Jean-François Muir

Long-term oxygen therapy (LTOT) is indicated in stage-IV COPD. It increases survival when used 24h/24, ideally, and at least 15h/24. There is no indication for prescribing nocturnal oxygen therapy without de LTOT. Ambulatory oxygen therapy is indicated in patients with COPD who benefit from LTOT in case of significant exercise-induced desaturation. In that regard, recent technologies allow to provide patients with small-size, stand-alone and portable oxygen units. Non-invasive ventilation (NIV) is a type of mechanical ventilation administered through a mouthpiece, a nasal mask or a facial mask. It should not be confused with continuous positive airway pressure (CPAP), indicated in the treatment of obstructive sleep apnea, which does not improve alveolar ventilation in hypercapnic patients. In patients with COPD, long-term NIV does not provide any benefits in terms of survival instead, it improves arterial gasometry, clinical symptoms, quality of life and the frequency of severe exacerbations.

Respiratory failure frequently complicates the care of elderly patients with or without chronic lung disease. Recent advances in techniques and applications of noninvasive ventilation provide an exceedingly useful means of managing respiratory compromise, and the clinical utilization of noninvasive mechanical ventilation has transformed the prognosis of acute and chronic respiratory failure in this age group. The majority of elderly patients can recover from an acute respiratory failure episode if adequate support is provided, although some may require long-term ventilatory assistance. Such assistance may be provided in the home setting if an adequate support system is available. As the size of the elderly population grows, an increased number of elderly patients with multifactorial respiratory failure will undoubtedly require episodic or sustained ventilatory assistance, and noninvasive ventilation can be provided for various forms of acute and chronic respiratory failure, including advanced chronic obstructive pulmonary disease, other parenchymal lung disease, and chest wall deformities. Health care organizations must incorporate long-term care facilities with ventilatory support capabilities into their health management strategies.

In a medical context, it is important to precise if the pleurisy is associated with signs of tamponnade, and/or clinical presentation of ominous organic distress (acute respiratory failure, septic, haemorragic, or cardiogenic shock) or pulmonary embolism. Presence of pleural tamponnade leads to immediate decompression pleural puncture which improves rapidly in general the clinical tolerance, and later permits etiologic treatment. In more severe conditions, pleural evacuation is done in parallel with cardiopulmonary resuscitation maneuvers. If hydropneumothorax is present, immediate drainage with a chest tube will be performed. In other situations, the presence of an abundant pleural effusion with clear fluid necessitates partial needle evacuation to authorize secondarily complementary investigations with pleural biopsy. If purulent pleurisy is discovered, immediate evacuation of pus is mandatory, with needle pleural lavage or chest tube. In all cases, the pleural fluid requires complete haematological, biochemical, and cytologic as well as bacteriological analysis. In the surgical emergency ward, if an opened wound is discovered (gun shot, blunt object or weapon), cardiocirculatory resuscitation is often mandatory, with immediate transfer to the operation ward for an exploratory thoracotomy. If a closed thoracic trauma is present, the problem is generally the management of an hemo(pneumo)thorax with chest tube drainage leading sometimes if the pleural bleeding persists to thoracotomy.

Chronic obstructive pulmonary disease is becoming the 3rd aetiology of death by disease. In its advanced presentation, it generates a chronic respiratory failure with hypoxia and frequent hypercapnia. Its complex management implies at that stage a medical treatment, physiotherapy and pulmonary rehabilitation, associated with long-term oxygentherapy. In the most severe stages, may be discussed long-term home mechanical ventilation with non invasive connection in order to avoid tracheotomy and to prevent acute respiratory episodes leading these patients in intensive care units and yet responsible for 15 000 deaths per year in our country.

In contrast with acute bronchitis, which is benign and very frequent, community acute pneumonia has to be considered as a serious illness with a mortality rate that can reach 10-15% in inpatients. In adult, pneumonia is usually due to bacteria and antibiotherapy is always required. Clinical diagnosis is based on presumption signs: fever, tachycardia, tachypnea, thoracic pain, localised rales and a global severity impression. A chest X-ray is required. The pathogens involved are usually Streptococcus pneumoniae or atypical organisms. In inpatients (severe pneumonia or presence of risk factors), other pathogens such as gram negative bacilli or anaerobes are possible. The accurate diagnosis is based on invasive methods, which are not justified in outpatients but indicated in severe pneumonia.