[Ventilatory response to upper limb exercise alter training in COPD]. / Respuesta ventilatoria al ejercicio post-entrenamiento de miembros superiores en la enfermedad pulmonar obstructiva crónica.

There are scarce studies evaluating the modification of ventilatory response to upper limb exercise (ULE) post-training in COPD patients. A prospective, randomized, controlled study was performed comparing two groups: training lower limbs (LL), vs. LL plus upper limb training (UL), in relation to their pre and post-training ventilatory response to ULE. A total of 43 COPD patients were included; 84% male, 6 (14%) GOLD moderate stage (II), 15 (35%) severe stage (III), and 22 (51%) very severe (IV); 28 patients completed the study. After ULE, in UL group (N = 14) a training increased isotime VT (p < 0.0001) was observed, as well as an increase in the inspiratory capacity isotime percentage (IC, 8.8%, p = 0.001), in the Ti isotime (29.3%, p = 0.022) and in the Ti/Tot isotime (37.4%, p = 0.0004). Also, Te isotime was reduced (26%, p = 0.009) and IC isotime was increased (p = 0.01) after ULE. In LL group (N = 14), training increased VT/Ti isotime (66.86%, p = 0.0005) after ULE. Also, after ULE a decrease in Ti isotime (27.9%, p = 0.015) and in Ti/Tot isotime (22.74%, p = 0.00016) were observed. A moderate correlation was observed between Δ respiratory rate and ΔIC after ULE, only for post-training in UL group (r = -0.53 , p < 0.001). Comparing both groups in relation to their responses to ULE, only in the UL group was a reduction observed in Te isotime (p = 0.049) and VT/Ti (p = 0.0015), higher Ti isotime (p = 0.0019), Ti/tot isotime (p = 0.000076) and IC isotime (% predictive, p = 0.01). UL training modified ventilatory response to ULE and it also reduced air trapping in COPD patients.

How reliable is the manual correction of the autoscoring of a level IV sleep study (ApneaLink™) by an observer without experience in polysomnography?

OBJECTIVE: This study aims to compare the manual correction of the automatic analysis of ApneaLink™ between a skilled observer in the interpretation of sleep studies and a subject trained only in the scoring of ApneaLink™ device. METHODS: Ninety-six subjects performed the ApneaLink™ and polysomnography (PSG) simultaneously in the sleep laboratory. Two blind observers, who were independent from the results of the PSG, performed first the automatic scoring and then the hand correction from the ApneaLink™ device. The scorers of ApneaLink™ represented two physicians with different levels of training (scorer A: 20 years of experience in reading polysomnography plus 3 years of experience in the interpretation of ApneaLink™, scorer B: 1 year of experience in the analysis of ApneaLink™). The interobserver agreement was assessed with the intraclass correlation coefficient (ICC) and kappa statistics. The diagnostic accuracy of the manual analysis ApneaLink™ device was evaluated by the area under the receiver operator curve (AUC-ROC). RESULTS: Ninety patients were included (69 men; mean age, 49.6; median RDI, 13.9; median BMI, 29.3 Kg/m(2)). The ICC between the manual apnea/hypopnea index from ApneaLink™ and the respiratory disturbance index of the PSG for each observer was similar (scorer A, 0.902; CI 95% 0.80-0.95; vs. scorer B, 0.904; CI 95% 0.86-0.94; p = 0.9). The agreement between the observers on the presence or absence of obstructive sleep apnea syndrome (OSAS) was very good (kappa, 0.83; CI 95% 0.69-0.98). The AUC-ROC was similar between the observers (scorer A, 0.88; CI 95% 0.78-0.98; scorer B, 0.83; CI 95% 0.71-0.95; p = 0.5). CONCLUSIONS: The non-expert observer showed a very good agreement with the expert observer on the results of the manual correction of the ApneaLink™ autoscoring. Both observers had similar diagnostic accuracy to identify subjects with OSAS when compared with PSG.

Accuracy of the clinical parameters and oximetry to initiate CPAP in patients with suspected obstructive sleep apnea.

