[Silica causes difficulties]. / La silice cause des difficultés.

Silicosis and sarcoidosis are two very distinct entities in the literature. All the additional non-invasive examinations, including the chest CT scan, often do not differentiate them. The history, including occupational exposure to identified silica particles, is a discriminating factor. However, due to the pathogenic power of silica, it would be possible to have the simultaneous development of these two pathologies in the same patient. To illustrate this situation, here is the case of a 62-year-old patient, who presented initially with a picture of dyspnea and productive cough. The chest CT showed micronodular peribronchovascular infiltrates and mediastinal lymphadenopathy. The other additional examinations did not find anything specific. In the diagnostic process, the patient had multiple endoscopic samples which did not make it possible to be conclusive on one or the other of these pathologies. He therefore underwent a surgical lung biopsy which revealed histological lesions compatible with the two pathologies. Recent studies suggest that inhaled particles, especially silica, could be responsible for the pattern of sarcoidosis. However, it is difficult to say whether, in this case, silica was responsible for the development of sarcoidosis.

Airway stent current practices evaluation: Survey among French bronchoscopy practitioners.

BACKGROUND: Airway stenting (AS) is performed for the treatment of benign or malignant central airway stenosis. In France, more than 30 centers practice AS. The aim of this survey was to evaluate the current practice around airway stenting among French bronchoscopy practitioners. METHOD: We performed an online survey sent to the GELF group (Groupe d'Endoscopie de Langue Française) mailing list. The first part comprised 10 questions about the different attitudes before AS and the second part included 10 questions about the management after AS. RESULTS: Thirty-six participants answered to the first part of the questionnaire and thirty-three to the second. There were some similarities, for example the absence of prophylactic antibiotic treatment before procedure (86%), use of saline nebulization, and removing or replacing the airway stent in case of persistent chest congestion or infection (73%). We also noted an important heterogeneity of the practices with several differences concerning systematic endoscopic control, bacteriological sampling before procedure (44%) and systematically AS replacement. CONCLUSION: This survey shows that AS management in France varies between practitioners. Respondents agreed on a few points, but disagreed on several important aspects of the management. These results emphasize the need of expert recommendations to improve AS management.

Clinical ACO phenotypes: Description of a heterogeneous entity.

BACKGROUND: Because ACO (Asthma-COPD-Overlap) does not fill out asthma or COPD (Chronic Obstructive Pulmonary Disease) criteria, such patients are poorly evaluated. The aim of this study was to screen asthma and COPD for an alternative diagnosis of ACO, then to determine subgroups of patients, using cluster analysis. MATERIAL AND METHODS: Using GINA-GOLD stepwise approach, asthmatics and COPD were screened for ACO. Clusterization was then performed employing Multiple Correspondent Analysis (MCA) model, encompassing 9 variables (age, symptoms onset, sex, BMI (Body Mass Index), smoking, FEV-1, dyspnea, exacerbation, comorbidity). Finally, clusters were compared to determine phenotypes. RESULTS: MCA analysis was performed on 172 ACO subjects. To better distinguish clusters, the analysis was then focused on 55 subjects, having at least one cosine squared >0.3. Six clusters were identified, allowing the description of 4 phenotypes. Phenotype A represented overweighed heavy smokers, with an early onset and a severe disease (27% of ACO patients). Phenotype B gathered similar patients, with a late onset (29%). Patients from Phenotypes C-D were slighter smokers, presenting a moderate disease, with early and late onset respectively (respectively 13% and 31%). CONCLUSIONS: By providing evidences for clusters within ACO, our study confirms its heterogeneity, allowing the identification of 4 phenotypes. Further prospective studies are mandatory to confirm these data, to determine both specific management requirements and prognostic value.

[Relationship between vaping and smoking among 15-year-olds in high school. Results of a descriptive cross-sectional and monocentric observational study conducted in the metropolitan area of Saint-Étienne]. / Relations entre vapotage et tabagisme chez les adolescents en classe de seconde. Résultats d'une étude observationnelle descriptive transversale et monocentrique menée dans l'agglomération stéphanoise.

