Clinical standards for diagnosis, treatment and prevention of post-COVID-19 lung disease

BACKGROUND: The aim of these clinical standards is to provide guidance on 'best practice' care for the diagnosis, treatment and prevention of post-COVID-19 lung disease.METHODS: A panel of international experts representing scientific societies, associations and groups active in post-COVID-19 lung disease was identified; 45 completed a Delphi process. A 5-point Likert scale indicated level of agreement with the draft standards. The final version was approved by consensus (with 100% agreement).RESULTS: Four clinical standards were agreed for patients with a previous history of COVID-19: Standard 1, Patients with sequelae not explained by an alternative diagnosis should be evaluated for possible post-COVID-19 lung disease; Standard 2, Patients with lung function impairment, reduced exercise tolerance, reduced quality of life (QoL) or other relevant signs or ongoing symptoms ≥4 weeks after the onset of first symptoms should be evaluated for treatment and pulmonary rehabilitation (PR); Standard 3, The PR programme should be based on feasibility, effectiveness and cost-effectiveness criteria, organised according to local health services and tailored to an individual patient's needs; and Standard 4, Each patient undergoing and completing PR should be evaluated to determine its effectiveness and have access to a counselling/health education session.CONCLUSION: This is the first consensus-based set of clinical standards for the diagnosis, treatment and prevention of post-COVID-19 lung disease. Our aim is to improve patient care and QoL by guiding clinicians, programme managers and public health officers in planning and implementing a PR programme to manage post-COVID-19 lung disease.

Cardiovascular and Venous Thromboembolic Events After Hospital Discharge for COVID-19: A Prospective Single Center Study

Coronavirus disease 2019 (COVID-19) is associated with an increase in venous thrombotic and cardiovascular (CV) events has been reported during hospitalization. No systematic ultrasound follow-up to evaluate sequelae was ever that took place carried out prospectively associated with the evaluation of CV morbidity-mortality at 3 months post-discharge. Consecutive patients hospitalized for COVID-19 in the Amiens-Picardie University Hospital between 1st February and 31st August 2020 were included. The primary objective was the thrombosis incidence at 3 months after hospital discharge. Thrombosis was defined as either venous thromboembolism (VTE) or a CV event (CVE: myocardial infarction (MI), stroke or peripheral arterial disease). A secondary objective was to determine the risk factors for thrombotic events. We included 498 patients (279 men; 56%) of median age 66 (55-76) years. The primary composite outcome occurred in 27 patients (5.4%); 19 patients (3.8%) presented a CVE (stroke, n = 5; MI, n = 9; and peripheral arterial disease, n = 5). Two patients (0.8%) presented VTE. Six patients (1.2%) died. In multivariate analysis, a previous CVE was associated with thrombosis (OR 3.11; 95% CI 1.17-8.24). COVID-19 was significantly associated with thrombotic events post hospital discharge. Special attention should be given to CVE in the follow-up of patients with a previous thrombotic event.

Amikacin Liposomal Inhalation Suspension (ALIS) in the treatment of Mycobacterium abscessus lung infection: a French observational experience

Background

Mycobacterium abscessus infections remain difficult to manage in both cystic fibrosis (CF) and non-CF patients and reported clinical outcomes are largely unsatisfactory. Clinical trial data are limited and no approved therapies are currently available for the management of M abscessus lung diseases. As an alternative, cohort studies may provide insightful information into the management of M abscessus pulmonary disease.

Methods

Based on a retrospective observational cohort study, we investigated the safety and efficacy of amikacin liposome inhaled suspension (ALIS) as an adjunct to a standard antibiotic regimen for M abscessus lung infection in both CF and non-CF patients. We also assessed the association of patient drug compliance with culture conversion and clinical outcomes.

Results

Twenty-six patients had long-term follow-up data available. Culture conversion was achieved in 54% (14/26) of the patients with no difference between CF and non-CF patients after an average treatment duration of 10 months. Patient treatment compliance was significantly better in the converter group compared to nonconverters with an odds ratio of 44.78 associated with good compared to poor patient compliance. Overall, 9 patients (35%) experienced an adverse event that led to treatment discontinuation.

Conclusions

ALIS appears beneficial in both CF and non-CF populations with M abscessus lung disease.