OBJECTIVE: The aim of this study was to assess the accuracy of oximetry and the clinical parameters for the prescription of continuous positive airway pressure (CPAP) in patients with suspected obstructive sleep apnea syndrome (OSAS). METHODS: All participants (135) performed oximetry (WristOx 3100™) and polysomnography (PSG) simultaneously in the sleep laboratory. The patients completed the Epworth sleepiness scale, the Berlin questionnaire, and a clinical history. Two blind independent observers decided to prescribe CPAP according to the results of the PSG (gold standard, observer A), oximetry (alternative method, observer B), and the clinical parameters. The accuracy of observer B on the indication of CPAP, using different cutoff points of the adjusted desaturation index (ADI3 and ADI4), was evaluated by the area under the receiver operating characteristics curve (AUC-ROC). The interobserver agreement for the indication of CPAP was assessed using kappa statistics. RESULTS: One hundred nineteen subjects were included (92 men; mean age, 53; median respiratory disturbance index, 22.6; median BMI, 27.5 kg/m(2)). Depending on the criteria used in oximetry, the sensitivity and specificity of observer B to initiate a CPAP trial ranged from 79.8% to 92.5% and of 92% to 96%, respectively. The best performance for the indication of CPAP was noted with the adjusted O(2) desaturation index ≥ 3% (AUC-ROC, 0.923). The inter-rater agreement for the prescription of CPAP was good (kappa, 0.60 to 0.79). CONCLUSION: This simulated study has shown that the use of oximetry plus clinical data has made it possible to indicate CPAP reliably in nearly 90% of the population with OSAS.

[Guidelines for COPD prevention, diagnosis and treatment in Argentina]. / Recomendaciones para la prevención, diagnóstico y tratamiento de la EPOC en la Argentina.

Since morbidity, mortality and socioeconomic costs from Chronic Obstructive Pulmonary Disease (COPD) are widely increasing, a group of respiratory medicine specialists was summoned by the AAMR to update basic knowledge on COPD and to issue recommendations for its prevention, diagnosis and treatment. The authors review the definition of COPD together with current knowledge on pathophysiology. Clinical presentation, functional evaluation and imaging are summarized. Early diagnosis through pulmonary function tests -mainly spirometry- and the role of smoking cessation are stressed. Smoking cessation strategies are described as well as pharmacological and non-pharmacological treatment. Long acting bronchodilators are considered the first pharmacological option for treatment due to its effectiveness and patient compliance. Inhaled corticosteroids are indicated in combination with long-acting bronchodilators in patients who present persistent airway obstruction associated with frequent exacerbations since they reduce their number although further studies are needed to confirm their cost/benefit. Annual influenza vaccination is recommended in all patients. In the non-pharmacological section, surgery for emphysema is suggested in very specific cases. Respiratory rehabilitation is a useful tool for patients with daily activities limitation. Long-term oxygen therapy at home improves survival in patients with severe chronic hypoxemia. Non-invasive home ventilation in chronic patients has limited indications in specific subgroups. Acute exacerbations should be aggressively treated with bronchodilators, oxygen, antibiotics, corticosteroids and eventually mechanical ventilation, as invasive as not invasive respiratory support. The importance of public education as well as of individual patients and their families is deemed essential in the prevention and treatment of the disease.

Comparison of the automatic analysis versus the manual scoring from ApneaLink™ device for the diagnosis of obstructive sleep apnoea syndrome.

OBJECTIVE: The purpose of this study was to compare the performance of the automated detection versus the manual scoring from the ApneaLink™ device to diagnose obstructive sleep apnoea syndrome (OSAS). METHODS: All participants (96) performed the ApneaLink™ (AL) and polysomnography (PSG) simultaneously in the sleep laboratory. The two recordings were interpreted blindly. The hypopnoea criterion used for the analysis of both automatic and manual ApneaLink™ was a fall in airflow ≥50% of baseline for ≥10 s. The agreement between AL and PSG and the interobserver concordance was calculated. ROC analysis, sensitivity and specificity were assessed for the different ApneaLink™ and OSAS criteria. RESULTS: Ninety patients were included (69 men; mean age, 49.6; median RDI, 13.9; median BMI, 29.3 kg/m(2)). The automatic apnoea/hypopnoea index (AHI-a) showed a lower agreement with the respiratory disturbance index (RDI) than the manual apnoea/hypopnoea (AHI-m) [AHI-a/RDI: intraclass correlation coefficient (ICC) 0.88 versus AHI-m/RDI: ICC 0.91]. The manual scoring (MS) showed a similar sensitivity and a higher specificity than the automatic scoring (AA) for the detection of OSAS, defined as an RDI ≥ 5 (sensitivity and specificity AA and MS: 89%/89%, 60%/86.7%, respectively). The accuracy of the automatic and manual scoring of the AL was similar when OSAS was defined as an RDI ≥ 20 or 30. The ApneaLink™ manual scoring had a very good interobserver agreement (k = 0.86). CONCLUSIONS: The manual scoring of an ApneaLink™ recording was better than the automatic scoring in terms of agreement with RDI and to discriminate patients with OSAS. The hand scoring did not improve the accuracy of automatic scoring in patients with severe OSAS.

