[Bronchodilator response in elderly patients]. / Respuesta a broncodilatadores en pacientes ancianos.

Asthma in the elderly is more severe and a decreased bronchodilating response has been suggested as a contributing factor. There is no agreement on the best way of expressing reversibility. The aim of this study was to evaluate bronchodilator response in elderly patients with asthma with different levels of airway obstruction and expressing reversibility by different indices. A total of 72 asthmatic patients were studied: (FEV1/FVC < 1.64 SEE below predicted). Two groups were considered: Group I: > or = 65 years (71.0 +/- 11.7 years; FEV1 54.0 +/- 16.7% of predicted) and Group II: < 40 years (23.0 +/- 7.7 years, FEV1 67.6 +/- 16.1%). Response to bronchodilators expressed as delta absolute, delta%predicted or delta%maximal was not different between the two groups. Reversibility expressed as delta%initial, however, was lower in younger patients (> 65 years: 22.2 +/- 16.6% vs 40 years: 11.8 +/- 9.9%, p = < 0.005). A covariance analysis was performed using baseline FEV1 as covariate and bronchodilator response was not different between the two groups. Neither delta absolute (r = 0.13, p = NS), delta%predicted (r = 0.06, p = NS) nor delta maximal (r = 0.09, p = NS) showed correlation with age. delta%initial showed weak but significant correlation with age (r = 0.28, p = < 0.05) and marked dependence on baseline FEV1 (r = 0.47, p = < 0.001). Bronchodilator reversibility in the elderly asthmatics is preserved. Expressing reversibility as delta%initial produces differences depending on baseline airway obstruction.

[Medical ethics in the world's market. Hippocratic fidelity or enterprise fidelity]. / La ética médica en el mundo del mercado. Fidelidad hipocrática o fidelidad a la empresa.

The advance which resulted in the mean survival increase from 50 to 75 years between 1920 and 1990 also provoked the rise in health care costs, and the so called "health crisis". In order to contain it, market tactics were put to action, health care was considered a commodity, patients "consumers" and hospitals or physicians "providers". Economists, accountants and business advisors in charge of "Health Maintenance Organizations" (HMO) started the very profitable activity of intervening between patients and physicians. Rationing, use of general practice guides, suboptimal treatments, risk avoidance and other market tactics changed the practice of a profession into a business enterprise. The HMO decides if, when, how and how much will be given to any "consumer". Use of technology more impersonal and easily administered is the leading feature of to-day's medicine over the intellectual activity of the physician who hears, understands, makes the physical examination, diagnosis and treatment. The increasing depreciation of his task obliges the physician to enlarge the number and decrease his communication with his patients. His fiduciary obligation is subordinated to market needs and his practice increasingly compromises his moral integrity. The HMO boasts of the quality of the service given, this is the timely use of to-day's appropriate resources. Nobody wants the 1950 car or medical practice. Tomorrow's practice however depends on increasing knowledge, that is, on research, an activity which is not the HMO object. The academic-medical center, the very place where the interaction of teaching and investigating promotes the excellence is discriminated by the HMO because of its compromise with fiduciary activity imposed by 2500 years of jewish-christian philosophy. The future of these institutions (state's Cinderella's) is progressively compromised; when we loose them how long will it take to recover them? The politicians are always ready to create new hospitals, after they are built consuming large amounts of money, they become disinterested. All hospitals in our country are completely active only 4 hours/day, their physicians travel afterwards to their diverse places of activity consuming much of their time in getting there and complying with the bureaucratic tasks imposed by HMO. In our country with 14% unemployment and 1/3 of the population without any health coverage, the institution of universal health insurance is mandatory. Preventive medicine is not effective for people who lack the means for adequate nutrition, education or transportation, they do not visit doctors or use medicines.

Evaluation of bronchodilator response in patients with airway obstruction.

