Françoise Zerah-Lancner

Quantitative analysis of ciliary beating in primary ciliary dyskinesia: a pilot study

BackgroundPrimary ciliary dyskinesia (PCD) is a rare congenital respiratory disorder characterized by abnormal ciliary motility leading to chronic airway infections. Qualitative evaluation of ciliary beat pattern based on digital high-speed videomicroscopy analysis has been proposed in the diagnosis process of PCD. Although this evaluation is easy in typical cases, it becomes difficult when ciliary beating is partially maintained. We postulated that a quantitative analysis of beat pattern would improve PCD diagnosis. We compared quantitative parameters with the qualitative evaluation of ciliary beat pattern in patients in whom the diagnosis of PCD was confirmed or excluded.MethodsNasal nitric oxide measurement, nasal brushings and biopsies were performed prospectively in 34 patients with suspected PCD. In combination with qualitative analysis, 12 quantitative parameters of ciliary beat pattern were determined on high-speed videomicroscopy recordings of beating ciliated edges. The combination of ciliary ultrastructural abnormalities on transmission electron microscopy analysis with low nasal nitric oxide levels was the “gold standard” used to establish the diagnosis of PCD.ResultsThis “gold standard” excluded PCD in 15 patients (non-PCD patients), confirmed PCD in 10 patients (PCD patients) and was inconclusive in 9 patients. Among the 12 parameters, the distance traveled by the cilium tip weighted by the percentage of beating ciliated edges presented 96% sensitivity and 95% specificity. Qualitative evaluation and quantitative analysis were concordant in non-PCD patients. In 9/10 PCD patients, quantitative analysis was concordant with the “gold standard”, while the qualitative evaluation was discordant with the “gold standard” in 3/10 cases. Among the patients with an inconclusive “gold standard”, the use of quantitative parameters supported PCD diagnosis in 4/9 patients (confirmed by the identification of disease-causing mutations in one patient) and PCD exclusion in 2/9 patients.ConclusionsWhen the beat pattern is normal or virtually immotile, the qualitative evaluation is adequate to study ciliary beating in patients suspected for PCD. However, when cilia are still beating but with moderate alterations (more than 40% of patients suspected for PCD), quantitative analysis is required to precise the diagnosis and can be proposed to select patients eligible for TEM.

Airway Responsiveness Measured by Forced Oscillation Technique in Severely Obese Patients, before and after Bariatric Surgery

Background. The influence of obesity on airway responsiveness remains controversial. Objective. This study was designed to investigate airway responsiveness, airway inflammation, and the influence of sleep apnea syndrome (SAS), in severely obese subjects, before and after bariatric surgery. Methods. A total of 120 non-asthmatic obese patients were referred consecutively for pre-bariatric surgery evaluation. Lung function, airway responsiveness to methacholine, exhaled nitric oxide measurement, and sleep studies were performed. Airway hyperresponsiveness (AHR) was defined as a 50% or greater increase in respiratory resistance measured using the forced oscillation technique in response to a methacholine dose ≤2000 μg. Forced expiratory volume in 1 second (FEV1) was measured after the last methacholine dose. Airway responsiveness was reevaluated after weight loss in patients with a pre-surgery AHR. Results. AHR was found in 16 patients. The percent FEV1 decrease or percent respiratory resistance increase in response to methacholine was related to baseline expiratory airflow (forced expiratory flow at 50%) (r = 0.26, p < .006 and r = 0.315, p = .0005, respectively) but not to body mass index (BMI) or exhaled nitric oxide. Both airway responsiveness parameters were significantly related to forced expiratory flow at 25–75%/forced vital capacity, a measure of airway size relative to lung size (r = 0.27, p < .005 and r = 0.25, p < .007, respectively). Sleep apnea was not significantly associated with AHR or airway inflammation. About 11 patients with AHR were reevaluated 18 months to 2 years after surgery, with no change in AHR associated with weight loss. Conclusion. Airway responsiveness is not related to BMI or to SAS. AHR in severely obese patients might be related to distal airway obstruction or low relative airway size.

Polypectomy compared with ethmoidectomy in the treatment of nasal polyposis.