Gender and perception of dyspnea. The role of the variation in the forced expiratory volume in one second.

During bronchoconstriction women perceive more breathlessness than men. The aims of study were 1) to evaluate if quality of dyspnea in bronchoconstriction was different in women and men 2) to assess if gender difference in the perception of dyspnea could be related to the level of bronchoconstriction. 457 subjects (257 women) inhaled methacholine to a 20% decrease in FEV1, or 32 mg/ml. Dyspnea was evaluated using the modified Borg scale and a list of expressions of dyspnea. Borg scores were recorded immediately before the challenge test baseline and at the maximum FEV1 decrease. The prevalence of descriptors of dyspnea reported by women and men was similar. Dyspnea was related to the level of FEV1 (FEV1: OR 1.05, 95%CI 1.01-1.09, p 0.0095), females (OR 2.90, 95%CI 1.33-6.33, p 0.0072), younger subjects (OR 0.93, 95%CI 0.89-0.97, p 0.0013) and body mass index (BMI) (OR 1.11, 95%CI 1.01-1.23, p 0.023). As the FEV1 fell less than 20% from baseline, only the FEV1 was significantly associated with dyspnea (FEV1:OR 1.15, 95%CI 1.07-1.24, p 0.0002). Instead, if the FEV1 fell higher > or = 20%, the presence of dyspnea was related to the degree of bronchoconstriction (FEV1: OR 1.04, 95%CI 1.01-1.09, p 0.0187), females (OR 3.02, 95%CI 1.36-6.72, p 0.0067), younger subjects (OR 0.92, 95%CI 0.88-0.96, p 0.0007) and BMI (OR 1.12, 95%CI 1.01-1.23, p 0.023). The quality of dyspnea during the bronchoconstriction was similar in women and men; women showed a higher perception of dyspnea than men only when the FEV1 fell more than 20% from baseline.

Utility of ApneaLink for the diagnosis of sleep apnea-hypopnea syndrome.

Portable sleep studies may play an important role to take decisions on patients referred for suspicion of Sleep Apnea-Hypopnea Syndrome (SAHS). The aim of this study was to evaluate the diagnostic accuracy of automated analysis of ApneaLink in patients with suspicion of SAHS. All participants (75) performed the ApneaLink and polysomnography (PSG) simultaneously in the sleep laboratory. The two recordings were interpreted blindly. The ApneaLink software calculated: (1) risk indicator (RI)-a combination of apnea/hypopnea index (AHI) plus inspiratory flow limitation events and (2) the AHI. ApneaLink and SAHS were defined in three ways: AHI or respiratory disturbance index (RDI) >or= 5, 10 and 15 respectively. ROC curves analysis was performed. The sensitivity (S), specificity (E) and positive and negative likelihood ratio (LR+, LR-) for the different thresholds for RI or AHI were calculated; 66 patients were included (47 men, mean age 51, median RDI 10.6, mean BMI 29.3 kg/m2). The best cut off points of RI were: SAHS = RDI >or= 5: RI > 9 (S 80%, E 100%, LR- 0.20); SAHS =RDI >or= 10: RI > 13 (S 92%, E 93%, LR+ 13.7 LR- 0.089); SAHS = RDI >or= 15 =: RI > 16 (S 93.5%, E 91%, LR+10.9, LR- 0.071). The AHI had a similar diagnostic accuracy to RI for the different definitions of SAHS. The RI and AHI obtained from automated analysis of ApneaLink were highly sensitive and specific to diagnose moderate to severe SAHS.

Validation of the WristOx 3100 oximeter for the diagnosis of sleep apnea/hypopnea syndrome.

