Management of acute exacerbations of chronic obstructive pulmonary disease (COPD). Guidelines from the Société de pneumologie de langue française (summary).

Chronic obstructive pulmonary disease (COPD) is the chronic respiratory disease with the most important burden on public health in terms of morbidity, mortality and health costs. For patients, COPD is a major source of disability because of dyspnea, restriction in daily activities, exacerbation, risk of chronic respiratory failure and extra-respiratory systemic organ disorders. The previous French Language Respiratory Society (SPLF) guidelines on COPD exacerbations were published in 2003. Using the GRADE methodology, the present document reviews the current knowledge on COPD exacerbation through 4 specific outlines: (1) epidemiology, (2) clinical evaluation, (3) therapeutic management and (4) prevention. Specific aspects of outpatients and inpatients care are discussed, especially regarding assessment of exacerbation severity and pharmacological approach.

Management of acute exacerbations of chronic obstructive pulmonary disease (COPD). Guidelines from the Société de pneumologie de langue française / Prise en charge des exacerbations de la bronchopneumopathie chronique obstructive (BPCO). Recommandations de la Société de pneumologie de langue française

Chronic obstructive pulmonary disease (COPD) is the chronic respiratory disease with the most important burden on public health in terms of morbidity, mortality and health costs. For patients, COPD is a major source of disability because of dyspnea, restriction in daily activities, exacerbation, risk of chronic respiratory failure and extra-respiratory systemic organ disorders. The previous French Language Respiratory Society (SPLF) guidelines on COPD exacerbations were published in 2003. Using the GRADE methodology, the present document reviews the current knowledge on COPD exacerbation through 4 specific outlines: (1) epidemiology, (2) clinical evaluation, (3) therapeutic management and (4) prevention. Specific aspects of outpatients and inpatients care are discussed, especially regarding assessment of exacerbation severity and pharmacological approach.(AU)

La bronchopneumopathie chronique obstructive (BPCO) est la maladie respiratoire chronique dont le poids sur la santé publique est le plus grand par sa morbidité, sa mortalité et les dépenses de santé qu'elle induit. Pour les individus atteints, la BPCO est une source majeure de handicap du fait de la dyspnée, de la limitation d'activité, des exacerbations, du risque d'insuffisance respiratoire chronique et des manifestations extra-respiratoires qu'elle entraîne. Les précédentes recommandations de la Société de pneumologie de langue française (SPLF) sur la prise en charge des exacerbations BPCO date de 2003. Se fondant sur une méthodologie adaptée de GRADE, le présent document propose une actualisation de la question des exacerbations de BPCO en développant un argumentaire couvrant quatre champs d'investigation : (1) épidémiologie, (2) évaluation clinique, (3) prise en charge thérapeutique et (4) prévention. Les modalités spécifiques de la prise en charge hospitalière et ambulatoire y sont discutées, particulièrement les aspects relevant de l'évaluation de la sévérité de l'exacerbation et de la prise en charge pharmacologique.(AU)

Five-year survival for lung cancer patients managed in general hospitals.

INTRODUCTION: In 2000, the college of pulmonologists of general hospitals undertook an epidemiological study (KBP-2000-CPHG) enrolling all new cases of histologically confirmed lung cancer managed in general hospitals. This paper reports the 5-year survival in these cases. METHODS: Vital status was available for 5447 out of 5667 patients included in the original study. The effect of different prognostic factors on mortality was assessed. RESULTS: At 5 years, 567 patients (10.4%) were still alive. Median survival for the 4880 (89.6%) deceased patients was 7 months. Univariate analysis identified age, smoking history, performance status, histological type and disease stage (TMN classification) as determinants of survival. For non-small cell lung cancer (n=4885) multivariate analysis identified five predictive factors for mortality - age, gender, histological type, performance status and stage. CONCLUSIONS: Five-year survival in lung cancer continues to be poor. As the risk factors for poor outcome at the time of diagnosis are not modifiable and pending, the results of screening studies reduction in mortality must rest on primary prevention.

[Intrahospital mortality during acute exacerbations of COPD. Study EABPCO-CPHG of the College of the Lung specialists of General hospitals (CPHG)]. / Mortalité intrahospitalière au cours des exacerbations aiguës de BPCO. Etude EABPCO-CPHG du Collège des pneumologues des hôpitaux généraux (CPHG).

