[Interstitial fibrosis in cryptogenic organizing pneumonia could be a predictive factor of relapses]. / La fibrose interstitielle pourrait être prédictive de rechute dans la pneumopathie organisée cryptogénique.

INTRODUCTION: Cryptogenic organizing pneumonia (COP) is a clinicopathologic syndrome characterized by a good prognosis with steroid therapy, but frequent relapses when the dose of corticosteroid is reduced or stopped. CASE REPORT: The purpose of this study was to identify histopathologic features related to the relapse of COP. Six cases of COP that had been diagnosed using open lung biopsy were selected for evaluation. The 6 cases were put into two groups composed of 3 patients who relapsed and 3 who did not relapse. Their pathologic features were examined and compared. CONCLUSIONS: Interstitial fibrosis of the lung parenchyma could correspond to histopathologic characteristics of relapses in COP.

[Alveolar hypoxemic interstitial pneumonia related to rituximab therapy]. / Une pneumopathie alvéolo-interstitielle hypoxémiante associée à la prise de rituximab.

INTRODUCTION: Rituximab is indicated for the treatment of low-grade lymphoma. Pulmonary toxicity related to rituximab is exceptional. CASE REPORT: Here we report a patient with non-Hodgkin lymphoma treated with "CHOP" chemotherapy (cyclophosphosphamide, adriamycin, vincristine and prednisolone) and rituximab who developed an interstitial pneumonia with acute respiratory failure. The differential diagnosis of this clinical and radiological diagnosis is discussed. CONCLUSION: Although cases of interstitial pneumonia associated with rituximab are rare, they may be severe and thus any patient experiencing respiratory symptoms on this therapy should be monitored closely.

[Unilateral neurogenic pulmonary edema. A case report]. / Un cas d'oedème pulmonaire neurogénique unilatéral.

A vascular lesion was identified in the posterior cerebral fossa in a 65-Year-old stroke victim. The patient suddenly developed unilateral pulmonary edema. Bilateral alveolar opacities is the usual radiological aspect of neurogenic pulmonary edema but a unilateral presentation is extremely rare. The differential diagnosis includes excessive vascular filling, infectious pneumonia, gastric fluid aspiration edema, and cardiogenic pulmonary edema. The mechanisms underlying neurogenic pulmonary edema are discussed.

[Comparison of volume preset and pressure preset ventilators during daytime nasal ventilation in chronic respiratory failure]. / Etude comparative de respirateurs à régulation de volume et à régulation de pression au cours de la ventilation nasale diurne en situation d'éveil dans l'insuffisance respiratoire chronique.

Both volume preset and pressure preset ventilators are available for domiciliary nasal ventilation. Owing to their technical characteristics, it has been suggested that impaired ventilatory mechanics might cause a drop in the tidal volume (Vt) delivered by pressure preset devices, thereby placing mechanical ventilation at risk of inefficacy. We have assessed two ventilator systems (one pressure preset and one volume preset) with regard to the tidal volume and end-tidal carbon dioxide tension (PetCO(2)) changes that may be achieved in a group of awake patients with stable chronic respiratory failure (CRF). Eleven patients with stable CRF were ventilated in the assist/control mode for two consecutive one-hour periods. One ventilator was tested each hour, in random order. The VIGIL'AIR(R) system was used to record Vt, Respiratory Rate (RR), and Inspiratory/Expiratory ratio (I/E). The deviation E (E=preset value - measured value) was calculated for each measurement. Changes in PetCO(2) and arterial oxygen saturation were determined respectively by a capnometer and a pulse oximeter. Comparison of the mean deviation of Vt calculated for the two ventilators revealed a difference in patients with chronic obstructive pulmonary disease (COPD). The deviation was greatest with the pressure preset ventilator (PPV), which gave mean measured values higher than the mean preset values. The same comparison failed to reveal any difference in restrictive CRF. Comparison of the volume preset and pressure preset ventilators for RR, I/E and PetCO(2) did not reveal any difference. Compared to the volume preset ventilator, the efficacy of PPV to ventilate is not affected by the restrictive or obstructive nature of CRF. Our results show that pressure-preset ventilator is an adequate alternative to the volume-preset device for daytime non invasive ventilation in chronic respiratory insufficiency.

