Risk factors for worsened quality of life in patients on mechanical ventilation. A prospective multicenter study.

OBJECTIVE: To identify risk factors for worsened quality of life (QoL) and activities of daily living (ADL) at 3 and 12 months after discharge from the Intensive Care Unit (ICU) in patients on mechanical ventilation (MV). DESIGN: A prospective, multicentric observational study was made. SETTING: Three ICUs in Argentina. PATIENTS: The study included a total of 84 out of 129 mainly clinical patients admitted between 2011-2012 and requiring over 24hours of MV. INTERVENTIONS: No interventions were carried out. VARIABLES: Quality of life was assessed with the EQ-5D (version for Argentina), and ADL with the Barthel index. RESULTS: The EQ-5D and Barthel scores were assessed upon admission to the ICU (baseline) and after three months and one year of follow-up. Comorbidities, delirium, ICU acquired weakness (ICUAW), and medication received were daily assessed during ICU stay. The baseline QoL of the global sample showed a median index of [0.831 (IQR25-75% 0.527-0.931)], versus [0.513 (IQR0.245-0.838)] after three months and [0.850 (IQR0.573-1.00)] after one year. Significant differences were observed compared with QoL in the Argentinean general population [mean 0.880 (CI 0.872-0.888), p<0.001; p<0.001; p0.002]. Individual analysis showed that 67% of the patients had worsened their QoL at three months, while 33% had recovered their QoL. In the multivariate analysis, the variables found to be independent predictors of worsened QoL were a hospital stay ≥21 days [OR 12.57 (2.75-57.47)], age ≥50 years [OR 5.61 (1.27-24.83)], previous poor QoL [OR 0.11 (0.02-0.54)] and persistent ICUAW [OR 8.32 (1.22-56.74)]. Similar results were found for the worsening of ADL. CONCLUSIONS: Quality of life is altered after critical illness, and its recovery is gradual over time. Age, length of hospital stay, previous QoL and persistent ICUAW seem to be risk factors for worsened QoL.

Circulating gonadal and adrenal steroids in amyotrophic lateral sclerosis: possible markers of susceptibility and outcome.

Although changes of circulating steroids have been reported in patients with sporadic amyotrophic lateral sclerosis (ALS), a full comparison of the adrenal and gonadal steroid profile between control subjects and ALS patients is lacking. Considering that respiratory failure is the most frequent cause of death in ALS, we looked into whether a relationship emerged between circulating steroids and respiratory parameters. Serum levels of adrenal and gonadal steroids were measured in 52 age- and gender-matched subjects (28 ALS and 24 controls) using radioimmunoassay techniques. We also evaluated respiratory parameters in ALS patients, including forced vital capacity (FVC), maximal inspiratory pressure (MIP), and maximal expiratory pressure (MEP). We found increased levels of testosterone in female ALS patients compared to healthy female subjects. Furthermore, control subjects showed a significant decline of testosterone, dehydroepiandrosterone and its sulfate, and a borderline decline of progesterone with increasing age. Instead, testosterone did not decline with increasing age in ALS patients. We also found that the dehydroepiandrosterone sulfate/cortisol ratio was positively associated with FVC, MIP, and MEP. Moreover, ALS patients showing higher testosterone levels and lower progesterone/free testosterone ratio presented a more rapid worsening of the monthly FVC. In conclusion, first our study revealed a differential steroid profile with age and gender in ALS patients relative to controls. Second, we demonstrated an association between some steroids and their ratios with respiratory function and disease progression. Thus, we hypothesize that the endogenous steroid profile could be a marker of susceptibility and prognosis in ALS patients.

Peak expiratory flow and the single-breath count test as markers of respiratory function in patients with myasthenia gravis.

