Tendencia de la mortalidad por fibrosis pulmonar idiopática en Chile / Trend in idiopathic pulmonary fibrosis in Chile

INTRODUCCIÓN: La Fibrosis Pulmonar Idiopática (FPI) es una de las enfermedades respiratorias crónicas del adulto de mayor impacto y letalidad, diversos estudios epidemiológicos muestran tendencias progresivas al aumento de las tasas de mortalidad por FPI. En Chile no existen reportes sobre las tendencias de las tasas de mortalidad por FPI. El objetivo del presente estudio es determinar las tendencias de la mortalidad por FPI en Chile entre los años 2002 y 2015. MÉTODO: Estudio descriptivo de diseño ecológico, a partir de la información de bases de datos secundarias de libre disposición de las estadísticas vitales del Departamento de Estadísticas e Información de Salud (DEIS) y del Instituto Nacional de Estadísticas (INE) de Ministerio de Salud de Chile entre los años 2002 y 2015 se obtuvieron las tasas crudas de mortalidad por fibrosis pulmonar idiopática en población de 45 años y más en ambos sexos y las tasas ajustadas por sexo y edad por regiones, se calculó también la frecuencia mensual de las muertes por FPI y se compararon las tasas medias de mortalidad por regiones. RESULTADOS: Se observó un incremento progresivo de la tasa nacional cruda de mortalidad por FPI entre los años 2002 a 2015, la que fue de 18,5 fallecidos por 100.000 habitantes en el año 2002 hasta 24,6 fallecidos por 100.000 habitantes en el año 2015 con una pendiente de ascenso por año de +0,27 por 100.000 habitantes (p = 0,013). En las mujeres las tasas fueron más altas que en los hombres, pero las pendientes de ascenso no presentaron diferencias entre sexos. En la gran mayoría de las regiones las tasas ajustadas presentaron tendencias significativas al ascenso y las tasas medias más altas se presentaron en las regiones del norte de Chile. Se observó un comportamiento estacional de las muertes siendo las frecuencias más altas en los meses de invierno. CONCLUSIONES: Las tasas de mortalidad por FPI en Chile presentan una tendencia progresiva al aumento, con marcadas diferencias regionales lo que lleva a considerar, entre otros factores, influencia ambiental y contaminación del aire y de suelos que se debieran investigar para poder realizar intervenciones de salud pública que permitan reducir la mortalidad de esta enfermedad en nuestro país.

BACKGROUND: Idiopathic Pulmonary Fibrosis (IPF) is one of the chronic respiratory diseases in adults with the greatest impact and high case fatality rate. Various epidemiological studies show progressive trends towards increasing IPF mortality rates. In Chile there are no national reports on country and regional trends in IPF mortality rates. The objective of this study is to determine trends in mortality due to IPF in Chile from year 2002 to 2015. METHOD: Epidemiological study of ecological design based on information from public databases of vital statistics of the Department of Health Statistics and Information (DEIS) and the National Institute of Statistics (INE) of the Ministry of Health of Chile. Crude mortality rates due to IPF in the population aged 45 years and over in both sexes were obtained from years 2002 to 2015. Besides the adjusted mortality rates for sex and age by region, the monthly frequency of IPF deaths during the same period and the average mortality rates by Chilean regions were calculated. RESULTS: A progressive increasing trend in the crude national IPF mortality rate was observed between years 2002 to 2015, which went from 18.5 deaths per 100,000 inhabitants in 2002 to 24.6 deaths per 100,000 inhabitants in 2015 with a slope of ascent per year of +0.27 per 100,000 inhabitants (p = 0.013); female rates were higher than men rates, but without differences in the slopes between sexes; in the vast majority of the regions the rates showed significant upward trends with the higher ones in the northern regions of Chile. A seasonal behavior of the death's frequency was observed being the highest in the winter term. CONCLUSIONS: Mortality rates due to IPF in Chile show a progressive upward trend, with marked regional differences which leads to consider, among other factors, environmental influence and air and soil contamination that should be investigated to carry out public health interventions that allow reducing the mortality of this disease in our country.

