Bronchiectasis: A Complex, Heterogeneous Disease. / Las bronquiectasias: una enfermedad compleja y heterogénea.

Most areas of respiratory medicine continue to use an Oslerian approach, based on signs and symptoms, in which the disease is the center of all activity. However, this paradigm is changing. Now that lung diseases have been recognized as heterogeneous and complex, we are moving towards more personalized, precise, patient-oriented medicine. The aim of this review was to define the current state of the knowledge on bronchiectasis, or, more accurately, the bronchiectasis syndrome, as a multidimensional, systemic, heterogeneous, complex disease. We explore the advances that have already been made, and above all the many steps that are still to be taken. We also propose some tools which might facilitate the application of these concepts in clinical practice, and help us continue our journey towards a more holistic view of this disease.

The overlap between bronchiectasis and chronic airway diseases: state of the art and future directions.

Bronchiectasis is a clinical and radiological diagnosis associated with cough, sputum production and recurrent respiratory infections. The clinical presentation inevitably overlaps with other respiratory disorders such as asthma and chronic obstructive pulmonary disease (COPD). In addition, 4-72% of patients with severe COPD are found to have radiological bronchiectasis on computed tomography, with similar frequencies (20-30%) now being reported in cohorts with severe or uncontrolled asthma. Co-diagnosis of bronchiectasis with another airway disease is associated with increased lung inflammation, frequent exacerbations, worse lung function and higher mortality. In addition, many patients with all three disorders have chronic rhinosinusitis and upper airway disease, resulting in a complex "mixed airway" phenotype.The management of asthma, bronchiectasis, COPD and upper airway diseases has traditionally been outlined in separate guidelines for each individual disorder. Recognition that the majority of patients have one or more overlapping pathologies requires that we re-evaluate how we treat airway disease. The concept of treatable traits promotes a holistic, pathophysiology-based approach to treatment rather than a syndromic approach and may be more appropriate for patients with overlapping features.Here, we review the current clinical definition, diagnosis, management and future directions for the overlap between bronchiectasis and other airway diseases.

Tratamiento de las bronquiectasias no debidas a fibrosis quística / Treatment of Non-Cystic Fibrosis Bronchiectasis

Las bronquiectasias presentan actualmente una importancia creciente tanto por el incremento en el número de diagnósticos que se realizan como por el impacto negativo que su presencia supone sobre la enfermedad de base que las genera. Un aspecto fundamental en estos pacientes es la colonización e infección de la mucosa bronquial por microorganismos potencialmente patógenos (MPP), causante en la mayoría de los casos del inicio del proceso inflamatorio crónico que termina con la destrucción y la dilatación del árbol bronquial que caracteriza a estos pacientes. El tratamiento de la colonización y de la infección bronquial crónica en estos pacientes se debe basar en la terapia antibiótica prolongada en sus distintas presentaciones, de las cuales la forma inhalada está adquiriendo un especial protagonismo en los últimos tiempos por su elevada eficacia y su escasa producción de efectos adversos importantes. Sin embargo, no debe pasarse por alto que el manejo del paciente con bronquiectasias debe ser multidisciplinar y multidimensional, dado que además del tratamiento antibiótico es imprescindible el trabajo de diferentes especialidades médicas y quirúrgicas para el manejo de las agudizaciones, los aspectos nutricionales, la fisioterapia respiratoria, la rehabilitación muscular, las complicaciones, la inflamación e hiperreactividad bronquial y la hipersecreción que caracteriza a estos pacientes(AU)

Bronchiectasis is currently growing in importance due to both the increase in the number of diagnoses made as well as the negative impact that its presence has on the baseline disease that generates it. A fundamental aspect in these patients is the colonization and infection of the bronchial mucous by potentially pathogenic microorganisms (PPM), which are the cause in most cases of the start of the chronic inflammatory process that results in the destruction and dilatation of the bronchial tree that is characteristic in these patients. The treatment of the colonization and chronic bronchial infection in these patients should be based on prolonged antibiotic therapy in its different presentations. Lately, the inhaled form is becoming especially prominent due to its high efficacy and limited production of important adverse effects. However, one must not overlook the fact that the management of patients with bronchiectasis should be multidisciplinary and multidimensional. In addition to antibiotic treatment, the collaboration of different medical and surgical specialties is essential for the management of the exacerbations, nutritional aspects, respiratory physiotherapy, muscle rehabilitation, complications, inflammation and bronchial hyperreactivity and the hypersecretion that characterizes these patients(AU)

[Diagnosis and treatment of bronchiectasis. Spanish Society of Pneumology and Thoracic Surgery]. / Diagnóstico y tratamiento de las bronquiectasias. SEPAR.