INTRODUCTION: Myasthenia gravis (MG) is an antibody-mediated autoimmune disease characterised by fluctuating, fatigable muscle weakness, frequently involving bulbar and respiratory muscles. Considering the severity of respiratory involvement in MG, routine evaluation of respiratory function is essential. The aim of this study was to identify a useful clinical marker of respiratory involvement in patients with MG. METHODS: We performed an observational study of patients with MG. All cases were evaluated with the single-breath count test, peak expiratory flow (PEF), a modified Medical Research Council dyspnoea scale (mMRC), and a neck strength assessment. The results of these parameters were correlated with forced vital capacity (FVC), maximal inspiratory pressure (MIP), and maximal expiratory pressure (MEP). RESULTS: The study included 45 patients with MG: 2 patients classified as grade I on the Myasthenia Gravis Foundation of America classification at the time of evaluation, 35 classified as grade II, 7 classified as grade III, and one classified as grade IV. Positive correlations were found between single-breath count test scores and FVC values (r = 0.57, P = .000), and between PEF and FVC values (r = 0.76, P = .000). Severity of dyspnoea according to the mMRC scale showed a negative correlation with FVC values (r = -0.31, P = .03). PEF also showed a significant correlation with MEP (r = 0.51, P = .002). CONCLUSIONS: PEF, the single-breath count test, and the mMRC scale are useful measures for evaluating respiratory function in patients with MG.

Peak expiratory flow and the single-breath counting test as markers of respiratory function in patients with myasthenia gravis. / El pico flujo espiratorio y la cuenta máxima son marcadores del compromiso respiratorio en la miastenia gravis.

INTRODUCTION: Myasthenia gravis (MG) is an antibody-mediated autoimmune disease characterised by fluctuating, fatigable muscle weakness, frequently involving bulbar and respiratory muscles. Considering the severity of respiratory involvement in MG, routine evaluation of respiratory function is essential. The aim of this study was to identify a useful clinical marker of respiratory involvement in patients with MG. METHODS: We performed an observational study of patients with MG. All cases were evaluated with the single-breath counting test, peak expiratory flow (PEF), a modified Medical Research Council dyspnoea scale (mMRC), and a neck strength assessment. The results of these parameters were correlated with forced vital capacity (FVC), maximal inspiratory pressure (MIP), and maximal expiratory pressure (MEP). RESULTS: The study included 45 patients with MG: 2 patients classified as grade I on the Myasthenia Gravis Foundation of America classification at the time of evaluation, 35 classified as grade II, 7 classified as grade III, and one classified as grade IV. Positive correlations were found between single-breath counting test scores and FVC values (r = 0.57, p = .000), and between PEF and FVC values (r = 0.76, p = .000). Severity of dyspnoea according to the mMRC scale showed a negative correlation with FVC values (r = -0.31, p = .03). PEF also showed a significant correlation with MEP (r = 0.51, p = .002). CONCLUSIONS: PEF, the single-breath counting test, and the mMRC scale are useful measures for evaluating respiratory function in patients with MG.

Acute fibrinous and organising pneumonia in Whipple's disease.

We report a case of acute fibrinous and organising pneumonia in Whipple's disease with lung improvement after antibiotic therapy. In our knowledge this is the first report of Whipple's disease with acute fibrinous and organising pneumonia.

[Argentine Consensus of home long term oxygen therapy]. / Consenso Argentino de Oxigenoterapia Crónica Domiciliaria.

A national meeting of specialists in Respiratory Medicine took place with the aim of updating in a consensus the indicating criteria, source and ways of administering Long Term Oxygen Therapy (LTOT). This is the only therapeutic intervention which improves the survival of patients with severe chronic obstructive pulmonary disease and respiratory insufficiency. We regulate its indication in patients with COPD, other obstructive and restrictive diseases, primary and secondary pulmonary hypertension with: 1) PaO2 lower or equal to 55 mmHg breathing air at rest; 2) PaO2 between 56 and 60 mmHg with polyglobulia, cor pulmonale or primary and secondary pulmonary hypertension evaluated in clinical stability by taking two samples of arterial blood gases, with two weeks' difference between them and more than one month after a new acute condition. Patients should receive this therapy more than 15 hours per day (better 24 hours) including sleeping time. Norms of study and indication, were established to set up the requirements of O2 during sleep and exercise. With respect to the sources it was concluded that the O2 concentrator is indicated for patients with very little home movements, and the sources, of O2 liquid for those with active social life. Indications for conventional and non conventional O2 administration were established. Complications and an algorithm of therapeutic failure were determined. Principles which should be contained in a future national law of OCD were delineated.

