Respiratory Medicine and Research最新文献

Background and objectives

Malignant pleural effusions (MPE) are a frequent and major turning point in neoplastic disease usually leading to poor life expectancy. Improve quality of life and relieve the dyspnea are the main objectives in this palliative care setting. This can be achieved by the placement of an indwelling catheter (IPC) or talc pleurodesis ideally performed by thoracoscopy route (talc poudrage). Beside to misidentify a trapped-lung, the latter requires a prolonged hospital stay and the IPC placement does not allow a high pleurodesis rate. To overcome these drawbacks, a combination of both technique could be proposed for the management of recurrent malignant pleural effusions. Safety and efficacy of this pragmatic approach are reported.

Methods

Consecutive patients who have been managed for recurrent MPE by a combination of talc poudrage for pleural symphysis by thoracoscopy route ending with the insertion of IPC using the same thoracic point of entry. Demographic data, hospital length of stay (LOS), procedural-related complications, patients’ quality of life (QoL) and success of pleurodesis were collected. Patients were followed-up for 6 months.

Results

The data of twenty-five consecutive patients undergoing the procedure were analyzed. Successful pleurodesis was obtained for 14/25 patients (66 %) at one month, 17/20 patients (85 %) at 3 months and 13/15 patients (86 %) at 6 months respectively. On average, the hospital LOS after the procedure was 3.24 days (IQR 1–4) with a median of 1 day. A prolonged hospitalization (>1 day) was never due to the procedure except for one patient (pneumothorax). No IPC related infection or procedure related deaths were noted.

Conclusion

Among patients with recurrent MPE, the combination of talc poudrage symphysis by thoracoscopy route and IPC placement on the same time results in a shortened hospital LOS and higher rate of pleurodesis. Further randomized clinical trials are needed to confirm these results.

Pulmonary hypertension (PH) continues to present significant challenges to the medical community, both in terms of diagnosis and treatment. The advent of the updated 2022 European Society of Cardiology (ESC) and European Respiratory Society (ERS) guidelines has introduced pivotal changes that reflect the rapidly advancing understanding of this complex disease. These changes include a revised definition of PH, updates to the classification system, and treatment algorithm. While these guidelines offer a critical framework for the management of PH, they have also sparked new discussions and questions. The 5th French Pulmonary Hypertension Network Meeting (Le Kremlin-Bicêtre, France, 2023), addressed these emergent questions and fostering a deeper understanding of the disease's multifaceted nature. These discussions were not limited to theoretical advancements but extended into the practical realms of patient management, highlighting the challenges and opportunities in applying the latest guidelines to clinical practice.

Background

Chronic obstructive pulmonary disease (COPD) is associated with airflow obstruction that threatens global health. During the hospitalization of patients with acute exacerbations of COPD (AECOPD), the high prevalence of pulmonary embolism (PE) seriously affects the prognosis of disease. This study aims to assess the differences in clinical data between patients with AECOPD and patients with AECOPD-PE, and to identify the relevant factors of PE.

Methods

We performed a retrospective case-control study in AECOPD patients between January 2018 and December 2021. Due to suspected PE, all patients underwent radiological examination. Patients without PE were included as controls. Clinical data and laboratory tests were recorded. Univariate analysis and multivariate logistic regression analysis were used to investigate the independent predictors of PE. Receiver operating characteristics (ROC) curves was performed to evaluate the effect of risk factors on PE prediction.

Results

A total of 191 patients were included for analysis, divided into the AECOPD group (96 cases) and AECOPD-PE group (95 cases). No statistic differences were detected in demographic characteristics between patients with AECOPD and patients with AECOPD and PE. Average PO₂ and PCO₂ levels, lung function, and Echocardiographic indicator were not associated with PE. The concentration of D-dimer, the proportion of simplified wells score ≥ 2, and the incidence rate of lower extremity deep vein thrombosis (DVT) remarkably increased in AECOPD-PE group than AECOPD individuals. At multivariate analysis, the above three indicators were closely relevant to the occurrence of PE. The AUC value for D-dimer combined with lower extremity DVT and Simplified Wells Score was 0.729.

Conclusions

D-dimer, lower extremity DVT, and simplified wells score ≥ 2 were relevant to higher risks of PE, which will help to improve clinicians’ understanding of PE secondary to AECOPD.

Background

Low vaccination rates against influenza and Streptococcus (S.) pneumoniae infections in COPD could impair outcomes. Understanding underlying factors could help improving implementation.

Objectives

To describe vaccination rates at inclusion in COPD cohorts and analyze associated factors.

Methods

Between 2012 and 2018, 5927 patients with sufficient data available were recruited in 3 French COPD cohorts (2566 in COLIBRI-COPD, 2653 in PALOMB and 708 in Initiatives BPCO). Data at inclusion were pooled to describe vaccination rates and analyze associated factors.