Bronchiectasis is the end result of several different diseases that share principles of management. The clinical course usually involves chronic bronchial infection and inflammation, which are associated with progression. The cause of bronchiectasis should always be investigated, particularly when it can be treated. We recommend evaluating etiology, symptoms, bronchial colonization and infection, respiratory function, inflammation, structural damage, nutritional status, and quality of life in order to assess severity and to monitor clinical course. Care should be supervised by specialized units, at least in cases of chronic bronchial infection, recurrent exacerbations, or when there is a cause that is likely to respond to treatment. Improving symptoms and halting progression are the goals of management, which is based on treatment of the underlying cause and of acute or chronic infections and on the drainage of secretions. Complications that arise must also be treated. Antibiotic prescription is guided by how well infection is being controlled, and this is indicated by the color of sputum and a reduction in the number of exacerbations. We recommend inhaled antibiotics in cases of chronic bronchial infection that does not respond to oral antibiotics, when these cause side effects, or when the cause is Pseudomonas species or other bacteria resistant to oral antibiotics. Inhaled administration is also advisable to treat initial colonization by Pseudomonas species.

Factores pronósticos en la EPOC / Prognostic factors in Chronic Obstructive Pulmonary Disease

Prolongar la supervivencia de los pacientes con enfermedad pulmonar obstructiva crónica (EPOC) es, y ha sido durante décadas, un objetivo complicado. Sin embargo, poco a poco esta percepción empieza a cambiar. De la mano de un mejor conocimiento etiopatogénico de la enfermedad, del análisis de las causas de muerte y sobre todo de la identificación de diversos factores pronósticos, se van dando pasos firmes que permiten afrontar el futuro con mayor optimismo. La presente revisión pretende analizar de forma pormenorizada los principales determinantes pronósticos que se han descrito en la literatura médica y valorar sus posibles implicaciones terapéuticas. Tradicionalmente se ha aceptado que el volumen espiratorio forzado en el primer segundo y su descenso acelerado a lo largo del tiempo era uno de los mejores predictores de mortalidad. Este hecho condicionó durante décadas el objetivo terapéutico en la EPOC. Sin embargo, hoy sabemos que la EPOC es una enfermedad con múltiples dimensiones, algunas de las cuales tienen importantes consecuencias pronósticas. La hiperinsuflación pulmonar, la tolerancia al esfuerzo, las exacerbaciones, la comorbilidad y las manifestaciones sistémicas, especialmente las resultantes de la esfera cardiovascular, son dimensiones que en los últimos años se han revelado como potentes predictores de muerte. El sustrato inflamatorio, tanto local como sistémico, parece estar detrás de muchas de estas manifestaciones y por ello merece especial consideración. Estos nuevos factores pronósticos tienen la virtud de ser potencialmente modificables, lo que subraya la necesidad de planificar intervenciones terapéuticas orientadas a revertir sus efectos cambiando de alguna forma la estrategia tradicional

Efforts over the last few decades to extend the life expectancy of patients with chronic obstructive pulmonary disease (COPD) have faced difficulties, but our perception of the problems involved is now starting to change. Improvements in our understanding of the pathogenic and etiological mechanisms of the disease, analysis of the causes of death, and, in particular, identification of the relevant prognostic factors have resulted in firm advances that allow us to face the future with greater optimism. The aim of this review is to provide a detailed analysis of the chief prognostic factors described in the literature and to evaluate the therapeutic implications of these findings. The traditional view maintained that the accelerated decline in forced expiratory volume in 1 second over time was one of the best predictors of mortality, and this belief has for decades determined the strategies used to treat COPD. However, we now know COPD to be a multidimensional disease and are aware that some of its other manifestations have important prognostic implications. Lung hyperinflation, exercise tolerance, exacerbations, comorbidity, and systemic manifestations­in particular those related to the cardiovascular system­have all been shown in recent years to be strong predictors of mortality. The inflammatory substrate, whether local or systemic, merits special consideration because it appears to be the cause of many of these manifestations. These newly identified prognostic factors are of great interest in that it may be possible to moderate their influence, a circumstance that highlights the need to change the traditional treatment approach and devise therapeutic interventions oriented towards reversing the effects of these factors