[Mortality rate for asthma and chronic obstructive pulmonary disease in Argentina from 1980-1998]. / Mortalidad por asma y enfermedad pulmonar obstructiva crónica en Argentina en el período 1980-1998.

UNLABELLED: The objective was to determine annual mortality rate for asthma and chronic obstructive pulmonary disease (COPD) from 1980 to 1998, in Argentina. Data base on death certificates from the National Ministry of Health were evaluated. They were individualized for COPD: ICD-9: 490 to 496 and ICD-10: J-40 to J47; for asthma: ICD-9: 493 and ICD-10: J44, J45-J46. Global mortality rate was calculated from each code and for 24 provinces. For asthma, the adjusted mortality rate for 5-34 year-old patients was calculated. Population data were provided by National Institute of Statistics and Census. Global mortality rate for asthma increased from 3.37 in 1980 to 3.96/100,000 in 1985 and decreased from 3.16 in 1991 to 1.74 in 1997 (-30.8%, p < 0.0001) and increased to 2.18 in 1998. Asthma's 5-34 year old mortality rate increased from 0.72 in 1980 to 1.12/100,000 in 1986, and decreased to 0.35 in 1998 (-70%, p < 0.0001). Global mortality rate for COPD increased from 12.76/100,000 in 1980 to 27.16/100,000 in 1998 (+113%, p < 0.0001). There were marked inter-provinces differences for asthma and COPD. IN CONCLUSION: as in developed countries, Argentine mortality rate for asthma has decreased, probably related to dissemination of international and national guides. On the other hand, COPD has increased significantly.

[Exercise training in chronic obstructive pulmonary disease. Comparative study of aerobic training of lower limbs vs. combination with upper limbs]. / Entrenamiento muscular en la enfermedad pulmonar obstructiva crónica severa. Estudio comparativo del entrenamiento aerobico de miembros inferiores vs. combinacion con miembros superiores.

A prospective, randomized and controlled study has been performed in 28 patients with severe COPD. A group of 14 has been trained with their lower limbs (LL), while another similar group of 14 patients was also trained with their upper limbs (UL). Results showed improvement in both groups in the endurance test for LL, dyspnea scale, efficiency and muscular working capacity. A considerable improvement was observed in the oxygen uptake at the anerobic threshold (VO2AT) which suggests a training effect, expressed through an improvement in exercise tolerance. Only the group who trained UL showed a remarkable improvement in the dyspnea scale, endurance test and maximal static mouth pressure, showing a better intrinsic working capacity and participation of the UL muscles producing those manoeuvres. At the end of training, quality of life was significantly increased and the hospitalization rate was lower in both groups. According to these findings, it is suggested that patients with severe COPD included in training programmes add UL exercises to the LL usually carried out.

[Normograms of spirometric values for the city of Buenos Aires]. / Valores espirométricos normales para la ciudad de Buenos Aires.

There is a large variability between the different normograms of spirometric values, so that we designed our normogram for Buenos Aires and Gran Buenos Aires. We performed forced spirometry, under American Thoracic Society standardization, in 237 normal subjects (105 females) between 18 to 86 years old, and 144 to 194 cm. We measured Forced Vital Capacity (FVC), forced Expiratory Volume in one second (FEV1), and forced expiratory flow during the middle half of the Forced vital capacity (FEF25-75), in previously calibrated by the explosive decompressor spirometers. Linear regression using height and age was used for each measured value for each sex. The values obtained were in normal distribution, so that we determined the Low Limit of Normality calculating the 95% confidence interval to one tail, and this should replace the common method of the fixed percent of each value to determine the lower limit of normality for a predicted value.

Discriminación de la limitación al ejercicio en pacientes EPOC severa en pruebas máximas y submáximas / Discrimination of exercise limitation in submaximal and maximal exercise tests in severe COPD patients