Infection grave à SARS-CoV-2 : évolution du profil des patients admis en réanimation entre les deux premières vagues

Introduction

Méthodes

Résultats

Conclusion

Impact de la corticothérapie systémique sur les séquelles respiratoires des infections à SARS-CoV-2

Introduction

Depuis 2019, l’épidémie de COVID-19 (infection à SARS-CoV-2) est responsable de 4 millions de décès dans le monde. Il n’existe, à ce jour, aucun traitement spécifique. La corticothérapie fait partie, depuis octobre 2020, du standard of care, suite à la publication de plusieurs études (dont la cohorte RECOVERY, NEJM 2020) montrant une amélioration significative de la survie lorsqu’elle est utilisée à la phase aiguë des pneumopathies hypoxémiantes. Cependant, peu de données sont disponibles concernant son impact sur l’atteinte résiduelle. Notre étude a donc cherché à savoir si le recours aux corticoïdes à la phase aiguë des infections à SARS-CoV-2 réduit la survenue de séquelles respiratoires à 3 mois, 6 mois et 1 an.

Méthodes

Il s’agit d’une étude observationnelle, rétrospective, réalisée au CHU d’Amiens entre mars et octobre 2020 concernant les patients ayant été hospitalisés dans une unité COVID. Ces patients étaient convoqués à 3 mois pour la réalisation d’un examen clinique, d’un scanner thoracique, d’explorations fonctionnelles respiratoires et d’un test de marche de 6 minutes. L’évaluation à 6 mois et 12 mois étaient optionnelles.

Résultats

Trois cent neuf patients ont été inclus. Parmi eux, 74 patients (23,9 %) avaient reçu une corticothérapie. À 3 mois, les patients ayant reçu une corticothérapie présentaient significativement plus de lésions en verre dépoli et une atteinte radiologique plus étendue ; ce qui n’était plus le cas à 6 mois et à 1 an. Il n’y avait pas de différence significative concernant les séquelles fonctionnelles à 3 mois comme sur le plus long terme.

Conclusion

Les patients ayant reçu une corticothérapie étaient peu nombreux et les plus graves, issus de la « première vague », ce qui peut expliquer les différences retrouvées lors de l’évaluation à 3 mois. Les séquelles respiratoires à 6 mois et 1 an semblent moins importantes dans le groupe ayant reçu une corticothérapie, mais le nombre de patients est insuffisant pour conclure. Cette étude n’a pas permis de mettre en évidence de différence significative à long terme entre les patients ayant reçu ou non une corticothérapie. Il semble nécessaire de poursuivre cette étude en appariant les patients sur la gravité initiale.

Évaluation à 3 mois du retentissement de l’infection par le SARS CoV-2 sur la fonction thyroïdienne

Les infections virales peuvent induire des thyroïdites subaiguës ou un syndrome de “basse T3” central ou périphérique pour les formes sévères.

Objectifs

Évaluer la fonction thyroïdienne 3 mois après une hospitalisation pour COVID-19 au CHU d’Amiens. Comparer -les taux de TSH, T4L, T3L à 3 mois chez les patients de réanimation vs unités COVID -les taux à 3 mois (M3) aux taux initiaux disponibles (M0)

Méthodes

Dosage prospectif lors de la consultation de suivi de l’étude “SARS-COv-2SeqCov” proposée aux 467 patients hospitalises entre février et juin 2020.

Résultats

Le bilan a été réalisé chez 141 patients ; ont été exclus ceux aux antécédents thyroïdiens. La TSH médiane était de 1,80 mUI/L [1,33–2,37], la T4L et la T3L médiane de 13,6[12,38–15,20] et 4,23 [4–4,88]pmol/l. 5 patients (4,1 %) avaient une hypothyroïdie fruste. Il n’y avait pas de différence significative entre les patients survivants de réanimation (1,66 mUI/L [1,29–2,08] ; n = 44) vs unités COVID (1,79 mUI/L [1,33–2,37] ;n = 70). Le seul facteur intercurrent M0–M3 (produits de contraste, corticoïdes, amiodarone) influençant significativement la TSH était l’amiodarone : 2,1 [2,05–5,92] vs 1,7 mUI/L [1,33–2,29], (p = 0,038).

La TSH M3 était plus élevée qu’à M0 (n = 34) : 1,49 [1,22–1,81] mUI/L vs 1,03 [0,66–1,81], p = 0,041.

Conclusion

Aucune thyroïdite subaiguë clinique n’a été observée mais les 5 hypothyroïdies frustes peuvent suggérer une thyroïdite paucisymptomatique initiale. La TSH médiane plus élevée à 3 mois laisse suggérer la récupération d’un syndrome de basse T3 central en phase infectieuse aiguë.