Seasonal variation in cryptogenic and noncryptogenic hemoptysis hospitalizations in France.

STUDY OBJECTIVE: To determine the potential role of seasonality in hospitalizations for cryptogenic and noncryptogenic hemoptysis in the French population. DESIGN: Retrospective analysis of hospital discharge data from a National Register. SETTING: All 29 French university hospitals, between July 1, 1994, and June 30, 1997. PATIENTS: Two thousand six hundred seventy-seven and 3,672 adult hospitalizations for cryptogenic and other hemoptysis, respectively. MEASUREMENTS: Cumulative monthly averages were determined, expressed as the percentage above or below the average monthly value during the entire study period. RESULTS: The distribution of cumulative monthly hospitalizations for cryptogenic hemoptysis peaked in March (32% above the average) and was lowest in summer (30% below the average; p < 0.001). Hospitalizations for noncryptogenic hemoptysis followed a similar seasonal pattern (p < 0. 001). In the 16- to 34-year-old individuals, cryptogenic hemoptysis, compared with noncryptogenic hemoptysis, showed a higher incidence with a larger seasonal amplitude (p < 0.001). CONCLUSIONS: A better understanding of the fundamental pathophysiologic mechanisms underlying this respiratory and hemorrhagic condition may be helpful in developing preventive measures, especially in patients with a risk of recurrence.

[Impact of acute respiratory failure on survival of COPD patients managed with long-term non-invasive ventilation and oxygen therapy]. / Impact de la décompensation respiratoire aiguë sur la survie des BPCO prises en charge au long cours par ventilation non invasive et oxygénothérapie.

Our study aimed to assess the impact of acute respiratory failure (ARF) on survival of patients with chronic obstructive pulmonary disease (COPD) receiving long-term oxygen therapy (LTOT) plus nasal intermittent positive pressure ventilation (NIPPV). Survival was analysed retrospectively in 24 patients with severe COPD initiated to NIPPV in addition to LTOT. Fourteen patients were established on NIPPV following exacerbation of acute respiratory failure which has required mechanical ventilation (group 1). Ten patients (group 2) have never been hospitalized for ARF. Comparison of clinical details at baseline, 6 months, 1, 2, and 3 years for the two groups failed to reveal any difference with the exception of prior episodes of ARF. The probability of survival at 3 years was 65% (95% confidence interval [CI] 43-86) for the overall population, 46% (95% CI 15-77) in group 1, and 74% (95% CI 42-105) in group 2. The difference between the two groups was statistically significant. We show that ARF requiring mechanical ventilation appears to be a factor that is negatively correlated with survival for patients treated by LTOT plus NIPPV. This data suggests that NIPPV should be tried before ARF arising in COPD patients who present a deterioration in chronic respiratory failure with hypercapnia.

alpha - and beta -phosphorylated amines and pyrrolidines, a new class of low toxic highly sensitive 31P NMR pH indicators. Modeling of pKa and chemical shift values as a function of substituents.

Fourteen linear and cyclic alpha- and beta-aminophosphonates in which the P-atom is substituted by alkoxy groups have been synthesized and evaluated as (31)P NMR pH markers in Krebs-Henseleit buffer. pK(a) values varied with substitution in the range 1.3-9.1, giving potentially access to a wide range of pH. Temperature had a weak influence on pH and a dramatic increase in ionic strength slightly modified the pK(a) of the pyrrolidine diethyl(2-methylpyrrolidin-2-yl)phosphonate (DEPMPH). All compounds displayed a 4-fold better NMR sensitivity than inorganic phosphate or other commonly used phosphonates, as assessed by differences delta(b)-delta(a) between the chemical shifts of the protonated and the unprotonated forms. In isolated perfused rat hearts, a non-toxic concentration window of 1.5-15 mm was determined for three representative compounds. Using empirical linear relationships, the experimental values of pK(a), delta(a), and delta(b) have been correlated with the two-dimensional structure, i.e. the chemical nature of substituents bonded to the secondary amine and P-atom. The data suggest that DEPMPH and its cyclic and linear variants are ideal versatile (31)P NMR probes for the study of tenuous pH changes in biological processes.

A comparison of two long-acting beta-agonists, oral bambuterol and inhaled salmeterol, in the treatment of moderate to severe asthmatic patients with nocturnal symptoms. The French Bambuterol Study Group.