No existe evidencia sobre la limitación por síntomas al ejercicio comparando pruebas máximas y submáximas en pacientes con EPOC. Objetivos: Comparar la referencia de limitación por disnea o fatiga entre una prueba de ejercicio máxima y submáxima. Métodos: Se incluyeron pacientes con EPOC moderada y severa (definición GOLD). Se clasificó como limitados por fatiga (LF) si en cicloergometría máxima tenían una diferencia = 2 puntos en la escala de Borg para fatiga de miembros inferiores vs. disnea. Se los clasificó como limitados por disnea (LD) por lo inverso. Se les realizó pruebas ergométricas submáximas, evaluándolos igual. Resultados: Se evaluaron 15 pacientes LD y 18 LF. En pacientes LF predominaban mujeres (LF 55.5 vs LD 26.6% p: 0.034), tenían menor índice peso/talla (LF 24.1 ± 3.2 vs. LD 26.8 ± 2.1; p<0.04) y menor obstrucción al flujo aéreo (LF 47 ± 13.8% vs. LD 34.5 ± 11.1%, p<0.047). En pacientes con LF, las pruebas máximas y submáximas fueron concordantes (Borg 2.8 ± 2; 2.5 ± 2.2, p=NS), pero no en aquéllos con LD (Borg 5.7 ± 2.1; 3.3 ± 1.6, p=0.014). Las pruebas submáximas son específicas (100%: fatiga y 93.3%: disnea) y tienen pobre sensibilidad (44%: fatiga y 35.7%: disnea) para clasificar a los pacientes en la causa de limitación. Conclusión: Los pacientes con LF presentan menor grado de obstrucción bronquial e índice peso-talla. En pacientes LF las pruebas máximas y submáximas fueron concordantes. Las pruebas submáximas son específicas pero tienen poca sensibilidad para clasificar por causa de limitación por síntomas.

There are no data about symptoms of activity limitation in COPD patients when maximal and submaximal exercise tests are compared. Objective: To compare the activity limitation by dyspnea or fatigue between maximal and submaximal exercise tests. Methods: Moderate and severe COPD patients were included (GOLD definition). They were classified as fatigue limited (FL) if Borg scale of fatigue at maximal exercise was = 2 points vs. dyspnea; and dyspnea limited (DL) if it was the reverse. Each patient was evaluated in the same way with submaximal cycloergometry. Results: 15 patients in the LD group and 18 patients in the LF group were evaluated. The LF patients were mainly women (FL 55.5 vs. DL 26.6% p: 0.034), had a low body-mass index (FL 24.1 ± 3.2 vs. DL 26.8 ± 2.1; p<0.04) and less airway obstruction (FL 47 ± 13.8% vs. DL 34.5 ± 11.1%, p<0.047). Maximal and submaximal tests were concordant in FL patients (Borg 2.8 ± 2; 2.5 ± 2.2, p=NS), but not in DL patients (Borg 5.7 ± 2.1; 3.3 ± 1.6, p=0.014). Conclusions: FL COPD patients had less airway obstruction and body-mass index. In FL patients both tests were concordant. The submaximal exercise tests are specific but they have low sensitivity to determine the cause of symptom limitation.

Aeropollinic sampling at three different heights by personal volumetric collector (Partrap FA 52).

BACKGROUND: Aeropollinic sampling is usually performed by volumetric pollen traps located on the top of buildings at a height of 15-20 m. The present study aimed to determine whether pollen concentration is similar, at the same time, at different heights. METHODS: Pollen concentrations were measured at the same time for 3 days each month (March-October 1997), with three Partrap FA 52 devices respectively located at 1.5, 5, and 15 m above the ground. A Burkard sampler was used as control at the 15-m level. RESULTS: No significant difference in either the total count or the single pollen counts was observed between the Partrap and Burkard samplers at 15 m. The total pollen count did not differ significantly between the Partrap at 1.5 m and 15 m (130+/-19 and 123+/-18, respectively), whereas the sampler at 5 m collected an amount of pollen (84+/-14) significantly lower than at 1.5 and 15 m (P<0.0001 and P<0.001, respectively). The amount of Urticaceae pollen was significantly higher at 1.5 m (97+/-17) than at 15m (80+/-12) and 5m (58+/-11); P<0.02 and P<0.001, respectively. Regarding grass pollen, the collector at 5 m captured significantly less pollen (4.5+/-0.8) than at 1.5m (9.5+/-1.3) and 15m (7.2+/-1.3) (P=0.002 and P=0.02, respectively). No significant difference was observed between the data obtained from samplers at 1.5 and 15 m. In addition, the Oleaceae, Cupressaceae, and Corylaceae pollen counts were significantly higher when collected at 15 than at 5 and 1.5 m. CONCLUSIONS: These data show that differences exist in pollen sampling performed at different heights.