Results

Mean age was 66 years, 34 % were women, 35 % were current smokers, mean FEV1 was 58 % predicted, 22 % reported ≥2 exacerbations in the year prior to inclusion, mMRC dyspnea grade was ≥2 in 59 %, 52 % had cardiovascular comorbidities and 9 % a history of asthma. Vaccinations rates in the year prior to study entry were 34.4 % for influenza + S. pneumoniae, 17.5 % for influenza alone and 8.9 % for S. pneumoniae alone. In multivariate analyses, influenza vaccination rate was greater in older age, smoking status, low FEV1, exacerbation history, mMRC dyspnea>2, asthma history, hypertension, diabetes mellitus, and the year of inclusion. SP vaccination was associated with type of practice of the respiratory physician, age, smoking status, FEV1, exacerbation history, dyspnea grade, asthma history and the year of inclusion.

Conclusion

Rates of vaccination against influenza and S. pneumoniae infection at inclusion in COPD cohorts remain insufficient and vaccination appears restricted to patients with specific features especially regarding severity and comorbidities, which is not consistent with current recommendations.

Background

Non-invasive ventilation (NIV) is a standard of care for hypercapnic chronic respiratory failure (CRF). Obstructive sleep apnea syndrome (OSA) frequently contributes to hypoventilation in CRF patients. CPAP improves hypercapnia in selected COPD and obese patients, like NIV. We aimed to describe the profile of patients switching from NIV to CPAP in a cohort of patients on long-term ventilation and to identify the factors associated with a successful switch.

Methods

In this case-control study, 88 consecutive patients who were candidates for a NIV-CPAP switch were compared with 266 controls among 394 ventilated patients treated at the Dijon University Hospital between 2015 and 2020. They followed a standardized protocol including a poly(somno)graphy recorded after NIV withdrawal for three nights. CPAP trial was performed if severe OSA was confirmed. Patients were checked for recurrent hypoventilation after 1 and 23[14–46] nights under CPAP.

Results

Patients were 53% males, median age 65 [56–74] years, and median BMI 34 [25–38.5] kg/m². Sixty four percent of patients were safely switched and remained on long-term CPAP. In multivariate analysis, the probability of a NIV-CPAP switch was correlated to older age (OR: 1.3 [1.01–1.06]), BMI (OR: 1.7 [1.03–1.12]), CRF etiology (OR for COPD: 20.37 [4.2–98,72], OR for obesity: 7.31 [1.58–33.74]), circumstances of NIV initiation (OR for acute exacerbation: 11.64 [2.03–66.62]), lower pressure support (OR: 0.90 [0.73–0.92]), lower baseline PaCO₂ (OR: 0.85 [0.80–0.91]) and lower compliance (OR: 0.76 [0.64–0.90]). Among 72 patients who went home under CPAP, pressure support level was the only factor associated with the outcome of the NIV-CPAP switch, even ^{after adjustment for BMI and age (p = 0.01}) with a non-linear correlation. Etiology of chronic respiratory failure, age, BMI, baseline PaCO₂, circumstances of NIV initiation, time under home NIV or NIV compliance were not predictive of the outcome of the NIV-CPAP switch.

Conclusions

A NIV-CPAP switch is possible in real life conditions in stable obese and COPD patients with underlying OSA.

Background

Studies have shown improvement in overall survival with anti-PD1/PD-L1 molecules in combination with cisplatin/carboplatin and etoposide as a first-line treatment for Small Cell Lung Cancer (SCLC). However, first-line efficacy remains limited and well below that observed in Non-Small Cell Lung Cancer (NSCLC). Etoposide may have a detrimental effect on lymphocyte activation, which could explain the limited benefit of immunotherapy in the first line and the lack of benefit in the second line for patients previously exposed to high levels of etoposide.

Methods

We initiated a multicenter, single-arm, open-label phase II study of a chemotherapy regimen with durvalumab, combined with carboplatin and paclitaxel for extensive disease SCLC. Eligible patients will receive durvalumab plus carboplatin and paclitaxel every 3 weeks for up to 4 cycles, followed by durvalumab every 4 weeks until progression or unacceptable toxicity. A total of 67 patients will be enrolled in this study, with a 12-month enrollment period and 36-month follow-up. The primary endpoint is Overall Survival (OS) rate at 12 months. Secondary endpoints are best response rate, OS, OS at 24- and 36 months, progression free survival (PFS), duration of response, quality of life and safety.

Results

This study aims to establish the efficacy of durvalumab combined with carboplatin and paclitaxel in patients with extensive disease Small Cell Lung Cancer.

Clinical trial registration

EU CT: 2023-504670-38-00.