The aim of this study was to define the most useful index of expressing bronchodilator response and to distinguish between asthma and COPD. A prospective study was carried out of bronchodilator response in 142 asthmatics and 58 COPD patients in a university hospital. Reversibility was expressed as: 1. absolute change (delta abs); 2. % of initial (delta %init); 3. % of predicted (delta %pred) and 4. % of maximum possible response (delta %max). Dependence on forced expirations volume in 1 sec (FEV1) as % of predicted and sensitivity and specificity for diagnosis of asthma were established. A relationship between delta abs and initial FEV1 was not found in asthma (delta abs vs. % initial FEV1. r = 0.07) or COPD (r = 0.02). delta %pred did not show a correlation in asthma (r = 0.10) or COPD (r = 0.06). delta %init was dependent on the baseline value in asthma (r = 0.38, P < or = 0.001) but not in COPD (r = 0.18, P = n.s.). delta max was dependent in both. The combination of best sensitivity and specificity to separate asthma and COPD was obtained with delta abs (70.4 or 70.6%). The worst specificity for asthma diagnosis was obtained with delta %init (50%). The best likelihood ratios were obtained with delta abs and delta %pred and the worst likelihood ratio with delta %init. delta %init is not recommended as an index for differential diagnosis between asthma and COPD; 2) delta %init overscores bronchodilator response in patients with low FEV1. The independence of each bronchodilator response index should be verified in clinical trials for each selected sample.

[Beta-agonists: new perspective in the treatment of asthma?]. / Beta-agonistas una nueva perspectiva en el tratamiento del asma?

Beta-agonists (beta 2) are the first treatment for acute asthma. Metered dose inhalers are preferable to nebulizers. During regular treatment, long-acting beta 2 show better results than sabutamol. Clinically relevant antiinflammatory activity has not been demonstrated. During regular treatment, tolerance to bronchodilator effects has not been detected but decrease of bronchoprotective effect is seen. These findings do not show clinical relevance. Short or long-acting beta 2 remain an appropriate and reliable treatment option for patients with asthma. Salmeterol and formoterol show similar action and adverse effects. The most rational treatment strategy seems to be: a) use inhaled steroids as the first and main regular treatment; b) when doses higher than 1,000-1,200 mcg/d of BCM or BUD are required, try long-acting beta-agonists; c) if that treatment is not effective enough, continue to increase inhaled steroid doses to identify patients responsive to higher doses.

Is asthma in the elderly really different?

To examine the nature of asthma in the elderly, we compared older (group 1: 65 years or older, n = 50) with younger patients (group 2: <40 years, n = 99) and to determine the influence of long-standing disease, elderly asthmatics with early onset (group A: onset before 40, n = 22) were compared with patients developing symptoms later in their lives (group B: onset after 40, n = 22). Blood eosinophilia and IgE value >/=100 IU/l were more frequent in younger patients. Short symptom-free periods were more frequent among older asthmatics (78.5 vs. 45.4%, p < 0.001). Only 31.2% of older patients had only mild symptoms. Requirement of systemic steroids was higher in the elderly population. The worst FEV1 was lower in older patients (54.4 +/- 17.3 vs. 71.8 +/- 18.5%, p

[Non-invasive mechanical ventilation as treatment for severe pneumonia in an HIV positive patient]. / Ventilacion mecanica no invasiva como tratamiento de la neumonia severa en un paciente con serologia HIV positiva.

A 27 year-old HIV+ patient was admitted to the hospital for probable Pneumocystis carinii pneumonia (PCP). He was severely dyspneic, with respiratory rate of 44 x min and accessory respiratory muscle contraction. The alveolar-arterial quotient was 0.35. Ventilation by BiPAP was applied during 12 hours. After BiPAP a/AO2 was O.42, with amelioration of dyspnea, decrease of respiratory rate (25 x min) and without using of accessory respiratory muscles. No complications occurred. At the end of hospital stay a/AO2 was 0.68. CPAP application but not BiPAP has been reported in PCP. Our patient showed evident improvement after BiPAP, suggesting that this method of ventilation is useful and should be incorporated to the routine management of these patients.

Effects of spontaneous and hypercapnic hyperventilation on inspiratory effort sensation in normal subjects.

In order to elucidate if the inspiratory effort sensation (IES) associated with carbon dioxide (CO2) is independent of the concomitant increase in the ventilation, we studied 23 normal resting volunteers (mean age 34 +/- 11 yr) during CO2 rebreathing. Our main goal was to compare the IES at the same ventilation level under hypercapnic and isocapnic conditions. The protocol included: (1) basal measurements (BASAL); (2) hypercapnic ventilation (HV); (3) screen copy of ventilatory pattern during hypercapnia (COPY); (4) screen copy at basal end-tidal (partial) carbon dioxide pressure (PETCO2) (ISO); and (5) recovery (REC). During HV, PETCO2 increased to 54.8 +/- 0.78 mm Hg (p < 0.001) and ventilation (VE) from 12.0 +/- 0.50 to 28.1 +/- 1.19 L/min (p < 0.001). Borg value increased from 0.11 +/- 0.06 to 3.4 +/- 0.23 (p < 0.001). These values were not different during HV and COPY. During ISO, PETCO2 was 40.2 +/- 0. 59 mm Hg (not significant [NS] from BASAL), while VE remained unchanged: 29.9 +/- 1.29 L/min (NS from HV and COPY). Interestingly, the Borg value during the ISO decreased to 1.86 +/- 0.28 (p < 0.001 compared with HV and COPY). The increased IES induced by hypercapnic ventilation was reduced at the same ventilation level during isocapnic conditions. We suggest that CO2 generates an IES independent of the concomitant increase in ventilation.

