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BackgroundChronic obstructive pulmonary disease (COPD) is a common treatable disease often diagnosed in patients with risk factors after a prolonged period with suggestive symptoms. Our qualitative study aimed to identify barriers to establishing diagnosis in the natural history of this condition.MethodsAn inductive thematic analysis was performed on structured interviews with patients, general practitioners (GPs) and pulmonologists in France. Inclusion depended on criteria to generate two purposive samples (patients and physicians). Recruitment occurred online. Data collection proceeded until 15 patients and 15 physicians (eight pulmonologists, seven GPs) were interviewed. Data saturation was checked and achieved. The interviews were transcribed and coded in NVivo and triangulated between two researchers. The article respects the consolidated criteria for reporting qualitative research guidelines.ResultsThree phases in the patients’ clinical pathway to diagnosis and 12 barriers were found: Phase 1 (symptoms before consultation; n=4), lack of COPD knowledge, symptom denial, fear of lung cancer, and delayed general practice consultations; Phase 2 (primary care; n=3), letting bronchitis become chronic, priority to diseases with similar symptoms and/or more serious diseases, lack of COPD screening devices, time and curative treatments; Phase 3 (specialised medicine; n=5), treatment before diagnosis, late referral to pulmonologists, difficulty in accessing specialists and examination results, patient’s reluctance to undergo further examinations, and need for additional tests to confirm a diagnosis.ConclusionPeople unaware of their COPD condition can encounter up to 12 barriers, which may combine before obtaining a formal diagnosis. Patients, GPs, pulmonologists and the state health authorities share responsibility for addressing these barriers and enhancing the care pathway.

Purpose: Non-invasive ventilation (NIV) is the reference standard for managing chronic hypoventilation in patients with Duchenne muscular dystrophy (DMD). In these patients, upper airway obstruction under NIV may compromise efficacy and adherence. We aim to describe a novel pattern of expiratory obstructive events occurring during nocturnal barometric NIV. Methods: We retrospectively included all patients with DMD who underwent full-night polygraphy during NIV as part of their usual follow-up between May 2018 and July 2019. Results: We provide a step-by-step description of this previously undescribed pattern of obstruction. Expiratory obstructions lead to end-inspiratory breath-holding and impossibility to take another inspiratory breath with a barometric mode until expiration occurs. These events were observed in 4 (36%) of 11 DMD patients under barometric NIV. Conclusion: Expiratory obstructions may be common in DMD patients receiving NIV and should be sought out routinely. This previously undescribed variant of obstructive event must be identified.

IntroductionThere is a growing trend towards outpatient or home initiation of long-term non-invasive ventilation (NIV) instead of in-hospital initiation. However, evidence supporting the non-inferiority of this strategy is limited in people with neuromuscular diseases (NMDs) or restrictive thoracic disorders (RTDs).MethodsSystematic review and network meta-analysis (NMA) to compare the effect of three NIV initiation settings (home, outpatient and in-hospital) on long-term NIV efficacy in people with NMD or RTD. We used MEDLINE, Web of Science and the CENTRAL (Cochrane Central Register of Controlled Trials) to identify randomised controlled trials (RCTs), controlled and uncontrolled prospective studies comparing NIV efficacy between home and outpatient, and in-hospital initiation. Studies published between January 2000 and February 2023 with endpoints ≥1 month were included. The main outcomes were diurnal arterial carbon dioxide pressure (PaCO2) (primary), oxygen partial blood pressure (PaO2), bicarbonate (HCO3−), quality-of-life and NIV adherence.ResultsEight studies (five RCTs), comprising 350 individuals with PaCO2 measurements (144, 119 and 87 individuals for in-hospital, home and outpatient NIV initiation, respectively) were included. Home and outpatient initiation were not inferior to in-hospital initiation in terms of mean PaCO2 change (Δ) based on the adjusted Bayesian NMA model. No significant difference was found for any secondary outcomes: PaO2, HCO3−, adherence and quality of life.ConclusionDespite the limited number of studies included in this NMA, we found no evidence suggesting that home or outpatient NIV initiation is less effective than in-hospital initiation for individuals with NMD or RTD who are deemed suitable for home or outpatient care. Home NIV initiation may therefore be a particularly valuable strategy, especially when hospital resources are limited or when patient autonomy is compromised.PROSPERO registration numberCRD42023403339.

This cross-sectional study evaluated health-related quality of life (HRQoL) in patients with slowly progressive neuromuscular disorders dependent on mechanical ventilation (MV; ≥16 hours/day). 119 participants, with 9 years (25th–75th percentiles: 4–15 years) of MV dependence, were included. MV was applied via a tracheostomy in 80 participants (67.2%) and non-invasive interfaces in 39 participants (32.8%), including 28 participants (71.8%) with daytime mouthpiece ventilation. HRQoL was rated good or excellent by 81 participants (68.1%), independently from age, diagnosis or respiratory autonomy. On multivariate analysis, time since MV initiation, independence from family member(s), residence in a rural area, ability to go outdoors with MV and tracheostomy were associated with better HRQoL.

Pulmonary rehabilitation (PR) improves health-related quality-of-life (HRQoL) in individuals with chronic obstructive pulmonary disease (COPD), notably by increasing exercise tolerance. Easy-to-implement sit-to-stand tests can facilitate the assessment of exercise tolerance in routine practice. This retrospective study conducted in a real-life setting was designed to describe the non-paced 3-min sit-to-stand test (3-STST) and to evaluate its relationship with HRQoL (VQ11 questionnaire) to identify the determinants of 3-STST performance and to analyze the evolution of 3-STST performance and HRQoL over the course of a community-based PR program. Seventy-one COPD patients (age 69 ± 10 years old; 51% with GOLD spirometric stages III–IV) were included. Mean ± SD 3-STST performance at the initial PR assessment was 43 ± 15 repetitions. This performance was significantly associated with HRQoL and other indicators of clinical severity (lung function, dyspnea, and functional capacities). During the multivariate analysis, younger age, exertional dyspnea with mMRC ≤ 1, and better HRQoL were significantly associated with better 3-STST performance. From the initial to second PR assessment, changes in 3-STST performance were significantly associated with changes in HRQoL. This study provides evidence that the non-paced 3-STST is feasible and might be clinically relevant in the assessment of patients with COPD referred for community-based PR. This test deserves to be prospectively validated.

Fractional Brownian motion is a self-affine, non-Markovian and translationally invariant generalization of Brownian motion, depending on the Hurst exponent \\(H\\). Here we investigate fractional Brownian motion where both the starting and the end point are zero, commonly referred to as bridge processes. Observables are the time \\(t_+\\) the process is positive, the maximum \\(m\\) it achieves, and the time \\(t_ max\\) when this maximum is taken. Using a perturbative expansion around Brownian motion (\\(H=12\\)), we give the first-order result for the probability distribution of these three variables, and the joint distribution of \\(m\\) and \\(t_ max\\). Our analytical results are tested, and found in excellent agreement, with extensive numerical simulations, both for \\(H>12\\) and \\(H<12\\). This precision is achieved by sampling processes with a free endpoint, and then converting each realization to a bridge process, in generalization to what is usually done for Brownian motion.