Christine Lamberto

Imaging of sarcoidosis of the airways and lung parenchyma and correlation with lung function

Imaging has a prominent role in the assessment of sarcoidosis diagnosis and outcome, which are extremely variable. Chest radiography staging helps predict the probability of spontaneous remission, and stage IV is associated with higher mortality. However, the reproducibility of reading is poor and changes in radiography and lung function are inconsistently correlated, which may be problematic for the monitoring of disease and treatment response. Chest computed tomography (CT) makes a great diagnostic contribution in difficult cases. Bilateral hilar lymphadenopathy with peri-lymphatic micronodular pattern is highly specific for sarcoidosis. CT is important for the investigation of pulmonary complications, including aspergilloma and pulmonary hypertension. CT improves the yield of bronchoscopy for obtaining a positive endobronchial or transbronchial biopsy. CT findings may also discriminate between active inflammation and irreversible fibrosis, with occasional influence on therapeutic decisions. Three CT patterns of fibrotic sarcoidosis are identified, with different functional profiles: predominant bronchial distortion is associated with obstruction; honeycombing is associated with restriction and lower diffusing capacity of the lung for carbon monoxide; whereas functional impairment is relatively minor with linear pattern. The clinical impact of correlations between CT severity scores and functional impairment is uncertain, except for its utility elucidating the mechanisms of airflow limitation, which include bronchial distortion, peribronchovascular thickening, air-trapping and bronchial compression by lymphadenopathy.

High-resolution computed tomographic imaging of airways in sarcoidosis patients with airflow obstruction.

Objective: To investigate airway involvement in patients with pulmonary sarcoidosis and airflow obstruction (AO) using high-resolution computed tomography. Methods: Forty-two sarcoidosis patients with AO and 42 matched sarcoidosis patients without AO were retrospectively analyzed. High-resolution computed tomographic patterns of airway involvement were bronchial distortion, peribronchovascular thickening, small airway obstruction, and bronchial compression by enlarged lymph nodes. Results: Interobserver agreement was good (&kgr; > 0.8). High-resolution computed tomographic patterns of airway involvement were found more frequently, scored higher, and were more often multiple (P < 0.05) in patients with AO than those without. Functional improvement under treatment was observed more frequently in patients with predominant peribronchovascular thickening compared with patients with predominant bronchial distortion (P < 0.03). Conclusions: In pulmonary sarcoidosis patients with AO, high-resolution computed tomography is a reliable tool to identify underlying airways involvements, which are often multiple, and enables prediction of the therapeutic response.

Moderate exercise in hypoxia induces a greater arterial desaturation in trained than untrained men

During moderate exercise breathing a low inspired O2 fraction (FIO2), arterial O2 desaturation may depend on the fitness level. Seven trained (TM) and seven untrained men (UTM) cycled in normoxia and in hypoxia (FIO2=0.187, 0.173, 0.154, 0.13 and 0.117). We compared TM and UTM at submaximal intensities below the ventilatory threshold. Ventilatory variables were monitored and arterial oxygen saturation was measured by pulse oximetry. O2 saturation was not different between groups at sea level. In hypoxia, O2 saturation was lower in TM than in UTM at FIO2=0.154 (87.3 ± 2.9% vs 90.4 ± 1.5% at 90 W) and below. Both the ventilatory‐equivalent and the end‐tidal O2 pressure were lower in TM at sea level and at every FIO2, with the differences between TM and UTM becoming apparent at lower exercise intensity and increasing in magnitude as the severity of hypoxia increased. O2 saturation was correlated with the ventilatory parameters at every FIO2 and the correlations were stronger in severe hypoxia. These results demonstrate that a moderate exercise carried out in hypoxia, contrary to normoxic conditions, can lead to a greater arterial desaturation in TM compared with UTM. This phenomenon could be partly attributed to a relative hypoventilation in trained subjects.

Swimmers can train in hypoxia at sea level through voluntary hypoventilation.

This study used an innovative technique of pulse oximetry to investigate whether swimmers can train under hypoxic conditions through voluntary hypoventilation (VH). Ten trained subjects performed a front crawl swimming series with normal breathing (NB), VH at high (VHhigh) and low pulmonary volume (VHlow). Arterial oxygen saturation was continuously measured via pulse oximetry (SpO2) with a waterproofed forehead sensor. Gas exchanges were recorded continuously and lactate concentration ([La]) was assessed at the end of each test. In VHlow, SpO2 fell down to 87% at the end of the series whereas it remained above 94% in VHhigh during most part of the series. Ventilation, oxygen uptake and end-tidal O2 pressure were lower in both VHhigh and VHlow than in NB. Compared to NB, [La] significantly increased in VHlow and decreased in VHhigh. This study demonstrated that swimmers can train under hypoxic conditions at sea level and can accentuate the glycolytic stimulus of their training if they perform VH at low but not high pulmonary volume.