OBJECTIVE: To evaluate the diagnostic accuracy of the Nonin WristOx 3100 and its software (nVision 5.0) in patients with suspicion of sleep apnea/hypopnea syndrome (SAHS). METHODS: All participants (168) had the oximetry and polysomnography simultaneously. The two recordings were interpreted blindly. The software calculated: adjusted O(2) desaturation index [ADI]-mean number of O(2) desaturation per hour of total recording analyzed time of > or = 2%, 3%, 4%, 5%, and 6% (ADI2, 3, 4, 5, and 6) and AT90-accumulated time at SO(2) < 90%. The ADI2, 3, 4, 5, and 6 and the AT90 cutoff points that better discriminated between subjects with or without SAHS arose from the receiver operating characteristic curve analysis. The sensitivity (S), specificity (E), and positive and negative likelihood ratio (LR+, LR-) for the different thresholds for ADI were calculated. RESULTS: One hundred and fifty-four patients were included (119 men, mean age 51, median apnea/hypopnea index [AHI] 14, median body mass index [BMI] 28.3 kg/m(2)). The best cutoff points of ADI were: SAHS = AHI > or = 5: ADI2 > 19.3 (S 89%, E 94%, LR+ 15.5 LR- 0.11); SAHS =AHI > or = 10: ADI3 > 10.5 (S 88%, E 94%, LR+ 15 LR- 0.12); SAHS = AHI > or = 15: ADI3 > 13.4 (S 88%, E 90%, LR+ 8.9, LR- 0.14). AT90 had the lowest diagnosis accuracy. An ADI2 < or = 12.2 excluded SAHS (AHI > or = 5 and 10; S 100%, LR- 0) and ADI3 > 4.3 (AHI > or = 5 and 10) or 32 (AHI > or = 15) confirmed SAHS (E 100%). CONCLUSIONS: A negative oximetry defined as ADI2 < or = 12.2 excluded SAHS defined as AHI > or = 5 or 10 with a sensitivity and negative likelihood ratio of 100% and 0%, respectively. Furthermore, a positive oximetry defined as an ADI3 > 32 (SAHS = AHI > or = 15) had a specificity of 100% to confirm the pathology.

[New argentine consensus of respiratory rehabilitation 2008]. / Nuevo Consenso Argentino de Rehabilitación Respiratoria ActualizaciOn 2008.

Respiratory rehabilitation (RR) is a multidisciplinary program of care for patients with chronic respiratory impairment, individually tailored, designed to optimize physical and social performance and patient autonomy. It is particularly indicated in chronic obstructive pulmonary disease (COPD) patients with exercise intolerance. The objectives of respiratory rehabilitation are: reduction in symptoms and exercise intolerance, improvement of health-related quality of life, and reduction of health costs. A group of neumonologists, nutritionists and physical therapists performed a systematic review of the evidence in RR to update previous local guidelines. Inclusion and exclusion criteria, guidelines for initial evaluation and follow up and resources needed are defined. Training characteristics are recommended regarding frequency of the visits, intensity, progression and duration of the exercise training. Aerobic training was recommended for lower limb (1A), upper limb (1B). Strength training must be added (1B). Respiratory muscle training and other physiotherapy techniques were recommended only for specific patients (1C). In addition recommendations have been made for educational objectives of the program including smoking cessation, nutritional and psychological support. The positive impact of RR on reductions of health care costs and reductions on hospitalizations (Evidence A) and mortality (Evidence B) were analized. Respiratory rehabilitation is a key component in the modern treatment of COPD patients. This consensus statement was prepared based on the most recent scientific evidence and adjusted to the local environment with the aim of being implemented nationally.

Overestimation of thoracic gas volume during the airway resistance maneuver. A potential error in the diagnosis of air trapping.

There are no data published about the agreement between the measurement of thoracic gas volume (TGV) during the airway resistance (TGV-Raw) and the conventional technique described by Dubois. The aim of this study was to establish the agreement between both methods to measure TGV. We studied eighty consecutive subjects. Only sixty-six performed acceptable plethysmography maneuvers. The patients were measured with a constant volume plethysmograph (Medical Graphics 1085 DL). TGV was performed in the same patient with two techniques: 1) during the airway resistance (Raw) measurement (TGV-Raw) and 2) during quiet breathing at the end of expiration (TGV). The panting frequency was 1 to 2 Hz with both maneuvers. The differences between both techniques were expressed in percentage (deltaTGV %) and absolute values (deltaTGV). The TGV-Raw of the whole group was higher than TGV (3.69 +/- 1.08 l vs 3.28 +/- 1.05 l, p < 0.001). Similarly, the subgroups of patients had a greater TGV-Raw than TGV (Normal: 3.44 +/- 0.77 l vs 2.98 +/- 0.72 l , p < 0.001; Obstructive: 4.08 +/- 1.19 l vs 3.71 +/- 1.15 l, p < 0.001; Restrictive: 2.62 +/- 0.49 l vs 2.25 +/- 0.51 l, p < 0.01). There was a considerable lack of agreement between the TGV-Raw and TGV, with discrepancies of up to +0.95 l or +34%. The deltaTGV % was similar between the patients' subgroups and between the subjects with different degree of airflow obstruction (Normal: 16.5 +/- 10%, Obstructive: 10.8 +/- 9.4%, Restrictive: 18 +/- 14.3%, p NS; mild obstruction: 10.7 +/- 11%, moderate obstruction: 12.3 +/- 5.7, severe obstruction: 10.1+/- 6.6, p NS). In conclusion, TGV-Raw was larger than TGV. This was because the patients generally panted at a volume above FRC when performing the TGV-Raw maneuver. TGV-Raw should not be used to estimate FRC because FRC would be overestimated and the diagnosis of air trapping may be erroneous.