Hipoxemia silenciosa y uso de oxímetro de pulso en el hogar para detección precoz de complicaciones por Covid-19: reporte de un caso y revisión de la literatura / Silent hypoxemia and use of pulse oximeter at home for early detection of complications from Covid-19: a case report and review of the literature

Silent hypoxemia is one of the clinical presentations caused by SARS-CoV-2. It is still considered a medical mystery, as there are inconsistencies between arterial oxygen saturation levels and respiratory symptoms; a clinical scenario that had not been seen before. Their main risk is that it delays medical assistance because they do not have breathing difficulties and, when they consult, the lung damage is quite advanced. The early detection of hypoxia can favor the premature diagnosis of COVID-19 pneumonia and start treatment without delay. The pulse oximeter is presented as a useful, inexpensive, and easy-to-use tool for monitoring oxygen saturation at home in mild illness and detecting silent hypoxemia. This work presents the case of a patient with COVID-19 who, thanks to the use of a pulse oximeter at home, was able to detect silent hypoxemia and favored the early diagnosis of SARS-CoV-2 pneumonia. (AU)

Prevención no farmacológica de las exacerbaciones en la EPOC: efecto antiinflamatorio de la actividad física / Non-pharmacological prevention of exacerbations in COPD: anti-inflammatory effect of physical activity

The chronic obstructive pulmonary disease (COPD) is the chronic respiratory condition most prevalent in adults, caused mainly by smoking. Its burden is progressively increasing and, according to the World Health Organization, is one of the main causes of mortality and disability around the world. Patients with COPD present acute worsening of the disease, defined as acute exacerbations, which are the main cause of hospitalizations and deaths. Therefore, it is crucial to identify effective interventions focused in their prevention. Patients with COPD present dyspnoea and intolerance to exercise responsible for a progressive reduction in the level of physical activity, which is an independent risk factor for future exacerbations and mortality. On the other hand, it has been demonstrated that COPD patients with low level of physical activity present higher marker levels of systemic inflammation. Interventions able to increase the level of physical activity in COPD patients have demonstrated positive effects in quality of life and a few clinical trials suggest that improving physical activity is able to prevent exacerbations. We hypothesize that these effects could be explained by changes in systemic inflammation secondary to an increase of physical activity. (AU)

Déficit de Alfa-1-antitripsina y su tratamiento / Alpha-1 antitrypsin deficiency and its treatment

Alpha-1 antitrypsin deficiency (AATD) is a genetic disorder caused by a mutation in the codifying gene for the alpha-1 antitrypsin (AAT) protein, which has anti-elastase activity. While there is extensive genetic variability, the most common genotypes associated with AATD are PI*Z y PI*S. Most clinical manifestations are pulmonary (i.e. emphysema) and hepatic, though other pathologies, such as panniculitis and Wegener's granulomatosis, can also present with this disorder. To date, there is no cure for AATD, and treatment options are focused on reducing the frequency of exacerbations and relieving symptoms; among these, augmentation therapy, which raises AAT levels through serum injections of the protein to correct the deficit, has been the most effective. Novel findings of this therapy are discussed, along with research efforts that explore new treatment options based on gene therapy or the use of protein chaperones, for instance. In Chile, no epidemiological studies on AATD have been conducted, so it is unknown exactly how many individuals are affected or if they receive adequate treatment. (AU)

Dificultades en la elección de una ecuación de referencia para la interpretación de los resultados de capacidad de difusión de monóxido de carbono / Difficulties in the selection of a reference equation for the interpretation of the results of DLCO

Introduction: In the absence of national reference equations, the ATS recommends comparing the results of the diffusion capacity of healthy subjects in a representative sample of the population with international equations and choosing among them, the one that provides the lowest sum of the residues. Objective: To compare reference equations available in the literature and identify which best meets the selection criteria. Methods: We reviewed 10 reference equations, for each one we calculated the sum of the residues for a sample of 71 healthy subjects and described the characteristics that affect the variability of each one. Results: Since 1985 we have used the single breath method. Only Thompson et al prediction equations 2008 were obtained with instantaneous reading of CO. Equations with the lowest sum of residues (Miller, Roca and Cotes) include smokers and former smokers. Conclusions: We need an equation in non-smokers with methodology that ensures low variability.