Effects of a 4-week training with voluntary hypoventilation carried out at low pulmonary volumes.

This study investigated the effects of training with voluntary hypoventilation (VH) at low pulmonary volumes. Two groups of moderately trained runners, one using hypoventilation (HYPO, n=7) and one control group (CONT, n=8), were constituted. The training consisted in performing 12 sessions of 55 min within 4 weeks. In each session, HYPO ran 24 min at 70% of maximal O(2) consumption ( [V(02max)) with a breath holding at functional residual capacity whereas CONT breathed normally. A V(02max) and a time to exhaustion test (TE) were performed before (PRE) and after (POST) the training period. There was no change in V(O2max), lactate threshold or TE in both groups at POST vs. PRE. At maximal exercise, blood lactate concentration was lower in CONT after the training period and remained unchanged in HYPO. At 90% of maximal heart rate, in HYPO only, both pH (7.36+/-0.04 vs. 7.33+/-0.06; p<0.05) and bicarbonate concentration (20.4+/-2.9 mmolL(-1) vs. 19.4+/-3.5; p<0.05) were higher at POST vs. PRE. The results of this study demonstrate that VH training did not improve endurance performance but could modify the glycolytic metabolism. The reduced exercise-induced blood acidosis in HYPO could be due to an improvement in muscle buffer capacity. This phenomenon may have a significant positive impact on anaerobic performance.

Prolonged expiration down to residual volume leads to severe arterial hypoxemia in athletes during submaximal exercise.

The goal of this study was to assess the effects of a prolonged expiration (PE) carried out down to the residual volume (RV) during a submaximal exercise and consider whether it would be worth including this respiratory technique in a training programme to evaluate its effects on performance. Ten male triathletes performed a 5-min exercise at 70% of maximal oxygen consumption in normal breathing (NB(70)) and in PE (PE(70)) down to RV. Cardiorespiratory parameters were measured continuously and an arterialized blood sampling at the earlobe was performed in the last 15s of exercise. Oxygen consumption, cardiac frequency, end-tidal and arterial carbon dioxide pressure, alveolar-arterial difference for O(2) (PA(O2) - Pa(O2)) and P(50) were significantly higher, and arterial oxygen saturation (87.4+/-3.4% versus 95.0+/-0.9%, p<0.001), alveolar (PA(O2)) or arterial oxygen pressure, pH and ventilatory equivalent were significantly lower in PE(70) than NB(70). There was no difference in blood lactate between exercise modalities. These results demonstrate that during submaximal exercise, a prolonged expiration down to RV can lead to a severe hypoxemia caused by a PA(O2) decrement (r=0.56; p<0.05), a widened PA(O2) - Pa(O2) (r=-0.85; p<0.001) and a right shift of the oxygen dissociation curve (r=-0.73; p<0.001).

Chronic beryllium disease: azathioprine as a possible alternative to corticosteroid treatment

To the Editor: Chronic beryllium disease (CBD) is a chronic granulomatous disease that mainly affects the lungs. It occurs after beryllium exposure in genetically susceptible individuals with, most commonly, the HLA-DPβ1 (Glu69) polymorphism [1]. Beryllium particles are slowly washed out, causing delayed onsets of the disease and flare ups long after exposure to beryllium [2, 3]. The clinical, radiological and pathological presentation of CBD is very similar to sarcoidosis. Thus, misdiagnosis is not uncommon, as reported by Fireman et al . [4] and Muller-quernheim et al. [5]. These authors managed to correct the diagnosis of chronic sarcoidosis to CBD in 4–6% of patients, thanks to a careful retrospective screening for beryllium exposure [4, 5]. In CBD, lungs are damaged by diffuse noncaseating granulomas and this may lead to fibrosis. The US Beryllium Case Registry determined the following specific criteria for CBD diagnosis: a beryllium exposure history; relevant clinical and radiological signs (breathlessness, reduced pulmonary capacity and diffuse interstitial opacities); evidence of beryllium sensitisation with positive beryllium lymphocyte proliferation test in blood or in bronchoalveolar lavage (BAL); and histopathological features such as noncaseating granulomas or mononuclear tissue infiltration without any infection. Long-term prognosis of CBD is poor with a mortality rate ranging from 5.8% …

Physiopathologie des pneumopathies interstitielles diffuses

Chronic interstitial lung disease (ILD) groups a number of diseases with the common feature of radiological pulmonary infiltration, typical functional syndrome, and diffuse involvement of the deep pulmonary parenchyma identified histologically. Correlations between histological and radiological findings have enabled progress in both fields, leading to better interpretation of the radiological findings and optimizing the etiological diagnosis. Besides the signs themselves, their distribution in relation to the normal lung structures is highly contributive. Function tests can be used to quantify the impact on the respiratory system and assess the effect of treatment. Evidence-based criteria will progressively replace the consensual criteria enabling more effective evaluation of treatment in difficult pathological conditions such as idiopathic pulmonary fibrosis.