Haemoptysis is a serious symptom with various aetiologies. Our aim was to define the aetiologies, outcomes and associations with lung cancer in the entire population of a high-income country.This ...retrospective multicentre study was based on the French nationwide hospital medical information database collected over 5 years (2008-2012). We analysed haemoptysis incidence, aetiologies, geographical and seasonal distribution and mortality. We studied recurrence, association with lung cancer and mortality in a 3-year follow-up analysis.Each year, ~15 000 adult patients (mean age 62 years, male/female ratio 2/1) were admitted for haemoptysis or had haemoptysis as a complication of their hospital stay, representing 0.2% of all hospitalised patients. Haemoptysis was cryptogenic in 50% of cases. The main aetiologies were respiratory infections (22%), lung cancer (17.4%), bronchiectasis (6.8%), pulmonary oedema (4.2%), anticoagulants (3.5%), tuberculosis (2.7%), pulmonary embolism (2.6%) and aspergillosis (1.1%). Among incident cases, the 3-year recurrence rate was 16.3%. Of the initial cryptogenic haemoptysis patients, 4% were diagnosed with lung cancer within 3 years. Mortality rates during the first stay and at 1 and 3 years were 9.2%, 21.6% and 27%, respectively.This is the first epidemiological study analysing haemoptysis and its outcomes in an entire population. Haemoptysis is a life-threatening symptom unveiling potentially life-threatening underlying conditions.
Noninvasive ventilation (NIV) represents an effective treatment for chronic respiratory failure. However, empirically determined NIV settings may not achieve optimal ventilatory support. Therefore, ...the efficacy of NIV should be systematically monitored. The minimal recommended monitoring strategy includes clinical assessment, arterial blood gases (ABG) and nocturnal transcutaneous pulsed oxygen saturation (SpO
). Polysomnography is a theoretical gold standard but is not routinely available in many centers. Simple tools such as transcutaneous capnography (TcPCO
) or ventilator built-in software provide reliable informations but their role in NIV monitoring has yet to be defined. The aim of our work was to compare the accuracy of different combinations of tests to assess NIV efficacy.
This retrospective comparative study evaluated the efficacy of NIV in consecutive patients through four strategies (A, B, C and D) using four different tools in various combinations. These tools included morning ABG, nocturnal SpO
, TcPCO
and data provided by built-in software via a dedicated module. Strategy A (ABG + nocturnal SpO
), B (nocturnal SpO
+ TcPCO
) and C (TcPCO
+ builtin software) were compared to strategy D, which combined all four tools (NIV was appropriate if all four tools were normal).
NIV was appropriate in only 29 of the 100 included patients. Strategy A considered 53 patients as appropriately ventilated. Strategy B considered 48 patients as appropriately ventilated. Strategy C misclassified only 6 patients with daytime hypercapnia.
Monitoring ABG and nocturnal SpO
is not enough to assess NIV efficacy. Combining data from ventilator built-in software and TcPCO
seems to represent the best strategy to detect poor NIV efficacy. Trial registration Institutional Review Board of the Société de Pneumologie de Langue Française (CEPRO 2016 Georges).
In the May 2017 issue of the European Respiratory Journal (ERJ), Johnson et al. 1 proposed the term “chronic breathlessness syndrome” to describe the clinical situation in which “breathlessness that ...persists despite optimal treatment of the underlying pathophysiology and results in disability for the patient”. The term “disability” in this definition corresponds to “physical limitations and/or a variety of adverse psychosocial, spiritual or other consequences”, which very closely matches the World Health Organization definition of the word 2. The relationship between breathlessness and disability was well captured in the foreword of a document published in 2013 by the Forum of International Respiratory Societies 3, which begins: “When we are healthy, we take our breathing for granted …. But when our lung health is impaired, nothing else but our breathing really matters”. This has become the “catch phrase” of the French lung health foundation (“Fondation du Souffle”, www.lesouffle.org). The explicit definition of “chronic breathlessness” as proposed by Johnson et al. 1 differs very little from the implicit definition of “refractory breathlessness”, the term previously used in many studies, and which was proposed as a distinct entity by some of the authors of a previously published ERJ article 4. Johnson et al. 1 submit that defining and naming this new syndrome will improve the visibility of a distressing and debilitating condition that is too often overlooked and neglected 5. They postulate that this enhanced visibility will result in improved care and organisation of care, stronger research 6, and greater empowerment for patients and their caregivers. The Editorial by Basoééééééééééêèôéééôéêèéééôèéèééééééééôôééôééééôôôéééééôéêèéééééôéôôéééôéêèéôôééééôğlu 7 published in the May 2017 issue of the ERJ throws new light on this notion of empowerment. Making a daring but fascinating parallel between untreated dyspnoea and torture, Basoééééééééééêèôéééôéêèéééôèéèééééééééôôééôééééôôôéééééôéêèéééééôéôôéééôéêèéôôééééôğğlu 7 reminds us how and why addressing dyspnoea in general (and probably “chronic breathlessness” in particular) is a fundamental issue not only from the point of view of medicine per se, but also from the point of view of human rights (on this, see also 8). He also makes a very convincing case for the importance of empowerment in the management of dyspnoea. Still in the same issue of the ERJ, Calverley 9 comments on the new syndrome and, like us, concurs with Johnson et al. 1 about the relevance of making breathlessness a foremost concern of every clinician.
