Inhaloterapia: recomendaciones para Argentina 2021 / Inhalotherapy: recommendations for Argentina 2021

Resumen En las últimas décadas ha habido un importante desarrollo de dispositivos inhalados (DI) que permiten aumentar la eficacia de las drogas y disminuir los eventos adversos. Su correcto uso es de fundamental importancia para el control de las enfermedades respiratorias obstructivas. En la Argentina no existen recomendaciones locales sobre el uso de los DI. Se revisó la base biofísica, indicación, ventajas y limitaciones, técnica de correcto uso, errores frecuentes, mantenimiento y limpieza de cada DI. El uso de nebulizaciones ha quedado restringido a la administración de drogas que no están disponibles en otros DI (ejemplo: tratamiento de fibrosis quística), o ante la falla de los otros DI. No deben ser usados durante la pandemia de SARS-CoV2. Los inhaladores de dosis medida (aerosol) deben ser indicados siempre con aerocámaras (AC), las que reducen la incidencia de eventos adversos y aumentan el depósito de la droga en el pulmón. Son los dispositivos de elección junto a los inhaladores de polvo seco. Los aerosoles se deben usar en pacientes que no generan flujos inspiratorios altos. Los inhaladores de polvo seco deben recomendarse en aquellos que pueden realizar flujos inspiratorios enérgicos. Se revisaron los diferentes DI en fibrosis quística y en pacientes con asistencia respiratoria mecánica. La elección del DI dependerá de varios factores: situación clínica, edad, experiencia previa, preferencia del paciente, disponibilidad de la droga y entrenamiento alcanzado con el correcto uso.

Abstract Last decades, a broad spectrum of inhaled devices (ID) had been developed to enhance efficacy and reduce adverse events. The correct use of IDs is a critical issue for controlling obstructive respiratory diseases. There is no recommendation on inhalation therapy in Argentina. This document aims to issue local recommendations about the prescription of IDs. Each device was reviewed regarding biophysical laws, indication, strength, limitations, correct technique of use, frequent mistakes, and device cleaning and maintenance. Nebulization should be restricted to drugs that are not available in other IDs (for example, for treatment of cystic fibrosis) or where other devices fail. Nebulization is not recommended during the SARS-CoV2 pandemic. A metered-dose inhaler must always be used with an aerochamber. Aerochambers reduce the incidence of adverse events and improve lung deposition. Metered-dose inhalers must be prescribed to patients who cannot generate a high inspiratory flow and dry powders to those who can generate an energetic inspiratory flow. We reviewed the use of different IDs in patients with cystic fibrosis and under mechanical ventilation. The individual choice of an ID will be based on several variables like clinical status, age, previous experience, patient preference, drug availability, and correct use of the device.

[Inhalotherapy: Recommendations for Argentina 2021]. / Inhaloterapia: Recomendaciones para Argentina 2021.

Last decades, a broad spectrum of inhaled devices (ID) had been developed to enhance efficacy and reduce adverse events. The correct use of IDs is a critical issue for controlling obstructive respiratory diseases. There is no recommendation on inhalation therapy in Argentina. This document aims to issue local recommendations about the prescription of IDs. Each device was reviewed regarding biophysical laws, indication, strength, limitations, correct technique of use, frequent mistakes, and device cleaning and maintenance. Nebulization should be restricted to drugs that are not available in other IDs (for example, for treatment of cystic fibrosis) or where other devices fail. Nebulization is not recommended during the SARS-CoV2 pandemic. A metered-dose inhaler must always be used with an aerochamber. Aerochambers reduce the incidence of adverse events and improve lung deposition. Metered-dose inhalers must be prescribed to patients who cannot generate a high inspiratory flow and dry powders to those who can generate an energetic inspiratory flow. We reviewed the use of different IDs in patients with cystic fibrosis and under mechanical ventilation. The individual choice of an ID will be based on several variables like clinical status, age, previous experience, patient preference, drug availability, and correct use of the device.