[SARS-CoV-2 infection: Available data on 15th April 2021]

INTRODUCTION

Since January 2020, when the first cases of SARS-CoV-2 infection were diagnosed in France, pulmonologists have been at the heart of the crisis and should be responsible for the management of acute COVID-19 (and any possible sequelae) BACKGROUND: Many drugs have been evaluated or are currently under evaluation as possible specific treatment for SARS-CoV-2. Nevertheless, as of April 15, 2021, the only recommended treatment in current practice is the "standard of care", i.e. the symptomatic management of infection with SARS-CoV-2. This review presents the state of knowledge on COVID-19 in the acute phase (virological, immunological, epidemiological and therapeutic data) available on 15th April, 2021.

OUTLOOK

A large number of clinical trials are currently ongoing. It is important to propose to patients the opportunity to participate in clinical trials and to structure the research in order to complete the studies.

CONCLUSION

Current management is based on oxygen therapy, thromboprophylaxis and in some cases corticosteroids. No antiviral therapy is currently recommended. These data are constantly evolving.

[Guide for management of patients with possible respiratory sequelae after a SARS-CoV-2 pneumonia. Support proposals developed by the French-speaking Respiratory Medicine Society. Version of 10 November 2020]

La Société de Pneumologie de Langue Française (SPLF) propose un guide pour la prise en charge thérapeutique des patients ayant d’éventuelles séquelles respiratoires après avoir présenté une pneumonie à SARS-CoV-2 (COVID-19). Les propositions s’appuient sur les données connues des précédentes épidémies, les données préliminaires publiées sur le suivi après COVID-19 et les avis d’experts. Les propositions ont été élaborées par un groupe d’experts puis soumises selon la méthode Delphi à un panel composé de 22 pneumologues. Dix-sept propositions ont été validées, qui vont des examens complémentaires à réaliser après le bilan minimal proposé dans le guide de suivi de la SPLF à la place de la corticothérapie inhalée ou systémique et des médicaments antifibrosants. Ces propositions pourront évoluer dans le temps au fil des connaissances sur le sujet. Ce guide insiste sur l’importance de la discussion multidisciplinaire.

Correlation between the Epworth Sleepiness Scale and the Maintenance of Wakefulness Test in Obstructive Sleep Apnea Patients Treated with Positive Airway Pressure

BACKGROUND

The Epworth sleepiness scale (ESS) is often used to evaluate the impact of treatment in patients with obstructive sleep apnea hypopnea syndrome (OSA). We aimed to evaluate the correlation between ESS and the Maintenance of Wakefulness Test (MWT) in a population of OSA patients treated with positive airway pressure (PAP).

METHODS

We retrospectively included all patients during a 2-year period who were diagnosed with OSA in our sleep clinic and required PAP therapy. ESS was evaluated at baseline and after PAP therapy for all patients, and all had a concomitant MWT. Correlation between final ESS, change in ESS, and MWT were evaluated using Spearman's correlation. Given that MWT is considered as the gold standard, the diagnostic performance of ESS was evaluated against MWT.

RESULTS

Hundred thirty-four OSA patients were included. At the time of MWT, 89.6% of the patients were compliant (PAP use ≥4hours/night), and only 9 (6.7%) had persistent sleepiness despite PAP treatment (mean sleep latency at MWT<19.4min). Moderate correlation was observed between final ESS and MWT (Spearman's correlation coefficient=-0.42), but no correlation was found between change in ESS and MWT. Diagnostic performance was as follows for final ESS: sensitivity=55.6%, specificity=84.8%, PPV=20.8%, and NPV=96.4%.

CONCLUSIONS

ESS was moderately correlated with MWT in a population of OSA patients compliant with PAP therapy. In this population, ESS showed poor diagnostic performance in identifying patients with persistent excessive daytime sleepiness. CLINICALTRIALS.

GOV IDENTIFIER

NCT03629834.

Multidisciplinary advisory teams to manage multidrug-resistant tuberculosis: the example of the French Consilium

SETTING: The World Health Organization (WHO) recommends that multidrug-resistant tuberculosis (MDR-TB) treatment should be managed in collaboration with multidisciplinary advisory committees (consilia). A formal national Consilium has been established in France since 2005 to provide a centralised advisory service for clinicians managing MDR-TB and extensively drug-resistant (XDR-TB) cases.OBJECTIVE: Review the activity of the French TB Consilium since its establishment.DESIGN: Retrospective description and analysis of the activity of the French TB Consilium.RESULTS: Between 2005 and 2016, 786 TB cases or contacts of TB cases were presented at the French TB Consilium, including respectively 42% and 79% of all the MDR-TB and XDR-TB cases notified in France during this period. Treatment regimens including bedaquiline and/or delamanid were recommended for 42% of the cases presented at the French TB Consilium since 2009. Patients were more likely to be presented at the French TB Consilium if they were born in the WHO Europe Region, had XDR-TB, were diagnosed in the Paris region, or had resistance to additional drugs than those defining XDR-TB.CONCLUSION: The French TB Consilium helped supervise appropriate management of MDR/XDR-TB cases and facilitated implementation of new drugs for MDR/XDR-TB treatment.