Although immune modulation is a promising therapeutic avenue in coronavirus disease 2019 (COVID-19), the most relevant targets remain to be found. COVID-19 has peculiar characteristics and outcomes, ...suggesting a unique immunopathogenesis.
Thirty-six immunocompetent non-COVID-19 and 27 COVID-19 patients with severe pneumonia were prospectively enrolled in a single center, most requiring intensive care. Clinical and biological characteristics (including T cell phenotype and function and plasma concentrations of 30 cytokines) and outcomes were compared.
At similar baseline respiratory severity, COVID-19 patients required mechanical ventilation for significantly longer than non-COVID-19 patients (15 7-22 vs. 4 (0-15) days; p = 0.0049). COVID-19 patients had lower levels of most classical inflammatory cytokines (G-CSF, CCL20, IL-1β, IL-2, IL-6, IL-8, IL-15, TNF-α, TGF-β), but higher plasma concentrations of CXCL10, GM-CSF and CCL5, compared to non-COVID-19 patients. COVID-19 patients displayed similar T-cell exhaustion to non-COVID-19 patients, but with a more unbalanced inflammatory/anti-inflammatory cytokine response (IL-6/IL-10 and TNF-α/IL-10 ratios). Principal component analysis identified two main patterns, with a clear distinction between non-COVID-19 and COVID-19 patients. Multivariate regression analysis confirmed that GM-CSF, CXCL10 and IL-10 levels were independently associated with the duration of mechanical ventilation.
We identified a unique cytokine response, with higher plasma GM-CSF and CXCL10 in COVID-19 patients that were independently associated with the longer duration of mechanical ventilation. These cytokines could represent the dysregulated immune response in severe COVID-19, as well as promising therapeutic targets. ClinicalTrials.gov: NCT03505281.
Obesity is commonly reported in COVID-19 patients and is associated with poorer outcomes. It is suggested that leptin could be the missing link between obesity and severe COVID-19. Our study aimed to ...unravel the link between adipokines, COVID-19 status, immune response, and outcomes in severe pneumonia.
In this prospective observational single-center study, 63 immunocompetent patients with severe pneumonia (36 non-COVID-19 and 27 COVID-19) were enrolled, most required intensive care. Clinical and biological characteristics (glucose metabolism, plasma adipokines, and cytokine concentrations) and outcomes were compared.
At similar baseline severity, COVID-19 patients required mechanical ventilation for significantly longer than non-COVID-19 patients (p = 0.0049). Plasma concentrations of leptin and adiponectin were respectively positively and negatively correlated with BMI and glucose metabolism (glycemia and insulinemia), but not significantly different between the two groups. Leptin levels were negatively correlated with IL-1β and IL-6, but the adipokines were not correlated with most other inflammatory mediators, baseline severity (SOFA score), or the duration of mechanical ventilation.
Adipokine levels were correlated with BMI but not with most inflammatory mediators, severity, or outcomes in severe pneumonia, regardless of the origin. The link between obesity, dysregulated immune response, and life-threatening COVID-19 requires further investigation.
ClinicalTrials.gov: NCT03505281.
