Can exhaled nitric oxide differentiate causes of pulmonary fibrosis?

BACKGROUND: Interstitial lung diseases (ILD) comprise a heterogeneous group of disorders, and when diagnosed at the stage of pulmonary fibrosis, the underlying lung disease can sometimes be difficult to identify. The aim of the present study was to determine whether there are differences in FENO (fraction of exhaled nitric oxide) between different subtypes of fibrotic ILD. METHODS: Sixty-one patients, with honeycombing on computed tomography (CT) scan, and whose FENO levels had been measured during chronic dyspnoea evaluation, were divided into four groups based on pulmonary fibrosis aetiology: idiopathic pulmonary fibrosis (IPF), chronic hypersensitivity pneumonitis (HP), connective tissue disease-associated ILD disorders (CTD-ILD), drug-induced pneumonia. The FENO values of each group were compared and CT scan features were analysed to identify the mechanisms involved in FENO change. RESULTS: The median FENO value of patients with chronic HP was 51 ppb (IQR 36-74), higher than that of the other groups (22 ppb (IQR 17-30) in IPF, 19 ppb (IQR 17-21) in drug-induced pneumonia, and 25 ppb (IQR 17-37) for CTD-ILD; p = 0.008). At the cut-off value of 41 ppb, the optimal sensitivity and specificity to diagnose HP with FENO were respectively 76.9% and 85.4%. On CT scans, only extensive lobular areas with decreased attenuation, a recognized marker of bronchiolar disease, were associated with high FENO values (p = 0.0002). CONCLUSION: FENO could be a tool for differentiating chronic HP from other types of pulmonary fibrosis. The mechanism involved seems to be bronchiolar disease.

[Respimat®, first Soft Mist™ inhaler: new perspectives in the management of COPD]. / Respimat(®), premier inhalateur « Soft Mist ¼ : intérêt dans la prise en charge de la BPCO.

INTRODUCTION: In COPD, inhaler choice should be based on the likelihood that the patient will be able to use the device correctly in order to favour adherence and compliance, and therefore treatment efficacy. SATE OF THE ART: Performances of usual inhalers are limited by the necessity of a good coordination of patient inspiration and inhaler activation (pressurized metered dose inhalers), or a sufficient inspiratory flow (dry powder inhalers). Respimat®, the first "Soft Mist™ inhaler" (SMI), releases the drug solution as a low and sustained soft mist, so that lung deposition is both improved and reproducible. PERSPECTIVES: In clinical studies, Respimat® has been shown to allow equivalent bronchodilator response and tolerability to metered dose or dry powder inhalers, but with lower doses of active drugs. Furthermore, studies assessing inhaler preference in COPD showed that patients preferred Respimat® to usual inhalers. CONCLUSION: Respimat® SMI offers new perspectives for the management of chronic respiratory diseases, particularly in newly diagnosed or poorly compliant patients.

Organising pneumonia can be the inaugural manifestation in connective tissue diseases, including Sjogren's syndrome.

Connective tissue diseases are known to be one of the causes of organising pneumonia (OP). However, this association is rare and signs of OP usually occur in the context of an already diagnosed disease. We report three cases of OP preceding the articular symptoms of the underlying connective tissue disease by 3-6 months in two cases of rheumatoid arthritis and by 36 months in one patient with primary Sjögren's syndrome. The diagnosis of post-infectious OP had initially been suspected in the three cases and the patients had not been followed up further. The occurrence of OP preceding articular or any other extrapulmonary involvement of connective tissue disease had been reported in only four cases in the literature and, to our knowledge, no case preceding Sjögren's syndrome had ever been reported. These observations suggest that exhaustive investigations should be considered when OP is diagnosed, including antinuclear auto-antibodies and investigations for Sjögren's syndrome, even when there are no clinical signs suggesting an underlying connective tissue disease. These investigations should also be repeated during the course of the disease, especially in the case of OP continuing to progress under treatment and, of course, if signs of connective tissue disease appear.