[Risks associated with the use of non-steroidal anti-inflammatory drugs during pneumonia]

INTRODUCTION

Outpatient treatment of community-acquired pneumonia (CAP) patients with non-steroidal anti-inflammatory drugs (NSAIDs) is frequent, although this is not based on clinical recommendations and there is no scientific evidence supporting better symptom relief in comparison to acetaminophen.

STATE OF THE ART

Experimental data suggest that NSAIDs alter the intrinsic functions of neutrophils, limit their locoregional recruitment, alter bacterial clearance and delay the resolution of inflammatory processes during acute bacterial pulmonary challenge. In hospitalized children and adults with CAP, observational data suggest a strong and independent association between the outpatient exposure to NSAIDs and the occurrence of pleuropulmonary complications (pleural empyema, excavation, and abscess). In the only study taking into account possible protopathic bias, the association still persists. Other markers of morbidity have been described, including delay in hospital management, prolonged antibiotic therapy, and higher transfer rate to an intensive care unit.

PERSPECTIVES

Data describing the role of self-medication and the biological mechanisms involved are needed.

CONCLUSIONS

Intake of NSAIDs during outpatient treatment of CAP is probably the second modifiable factor of morbidity after inadequate antibiotic therapy. In light of existing data in children and adults, health authorities should urgently reassess the risk-benefit ratio of NSAIDS in CAP.

[Endobronchial ultrasound with transbronchial needle aspiration: Evaluation of clinical practice]

INTRODUCTION

Endobronchial ultrasound with transbronchial needle aspiration (EBUS-TBNA) has undergone a large increase in France since 2007. The aim is to study the evolution of the indications for EBUS-TBNA in our region during the period 2008-2013.

MATERIAL AND METHODS

We conducted a retrospective observational study including all the patients who underwent an EBUS-TBNA procedure in Picardie from 2008 to 2013. The respective proportion for each indication was noted.

RESULTS

During the study period, 1036 EBUS-TBNA procedures were performed with a continuous increase in number (86 in 2008 versus 275 in 2013). We observed an increase in the proportion of procedures performed for a suspected diagnosis of sarcoidosis (OR=1.31; IC 95% [1.09-1.58]; P=0.005) and for the simultaneous diagnosis and staging of lung cancer (OR=1.12; IC 95% [1.02-1.24]; P=0.022). For the diagnosis of sarcoidosis, we observed an improvement in the diagnostic yield between the periods [2008-2010] and [2011-2013] (42.9% versus 72.5%).

CONCLUSION

A continuous increase in the number of EBUS-TBNA procedures was observed during the period 2008-2013. It was associated with a modification in practice with an increased proportion of procedures performed for the diagnosis of sarcoidosis.

[Mediastinitis after endobronchial ultrasound-guided transbronchial needle aspiration]

INTRODUCTION

Endobronchial ultrasound guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive procedure used for the diagnosis of mediastinal and hilar lymphadenopathy.

OBSERVATION

We describe a case of mediastinitis appearing 15 days after an EBUS-TBNA procedure in a 79 years old male patient. The mediastinitis was treated surgically by thoracotomy with a wide excision of infected tissue requiring transplantation of a serratus anterior muscle flap pedicled on a branch of the thoracodorsal artery. It was coupled with broad spectrum antibiotics. This medico-surgical management led to a favorable outcome. Microbiological analysis of the mediastinal collections revealed two pathogens: Streptococcus constellatus (a germ present in the normal flora of the oral cavity) and Mycobacterium tuberculosis. A standard first line quadruple antituberculous drug regimen was subsequently given to the patient.

CONCLUSION

This episode of Streptococcus constellatus mediastinitis was a complication of the EBUS-TBNA procedure. The operating channel of the bronchoscope had probably been contaminated when aspirating the oral cavity secretions with subsequent needle contamination and a direct bacterial inoculation during the transbronchial mediastinal puncture. The severity of such a complication justifies a medical consultation in cases of fever or chest pain following an EBUS-TBNA procedure.