INTRODUCTION: The initiation of smoking among adolescents by vaping is a subject of controversy. This study focuses on the prevalence of electronic cigarette use among teenagers and its connection with the consumption of tobacco. METHODS: A cross-sectional and monocentric study was conducted in the spring of 2018 and included 1435 students (15-16years old) from the metropolitan area of Saint-Étienne in France. RESULTS: Nearly half of the adolescents experimented with e-cigarettes (50.30%) or tobacco (50.40%). Nearly a quarter are vapers (23.60%) or smokers (28.20%), with low daily use (3.65% for vaping and 9.40% for smoking). In regard to the link between smoking and vaping, 64.85% of adolescents are "non-smokers and non-vapers", 17.60% "smokers and vapers", 11.25% "smokers and non-vapers", and 6.30% "non-smokers and vapers". DISCUSSION: The portrait-types of the vaper and the smoker are similar: boy rather than girl, educated in private school rather than public, and enrolled in a vocational rather than a general educational course. On one hand, the use of electronic cigarettes in non-smoking adolescents does not appear to be a major mode of entry into smoking or nicotine addiction. On the other hand, the use of electronic cigarettes among adolescent's smokers seems to have a beneficial effect on their smoking habit (stopping or reducing the consumption of tobacco).

Diagnostic of mediastinal lymphadenopathy in extrathoracic cancer: A place for EBUS-TBNA in real life practice?

INTRODUCTION: Mediastinal lymphadenopathy in patients with extrathoracic malignancy is common. To obtain tissue proof of metastatic spread, EBUS-TBNA is an alternative to mediastinoscopy or thoracoscopy, but there are limited data about its diagnostic performance. The aim of this study was to determine the diagnostic accuracy of EBUS-TBNA for the evaluation of mediastinal lymphadenopathy in patients with extrathoracic cancers. METHODS: We performed a multicenter retrospective study based on an online questionnaire to collect data from January 2011 to December 2012 in all patients with proven extrathoracic malignancy (current or past) and suspected mediastinal lymph node metastases who underwent EBUS-TBNA for diagnosis. RESULTS: Hundred and eighty-five patients were included. Extrathoracic malignancies observed were urological (43), breast (35), gastrointestinal (33), head and neck (30), melanoma (11), lymphoma (6), and others (27). EBUS-TBNA confirmed malignancy in 93 patients (50.3%): concordant metastases in 67 (36.2%); new lung cancer in 25 (13.5%); and 1 unidentified cancer. The diagnostic accuracy, sensitivity, specificity, negative predictive value, and positive predictive value were respectively 54.6%, 68.4%, 100%, 53.3%, and 100%. CONCLUSION: Mediastinoscopy remain the reference, but EBUS-TBNA may be considered as first line investigation in patients with suspected mediastinal lymph node metastases and extrathoracic malignancy. It prevented a surgical procedure in 50.3% of patients.

Implementation of a self-administered questionnaire to detect lung carcinogens.

BACKGROUND: Between 10 and 20% of lung cancers are of occupational origin. Screening for occupational risk factors is part of the diagnostic workup. A self-administered questionnaire to detect lung carcinogens of occupational origin, the RECAP questionnaire, was drawn up and validated with a view to limiting under-declaration of lung cancer as an occupational disease (OD). AIMS: Optimal administration conditions were investigated, to facilitate systematic use in the management of patients admitted to hospital with lung cancer. METHODS: The various care pathways of lung cancer patients were first studied in two centres, to identify the health-care professionals involved in medical management, the various care sites and the stages of treatment. A focus group of health-care professionals was set up, and semi-directive interviews were conducted with 24 patients. RESULTS: Caregivers tended to suggest that a physician or nurse should present the RECAP questionnaire, whereas patients rather chose non-caregiver staff, seeing the undertaking as being 'administrative' in nature. Some caregivers and patients thought the questionnaire should not be administered at the outset of treatment, due to the psychological trauma entailed by diagnosis. Administration during chemotherapy was recommended by patients, as they are more freely available at that time, and by caregivers, who thought patients better able to pay attention then. CONCLUSIONS: The study highlighted patients' lack of information on how lung cancer can be recognized as an OD. Implementing the RECAP questionnaire should facilitate patients' claims for insurance cover for lung cancer as an OD.