Introducción: En ausencia de ecuaciones de referencia nacionales, la ATS recomienda comparar los resultados de capacidad de difusión de monóxido de carbono de sujetos sanos en una muestra representativa de la población, con ecuaciones internacionales y escoger entre estas, aquella que presente la menor suma de los residuos. Objetivo: Comparar las ecuaciones de referencia disponibles en la literatura e identificar cuál cumple mejor los criterios de selección. Método: Revisamos 10 ecuaciones de referencia; calculamos la suma de los residuos de cada una de ellas para una muestra de 71 sujetos sanos y describimos las características que inciden en la variabilidad de cada una. Resultados: Desde 1985 se ha utilizado el método de respiración única. Sólo las ecuaciones de Thompson y cols. 2008fueron obtenidas con lectura instantánea. Las ecuaciones que presentan menor suma de residuos (Miller, Roca y Cotes) incluyen fumadores y ex fumadores. Conclusiones: Es necesaria una ecuación nacional en sujetos sanos no fumadores, con metodología que asegure baja variabilidad.

Programa de incentivo de la actividad física apoyado con contadores de pasos en la enfermedad pulmonar obstructiva crónica / A program of physical activity enhancement using pedometers in chronic obstructive pulmonary disease

Introducción: La actividad física diaria está reducida en la EPOC lo que se asocia a una mayor morbimortalidad. La indicación médica de caminar más se ha demostrado poco eficaz y, en nuestro medio, se desconoce el beneficio del uso de los contadores de pasos en la EPOC. Objetivo: Determinar el efecto de los contadores de pasos para incentivar la actividadfísica en la EPOC. Método: 55 Pacientes con EPOC fueron incorporados a un programa de tres meses destinado a aumentar su actividad física y fueron asignados aleatoriamente a dos grupos: en uno el paciente autocontroló su actividad con un contador de pasos (grupo experimental) y en el otro se siguió el manejo habitual (grupo control). Al comienzo y al final del estudio se realizaron las siguientes mediciones: promedio de pasos caminados por día medidos en una semana, espirometría, caminata de seis minutos (C6M), disnea con escala de la Medical Research Council Modificada (mMRC) y calidad de vida mediante cuestionario de Saint George (SGRQ) y COPD Assessment Test (CAT). Resultados: 69 por ciento de los pacientes eran hombres, edad promedio 68 años, VEF1ICVF = 55 por ciento, VEF(1)63 por ciento predicho. El grupo experimental (n = 29) y el control (n = 26) presentaron características basales comparables. El grupo experimental presentó una diferencia significativa en el incremento de los pasos por día en comparación con el grupo control (mediana de 2073,5 versus -68, p < 0,001). También hubo diferencia en la reducción del componente síntomas del SGRQ (promedio de -9,65 versus 0,05 puntos, grupo experimental versus control, p = 0,048). Conclusión: Un programa de incentivo de la actividad física apoyado con contadores de pasos es útil para incentivar la actividad física en la EPOC.

Introduction: The level of daily physical activity is reduced in COPD and has a negative effect on the morbidity and mortality of this condition. Usual advice is not sufficient to reverse the sedentary condition. Pedometers are widely used but their effects in COPD have not been tested in our country. Aim: To determine the effect of pedometers on physical activity in COPD patients. Method: 55 COPD patients were recruited for a 3 months individual program promoting daily physical activity enhancement and were randomly assigned either to a pedometer-based program (experimental group) or to usual care (control group). At the beginning and at the end of the intervention period we measured the average daily steps over one week, exercise capacity using the six-minute walking test (6MWT), the MMRC dyspnoea score, the Saint George Respiratory Questionnaire (SGRQ) and the COPD assessment Test (CAT) to estimate quality of life. Results: 69% of the subjects were male, mean age 68 years, mean FEV1IFVC 55%, mean FEV163% of predicted value. Experimental (n = 29) and control group (n = 26) had comparable baseline characteristics. There was a significant difference in the increase of steps/day in the experimental group in comparison with the control group (median value = 2073.5 versus -68, p < 0.001). Also, a significant difference was observed in the symptoms subscale score of the SGRQ (reduction of 9.65 versus 0.05points, experimental versus control group, p = 0.048). Conclusions: Pedometers are a useful tool to increase physical activity level in COPD.

Educación en los programas de rehabilitación respiratoria de los pacientes con enfermedad pulmonar obstructiva crónica / Education in pulmonary rehabilitation programs for patients with chronic obstructive pulmonary disease

Education is considered a core component of pulmonary rehabilitation. Rather than to simply provide didactic education, the recommendation now is to promote self-efficacy through teaching self-management skills (quality evidence B, moderate recommendation). The main components of self-management education are the use of action plan for early treatment of exacerbations, breathing strategies and bronchial hygiene techniques and the adherence to exercise at home. There still need of evidence about which mechanisms of self-management education have the most perdurable effects.