This multicentre study was set up to compare the efficacies of two long-acting beta 2-agonists, oral bambuterol (20 mg nocte) and inhaled salmeterol (50 micrograms b.i.d.), for the treatment of moderate to severe asthmatics who were considered to be on optimal steroid/bronchodilator therapy, but continued to have troublesome nocturnal symptoms. The study was of double-blind, parallel-group design and comprised a 2-week run-in on previous maintenance therapy followed by a 6-week study treatment period. There were 117 randomized asthmatic patients aged 20-70 years (65 women and 52 men with a mean age of 45 and predicted FEV1 of 64%), who had been taking 800-2000 micrograms inhaled steroid and/or up to 20 mg oral steroid per day for at least 4 weeks. They were asked to complete daily diary cards, recording morning and evening PEF, daily symptoms, nocturnal awakenings, rescue medication and subjective tremor. There was a significant increase in both morning and evening PEF respectively, on bambuterol (28 l min-1, 20 l min-1, P < 0.05) and salmeterol (29 l min-1, P < 0.001; 23 l min-1, P < 0.01) when compared with run-in. The mean percentage fall in overnight PEF was reduced by 8.3% (P < 0.001) on bambuterol and by 6.8% (P < 0.001) on salmeterol. Nocturnal awakenings and daytime symptoms due to asthma were significantly lowered by both treatments, as was the consumption of rescue bronchodilator. Tremor scores were very low during both run-in and study treatments. No significant treatment difference between bambuterol and salmeterol was detected for any of the above variables. Once-daily oral bambuterol provides a highly effective alternative to twice-daily inhaled salmeterol for relief of nocturnal symptoms in patients with moderate to severe asthma.

[Percutaneous vertebroplasty complicated by pulmonary embolus of acrylic cement]. / Une vertébroplastie percutanée compliquée d'une embolie pulmonaire de ciment acrylique.

Although venous escape of cement has been frequently noted during percutaneous vertebroplasty, no case of pulmonary embolus directly linked to this manoeuvre has been described in the literature. We report a case of pulmonary embolus of acrylic cement occurring immediately after the procedure. Outcome was favorable following anticoagulant therapy despite the persistence of some vascular obstruction suggesting the association of residual fibrinous matter in the pulmonary artery.

[Silicone tracheobronchial endoprosthesis]. / Endoprothèses trachéobronchiques en silicone.

Silicone endoprostheses are used to replace loss of support in tracheobronchial cartilage. The main silicone stents are similar to those of the Montgomery T tube, the Westaby, Dumon and Cooper-Hood prostheses. The major indications are malignant tumours and benign stenosis after anastomotic resection or graft. All have in common a degree of narrowing greater than 50%. An initial bronchoscopy enables a precise assessment of the zone to support. The prostheses are then put in place using a rigid bronchoscope. An annual bronchoscopic review is recommended associated with clinical supervision. Their removal is simple even after being in position for a long period. A multicentre study (Marseille, Saint-Etienne, Brescia and Barcelona) report their experience of 1574 prostheses positioned in 1058 patients. The localisation was tracheal (54%), left main bronchus (21%), right main bronchus (18%). The average time in place was 1.2 years for benign tumours(maximum 6.2 years) and four months for malignant tumours (maximum 4.7 years). Complications were rare and included migrations (9.5%), granulomas (7.9%) and obstructions (3.6%). Thanks to their being well tolerated, their simplicity in handling, silicone prostheses are currently an essential choice to re-establish patency of the airways in patients presenting with benign or malignant tracheobronchial pathology.

[A rare case of severe pulmonary artery hypertension. Thrombosing pulmonary microangiopathy due to tumor]. / Une hypertension artérielle pulmonaire sévère de cause rare: la microangiopathie pulmonaire tumorale thrombosante.

We report a case of acute respiratory insufficiency with acute cor pulmonale and a fatal outcome. Right cardiac catheterisation enabled a diagnosis of precapillary pulmonary arterial hypertension to be made with a mean pulmonary arterial pressure of 61 mmHg and a pulmonary capillary pressure of 12 mHg. An autopsy was carried out and this revealed a microscopic pulmonary tumour emboli with lymphangitis carcinomatosis. In particular, it showed an association of fibrocellular proliferation at the level of the intima in the small calibre pulmonary arteries and arterioles permitting the unusual diagnosis of thrombosing pulmonary microangiomathy due to tumour. The physiopathological mechanism of this particular form of pulmonary tumour emboli is discussed; it would be secondary to an activation of the coagulation systems by the embolic tumour cells. Once activated, it is the lesions in the intima and not the carcinoma cells which generate the pulmonary arterial hypertension by vascular obstruction.

