J.-F. Muir

Ventilation à domicile chez les patients atteints de bronchopneumopathie chronique obstructive (BPCO)

Resume Introduction La bronchopneumopathie chronique obstructive (BPCO) est un motif croissant d’indication a la ventilation a domicile (VAD) souvent par une ventilation non invasive (VNI). Cette revue generale a pour objectif de detailler les elements physiopathologiques et les resultats des etudes cliniques qui etayent aujourd’hui les recommandations des societes savantes internationales. Etat des connaissances Les etudes publiees ne sont pas toujours controlees, sont souvent de trop courte duree ou grevees d’aleas methodologiques importants. Les deux etudes controlees et de duree ≥ 12 mois sont concordantes pour suggerer que la VNI n’ameliore pas la survie. En consequence, une VAD peut etre envisagee en situation d’echec de l’oxygenotherapie de longue duree, dans un contexte d’aggravation progressive de l’etat clinique et respiratoire et la survenue de frequents episodes d’insuffisance respiratoire aigue hypercapnique. La presence d’une hypercapnie diurne ≥ 55 mmHg (7,3 kPa) est une condition necessaire mais non suffisante pour indiquer ce traitement. Conclusion La VAD ne doit etre envisagee que chez des patients selectionnes, pour lesquels la symptomatologie clinique et la frequence des exacerbations doivent etre pris en compte. Dans l’attente d’une caracterisation des patients repondeurs, une re-evaluation reguliere du traitement est necessaire au decours.

Traduction française et adaptation culturelle du questionnaire SRI. Questionnaire de qualité de vie liée à la santé des patients insuffisants respiratoires chroniques traités par ventilation à domicile

INTRODUCTION We performed the French translation and cross-cultural adaptation of the Severe Respiratory Insufficiency (SRI) questionnaire. Written and validated in German, this questionnaire evaluates health-related quality of life in patients treated with domiciliary ventilation for chronic respiratory failure. METHODS Four bilingual German-French translators and a linguist were recruited to produce translations and back-translations of the questionnaire constituted of 49 items in seven domains. Two successive versions were generated and compared to the original questionnaire. The difficulty of the translation and the naturalness were quantified for each item using a 1-10 scale and their equivalence to their original counterpart was graded from A to C. The translated questionnaire was finally tested in a pilot study, which included 15 representative patients. RESULTS The difficulty of the first translation and the first back-translation was respectively quantified as 2.5 (range 1-5.5) and 1.5 (range 1-6) on the 10-point scale (P=0.0014). The naturalness and the equivalence of 8/49 items were considered as insufficient, which led to the production of a second translation and a second back-translation. The meanings of two items needed clarification during the pilot study. CONCLUSION The French translation of the SRI questionnaire represents a new instrument for clinical research in patients treated with domiciliary ventilation for chronic respiratory failure. Its validity needs to be tested in a multicenter study.

Article originalTraduction française et adaptation culturelle du questionnaire SRI. Questionnaire de qualité de vie liée à la santé des patients insuffisants respiratoires chroniques traités par ventilation à domicileThe French translation and cultural adaptation of the SRI questionnaire. A questionnaire to assess health-related quality of life in patients with chronic respiratory failure and domiciliary ventilation☆

INTRODUCTION We performed the French translation and cross-cultural adaptation of the Severe Respiratory Insufficiency (SRI) questionnaire. Written and validated in German, this questionnaire evaluates health-related quality of life in patients treated with domiciliary ventilation for chronic respiratory failure. METHODS Four bilingual German-French translators and a linguist were recruited to produce translations and back-translations of the questionnaire constituted of 49 items in seven domains. Two successive versions were generated and compared to the original questionnaire. The difficulty of the translation and the naturalness were quantified for each item using a 1-10 scale and their equivalence to their original counterpart was graded from A to C. The translated questionnaire was finally tested in a pilot study, which included 15 representative patients. RESULTS The difficulty of the first translation and the first back-translation was respectively quantified as 2.5 (range 1-5.5) and 1.5 (range 1-6) on the 10-point scale (P=0.0014). The naturalness and the equivalence of 8/49 items were considered as insufficient, which led to the production of a second translation and a second back-translation. The meanings of two items needed clarification during the pilot study. CONCLUSION The French translation of the SRI questionnaire represents a new instrument for clinical research in patients treated with domiciliary ventilation for chronic respiratory failure. Its validity needs to be tested in a multicenter study.

Cohorte nationale de patients emphysémateux et déficitaires en alpha-1 antitrypsine

Matériels et méthodes Il s’agit d’une étude de cohorte prospective multicentrique, incluant tous les patients en France métropolitaine, présentant un déficit en alpha-1 antitrypsine associé à un emphysème (diagnostic au TDM) et à un trouble ventilatoire obstructif. Tous les pneumologues seront sollicités. Les patients répondant aux critères d’inclusion seront suivis tous les 6 mois pendant 5 ans. Des données cliniques, spirométriques, ainsi que des données relatives à la qualité de vie et à la prise en charge thérapeutique des patients seront recueillies. Le critère de jugement principal sera le VEMS. Les critères de jugement secondaires seront : la qualité de vie, les exacerbations nécessitant une hospitalisation et la mortalité.