La educación es considerada un componente central de la rehabilitación pulmonar. En vez de entregar educación orientada a la mera entrega de conocimientos la tendencia actual es propiciar la autoeficacia del paciente dando especial énfasis a la enseñanza de las habilidades del autocuidado (calidad de la evidencia B, fuerza de la recomendación moderada). Los principales componentes de la educación en el autocuidado son: el reconocimiento y tratamiento precoz de las exacerbaciones agudas mediante el uso de su propio "plan de acción", las técnicas de respiración y de drenaje bronquial y la enseñanza orientada a fortalecer la adherencia a los programas de ejercicio en el hogar. Aún faltan estudios que demuestren cuales son los mecanismos más efectivos para lograr que la educación en el autocuidado tenga efectos perdurables en el tiempo.

Manejo nutricional en los programas de rehabilitación respiratoria de los pacientes con enfermedad pulmonar obstructiva crónica / Nutritional management in pulmonary rehabilitation programs for patients with chronic obstructive pulmonary disease

It is estimated that at least one third of patients with moderate to severe Chronic Obstructive Pulmonary Disease (COPD) have a significant alteration of their body composition, which is associated with deleterious clinical effects and higher mortality. However, there is a lack of evidence to support that dietary, pharmacological or both nutritional interventions have significant clinical benefits in COPD patients who are participating in a pulmonary rehabilitation program. At the present time the recommendation is to establish a nutritional diagnosis of the COPD patients from the beginning of the pulmonary rehabilitation program using the measurement of body mass index (BMI) and the estimation of the nutritional risk, which means a significant weight loss during a given period of time, followed by an individualized dietary and educational supplementation guide during at least 12 weeks.

Se estima que al menos un tercio de los pacientes con enfermedad pulmonar obstructiva crónica moderada y severa tienen una alteración significativa en su composición corporal, lo cual se asocia con efectos clínicos deletéreos y con una mayor mortalidad. Sin embargo, hay evidencia insuficiente para respaldar que los pacientes que participan en un programa de rehabilitación respiratoria se beneficien en forma significativa de las intervenciones nutricionales dietarias, farmacológicas o la asociación de ambas, aunque aparentemente los últimos estudios publicados parecen sugerirlo. La recomendación actual es establecer desde que el paciente ingresa a un programa de rehabilitación respiratoria tanto el diagnóstico nutricional mediante la determinación del índice de masa corporal como el riesgo nutricional que corresponde a una baja involuntaria significativa de peso en determinado intervalo de tiempo, entregando al paciente un plan de alimentación y educación individualizado que debiera tener una duración mínima de 12 semanas.

Uso de modelos simuladores como metodología docente para la carrera de medicina / Use of simulator models like educational methodology for the medicine carrer

Introduction: Usefulness of high tech clinical simulators as learning tools, are partially established. Objective: To determine utility of an Emergency Care Simulator (ECS) as a learning tool inmedicine. Methods: Study was conducted in 2007, during the respiratory diseases rotation of third year medical students. Informed consent was required to participants. They were divided in two groups: Study Group (SG) and Control group (CG). Both were submitted to the same regular respiratory diseases learning activities. Only the SG had a session with the ECS. The simulated scenario referred to a young man with severe community pneumonia. At the end of the activities every student from those groups answered a modified essay and a questionnaire about this disease problem (maximum score was 70 points). The SG also responded a list of12 statements to get their opinion on this experience. Results: 63 students participated in the study, 42 in the SG and 21 in the CG. All the SG answered the questionnaire and 31 answeredthe modified essay. All the CG answered the modified essay. The scores in the essay were (mean +/- SD) 44, 3 +/-12,9 and 35,5+/-14,7 for the SG and CG, respectively (p=0,026). 80 percent ofthe SG agreed that the experience was useful to learn; entertaining and allowing the application of previous knowledge. Less than 50 percent felt the simulation real enough. Conclusions: A learning activity about severe community acquired pneumonia with the METI ECS simulator apparently was useful for students learning and well evaluated by them.

Reversibilidad espirométrica en pacientes con enfermedad pulmonar obstructiva crónica: ¿debe emplearse 200 ó 400 µg de salbutamol? / Spirometric reversibility in COPD patients: 200 or 400 mg salbutamol should be used?