Effect of the definition of hypopnea on apnea/hypopnea index.

The objective of this study was to determine whether different decreases in oxygen saturation (SaO2) or the presence of electroencephalographic arousals (EEGA) in the definition of hypopnea modify hypopnea index and apnea/hypopnea index and the prevalence of obstructive sleep apnea/hypopnea syndrome (OSAHS). A total of 20 polysomnographies performed in patients with OSAHS were analyzed. There are four different definitions of hypopnea: > or = 30% reduction in airflow or 50% decrease in abdominal movement associated with decreases SaO2 > or = 3% (type 1); decreases SaO2 > or = 3% or EEGA (type 2); decreases SaO2 > or = 4% (type 3); decreases SaO2 > or = 4% or EEGA (type 4). The prevalence of OSAHS was calculated for an apnea/hypopnea index (AHI) > or = 10 and > or = 15. Hypopnea index (HI) and AHI types 2 and 4 were higher than type 3 (HI: type 2: 20 +/- 10.6, type 4: 18.6 +/- 10, type 3: 11.4 +/- 10, p < 0.001; AHI: type 2: 23.3 +/- 11.6, type 4: 21.4 +/- 11.2, type 3: 14.7 +/- 11.6, p < 0.001). No differences were observed between HI and AHI types 1 and 2 (HI: type 1: 17.4 +/- 10, type 2: 20 +/- 10.6; AHI: type 1: 20.6 +/- 11.8, type 2: 23 +/- 11.6, p > 0.05). The prevalence of OSAHS was 30-55% in type 3, 70-85% in type 4 (p < 0.05), and 70-85% in types 1 and 2 (p > 0.05). In our patient's population, the presence of EEGA in the definition of hypopnea significantly increased the HI, the AHI and the prevalence of OSAHS when associated with a > or = 4% decrease in SaO2.

[Argentine Consensus of Respiratory Rehabilitation]. / Consenso Argentino de Rehabilitación Respiratoria.

A group of pulmonologists and physical therapists from the Asociacion Argentina de Medicina Respiratoria revised the scientific literature on Respiratory Rehabilitation (RR) to elaborate evidence-based national recommendations to promote its use. RR is a multidisciplinary program of care for patients with chronic respiratory impairment, individually tailored, designed to optimize physical and social performance and autonomy of patients. It is particularly indicated in patients with Chronic Obstructive Pulmonary Disease (COPD) with exercise intolerance. Inclusion and exclusion criteria, guidelines for initial evaluation and follow up have been defined. The resources needed were defined. It was recommended a hospital ambulatory program with domiciliary complement. A pulmonologist and physical therapist were required for the program as minimum. Aerobic training was recommended for lower limb (LL) (Evidence A) and upper limb (UL) (Evidence B), strength training for LL and UL (Evidence C), as well as respiratory muscles training by resistive inspiratory threshold load (Evidence D) and other physiotherapy techniques were recommended for specific patients. In addition recommendations have been made for educational objectives of the program, nutritional and psychological support. The positive impact of RR on health care was analyzed through the reduction in exacerbation of COPD, length of hospital stay and cost. RR is a key component in the treatment of COPD patients. This evidenced-based consensus statement was prepared to provide recommendations to be implemented nationally.

Pulse oximetry for the detection of obstructive sleep apnea syndrome: can the memory capacity of oxygen saturation influence their diagnostic accuracy?

Objective. To assess the diagnostic ability of WristOx 3100 using its three different recording settings in patients with suspected obstructive sleep apnea syndrome (OSAS). Methods. All participants (135) performed the oximetry (three oximeters WristOx 3100) and polysomnography (PSG) simultaneously in the sleep laboratory. Both recordings were interpreted blindly. Each oximeter was set to one of three different recording settings (memory capabilities 0.25, 0.5, and 1 Hz). The software (nVision 5.1) calculated the adjusted O2 desaturation index-mean number of O2 desaturation per hour of analyzed recording ≥2, 3, and 4% (ADI2, 3, and 4). The ADI2, 3, and 4 cutoff points that better discriminated between subjects with or without OSAS arose from the receiver-operator characteristics (ROCs) curve analysis. OSAS was defined as a respiratory disturbance index (RDI) ≥ 5. Results. 101 patients were included (77 men, mean age 52, median RDI 22.6, median BMI 27.4 kg/m(2)). The area under the ROCs curves (AUC-ROCs) of ADI2, 3, and 4 with different data storage rates were similar (AUC-ROCs with data storage rates of 0.25/0.5/1 Hz: ADI2: 0.958/0.948/0.965, ADI3: 0.961/0.95/0.966, and ADI4: 0.957/0.949/0.963, P NS). Conclusions. The ability of WristOx 3100 to detect patients with OSAS was not affected by the data storage rate of the oxygen saturation signal. Both memory capacity of 0.25, 0.5, or 1 Hz showed a similar performance for the diagnosis of OSAS.