Consequences of atmospheric pollution fluctuations in patients with COPD

INTRODUCTION Fluctuations in atmospheric pollution are responsible for an important morbidity and mortality in the patients suffering from chronic obstructive pulmonary disease (COPD). BACKGROUND Epidemiological studies show a significant increase in the mortality and hospitalization rates in COPD patients in relation to moderate increases in atmospheric pollution. In vitro and in vivo studies demonstrate a pro-inflammatory role and an oxidative toxicity of atmospheric particles and secondary morphological and functional changes in the respiratory epithelium and the immune system. An excess of particulate matter, ozone, NO(2), SO(2) and CO is directly correlated to the number of episodes of acute respiratory failure in different countries all over the world. The mechanisms implicated are complex and variable, dependent on the different pollutant agents, climatic variations and inter-individual susceptibility. VIEWPOINT Further experimental studies are necessary in order to clarify our fundamental understanding and, alongside better control of air quality, to reduce short-term respiratory complications. CONCLUSION The consequences of atmospheric pollution fluctuations on the exacerbation rate and therefore on the morbidity and mortality of patients with COPD emphasize the importance of preventive environmental management in the field of public health.

Ventilation non invasive : efficacité d’un nouveau mode ventilatoire chez les patients atteints du syndrome obésité-hypoventilation

Noninvasive ventilation is recommended to correct the nocturnal hypoventilation and relieve the symptoms of patients with the obesity-hypoventilation syndrome (OHS). The benefits of fixed pressure ventilation (S/T technology) are recognized but limited on account of the variability of nocturnal ventilatory requirements. The new technique AVAPS-AE (automatic EPAP) allows adjustment of the pressure according to the volume currently targeted. Its efficacy has not yet been evaluated. Our objectives are to evaluate firstly, whether AVAPS-AE optimizes the benefits of S/T technology on sleep architecture and quality, secondly, whether these benefits are associated with an improvement in gas exchange, symptoms, exercise tolerance, level of physical activity and quality of life of patients with OHS. In this multicenter trial, 60 newly diagnosed patients with OHS will be randomized to the control (S/T) and trial (AVAPS-AE) groups. A standardized titration procedure will be followed for the calibration of the ventilators. Functional evaluations (polysomnography, blood gases, impedance measurements and walking tests), questionnaires (physical activity, quality of life, quality of sleep and daytime somnolence) visual scales (fatigue, headaches) and a recording of activity will be undertaken after two months of ventilation.

Place de la trachéotomie au long cours dans l’insuffisance respiratoire chronique sévère à l’ère de la ventilation non invasive

INTRODUCTION At a time when non-invasive ventilation (NIV) is commonly used in acute as well as chronic respiratory failure, it is important to consider the current place, if any, of long-term tracheostomy. BACKGROUND Except in emergency situations where tracheostomy is mandatory to ensure safe access to the airway, long-term ventilation with tracheostomy (LTVT) is generally considered in the case of inability to wean from NIV after an episode of acute respiratory failure requiring endotracheal ventilation or because of the development of bulbar signs (swallowing, phonation) in advanced neuromuscular disease. It is also appropriate when ventilatory dependence on NIV exceeds 20 hours per day. Historical retrospective studies confirmed the feasibility of LTVT, but this has to be seen in perspective with the results obtained 20 years later with NIV. VIEWPOINT AND CONCLUSION Even if the indications for LTVT have diminished considerably since the emergence of NIV, tracheostomy remains mandatory in some situations of respiratory distress and it should be considered as a potential resource, possibly temporary in some cases in the light of recent work on the possibility of decanulation after LTVT.

Ventilation non invasive au cours de la réhabilitation respiratoire des patients atteints de BPCO

INTRODUCTION Pulmonary rehabilitation is currently the gold standard treatment for patients with chronic obstructive pulmonary disease (COPD). However, the workload achieved may be insufficient to obtain physiological benefits because of the restricted respiratory capacity. BACKGROUND In patients with COPD, changes in flow as well as biomechanical factors (distension) compromise respiratory adaptation to exertion. Some studies have shown that noninvasive ventilation (NIV) during exercise has a positive effect on respiratory muscle workload, physiological parameters and perceived exertion. However the evidence remains insufficient regarding the effects of the NIV during comprehensive pulmonary rehabilitation programs. OBJECTIVES The identification of criteria which determine responsive patients is necessary in order to reduce human and time costs and to optimize the use of NIV during exercise. CONCLUSIONS NIV is used during training to overcome dyspnoea and to increase muscle workload. Further studies are needed to verify the effectiveness of NIV in pulmonary rehabilitation.

Comment ventiler un patient atteint de maladie neuromusculaire

Resume Le reglage des ventilateurs doit tenir compte des mecanismes responsables de l’hypoventilation alveolaire chez les patients neuromusculaires. Ces mecanismes sont une insuffisance musculaire inspiratoire, une augmentation des resistances des voies aeriennes superieures et une baisse de la commande centrale. Le mode de ventilation preferentiel est le mode barometrique relaye par le mode volumetrique aux stades avances, au cours desquels la tracheotomie est frequemment realisee. Les logiciels des ventilateurs permettent une surveillance et une adaptation efficace du traitement. La kinesitherapie instrumentale est indissociable de la ventilation non invasive.

Indications de la VNI dans les maladies neuromusculaires

Resume Desormais, la mise en route de la VNI dans les pathologies neuromusculaires est anticipee, grâce a la connaissance de l’histoire naturelle de chaque maladie. Toutes les MNM ayant un tropisme sur les muscles respiratoires peuvent etre concernees par la VNI. Les criteres de VNI ont ete etablis lors de la conference de consensus de 1999, cependant, il faut savoir nuancer selon les etiologies. Le role de la VNI est primordial puisque l’insuffisance respiratoire est la principale cause de morbimortalite dans les MNM. La survie a ete considerablement amelioree, en particulier dans la dystrophie de Duchenne.