En las últimas décadas ha habido un importante desarrollo de dispositivos inhalados (DI) que permiten aumentar la eficacia de las drogas y disminuir los eventos adversos. Su correcto uso es de fundamental importancia para el control de las enfermedades respiratorias obstructivas. En la Argentina no existen recomendaciones locales sobre el uso de los DI. Se revisó la base biofísica, indicación, ventajas y limitaciones, técnica de correcto uso, errores frecuentes, mantenimiento y limpieza de cada DI. El uso de nebulizaciones ha quedado restringido a la administración de drogas que no están disponibles en otros DI (ejemplo: tratamiento de fibrosis quística), o ante la falla de los otros DI. No deben ser usados durante la pandemia de SARS-CoV2. Los inhaladores de dosis medida (aerosol) deben ser indicados siempre con aerocámaras (AC), las que reducen la incidencia de eventos adversos y aumentan el depósito de la droga en el pulmón. Son los dispositivos de elección junto a los inhaladores de polvo seco. Los aerosoles se deben usar en pacientes que no generan flujos inspiratorios altos. Los inhaladores de polvo seco deben recomendarse en aquellos que pueden realizar flujos inspiratorios enérgicos. Se revisaron los diferentes DI en fibrosis quística y en pacientes con asistencia respiratoria mecánica. La elección del DI dependerá de varios factores: situación clínica, edad, experiencia previa, preferencia del paciente, disponibilidad de la droga y entrenamiento alcanzado con el correcto uso.

Clinical characteristics and comorbidities of elderly asthmatics who attend allergy clinics.

BACKGROUND: To date, few studies have focused on the clinical and allergic characteristics of asthma in the elderly, defined as asthma in people aged 60 or over. Thus, we propose to identify and study the clinical and allergic characteristics and comorbidities of patients with asthma among the elderly. METHODS: A retrospective, observational, descriptive study was developed in five clinics and hospitals in Argentina. Allergy Physicians analyzed their patients' medical records in 2014 and included those adults over the age of 60, who had been diagnosed with asthma according to the GINA guidelines. Clinical and allergic characteristics were analyzed. RESULTS: A total of 152 patients diagnosed with asthma, of whom 73% were women and 11% ex-smokers, were included in this study, with a mean age of 66 years. Only 10.5% of the participants had onset asthma past the age of 60. Regarding asthma severity, 74.3% were diagnosed with moderate persistent asthma, and 7.2% with severe persistent asthma. Eighty-four percent of the patients were treated with an inhaled corticosteroid (ICS) along with a long-acting ß 2-adrenergic agent (LABA). More than half of the patients had two or more comorbidities simultaneously. Allergic comorbidities were the most frequent comorbidities, followed by arterial hypertension. Among allergic comorbidities, most patients presented allergies at the nasal level. There were no significant differences between the subpopulations of patients with late-onset asthma (LOA) and asthma with onset before the age of 60, i.e. early onset asthma (EOA) in most of their clinical characteristics. However, it was observed that EOA accounted for a higher percentage of patients with nasal allergies as compared to LOA (71% vs 46%, p <  0.05).It is worth mentioning that almost half of the patients with LOA had allergies at the nasal level. CONCLUSION: These results may provide a better understanding of the clinical characteristics of asthma in the elderly in Argentina, thus, enabling the development of future therapeutic strategies and a better quality of life for our elderly asthma patients.

Chronic Hypoxia Accentuates Dysanaptic Lung Growth.