Respuesta ventilatoria al ejercicio post-entrenamiento de miembros superiores en la enfermedad pulmonar obstructiva crónica / Ventilatory response to upper limb exercise after training in COPD

Está poco estudiada la modificación de la respuesta ventilatoria al ejercicio de miembros superiores (MS) post-entrenamiento en la EPOC. Se realizó un estudio prospectivo, aleatorio y controlado en pacientes con EPOC, entrenando un grupo los miembros inferiores (GC) y otro adicionalmente los MS (GM). Se comparó la respuesta ventilatoria al ejercicio de MS pre y post-entrenamiento. Se estudiaron 43 pacientes, 84% varones, estadio GOLD II (moderado) 6 (14%), GOLD III (grave) 15 (35%) y GOLD IV (muy grave) 22 (51%). Veintiocho pacientes completaron el estudio. Post-entrenamiento: se observó en el grupo GM (N = 14) incrementos del V T isotiempo (p < 0.0001) y del % de capacidad inspiratoria (CI) isotiempo (8.8%, p = 0.001), mayores Ti isotiempo (29.3%, p = 0.022) y Ti/Tot isotiempo (37.4%, p = 0.0004) al ejercicio de MS. Se redujo el Te isotiempo (26%, p = 0.009). La CI isotiempo se incrementó (p = 0.01). Post-entrenamiento: en el grupo GC (N = 14) se incrementó el V T/Ti isotiempo (66.86%, p = 0.0005), y disminuyeron el Ti isotiempo (27.9%, p = 0.015) y el Ti/Tot isotiempo (22.74%, p = 0.00016) al ejercicio de MS. Se observó correlación moderada entre la Δ de frecuencia respiratoria y la Δ de CI al ejercicio de MS, post-entrenamiento solo para el grupo GM (r = -0.53, p< 0.001). Comparando ambos grupos en la respuesta al ejercicio de MS, se observó en el grupo GM, reducción del Te isotiempo (p = 0.049) y del V T/Ti (p = 0.0015), mayores Ti isotiempo (p = 0.0019), Ti/tot isotiempo (p = 0.000076) y CI (% predictivo, p = 0.01). El entrenamiento de MS modificó la respuesta ventilatoria, y también redujo el atrapamiento aéreo que se generó por el ejercicio de MS en la EPOC.

There are scarce studies evaluating the modification of ventilatory response to upper limb exercise (ULE) post-training in COPD patients. A prospective, randomized, controlled study was performed comparing two groups: training lower limbs (LL), vs. LL plus upper limb training (UL), in relation to their pre and post-training ventilatory response to ULE. A total of 43 COPD patients were included; 84% male, 6 (14%) GOLD moderate stage (II), 15 (35%) severe stage (III), and 22 (51%) very severe (IV); 28 patients completed the study. After ULE, in UL group (N = 14) a training increased isotime VT (p < 0.0001) was observed, as well as an increase in the inspiratory capacity isotime percentage (IC, 8.8%, p = 0.001), in the Ti isotime (29.3%, p = 0.022) and in the Ti/Tot isotime (37.4%, p = 0.0004). Also, Te isotime was reduced (26%, p = 0.009) and IC isotime was increased (p = 0.01) after ULE. In LL group (N = 14), training increased VT/Ti isotime (66.86%, p = 0.0005) after ULE. Also, after ULE a decrease in Ti isotime (27.9%, p = 0.015) and in Ti/Tot isotime (22.74%, p = 0.00016) were observed. A moderate correlation was observed between Δ respiratory rate and ΔIC after ULE, only for post-training in UL group (r = -0.53 , p < 0.001). Comparing both groups in relation to their responses to ULE, only in the UL group was a reduction observed in Te isotime (p = 0.049) and VT/Ti (p = 0.0015), higher Ti isotime (p = 0.0019), Ti/tot isotime (p = 0.000076) and IC isotime (% predictive, p = 0.01). UL training modified ventilatory response to ULE and it also reduced air trapping in COPD patients.