The optimal dose of salbutamol for testing spirometric reversibility in patients with chronic obstructive pulmonary disease (COPD) has not been determined and either 200 or 400 µg are commonly used. The purpose of the present study is to test both doses in a group of patients with mild to severe COPD. Forty stable COPD patients were included to receive in random order both doses of salbutamol, with spirometry being performed before and after 15 min of their administration. Absolute and percent predicted changes were evaluated. For the latter, an increase in forced expiratory volume in one second (FEV1), slow vital capacity (SVC), forced vital capacity (FVC) and inspiratory capacity (IC) equal or greater than 10 percent predicted was considered clinically significant. No differences were found in absolute post-bronchodilator values between the two doses. In addition, the proportion of responders to 200 and 400 µg of salbutamol according to the percent predicted changes was similar with both doses. This was particularly true when all variables related to volume changes (SVC, FVC, and IC) were included in the analysis. In conclusion, the present results indicate that for testing spirometric reversibility in COPD patients the 200 µg dose of salbutamol is as effective as the 400 µg dose.

La óptima dosis de salbutamol que se debe emplear para evaluar la reversibilidad espirométrica en pacientes con enfermedad pulmonar obstructiva crónica (EPOC) no ha sido establecida, por lo que 200 ó 400 mg son corrientemente utilizados. El propósito del presente estudio fue evaluar el efecto de ambas dosis de salbutamol en un grupo de pacientes con enfermedad leve a grave. El estudio incluyó a 40 pacientes con EPOC estable a los cuales se les realizó una espirometría antes y 15 minutos después de recibir en orden aleatorio 200 ó 400 µg de salbutamol en dos días consecutivos. Los cambios se evaluaron en valores absolutos y en porcentaje del valor teórico. Se midió los cambios en VEF1, CVF, capacidad vital lenta (CVL) y capacidad inspiratoria (CI). Se consideró clínicamente significativo un aumento igual o mayor al 10 por ciento del valor teórico. No se observó diferencias en los valores absolutos post broncodilatador entre las dos dosis como tampoco expresados en porcentaje del valor teórico. Además, la proporción de pacientes que respondieron con 200 y 400 µg de salbutamol fue similar. Esto fue particularmente importante cuando se incluyó en el análisis todas las variables relacionadas con el cambio de volumen (CVL, CVF y CI). Concluimos que para evaluar la reversibilidad espirométrica en pacientes con EPOC, 200 µg de salbutamol son tan efectivos como 400 µg.

El sistema de la bolsa es útil como espaciador para la administración de los aerosoles presurizados / A plastic bag is useful as spacer device for pressurized aerosol delivery

It has been demostrated that the effect of inhaled medications is enhanced by spacer devices, but their sizes make them unpractical to carry around and they have additional cost. In order to test if a homemade cheap spacer is as effective as the commercial spacers, we tested a small plastic bag with a cardboard mouth piece. We recluted 17 patients over 16 years of age with an obstructive ventilatory limitation in spirometry with a significative response with 200 µg of albuterol. We randomized patients into two groups: one received the bronchodilator through a commercial spacer and the other through the homemade device. We observed that with the latter we obtained similar or better FEV1 and FVC increases. We conclude that the use of this cheap device can be used in patients with advantage over commercial ones.

Se ha demostrado que el depósito y efecto de los medicamentos administrados a través de los inhaladores presurizados mejora con el uso de espaciadores, pero la adherencia a estos accesorios no es buena por su costo y por su tamaño incómodo. Nuestro objetivo fue determinar si un sistema artesanal tipo reservorio, armado con una bolsa plástica unida a una boquilla de cartón, es efectivo como espaciador. Para esto, seleccionamos a 17 sujetos mayores de 16 años con espirometría con limitación ventilatoria obstructiva y respuesta espirométrica significativa a 200 µg de salbutamol en aerosol presurizado. Se les asignó aleatoriamente a dos grupos: uno con aerocámara y otro con bolsa. Con esta última se obtuvo aumento del VEF1 y de la CVF post broncodilatador de mayor magnitud que con la aerocámara, con diferencia estadística significativa. Nos parece que estos resultados validan al sistema de la bolsa como espaciador de aerosoles presurizados para el uso de los pacientes.