RATIONALE: Adults born and raised at high altitudes have larger lung volumes and greater pulmonary diffusion capacity compared with adults at low altitude; however, it remains unclear whether the air and tissue volumes have comparable increases and whether there is a difference in airway size. OBJECTIVES: To assess the effect of chronic hypoxia on lung growth using in vivo high-resolution computed tomography measurements. METHODS: Healthy adults born and raised at moderate altitude (2,000 m above sea level; n = 19) and at low altitude (400 m above sea level; n = 23) underwent high-resolution computed tomography. Differences in total lung, air, and tissue volume, mean lung density, as well as airway lumen and wall areas in anatomically matched airways were compared between groups. MEASUREMENTS AND MAIN RESULTS: No significant differences for age, sex, weight, or height were found between the two groups (P > 0.05). In a multivariate regression model, altitude was a significant contributor for total lung volume (P = 0.02), air volume (P = 0.03), and tissue volume (P = 0.03), whereby the volumes were greater for the moderate- versus the low-altitude group. However, altitude was not a significant contributor for mean lung density (P = 0.35) or lumen and wall areas in anatomically matched segmental, subsegmental, and subsubsegmental airways. CONCLUSIONS: Our findings suggest that the adult lung did not increase lung volume later in life by expansion of an existing number of alveoli, but rather from increased alveolarization early in life. In addition, chronic hypoxia accentuates dysanaptic lung growth by increasing the lung parenchyma but not the airways.

Neumonitis causada por terapia con sales de oro / Pneumonitis caused by gold salts therapy

La neumonitis inducida por sales de oro fue descripta por primera vez en 1960. Existen pocos casos bien documentados reportados a la fecha. Se describe un interesante caso de injuria pulmonar difusa reversible, desarrollada en una paciente con artritis reumatoidea en curso terapeútico con sales de oro. El desarrollo de síntomas respiratorios poco tiempo después de la aparición de un rash cutáneo típico inducido por oro, la ausencia de compromiso pleural, la respuesta favorable a la administración de corticoterapia y la interrupción de las sales de oro sugieren el diagnóstico.

Aspergilosis pulmonar: sindromes de hipersensibilidad / Pulmonary aspergillosis: hypersensitivity syndromes

Las especies de hongos del género Aspergillus, presentan especial predilección por el tejido pulmonar, originando variados cuadros clínicos según se presenten como síndromes de hipersensibilidad o infecciones invasivas y diseminadas. En esta oportunidad se presentan dos casos clínicos de hipersensibilidad pulmonar al Aspergillus con las formas de Alveolitis Alérgica Extrínseca y Aspergilosis Broncopulmonar Alérgica. Ambos tratados con Itraconazol 400 mg/día vía oral en forma exitosa y con negativización de la serología para Aspergillus. Esta patología debe ser sospechada en pacientes con broncoobstrucción, bronquiectasias e infiltrados pulmonares que no responden al tratamiento habitual o bien ante el antecedente de exposición al hongo. El tratamiento con Itraconazol por vía oral puede ser eficaz al disminuir la carga micótica en estos pacientes.

Neumonía eosinofílica crónica / Chronic Eosinophilic Pneumonia

Las enfermedades pulmonares eosinofílicas constituyen un variado grupo de patologías que tienen en común la presencia de eosinofilia periférica y tisular e infiltrados radiológicos. Dentro de este grupo se encuentran las neumonías eosinofílicas crónicas. Presentamos dos casos de esta patología en los cuales la biopsia pulmonar no fue necesaria para su diagnóstico. Ambos casos de sexo masculino consultan por síndrome febril y tos, con eosinofilia periférica y eritrosedimentación elevada. En la radiografía y tomografía computada de tórax se observan infiltrados intersticioalveolares periféricos y bilaterales. Examen parasitológico normal. El lavado bronquioalveolar es negativo para células neoplásicas, gérmenes comunes, micológico y tuberculosis, con aumento de Eosinófilos en el mismo. Presentan mejoría clínica y radiológica al tratamiento con corticoides. Actualmente es posible diagnosticar esta patología en base a la presentación clínica típica, los infiltrados radiológicos característicos, el aumento de porcentajes de Eosinófilos en el lavado bronquioalveolar y la rápida respuesta al tratamiento con corticoides, reservando la biopsia pulmonar para casos más dificultosos.