[Bench-test evaluation of spacer devices for fluticasone delivery to infants]. / Chambres d'inhalation pour délivrance de fluticasone chez le nourrisson au banc d'essai.

INTRODUCTION: Use of a spacer device to optimize the delivery of fluticasone to infants with asthma is an important issue and clinicians require guidance around the choice of device. This in vitro study characterizes the particle size and the fluticasone delivery via 9 spacers. METHODS: We used an in vitro infant nasal cast with two different inspiratory flow rates (50 and 100mL/s). Fluticasone particle size in the aerosol was evaluated by laser diffractometry and tracheal deposition by spectrophotometric assay. RESULTS: Significant differences in particle size were observed between the 9 spacers (similar D50 but D90 from 5.65±0.65 to 8.80±1.35µm). A 75 % or higher respirable fraction was obtained for only 5 spacers. The 50mL/s flow rate lead to the best drug delivery. At this flow, OptiChamber® (62±3 %) and Vortex® (91±8.5 %) had a tracheal deposition over 50 % of the initial dose of fluticasone, although the 7 other spacers exhibited a fluticasone deposition less than 25 %. DISCUSSION: This study shows a wide variation of drug delivery between the 9 spacers studied. We demonstrate that a low inspiratory flow and a spacer showing antistatic properties facilitate drug delivery.

[Foreign body of dental origin: How to retrieve the dentist's drill?]. / Corps étrangers d'origine dentaire : comment ramener la fraise du dentiste ?

INTRODUCTION: Inhalation of foreign bodies is an unusual complication of dental care. When it occurs immediately during the intervention, it is generally a dental tool, such as the little screwdrivers used for dental implant procedures. CASE REPORT: A 59-year-old man was referred to our hospital for asymptomatic inhalation of a small drill during dental surgery. Because the drill had a barbed tip, prompt removal was indicated. The foreign body was localized in a sub-segmental division of the left lower lobe (B10b) and could be removed via a flexible bronchoscope under a short general anesthetic without intubation. There was no significant injury of the bronchial mucosa. CONCLUSION: Inhalation of foreign bodies during dental interventions is unusual and sometimes asymptomatic but their removal is always indicated. In some cases, the removal can be performed with a flexible bronchoscope.

[Tracheobronchial prosthesis in Mounier-Kuhn syndrome: New perspectives]. / Prothèse trachéobronchique dans le syndrome de Mounier-Kuhn : nouvelles perspectives.

INTRODUCTION: Mounier-Kuhn syndrome or tracheobronchomegaly is a rare congenital condition, the management of which is complex. We report the case of a patient who was treated with interventional endoscopy. OBSERVATION: We describe the case of a 74-year-old man with a diagnosis of tracheobronchomegaly who was admitted in 2003 with a background of deteriorating respiratory status and the occurrence of postural syncope. He initially received a tracheobronchial silicone Y prosthesis, extended with metal prostheses at the tracheal and bronchial level. This arrangement remained stable until 2011. He then began to develop episodes of asphyxia related to posterior dislocation of the tracheobronchial prosthesis, after breakage of the metallic mesh tracheal prosthesis. A new tracheobronchial prosthesis Y was then placed, custom-made from a 3D model of the airways. This was clinically and functionally effective. DISCUSSION: This case describes the management of a patient with Mounier-Kuhn syndrome by interventional bronchoscopy, with the adaptation of prosthetic materials, on an individual basis, to the anatomy of the patient's airway.

Evaluation of the Aspergillus Western blot IgG kit for diagnosis of chronic aspergillosis.

