Home-based pulmonary rehabilitation in idiopathic pulmonary fibrosis.

INTRODUCTION: Idiopathic pulmonary fibrosis (IPF) is a severe chronic lung disease. Pulmonary rehabilitation could improve the quality of life of patients with this condition. METHODS: We prospectively evaluated the impact of an 8-week home-based pulmonary rehabilitation programme over 10 months in stable patients suffering from IPF. Exercise capacity, pulmonary function, dyspnoea and quality of life were analyzed before and after the rehabilitation programme. RESULTS: Seventeen patients were included and 13 completed the study. Mean functional vital capacity (FVC) was 2.15±0.79L and mean diffusing capacity for carbon monoxide (DLCO) was 7.81±3.99mL/min/mmHg. Six patients were treated with low dose oral steroids (20mg/day of prednisone) with or without immunosuppressive treatments; six were taking part in therapeutic trials. Mean endurance time (7.4±9.1 min vs. 14.1±12.1 min; P=0.01), number of steps per minute on a stepper (322±97 vs. 456±163; P=0.026), six-minute walk distance relative to heart rate (HR) (11±6 vs. 17±12; P=0.006), exercise dyspnoea (P=0.026), sensation of physical limitation on the SF-36 (25%±26 vs. 49%±38; P=0.047) and four out of seven visual analogue scales were significantly improved after rehabilitation. In contrast, no significant difference was observed in resting pulmonary function or in other items on quality of life questionnaires. CONCLUSION: A home-based programme of pulmonary rehabilitation is feasible in IPF patients. It significantly improved endurance parameters and physical limitation in this patient group without changing pulmonary function.

[Cardiopulmonary exercise testing in patients with pectus excavatum]. / Exploration fonctionnelle à l'exercice des patients présentant un pectus excavatum.

The functional consequences of physiologic impairments due to pectus excavatum (PE) are not known. This study was conducted to determine the exercise performance in patients with this condition. This prospective study included all patients presenting for PE during a 5-year period. Patients had a chest CT scan to measure the PE severity index, resting pulmonary function tests, cardiopulmonary exercise testing (CPET) with gas exchange analysis and echocardiography. Thirty-two patients were included, with a mean age of 25.9 years. The mean PE severity index was 3.72 ± 0.87. The maximal oxygen uptake (VO(2-max)) was 78.6 ± 22.1% predicted. Only four out of the 32 patients had a normal CPET. In the remaining patients, we observed three main patterns of limitation: 18 patients had a marked limitation in increasing their tidal volume (41 ± 5% of FVC at VO(2-max) versus 51 ± 7.5%); five patients had abnormal gas exchange with increased P(A-a)O(2) at VO(2-max) (47 ± 23 mmHg versus 20 ± 7.5 mmHg) associated with a patent foramen ovale without elevation of right pressure. The five last patients had cardiovascular impairment with a decreased oxygen pulse at VO(2-max) (57 ± 9% versus 90 ± 20%). They exhibited the most severe limitation (VO(2-max) = 55 ± 10%; P = 0.003). CPET abnormalities were predicted by neither PE index severity nor the results of resting pulmonary function tests. PE is associated with abnormal CPET, including impairments in ventilatory, cardiovascular responses and/or gas exchange, which may be of importance in disease management.

[Home-based pulmonary rehabilitation in idiopathic pulmonary fibrosis]. / Réhabilitation respiratoire à domicile au cours de la fibrose pulmonaire idiopathique.

INTRODUCTION: Idiopathic pulmonary fibrosis (IPF) is a severe chronic lung disease. Pulmonary rehabilitation could improve the quality of life of patients with this condition. METHODS: We prospectively evaluated the impact of an 8 week home-based pulmonary rehabilitation program over 10 months in stable patients suffering from IPF. Exercise capacity, pulmonary function, dyspnea and quality of life were analyzed before and after the rehabilitation program. RESULTS: 17 patients were included and 13 completed the study. Mean FVC was 2.15+/-0.79 L and mean DLCO was 7.81+/-3.99 ml/min/mmHg. Six patients were treated with low dose oral steroids ($20 mg/day of prednisone) with or without immunosuppressive treatments; 6 were taking part in therapeutic trials. Mean endurance time (7.4+/-9.1 min vs 14.1+/-12.1 min; p<0,01), number of beats per minute on a stepper (322+/-97 vs 456+/-163; p=0.026), 6 min walking distance to heart rate ratio (11+/-6 vs 17+/-12; p=0.006), exercise dyspnea (p=0.026), sensation of physical limitation at the SF-36 (25%+/-26 vs 49%+/-38; p=0.047) and 4 out of 7 visual analog scales were significantly improved after rehabilitation. In contrast, no significant difference was observed in resting pulmonary function or in other items of quality of life questionnaires CONCLUSION: A home-based program of pulmonary rehabilitation is feasible in IPF patients. It significantly improves endurance parameters and physical limitation in this patient group without changing pulmonary function.