OBJECTIVE To compare the 3-year results of 2 endoscopic surgical approaches in the management of nasal polyposis. DESIGN Retrospective medical record review. SETTING Private or institutional practice. PATIENTS A total of 127 patients with nasal polyposis were operated on by the same surgeon between January 1, 2003, and September 31, 2005. INTERVENTION The patients underwent radical ethmoidectomy (n = 77) and polypectomy (n = 50). MAIN OUTCOME MEASURES Outcome measures were global functional score, calculated by summing the scores (0-3) of each symptom (congestion, rhinorrhea, anosmia, hyperreactivity, and pain); global anatomical score (GAS), calculated by summing the score of polyp development for each nasal cavity; computed tomography score; adherence to corticosteroid therapy; oral corticosteroid consumption; and complication and subsequent operation rate. Efficacy was evaluated by comparing these data preoperatively and postoperatively (at 3 months, 1 year, and 3 years). RESULTS The global functional score and GAS were significantly improved 3 years after these techniques were performed (global functional score changes from 8.65 to 3.11 for ethmoidectomy and from 8.15 to 4.2 for polypectomy; GAS, from 5.95 to 1.83 for ethmoidectomy and from 6.57 to 3.58 for polypectomy). Congestion, pain, and GAS were improved to a significantly greater extent in the ethmoidectomy group. The subsequent operation rate for symptomatic polyp recurrence was comparable (9.1% vs 8.0%), with fewer local complications in the polypectomy group. CONCLUSION Polypectomy seems to represent a valuable alternative in the armamentarium of first-hand surgical procedures for treating nasal polyposis.

Offline exhaled nitric oxide in emergency department and subsequent acute asthma control.

Background. Few studies have evaluated exhaled NO measurement during acute asthma. Objectives. To evaluate exhaled NO fraction (FENO) and peak expiratory flow (PEF) time-courses during acute asthma treatment (β 2-agonist plus systemic steroid) and to assess whether FENO time-course predicts subsequent asthma control. Methods. Sixty-five asthmatic patients (mean ± SD, 34 ± 10 years) were prospectively enrolled in three Emergency Departments. Results. Sixteen patients were excluded (failure of offline FENO measurement at 100 mL/s [FENO 0.1], n = 4, and early discharge). The 49 remaining patients performed FENO 0.1 and PEF on admission, at the 2nd (H2) and 6th hour (H6). Follow-up using an Asthma Control Diary was obtained in 27 of 49 patients, whether they were hospitalized (n = 9) or discharged (n = 18). All but 2 patients had elevated FENO on admission (median [interquartile], 49 [26–78] ppb). Unlike PEF, mean FENO 0.1 of our sample was not significantly modified by treatment. No significant relationship was evidenced between exhaled NO and PEF variations. The variation of FENO 0.1 [H0 minus H6] was different in patients who were hospitalized (decrease of 8 ± 20 ppb) versus discharged (increase of 5 ± 20 ppb, p = 0.04). This variation of FENO 0.1 was correlated with the Diary score (control of subsequent week), an initial increase in FENO 0.1 being associated with better asthma control. Nevertheless, neither exhaled NO nor PEFR were good predictors of asthma control. Conclusions. An increase in FENO is observed in almost all patients with acute asthma, and its subsequent increase within 6 hours is associated with a better degree of asthma control in the subsequent week.

A functional tool to differentiate nasal valve collapse from other causes of nasal obstruction: the FRIED test

Nasal valve collapse is a dynamic abnormality that is currently diagnosed purely on the basis of clinical features and thus subject to certain interpretation. The aim of this study was to develop a new and reliable functional test to objectively characterize nasal valve collapse. This was an observational prospective study including consecutive patients referred to our center for exploration of chronic nasal congestion. The patients were classified into two groups according to their symptoms and clinical abnormalities: the nasal valve collapse (NV+) group when nasal valve collapse was clinically detected during moderate forced inspiration and/or when the feeling of nasal congestion improved during passive nasal lateral cartilage abduction (n = 32); and the no-nasal valve collapse (NV-) group for the others (n = 23). All patients underwent nasal functional tests (posterior rhinomanometry and acoustic rhinometry) before and after topical nasal decongestion. We compared the difference between the pressure flow of the inspiratory and expiratory phases during posterior rhinomanometry [flow rate inspiratory-expiratory difference (FRIED) test] between the two groups. The difference between the absolute value of inspiratory and expiratory flow was significantly higher in the NV+ group than in the NV- group both before and after topical decongestion. The cutoff value for the FRIED test was -0.008 l/s with a good sensitivity (82%) and a specificity of 59%. We suggest that the FRIED test constitutes an objective and easy-to-apply technique to diagnose nasal valve collapse in daily practice.

Investigating hyperventilation syndrome in patients suffering from empty nose syndrome

Patients with empty nose syndrome (ENS) following turbinate surgery often complain about breathing difficulties. We set out to determine if dyspnea in patients with ENS was associated with hyperventilation syndrome (HVS). We hypothesized that lower airway symptoms in ENS could be explained by HVS.