was conducted in a sample of the French general population aged 40-75 years (n=2758) to assess respiratory symptoms and level of knowledge of the disease in subjects with or at-risk of COPD (n=860, 31%).RESULTS:The high frequency of dyspnoea (MRC dyspnoea grade > or =1: 40%) contrasted with that of subjects spontaneously reporting respiratory problems (9%). Among these, 72% reported limitations in daily-life activities but only 14% considered that they were severely affected by their respiratory status. A very low proportion of subjects knew the term COPD (8%) and only 66% of these associated COPD with a respiratory disease.CONCLUSIONS:There is a wide gap between the high number of subjects at risk of COPD in the general population and the frequency of breathlessness in these subjects on one hand, and the poor knowledge of the disease, poor perception of symptoms, and under-diagnosis and under-use of spirometry on the other. Increasing awareness of COPD in the population is needed.

A 60 year old male patient was admitted to hospital with pulmonary and cerebral abscesses. A percutaneous lung biopsy under CT scanning showed actinomycosis. After 4 weeks antibiotic therapy with ceftriaxone and metronidazole there was an improvement in the pulmonary lesion but new cerebral lesions appeared. A neurosurgical cerebral biopsy showed evidence of metastatic squamous carcinoma, probably of pulmonary origin. The diagnosis had been delayed by the presence of the actinomycosis. His general condition did not permit anti-tumour treatment and the patient soon afterwards. In the presence of pulmonary actinomycosis an associated malignancy should be excluded.

Data on the individual and collective impact of chronic airflow obstruction at a population level are scarce. In a nationwide survey, dyspnoea, quality of life and missed working days were compared between subjects with and without spirometrically diagnosed chronic airflow obstruction. Subjects aged > or =45 yrs were recruited in French health prevention centres (n = 5,008). Results of pre-bronchodilator spirometry and questionnaires (European Community Respiratory Health Survey-derived questionnaire and European quality of life five-dimension questionnaire) were collected. Adequate datasets were available for 4,764 subjects aged 60+/-10 yrs (only 2% were aged > or =80 yrs). The prevalence of airflow obstruction (forced expiratory volume in one second/forced vital capacity of <0.70) was 7.5%. The vast majority (93.9%) of cases had not been diagnosed previously. Health status was significantly influenced by dyspnoea. Both were associated with the number of missed working days. Despite mild-to-moderate severity, subjects with chronic airflow obstruction exhibited more dyspnoea, poorer quality of life and higher numbers of missed working days (mean 6.71 versus 1.45 days.patient(-1).yr(-1) in patients without airflow obstruction, for the population with no known heart or lung disease). In conclusion, even mild-to-moderate airflow obstruction is associated with an impaired health status, which represents an additional argument in favour of early detection in chronic obstructive pulmonary disease.

In patients with hematological malignancy (HM) developing acute respiratory failure (ARF) bronchoalveolar lavage (BAL) is considered as a major diagnostic tool. However, the benefit/risk ratio of this invasive procedure is probably lower in the subset of patients with acute myeloid leukemia (AML). The study was to analyze the yield of BAL performed in HM patients (n=175) with AML or lymphoid malignancies (LM) admitted in intensive care unit (ICU) for ARF and pulmonary infiltrates. BAL was performed in 121 patients (53/73 AML patients (73%) and 68/102 LM patients (67%)) without a definite diagnosis at admission or contraindication for fiberoptic bronchoscopy. Life-threatening complications were noticed in 12/121 patients (10%). The overall diagnostic yield of BAL was 47% (25/53) in AML patients and 50% (34/68) in LM patients. A microorganism was recovered from BAL in 23% (12/53) of AML patients and 41% (28/68) of LM patients (P<0.005). BAL results induced significant therapeutic changes in 17% (9/53) of AML patients vs 35% (24/68) of LM patients (P=0.039). This study underlines the rather low diagnostic yield of BAL for infectious diagnosis and the low rate of therapeutic changes induced by its results in AML patients with ARF admitted in ICU.