COVID-19 pneumonia has specific features and outcomes that suggests a unique immunopathogenesis. Severe forms of COVID-19 appear to be more frequent in obese patients, but an association with ...metabolic disorders is not established. Here, we focused on lipoprotein metabolism in patients hospitalized for severe pneumonia, depending on COVID-19 status. Thirty-four non-COVID-19 and 27 COVID-19 patients with severe pneumonia were enrolled. Most of them required intensive care. Plasma lipid levels, lipoprotein metabolism, and clinical and biological (including plasma cytokines) features were assessed. Despite similar initial metabolic comorbidities and respiratory severity, COVID-19 patients displayed a lower acute phase response but higher plasmatic concentrations of non-esterified fatty acids (NEFAs). NEFA profiling was characterised by higher level of polyunsaturated NEFAs (mainly linoleic and arachidonic acids) in COVID-19 patients. Multivariable analysis showed that among severe pneumonia, COVID-19-associated pneumonia was associated with higher NEFAs, lower apolipoprotein E and lower high-density lipoprotein cholesterol concentrations, independently of body mass index, sequential organ failure (SOFA) score, and C-reactive protein levels. NEFAs and PUFAs concentrations were negatively correlated with the number of ventilator-free days. Among hospitalized patients with severe pneumonia, COVID-19 is independently associated with higher NEFAs (mainly linoleic and arachidonic acids) and lower apolipoprotein E and HDL concentrations. These features might act as mediators in COVID-19 pathogenesis and emerge as new therapeutic targets. Further investigations are required to define the role of NEFAs in the pathogenesis and the dysregulated immune response associated with COVID-19.Trial registration: NCT04435223.
Long term noninvasive ventilation (LTNIV) is a recognized treatment for chronic hypercapnic respiratory failure (CHRF). COPD, obesity-hypoventilation syndrome, neuromuscular disorders, various ...restrictive disorders, and patients with sleep-disordered breathing are the major groups concerned. The purpose of this narrative review is to summarize current knowledge in the field of monitoring during home ventilation. LTNIV improves symptoms related to CHRF, diurnal and nocturnal blood gases, survival, and health-related quality of life. Initially, patients with LTNIV were most often followed through elective short in-hospital stays to ensure patient comfort, correction of daytime blood gases and nocturnal oxygenation, and control of nocturnal respiratory events. Because of the widespread use of LTNIV, elective in-hospital monitoring has become logistically problematic, time consuming, and costly. LTNIV devices presently have a built-in software which records compliance, leaks, tidal volume, minute ventilation, cycles triggered and cycled by the patient and provides detailed pressure and flow curves. Although the engineering behind this information is remarkable, the quality and reliability of certain signals may vary. Interpretation of the curves provided requires a certain level of training. Coupling ventilator software with nocturnal pulse oximetry or transcutaneous capnography performed at the patient's home can however provide important information and allow adjustments of ventilator settings thus potentially avoiding hospital admissions. Strategies have been described to combine different tools for optimal detection of an inefficient ventilation. Recent devices also allow adapting certain parameters at a distance (pressure support, expiratory positive airway pressure, back-up respiratory rate), thus allowing progressive changes in these settings for increased patient comfort and tolerance, and reducing the requirement for in-hospital titration. Because we live in a connected world, analyzing large groups of patients through treatment of "big data" will probably improve our knowledge of clinical pathways of our patients, and factors associated with treatment success or failure, adherence and efficacy. This approach provides a useful add-on to randomized controlled studies and allows generating hypotheses for better management of HMV.