[Immediate postoperative respiratory complications after coronary surgery]. / Complicaciones respiratorias en el postoperatorio inmediato de la cirugía coronaria.

The influence of anesthesia, surgical procedure and special conditions of open-heart surgery upon respiratory function alterations is analyzed. Hypoxemia (present even in non-complicated open heart surgery) can be due to alveolar hypoventilation, ventilation-perfusion mismatch or shunt. The origin of atelectasias (present in 50-92% of patients) and pleural effusion (42-87%) is discussed. Phrenic nerve damage is usually secondary to thermal injury. Other less common complications are discussed. The influence of age, smoking and previous pulmonary diseases on respiratory complications is analyzed. Respiratory care after heart surgery (as time and requisites of extubations) and results of different methods (CPAP, PEEP, incentive inspirometry) are reviewed.

Case report: reactive hemophagocytic syndrome associated with disseminated strongyloidiasis.

The reactive hemophagocytic syndrome is a condition characterized by systemic proliferation of benign hemophagocytic histiocytes, fever, cytopenia, abnormal liver function, and frequently coagulopathy and hepatosplenomegaly. Its occurrence has been documented in association with viral, bacterial, fungal and parasitic infections; a wide spectrum of malignant neoplasms; some miscellaneous disorders; and phenytoin. Disseminated strongyloidiasis is reported in a patients with systemic lupus erythematosus treated with corticosteroids in whom a reactive hemophagocytic syndrome developed and who finally died. This reactive hemophagocytic syndrome is reported for the first time in strongyloidiasis and may not have been recognized in former patients.

Analysis of variability in interpretation of spirometric tests.

The objective of this study was to quantify the degree of disagreement in interpretation of spirometries and in the definition of the airway obstruction and response to bronchodilators (Bd) in different publications. Two surveys were carried out in which two groups of 15 pulmonologists were asked to identify in several spirometries the presence and degree of obstructive or restrictive defects (OD or RD), the response to Bd and whether the test was assessable or not. Three "problem' spirograms (PS) were included. For RD there was 76.1% of maximum agreement (MA). For OD the MA was 63.6%. Of the PS only 14% of the tests with a higher than 40% variation among the curves, 14% of those which did not include the graphic records and 33% of those with a considerably imperfect curve were considered nonassessable. The degree of disagreement for response to Bd was 24% (this implies 53.3% of possible maximal disagreement). Besides, every original article whose title or summary referred to "asthma', "chronic obstructive lung disease' or "chronic airflow obstruction' which was published from July 1991 to July 1993 in two respiratory medical journals (Chest and Thorax) was examined. Eleven different criteria to define obstruction were found. The most frequently used was FEV1/FVC < 70% (33.3%). Five different definitions of a positive response to Bd were found. The most popular was an increase in FEV1 > 15% of the initial value (76%). We conclude that there is very often disagreement in the interpretation of conventional spirometry. The definition of obstruction and reversibility in clinical trials is not uniform and great care must be taken when extrapolating the results from one publication to another since the composition of its samples could be substantially different.

Bilateral diaphragmatic paralysis after mediastinal radiotherapy.

A 35-year-old man presented bilateral phrenic paralysis 7 months after radio-therapy for treatment of Hodgkin's lymphoma. Diaphragmatic dysfunction appeared after complete lymphoma remission and 4 months after chemotherapy discontinuation. There were no other potential causes. Idiopathic diaphragmatic paralysis was unlikely because it is usually unilateral. Radiation-induced neuropathy is well documented in other nerves as the brachial plexus. The timing, the applied dose and the location of the nerve within the radiation field are suggestive of radiation-induced phrenic nerve damage. Partial recovery was achieved after 4 years' follow-up.