Respuesta ventilatoria al ejercicio post-entrenamiento de miembros superiores en la enfermedad pulmonar obstructiva crónica / Ventilatory response to upper limb exercise after training in COPD

Está poco estudiada la modificación de la respuesta ventilatoria al ejercicio de miembros superiores (MS) post-entrenamiento en la EPOC. Se realizó un estudio prospectivo, aleatorio y controlado en pacientes con EPOC, entrenando un grupo los miembros inferiores (GC) y otro adicionalmente los MS (GM). Se comparó la respuesta ventilatoria al ejercicio de MS pre y post-entrenamiento. Se estudiaron 43 pacientes, 84% varones, estadio GOLD II (moderado) 6 (14%), GOLD III (grave) 15 (35%) y GOLD IV (muy grave) 22 (51%). Veintiocho pacientes completaron el estudio. Post-entrenamiento: se observó en el grupo GM (N = 14) incrementos del V T isotiempo (p < 0.0001) y del % de capacidad inspiratoria (CI) isotiempo (8.8%, p = 0.001), mayores Ti isotiempo (29.3%, p = 0.022) y Ti/Tot isotiempo (37.4%, p = 0.0004) al ejercicio de MS. Se redujo el Te isotiempo (26%, p = 0.009). La CI isotiempo se incrementó (p = 0.01). Post-entrenamiento: en el grupo GC (N = 14) se incrementó el V T/Ti isotiempo (66.86%, p = 0.0005), y disminuyeron el Ti isotiempo (27.9%, p = 0.015) y el Ti/Tot isotiempo (22.74%, p = 0.00016) al ejercicio de MS. Se observó correlación moderada entre la Δ de frecuencia respiratoria y la Δ de CI al ejercicio de MS, post-entrenamiento solo para el grupo GM (r = -0.53, p< 0.001). Comparando ambos grupos en la respuesta al ejercicio de MS, se observó en el grupo GM, reducción del Te isotiempo (p = 0.049) y del V T/Ti (p = 0.0015), mayores Ti isotiempo (p = 0.0019), Ti/tot isotiempo (p = 0.000076) y CI (% predictivo, p = 0.01). El entrenamiento de MS modificó la respuesta ventilatoria, y también redujo el atrapamiento aéreo que se generó por el ejercicio de MS en la EPOC.(AU)

There are scarce studies evaluating the modification of ventilatory response to upper limb exercise (ULE) post-training in COPD patients. A prospective, randomized, controlled study was performed comparing two groups: training lower limbs (LL), vs. LL plus upper limb training (UL), in relation to their pre and post-training ventilatory response to ULE. A total of 43 COPD patients were included; 84% male, 6 (14%) GOLD moderate stage (II), 15 (35%) severe stage (III), and 22 (51%) very severe (IV); 28 patients completed the study. After ULE, in UL group (N = 14) a training increased isotime VT (p < 0.0001) was observed, as well as an increase in the inspiratory capacity isotime percentage (IC, 8.8%, p = 0.001), in the Ti isotime (29.3%, p = 0.022) and in the Ti/Tot isotime (37.4%, p = 0.0004). Also, Te isotime was reduced (26%, p = 0.009) and IC isotime was increased (p = 0.01) after ULE. In LL group (N = 14), training increased VT/Ti isotime (66.86%, p = 0.0005) after ULE. Also, after ULE a decrease in Ti isotime (27.9%, p = 0.015) and in Ti/Tot isotime (22.74%, p = 0.00016) were observed. A moderate correlation was observed between Δ respiratory rate and ΔIC after ULE, only for post-training in UL group (r = -0.53 , p < 0.001). Comparing both groups in relation to their responses to ULE, only in the UL group was a reduction observed in Te isotime (p = 0.049) and VT/Ti (p = 0.0015), higher Ti isotime (p = 0.0019), Ti/tot isotime (p = 0.000076) and IC isotime (% predictive, p = 0.01). UL training modified ventilatory response to ULE and it also reduced air trapping in COPD patients.(AU)

Recomendaciones para la prevención, diagnóstico y tratamiento de LA EPOC en la Argentina / Guidelines for COPD prevention, diagnosis and treatment in Argentina