INTRODUCTION: The objective of the present study was to determine the in-hospital mortality rate in the EAPCO-CPHG cohort and to identify risk factors. METHODS: All patients with COPD acute exacerbation admitted to the pneumology department of 68 French general hospitals between October 2006 and June 2007 were included in the EABPCO-CPHG cohort. RESULTS: At discharge, vital status was known for 1817 patients. Forty-five patients died during their hospital stay, i.e., an in-hospital mortality rate of 2.5%. Mutivariate analysis identified age (OR=1.07 [1.03-1.11]), grade greater than 2 dyspnea in stable state (OR=3.77 [1.68-8.57]), and number of clinical signs of severity during the acute exacerbation (OR=1.36 [1.11-1.55]) as independent risk factors for in-hospital mortality. CONCLUSIONS: In-hospital mortality in patients admitted to a pneumology department of a general hospital is quite low. Simple clinical criteria allow easy identification of at-risk patients and should enable management to be improved.

[Acute COPD exacerbations in women: EABPCO-CPHG study by the College of general hospital pneumologists]. / Les exacerbations aiguës de BPCO chez la femme : étude EABPCO-CPHG du Collège des pneumologues des hôpitaux généraux.

INTRODUCTION: Emerging evidence suggests that gender differences exist in the prevalence, susceptibility, severity and response to the treatment of COPD. This article compares the characteristics of acute exacerbation in male and female patients hospitalized for acute chronic obstructive pulomnary disease (COPD) exacerbation. METHODS: This observational study collected data from 1,824 patients admitted to the pneumology department in 68 general hospitals between October 2006 and June 2007. RESULTS: The 423 (23.2%) women were younger than the men (69.1 versus 70.6 years; p=0.016) and more frequently non-smokers (14.4% versus 4.2%; p<0.0001). Before the acute exacerbation, they more frequently reported asthma (18% versus 11.6%; p=0.0006) or bronchiectasis (10.4% versus 5.9%; p=0.002). They also more often presented consciousness disorders (6.4% versus 3.9%; p=0.033) and desaturation (SpO2<90%: 50.4% versus 42%; p=0.002) during acute exacerbation and their hypercapnia was more severe (50.7 versus 46.5mmHg; p<0.0001). During hospitalization, they were more frequently ventilated (23.9 versus 17.1%; p=0.002). There was no difference in the mortality between the sexes (1.4% versus 2.8%; p=0.11). Age and smoking behavior were closely related in the female patients: the smokers were younger (62.5 years) than the ex-smokers (73.7 years) or non-smokers (78.1 years). Of the six women who died during hospitalization, two were smokers and four ex-smokers. In addition, four were over 80 years old. CONCLUSION: The women hospitalized for acute COPD exacerbation differed from the men with respect to risk factors, steady-state COPD severity and exacerbation severity.

[Characteristics and management of acute exacerbations of COPD in hospital. EABPCO-CPHG study by the college of general hospital respiratory physicians]. / Caractéristiques et prise en charge des exacerbations aiguës de BPCO hospitalisées. Etude EABPCO-CPHG du Collège des pneumologues des hôpitaux généraux.

INTRODUCTION: A cohort was formed to explore the evolution of COPD patients treated in general hospitals for acute exacerbations (AE). The present article describes and compares patient characteristics according to whether COPD was diagnosed before the AE or not. METHODS: Data were analyzed for 1,824 patients admitted between October 2006 and June 2007 to 68 departments of respiratory medicine. RESULTS: Population characteristics were: male, 77%; mean age, 70.3+/-11.3 years; current smokers, 33%; baseline grade 3-4 dyspnoea, 47%; FEV1

[Five year survival for lung cancer patients managed in general hospitals]. / Survie à cinq ans des cancers bronchiques primitifs dans les centres hospitaliers généraux.

INTRODUCTION: In 2000 the College of Pulmonologists of General Hospitals undertook an epidemiological study (KBP-2000-CPHG) enrolling all new cases of histologically confirmed lung cancer managed in general hospitals. This paper reports the five year survival in these cases. METHODS: Vital status was available for 5447 out of 5667 patients included in the original study. The effect of different prognostic factors on mortality was assessed. RESULTS: At 5 years 567 patients (10.4%) were still alive. Median survival for the 4880 (89.6%) deceased patients was 7 months. Univariate analysis identified age, smoking history, performance status, histological type and disease stage (TMN classification) as determinants of survival. For non-small cell lung cancer (n=4885) multivariate analysis identified five predictive factors for mortality - age, gender histological type, performance status and stage. CONCLUSIONS: Five year survival in lung cancer continues to be poor. As the risk factors for poor outcome at the time of diagnosis are not modifiable and pending the results of screening studies reduction in mortality must rest on primary prevention.

[Acute exacerbations of COPD admitted to hospital: predictive factors of 3 year mortality]. / Exacerbations aiguës de BPCO hospitalisées: facteurs prédictifs de mortalité à trois ans.