Encuesta a neumonologos sobre el diagnostico y tratamiento de EPOC / Survey of chest physicians regarding COPD diagnosis and treatment

A survey on COPD diagnostic procedures, treatment and management was conducted in a group of 517 chest physicians randomized from a list of the 1121 affiliates to the Asociación Argentina de Medicina Respiratoria. One hundred eighty-seven responses were obtained (36.2% of the questionnaires mailed). They treat an average of 53.3 COPD patients every month. Twenty-four percent of them had mild, 41.8% moderate and 33.8% severe disease (GOLD criteria). Only clinical criteria for diagnosis of COPD, clinical criteria + spirometry (S), and clinical criteria + S + chest X ray were used by 2.9, 23.4 and 73.7% of responders, respectively. Seventy percent of responders believed that chronic asthma without bronchodilator response must be included in the COPD definition. Only 14.1% of responders performed S in every office visit. Cardiac function was assessed using clinical criteria, electrocardiogram and echocardiogram by 90.6, 80.6 and 73.8% of responders, respectively, while 98.3% stated that they trained most of their patients in the inhalation technique. Metered Dose Inhaled was the first option for bronchodilators administration (64.8%) followed by nebulization (16.5%), dry powder inhalation (13.7%) and oral administration (4.8%). First option for chronic therapy in severe COPD patients was the association of anticholinergic drug (AC) + short acting beta2-agonists (SABA) (65.5%), AC alone (18.8%), long acting beta2-agonists (LABA) (9.7%), inhaled corticosteroids (IC) (3.5%) and SABA alone (2.8%). Corticosteroids and antibiotics were prescribed in severe COPD exacerbation by 92.5 and 70% of responders, respectively. First choice antibiotic formulation was beta-lactamics + beta-lactamase inhibitors in 39% of the responders followed by fluorquinolones in 23.7%, macrolides in 17.5% and beta-lactamics in 12.5%. Lastly, 12.7% of COPD patients received long-term domiciliary oxygen therapy. 59.3% of them were prescribed pulmonary rehabilitation, 94.1% vaccination against in...

Se realizo una encuesta acerca de diagnostico y tratamiento de EPOC a un grupo de 517 especialistasen neumonologia, seleccionados al azar entre los 1121 integrantes de la Asociacion Argentina de Medicina Respiratoria. Se obtuvieron 187 respuestas (36.2%). Atienden en promedio 53.3 pacientes con EPOC/mes, a los cuales definen como leves el 24.2%, moderados el 41.8% y severos el 33.8% (criterios normativos GOLD).El criterio utilizado para el diagnostico de EPOC fue solo clinico en el 2.9%, clinico y espirometria (ESP) en el 23.4%y clinico, ESP y por imagenes en el 73.7%. El 70.1% de los encuestados incluye dentro de la definicion de EPOC al asma cronico de escasa respuesta a broncodilatadores. Solo el 14.1% manifiesta realizar espirometria en cada consulta. La evaluacion de la funcion cardiaca la realizan en EPOC severa por examen clinico (90.6%), electrocardiograma (80.6%) y ecocardiograma (73.8%). El 98.3% de los encuestados afirma que la mayoria de los pacientes son instruidosen la realizacion de maniobras de inhalacion de medicamentos. Eligieron como primera opcion para administrarbroncodilatadores en aerosol (64.8%), nebulizacion (16.5%), polvo (13.7%) y via oral (4.8%). El 65.5% eligio comoprimera opcion de tratamiento cronico a los anticolinergicos (AC) + beta2-agonistas de acción corta (BAAC), 18.8% ACsolos, 9.7% beta2-agonistas de accion larga (BAAL), 3.5% corticoides inhalados (CI) y 2.8% BAAC solos. Los corticoides sistemicos y los antibioticos fueron utilizados en las reagudizaciones severas por el 92.5% y el 70% de los encuestados, respectivamente. En esa situacion, como antibioticos de primera eleccion, fueron elegidos los beta lactamicos + inhibidores de beta-lactamasa por el 39.1% de los encuestados, fluorquinolonas (23.7%), macrolidos (17.4%) y betalactamicos...