Influence of external pH on ciliary beat frequency in human bronchi and bronchioles.

Ciliated respiratory epithelial cells have to tolerate variations in local pH caused by the respiratory cycle and potential ventilation-perfusion mismatches. We showed previously that peripheral bronchiolar cilia beat at a lower frequency than bronchial cilia, and have now investigated whether they show differences in tolerance to changes in pH. Using the image analysis system applied in the previous study, we compared variations in the ciliary beat frequencies (CBF) of bronchi and bronchioles sampled from human lung resections at various pH in vitro. Application of nonparametric tests (the variance of samples was not similar) indicated that CBF was not significantly modified when pH was varied between 7.5 and 10.5 for bronchi, and between 5.5 and 10.5 for bronchioles. Reversible and significantly lower CBF were observed below pH 7.0 for bronchi and below pH 5.0 for bronchioles. Extreme pH values such as 11.0 or 3.0 were lethal within a few minutes. Thus, respiratory ciliary beating is able to tolerate external pH variations between 3.5 and 10.5 without permanent impairment. In addition we found that alkaline pH values are more favourable than acidic ones and that bronchiolar ciliated cells are more tolerant to acidic pH than bronchial cells.

Altered sialylation of alveolar macrophages in HIV-1-infected individuals.

In previous studies, we have demonstrated that O-glycans at the surface of HIV-1-infected cell lines were hyposialylated. Moreover, we and others have shown that HIV+ individuals produced autoantibodies that react with hyposialylated CD43, on T cell lines. Since the autoantigen responsible for this abnormal immune response was not easily found in the peripheral blood cells of corresponding patients, we searched for its possible presence in other sites. Using fluorescence staining of alveolar macrophages with various lectins, we show that the binding of the PNA lectin specific for asialo O-glycans is much more efficient on cells from HIV-1-infected individuals. Moreover, the degree of reactivity of PNA is correlated with the clinical stage of the illness.

Ciliary beat frequency in human bronchi and bronchioles.

STUDY OBJECTIVE: This study aimed to determine the differences between ciliary beat frequencies of respiratory ciliated cells from peripheral bronchioles and from proximal bronchi in humans. DESIGN: Measurements were made from resected lungs. Ciliated cells were harvested by brushing the mucosa of each site immediately after surgery. Brushings with a cytology brush were performed on normal areas of the resected cartilaginous bronchus for proximal samplings and through a peripheral bronchiole close to the visceral pleura for peripheral samplings. For each site, at least 12 different measurements were made at 22 degrees C using an image analysis system. RESULTS: A highly significant difference between proximal bronchi (mean, 7.1 Hz; SD, 1.29) and peripheral bronchioles (mean, 4.6 Hz; SD, 1.39) (p < 0.0001) was found. CONCLUSION: Thus, cilia from peripheral bronchioles beat at a 35% lower beat frequency than cilia from proximal bronchi.

Efficacy and safety of videothoracoscopic lung biopsy in the diagnosis of interstitial lung disease.