Background: The definition of polycythemia, whether primary or secondary, is based on direct measurement of red cell mass (RCM) by isotope labelling method. Because of the lack of availability of ...isotopes, the use of hematocrit and hemoglobin values defined by the WHO recommendations has overtaken the use of the RCM, which can result in misdiagnosis of polycythemia.This determination is also useful for patients with myeloproliferative neoplasm (MPN) to separate two clinical entities: essential thrombocythemia and “masked” Polycythemia Vera, both of which result in high blood counts. These two conditions have different prognoses and therapeutic management. RCM measurement is also sometimes used in the follow-up of MPN with splanchnic thrombosis.The CO-rebreathing method is mainly used in sports to assess the RCM. It is minimally invasive, fast (<30 min) and its accuracy appears to be equivalent to the gold standard’s.To date, no study has compared RCM values obtained with CO-Rebreathing and with the state-of-the-art technique, i.e. isotopic labeling, in the diagnosis of polycythemia.Aims: Here, we present the result of a prospective bi-centric study comparing RCM obtained by CO-rebreathing and by isotopic measurement in a population referred to hematologists for suspicion of polycythemia.Methods: Forty-two patients were initially recruited for simultaneous RCM determination by Co-rebreathing and isotope labelling method. All patients signed an informed consent form. During the course of the study, two patients could not benefit from the Co-rebreathing measurement due to non-compliance with the inclusion criteria (smoking just before the examination) or due to the ergonomic complexity of using the spirometer. On the other hand, the isotope labelling method could not be performed for another patient. This prospective non-randomized study therefore included 39 patients (35 men and 4 women) with a median age of 57 years (range 19-91 years); three of them had Polycythemia Vera with a V617F JAK2 mutation.The isotope labelling method was performed according to the recommendations of the French Society of Radiopharmacy (SoFRa) in a nuclear medicine department using the labelling of the patient’s red blood cells (RBC) with technetium 99m.Co-rebreathing measurement was performed in a pneumology department immediately after the respiratory functional explorations and the determination of baseline HbCO. This method consists of labelling Hb with inspired carbon monoxide (CO), resulting in a temporary increase of COHb.Results: True polycythemia was defined by an increased red cell mass (RCM) above 125% of the theoretical one, for both techniques. All results were expressed as a percentage of the theoretical value.Comparing the RCM results obtained with these two methods, the two techniques were consistent for 31 patients (21 true polycythemia, 10 false polycythemia). For four patients, the CO-rebreathing measurement was underestimated, while for four others, the value obtained by CO-rebreathing was overestimated. Overall, the method yielded a sensitivity of 84% and a specificity of 71%.Summary/Conclusion: This study, carried out on a large series of patients, allows the validation of a simple, non-invasive and reliable tool for the measurement of RCM based on the use of CO-rebreathing, and which is well correlated with the reference isotopic method. It has the advantage of being more accessible to patients, for whom a hospital hosting a nuclear medicine department is too far.In addition, it will allow the measurement of RCM in countries where the isotopic method is no longer available, such as most European and North American countries.
We aimed to compare the mortality and comfort associated with high-flow nasal cannula oxygenation (HFNCO) and high-concentration mask (HCM) in older SARS-CoV-2 infected patients who were hospitalized ...in non-intensive care units. In this retrospective cohort study, we included all consecutive patients aged 75 years and older who were hospitalized for acute respiratory failure (ARF) in either an acute geriatric unit or an acute pulmonary care unit, and tested positive for SARS-CoV-2. We compared the in-hospital prognosis between patients treated with HFNCO and patients treated with HCM. To account for confounders, we created a propensity score for HFNCO, and stabilizing inverse probability of treatment weighting (SIPTW) was applied. From March 2020 to January 2021, 67 patients (median age 87 years, 41 men) were hospitalized with SARS-CoV-2-related ARF, of whom 41 (61%) received HFNCO and 26 (39%) did not. Age and comorbidities did not significantly differ in the two groups, whereas clinical presentation was more severe in the HFNCO group (NEW2 score: 8 (5–11) vs. 7 (5–8), p = 0.02, and Sp02/Fi02: 88 (98–120) vs. 117 (114–148), p = 0.03). Seven (17%) vs. two (5%) patients survived at 30 days in the HFNCO and HCM group, respectively. Overall, after SIPTW, HFNCO was significantly associated with greater survival (adjusted hazard ratio (AHR) 0.57, 95% CI 0.33–0.99; p = 0.04). HFNCO use was associated with a lower need for morphine (AHR 0.39, 95% CI 0.21–0.71; p = 0.005), but not for midazolam (AHR 0.66, 95% CI 0.37–1.19; p = 0.17). In conclusion, HFNCO use in non-intensive care units may reduce mortality and discomfort in older inpatients with SARS-CoV-2-related ARF.
First described in December 2019 in Wuhan (China), COVID-19 disease rapidly spread worldwide, constituting the biggest pandemic in the last 100 years. Even if SARS-CoV-2, the agent responsible for ...COVID-19, is mainly associated with pulmonary injury, evidence is growing that this virus can affect many organs, including the heart and vascular endothelial cells, and cause haemostasis, CNS, and kidney and gastrointestinal tract abnormalities that can impact in the disease course and prognosis. In fact, COVID-19 may affect almost all the organs. Hence, SARS-CoV-2 is essentially a systemic infection that can present a large number of clinical manifestations, and it is variable in distribution and severity, which means it is potentially life-threatening. The goal of this comprehensive review paper in the series is to give an overview of non-pulmonary involvement in COVID-19, with a special focus on underlying pathophysiological mechanisms and clinical presentation.
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