Factors associated with delayed screening of contacts of tuberculosis cases in the Somme, France

AIM

To analyze the factors associated with the time to initiating tuberculosis contact investigations in the Somme department, France.

METHODS

All reported tuberculosis cases and all their contacts screened between 2007 and 2011 were retrospectively included. Univariate and multivariate analyses were conducted to determine the factors associated with a "system delay"≤1 month and a "contact delay"≤0 days.

RESULTS

The mean time between the mandatory notification of a case of tuberculosis and the date set for the contact's screening (system delay) was 35.3 days and the average time between that date and when the contact was actually screened (contact delay) was 12.5 days. In multivariate analysis, a smear-positive sputum sample (OR: 3.68; 95% CI: 1.63-8.30) and a diagnosis at the university hospital (OR: 2.61; 95% CI: 1.14-5.96) were significantly associated with a system delay≤1 month. A smear-positive sputum sample (OR: 1.35; 95% CI: 1.08-1.69), male gender (OR: 1.21; 95% CI: 1.01-1.49), being born in a foreign country (OR: 1.31; 95% CI: 1.02-1.69), being a family member (OR: 1.37; 95% CI: 1.05-1.77), or being another type of close contact of the case (OR: 2.47; 95% CI: 1.81-3.36) were significantly associated with a contact delay≤0 days.

CONCLUSION

System and contact delays were longer than recommended, and the factors associated with the lengthening of these delays need to be taken into account.

[Results of endobronchial ultrasound-guided transbronchial needle aspiration in lung cancer: importance of the lymph node involvement prevalence]

OBJECTIVE

We studied the non-surgical invasive staging by endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) and we detailed the differences of our series, in order to understand the criteria allowing to achieve a better performance.

METHODS

Retrospective observational study conducted between 2007 and 2011, including all patients with proven NSCLC who underwent EBUS-TBNA.

RESULTS

For the 92 EBUS-TBNA performed, we found a sensitivity of 78%, a specificity of 93%, a positive predictive value (PPV) of 98%, a negative predictive value (NPV) of 45%, an accuracy of 80% and a prevalence of lymph node involvement at 84%. A learning curve has been demonstrated and a significant difference was found based on the number of punctures by procedure (P=0.02) or on histological type (P=0.02). By analyzing the data of the literature, we have been able to demonstrate that the accuracy and the negative predictive value are correlated with the prevalence. If we take into account this correlation, we can consider the results of our study close to those of the literature.

CONCLUSION

We highlighted a number of criteria that will influence the diagnostic yield of EBUS-TBNA. While some have already been described, other criteria such as histological type or patient selection criteria are less discussed. The key point is the correlation between the prevalence and EBUS-TBNA results. Results of the assessment of lymph node involvement techniques should be interpreted according to the prevalence of lymph node involvement.

Antiretroviral therapy in intensive care

Using antiretroviral therapy (ART) raises numerous issues in intensive care units (ICU): drug administration and kinetics issues in ventilated patients and/or with gastric tube, drug interactions, and risk of immune reconstitution inflammatory syndrome. This is why a lot of ICU physicians stop ART on admission and few initiate it during the ICU stay. However, the literature review suggests that the earlier the ART is started the more effective it is. Furthermore, stopping ART could be hazardous for some patients. The authors present the most frequent issues raised by ART use in an ICU and how to deal with them.

[Lymph node tuberculosis treatment: from recommendations to practice]

PURPOSE

Lymph node infection is the most frequent localization of extrapulmonary tuberculosis. However, there is still no consensus on the length of antimicrobial treatment.

METHODS

We conducted a retrospective study in the Department of infectious diseases and internal medicine in the Amiens Teaching Hospital, France. All patients diagnosed with lymph node tuberculosis between 1998 and 2007 were included; some patients presented with bi- or multifocal tuberculosis. The aim of the study was a practice analysis.

RESULTS

We studied 48 medical records, 16 were excluded for lack of more than 40% of data or because lymph node tuberculosis was non-active. The mean age of the 32 patients included was 49 years. The mean duration of treatment was 10.9 months (standard deviation 2.6, median 11, range 6-18). There was no statistical age difference between subgroups (lymph node tuberculosis versus multifocal tuberculosis). There was no significant difference between the 6-month treatment group and the 9-month treatment group in term of clinical response. One relapse was diagnosed, eight patients (25%) were lost to follow-up at 1 year after treatment. DISCUSSION AND REVIEW: No reliable published data was found as to the optimal duration of treatment. A high quality clinical trial should be carried out to suggest a consensus.