INTRODUCTION: COPD is a disease whose gravity is underestimated by doctors and patients. The development of acute exacerbations (AE) accelerates the progression of the disease and leads to increased financial costs, notably on account of hospitalisation. MATERIALS AND METHODS: An observational prospective study will be undertaken based on a cohort of consecutive patients hospitalised in departments of respiratory medicine in general hospitals. The main objective is to study the factors predictive of mortality at 3 years after one admission for AE. The secondary objectives are to describe the characteristics of the AE on arrival and 3 months after discharge from hospital. A register will be set up and a questionnaire will be completed for each patient, consisting of items concerning COPD, the AE and the condition of the patient and his treatments 3 months after discharge. The level of mortality at 3 years and the predictive factors will be calculated from the data in the register. EXPECTED RESULTS: Identification the characteristics of the AE and determination of a predictive score for mortality should allow optimisation of the management of patients suffering from COPD.

Phase II trial of temozolomide and cisplatin followed by whole brain radiotherapy in non-small-cell lung cancer patients with brain metastases: a GLOT-GFPC study.

BACKGROUND: Brain metastases (BM) considerably worsen the prognosis of non-small-cell lung cancer (NSCLC) patients. The usefulness and choice of chemotherapy remain uncertain in this indication since these patients are excluded from most clinical trials. We conducted a phase II study to determine the efficacy and tolerability of up-front chemotherapy with association of temozolomide and cisplatin in NSCLC patients with BM. PATIENTS AND METHODS: Fifty NSCLC patients with BM received temozolomide (200 mg/m(2)/day for 5 days every 28 days) and cisplatin (75 mg/m(2) at day 1 of each cycle), up to six cycles, followed by whole brain radiotherapy (WBRT). An evaluation was carried out every two cycles and after WBRT. WBRT was performed earlier in case of progressive disease at any time or stable disease after cycle 4. RESULTS: Eight objective responses were achieved (16%). Overall median survival was 5 months. Median time to progression was 2.3 months. Ten patients (20%) presented a grade 3/4 neutropenia and 11 patients (22%) presented a grade 3/4 thrombopenia. CONCLUSION: This study demonstrates a lack of efficacy of up-front chemotherapy with association of temozolomide and cisplatin in these patients. Nevertheless, it supports the feasibility of chemotherapy before brain radiotherapy in NSCLC patients with BM.

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.

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.

[Current surgical methods for the etiological diagnosis of mediastinal adenopathies]. / Méthodes chirurgicales actuelles pour le diagnostic étiologique des adénopathies médiastinales.

The aim of this work was to determine the role of video-thoracoscopy and mediastinoscopy for the diagnosis of lymph node enlargement in the mediastinum of unknown aetiology. From January 1992 to December 1993, 26 patients were seen for surgical biopsy of mediastinal lymph nodes. Relative localization and the requirement for an associated gesture determined the choice between axial mediastinoscopy, parasternal scopy and videothoracoscopy. Mediastinoscopy was performed for peritracheal or right hilar (Baréty) nodes and parasternal scopy for anterior mediastinal masses. Videothroacoscopy was performed when the lymph nodes were localized at the preceding sites or when an associated manoeuver was required. Mediastinoscopy was performed in 16 patients. Lymphorrea which subsided after 4 days occurred in one patient and the mean hospital stay was 2.6 days. Diagnosis was achieved in 15 cases. The delay from procedure to treatment was 11 days on the average. Parasternal scopy was used 3 times and gave the diagnosis in all cases. Videothoracoscopy was used for 7 patients including 2 cases with pulmonary biopsies. Diagnosis was established 7 times and the delay to treatment was 12 days. No diagnostic thoracotomie were performed during this period. When access to the mass to be biopsied is difficult with mediastinoscopy (aorto-pulmonary, subcarenal, triangular ligament) videothoracotomy can be useful. Post-operative follow-up is simple and a specific treatment can be instaured rapidly. Videothoracotomy should be an important supplementary method for mediastinoscopy and helping avoid thoracotomy.

[Surgical treatment of pneumothorax by video-thoracoscopy]. / Traitement chirurgical du pneumothorax par vidéo-thoracoscopie.

Between May and December 1991, 12 patients with spontaneous pneumothorax were treated surgically, using video-thoracoscopy. With this technique bullous lesions could be excised in 10 cases and pleurodesis could be performed in all patients. Morbidity and mortality were nil. The cosmetic and functional advantages of video-thoracoscopy were obvious. Long-term results remain to be evaluated. This technique has shown that it is possible in all cases to create pleurodesis (pleural poudrage or pleurectomy) and to treat parenchymatous lesions (excision of bullous systems). This suggests that the long-term results will be the same as those obtained with conventional surgery.