Immunoprecipitin detection (IPD) is the current reference confirmatory technique for anti-Aspergillus antibody detection; however, the lack of standardization is a critical drawback of this assay. In this study, we evaluated the performance of the Aspergillus Western blot (Asp-WB) IgG kit (LDBio Diagnostics, Lyon, France), a recently commercialized immunoblot assay for the diagnosis of various clinical presentations of chronic aspergillosis. Three hundred eight serum samples from 158 patients with aspergillosis sensu lato (s.l.) were analyzed. More specifically, 267 serum samples were derived from patients with Aspergillus disease, including 89 cases of chronic pulmonary aspergillosis, 10 of aspergilloma, and 32 of allergic bronchopulmonary aspergillosis, while 41 samples were from patients with Aspergillus colonization, including 15 cystic fibrosis (CF) and 12 non-CF patients. For blood donor controls, the Asp-WB specificity was 94%, while the kit displayed a sensitivity for the aspergillosis s.l. diagnosis of 88.6%, with a diagnostic odds ratio (DOR) of 119 (95% confidence interval [CI], 57 to 251). The DOR values were 185.22 (95% CI,78.79 to 435.45) and 43.74 (95% CI, 15.65 to 122.20) for the diagnosis of Aspergillus disease and Aspergillus colonization, respectively. Among the patients, the sensitivities of the Asp-WB in the diagnosis of Aspergillus colonization were 100% and 41.7% in CF and non-CF patients, respectively. The Asp-WB yielded fewer false-negative results than did IPD. In conclusion, the Asp-WB kit performed well for the diagnosis of various clinical presentations of aspergillosis in nonimmunocompromised patients, with an enhanced standardization and a higher sensitivity than with IPD, which is the current reference method.

Complete resolution of cerebral air embolism secondary to a transbronchial needle aspiration.

Air embolism following transbronchial needle aspiration (TBNA) is extremely rare. To date, only 1 case has been described (estimated incidence: 0.02-0.07%). Here, a 70-year-old patient developed a left upper-lobe alveolar syndrome with no response to well-conducted antibiotic treatments. Conventional bronchoscopy was normal, but virtual bronchoscopy showed that the tumor was contiguous to the left B3-B4 division. During a second bronchoscopy, a TBNA was performed without bleeding, and pathology later revealed primitive lung adenocarcinoma. Immediately after the puncture, an epileptic seizure occurred with right rotation of the head and a tonic seizure of the left arm followed by left hemiplegia. A brain CT scan performed almost immediately showed no abnormalities and a chest radiography did not show any pleural or mediastinal aeric image. A few hours later, clonic seizures occurred and brain MRI showed lesions compatible with air embolisms (right gyral cortical location). Several hyperbaric therapy sessions successfully cured the neurological deficit. Despite its rarity, each practitioner of TBNA has to be aware of this side effect and its early treatment. The mechanism of such accidents remains unclear, but probably involves high bronchial pressure and venous trauma. © 2013 S. Karger AG, Basel.

[Interest for evaluation of bronchial inflammation in asthma]. / Intérêt des méthodes non invasives d'évaluation de l'inflammation bronchique dans l'asthme.

Asthma is a heterogeneous chronic inflammatory disease. The respiratory functional tests are sometimes insufficient to confirm the diagnosis. Other tools are developed to estimate the bronchial inflammation such as tests of bronchial provocation, measure of exhaled nitric oxide, induced sputum and exhaled breath condensate. This review presents these non-invasive methods, approaches their interests on the identification of the disease and the treatment.

[Cost-effectiveness of lung volume reduction coil treatment in emphysema. STIC REVOLENS]. / Évaluation médico-économique de la réduction volumique endobronchique par spirales. STIC REVOLENS.

BACKGROUND: Medical therapeutic options for the treatment of emphysema remain limited. Lung volume reduction surgery is infrequently used because of its high morbi-mortality. Endobronchial lung volume reduction coil (LVRC(®), PneumRx, Mountain View, CA) treatment has been recently developed and has been shown to be feasible and associated with an acceptable safety profile, while resulting in improvements in dyspnea, exercise capacity and lung function. The objective of this study is to analyze the cost effectiveness of LVRC treatment in severe emphysema. METHODS: This prospective, multicenter study, randomized with a 1:1 ratio (LVRC vs conventional treatment) will include 100 patients who will be followed up for 1year. The primary outcome measure is the 6-month improvement of the 6-minute walk test: the percentage of patients showing an improvement of at least 54m will be compared between groups. A cost-effectiveness study will estimate the cost of LVRC treatment, the global cost of this therapeutic option and will compare the cost between patients treated by LVRC and by medical treatment alone. EXPECTED RESULTS: This study should allow validating the clinical efficacy of LVRC in severe emphysema. The cost-effectiveness study will assess the medical-economic impact of the LVRC therapeutic option.