[Malformations of the anterior chest wall]. / Malformations de la paroi thoracique antérieure.

INTRODUCTION: Pectus excavatum or funnel chest is the most common anterior chest wall deformity seen in children and adults. The sternal depression appears to be caused by overgrowth of the costal cartilages, also the cause of the less common deformities: pectus carinatum (pigeon breast) and pectus arcuatum. BACKGROUND: Usually the overgrowth involves the third to seventh costal cartilages but it can be more or less extensive. The cardiopulmonary functional consequences are insignificant in the protrusional deformities and inconsistent in pectus excavatum and the indications for surgery are mainly cosmetic. VIEWPOINT AND CONCLUSIONS: The procedural modalities are guided by morphological study of the CT scan. We describe a surgical technique that comprise subperichondrial excision of all deformed costal cartilages followed by transverse sternotomy to correct the sternal deformity, anteriorly in the case of pectus excavatum and posteriorly for pectus carinatum and arcuatum. As the perichondrial sheaths are totally preserved they are sutured in continuous layers to give a shortening effect. In the case of pectus excavatum the sternum is then secured anteriorly for about 6 months by a retrosternal metallic strut in an overcorrected position. The partially resected seventh cartilages are then sutured to the xiphoid. Other surgical techniques are described, including modified Ravitch's procedure, modelling osteochondroplasty, prosthetic reconstruction and Nuss's procedure. Results of the more important series are reported and discussed.

Relationship between tracheotomy and ventilator-associated pneumonia: a case control study.

The aim of the present study was to determine the relationship between tracheotomy and ventilator-associated pneumonia (VAP). The study used a retrospective case-control study design based on prospective data. All nontrauma immunocompetent patients, intubated and ventilated for >7 days, were eligible for inclusion in the study. A diagnosis of VAP was based on clinical, radiographical and microbiological criteria. Four matching criteria were used, including duration of mechanical ventilation (MV). The indication and timing of tracheotomy were at the discretion of attending physicians. Univariate and multivariate analyses were performed to determine risk factors for VAP in cases (patients with tracheotomy) and controls (patients without tracheotomy). In total, 1,402 patients were eligible for inclusion. Surgical tracheotomy was performed in 226 (16%) patients and matching was successful for 177 (78%). The rate of VAP (22 versus 14 VAP episodes.1,000 MV-days(-1)) was significantly higher in controls than in cases. The rate of VAP after tracheotomy in cases, or after the corresponding day of MV in controls, was also significantly higher in control than in case patients (9.2 versus 4.8 VAP episodes.1,000 MV-days(-1)). In multivariate analysis, neurological failure (odds ratio (95% confidence interval) 2.7 (1.3-5)), antibiotic treatment (2.1 (1.1-3.2)) and tracheotomy (0.18 (0.1-0.3)) were associated with VAP. In summary, the present study demonstrates that tracheotomy is independently associated with decreased risk for ventilator-associated pneumonia.

Positional hyperventilation-induced hypoxaemia in pectus excavatum.

The presented case is of a young male (aged 19 yrs) with a pectus excavatum who showed significant exercise intolerance, despite normal pulmonary function at rest, including carbon monoxide diffusing capacity. Clinical exercise testing led to a strong suspicion of a right-to-left shunt due to an abnormally wide alveolo-arterial oxygen gradient (26.4 kPa) at peak oxygen uptake, with severe arterial hypoxaemia (arterial oxygen tension 12.54 kPa). A right-to-left shunt was confirmed by transoesophageal echocardiography demonstrating a permeable foramen ovale, despite normal right heart pressures. The right-to-left venous flow was mainly dependent on the upright body position and the deep inspiration. Indeed, i.v. dobutamine infusion to selectively affect cardiac output and hyperventilation induced by tidal volume expansion at constant breathing rate in the supine position did not result in arterial oxygen desaturation or shunting. Closure of the foramen ovale through atrial umbrella placement dramatically improved clinical and physiological abnormalities. This observation demonstrates that a hyperventilatory manoeuvre in the upright position is able to detect a permeable foramen ovale favouring flow in the inferior vena cava in the direction of the abnormal pre-existing atrial channel in a patient with a pectus excavatum.