OBJECTIVE: The aim of this study was to determine the efficacy and safety of videothoracoscopic lung biopsy (VTLB) in the diagnosis of infiltrative lung disease (ILD) and compare the results of VTLB with the results previously obtained in patients with open lung biopsy at the same institution. METHODS: Forty-one patients undergoing VTLB between May 1991 and December 1994 were retrospectively studied and compared with 25 patients who have undergone OLB during the period from January 1987 to April 1991. The two groups were comparable with respect to age, sex, and severity of lung disease. RESULTS: Three of 41 patients (7%) who underwent VTLB with minithoracotomy. There was no significant difference between the group of VTLB (38 patients) and the group OLB (25 patients) with regard to, the number of biopsies (VTLB 1.8 +/- 0.4 versus OLB 2 +/- 0.6), or diagnostic yield (VTLB 37/38 versus OLB 25/25). In contrast, patients who underwent VTLB demonstrated a significant reduction of the operative time (VTLB 45.3 +/- 12.2 min), length of chest tube drainage (3.55 +/- 1.2 days), hospital stay (5.5 +/- 1.3 days), and analgesia (buprenorphine 0.85 +/- 0.44 mg; paracetamol 5.9 +/- 2.5 g) compared to patients who underwent OLB (55.6 +/- 11.2 min, 5.2 +/- 1.5 days; 7.1 +/- 2.3 days; buprenorphine 1.17 +/- 0.5 mg, paracetamol 8.9 +/- 2.3 g). Morbidity and mortality were similar in the two groups (morbidity VTLB 10.5%, OLB 12%; mortality VTLB 5.2%, OLB 8%). Regardless of the biopsy technique, the most serious complications and deaths occurred with the same frequency in those patients with a severe underlying disease. CONCLUSIONS: VTLB is a valid alternative to OLB in most cases. Along with a comparable efficacy, VTLB has several advantages that should make it the method of choice for patients with only minimally impaired respiratory function. In contrast, the role and advantages of VTLB compared to OLB in patients with severe lung disease, require further investigation.

Domiciliary nasal intermittent positive pressure ventilation in severe COPD: effects on lung function and quality of life.

The aim of this study was to determine the effect of domiciliary nasal intermittent positive pressure ventilation (NIPPV) on lung function and quality of life in hypercapnic patients with chronic obstructive pulmonary disease (COPD). Fourteen hypercapnic COPD patients in a stable clinical condition were evaluated in a prospective study of domiciliary NIPPV plus long-term oxygen therapy. Baseline data obtained during a 4 week run-in period were compared with measurements at the end of the 6 month study period. Spirometric parameters, arterial blood gas tensions, and quality of life were assessed. Quality of life was measured using the St George's Respiratory Questionnaire (SGRQ) and the French version of the Nottingham Health Profile (FVNHP). All patients completed 6 months of domiciliary NIPPV. Gastro-intestinal inflation was reported by eight patients. Daytime arterial oxygen tension and arterial carbon dioxide tension, improved after therapy. During the NIPPV study period, the total SGRQ score and impacts score both improved significantly; significant improvements were also noted in the total FVNHP score and the physical mobility, emotional reactions, and energy component scores. Domiciliary nasal intermittent positive pressure ventilation combined with long-term oxygen therapy has been found to improve blood gases in spontaneous ventilation, as well as the quality of life of patients with chronic obstructive pulmonary disease.

Video-assisted thoracoscopic treatment of spontaneous pneumothorax: technique and results of one hundred cases.

OBJECTIVE: This article describes the technique and results for an initial series of 100 pneumothoraces treated by video-assisted thoracoscopy. METHODS: From May 1991 to November 1994, 97 patients (78 male and 19 female patients) aged 37.2 +/- 17 years (range 14 to 92 years) underwent video-assisted thoracoscopy for treatment of spontaneous pneumothorax (primary in 75 patients, secondary in 22 patients). RESULTS: The procedure was unilateral in 94 patients and bilateral in three patients (total 100 cases). Pleural bullae were resected with an endoscopic linear stapler; a lung biopsy was performed in the absence of any identifiable lesion. Pleurodesis was achieved by electrocoagulation of the pleura (n = 3), "patch" pleurectomy (n = 3), subtotal pleurectomy (n = 20), or pleural abrasion (n = 74), including conversion to standard thoracotomy in five. One of these five patients had primary pneumothorax and four had secondary pneumothorax. There were no postoperative deaths. A complication developed in 10 patients: five patients with a primary pneumothorax (6.6%) and five with a secondary pneumothorax (27.7%). The mean postoperative hospital stay was 8.25 +/- 3.2 days. Mean follow-up is 30 months (range 7 to 49 months). Pneumothorax recurred in 3% of patients, all of whom were operated on at the start of our experience. Three percent of the patients had chronic postoperative chest pain. CONCLUSIONS: Video-assisted thoracoscopy is a valid alternative to open thoracotomy for the treatment of spontaneous primary pneumothorax. Its role for the management of secondary pneumothorax remains to be defined. In the long term, the efficacy of video-assisted thoracoscopic pleurodesis and surgeon experience should yield the same results as standard operative therapy.