La enfermedad pulmonar obstructiva crónica (EPOC) está aumentando marcadamente su morbimortalidad, costos e indicadores epidemiológicos. Por ello la Asociación Argentina de Medicina Respiratoria (AAMR) convocó a un grupo de especialistas para actualizar conocimientos básicos y efectuar recomendaciones para su diagnóstico, prevención y tratamiento. Se revisan definición, avances en fisiopatología, presentación clínica, diagnóstico por imágenes y evaluación funcional. Se enfatiza su diagnóstico temprano mediante exploración funcional -esencialmente espirometría- y la prevención a través de la cesación del tabaquismo. Se describen estrategias para dejar de fumar, tratamiento farmacológico y no farmacológico. La administración de broncodilatadores, preferentemente de acción prolongada, es la primera opción de tratamiento farmacológico. Los corticoides inhalados se indican en combinación con los broncodilatadores en pacientes con obstrucción al flujo aéreo persistente asociada con exacerbaciones frecuentes, si bien se requieren estudios que confirmen su relación costo/beneficio. La vacuna antigripal es recomendada en todos los pacientes. Con respecto a las intervenciones no farmacológicas, la cirugía del enfisema solo se recomienda en circunstancias especiales. La rehabilitación respiratoria es una herramienta útil en pacientes con limitación en la actividad física habitual. La oxígenoterapia crónica domiciliaria mejora la supervivencia en pacientes con hipoxemia crónica grave. La ventilación no invasiva domiciliaria fuera de las exacerbaciones, tiene indicaciones en pacientes seleccionados. Las exacerbaciones agudas deben tratarse con broncodilatadores, oxígeno, corticoides, antibióticos y, bajo ciertas circunstancias, asistencia respiratoria mecánica tanto no invasiva como invasiva. El papel de la educación pública, del paciente y su familia, es considerada esencial en la prevención y tratamiento.

Since morbidity, mortality and socioeconomic costs from Chronic Obstructive Pulmonary Disease (COPD) are widely increasing, a group of respiratory medicine specialists was summoned by the AAMR to update basic knowledge on COPD and to issue recommendations for its prevention, diagnosis and treatment. The authors review the definition of COPD together with current knowledge on pathophysiology. Clinical presentation, functional evaluation and imaging are summarized. Early diagnosis through pulmonary function tests -mainly spirometry- and the role of smoking cessation are stressed. Smoking cessation strategies are described as well as pharmacological and non-pharmacological treatment. Long acting bronchodilators are considered the first pharmacological option for treatment due to its effectiveness and patient compliance. Inhaled corticosteroids are indicated in combination with long-acting bronchodilators in patients who present persistent airway obstruction associated with frequent exacerbations since they reduce their number although further studies are needed to confirm their cost/benefit. Annual influenza vaccination is recommended in all patients. In the non-pharmacological section, surgery for emphysema is suggested in very specific cases. Respiratory rehabilitation is a useful tool for patients with daily activities limitation. Long-term oxygen therapy at home improves survival in patients with severe chronic hypoxemia. Non-invasive home ventilation in chronic patients has limited indications in specific subgroups. Acute exacerbations should be aggressively treated with bronchodilators, oxygen, antibiotics, corticosteroids and eventually mechanical ventilation, as invasive as not invasive respiratory support. The importance of public education as well as of individual patients and their families is deemed essential in the prevention and treatment of the disease.

Recomendaciones para la prevención, diagnóstico y tratamiento de LA EPOC en la Argentina / Guidelines for COPD prevention, diagnosis and treatment in Argentina

La enfermedad pulmonar obstructiva crónica (EPOC) está aumentando marcadamente su morbimortalidad, costos e indicadores epidemiológicos. Por ello la Asociación Argentina de Medicina Respiratoria (AAMR) convocó a un grupo de especialistas para actualizar conocimientos básicos y efectuar recomendaciones para su diagnóstico, prevención y tratamiento. Se revisan definición, avances en fisiopatología, presentación clínica, diagnóstico por imágenes y evaluación funcional. Se enfatiza su diagnóstico temprano mediante exploración funcional -esencialmente espirometría- y la prevención a través de la cesación del tabaquismo. Se describen estrategias para dejar de fumar, tratamiento farmacológico y no farmacológico. La administración de broncodilatadores, preferentemente de acción prolongada, es la primera opción de tratamiento farmacológico. Los corticoides inhalados se indican en combinación con los broncodilatadores en pacientes con obstrucción al flujo aéreo persistente asociada con exacerbaciones frecuentes, si bien se requieren estudios que confirmen su relación costo/beneficio. La vacuna antigripal es recomendada en todos los pacientes. Con respecto a las intervenciones no farmacológicas, la cirugía del enfisema solo se recomienda en circunstancias especiales. La rehabilitación respiratoria es una herramienta útil en pacientes con limitación en la actividad física habitual. La oxígenoterapia crónica domiciliaria mejora la supervivencia en pacientes con hipoxemia crónica grave. La ventilación no invasiva domiciliaria fuera de las exacerbaciones, tiene indicaciones en pacientes seleccionados. Las exacerbaciones agudas deben tratarse con broncodilatadores, oxígeno, corticoides, antibióticos y, bajo ciertas circunstancias, asistencia respiratoria mecánica tanto no invasiva como invasiva. El papel de la educación pública, del paciente y su familia, es considerada esencial en la prevención y tratamiento.(AU)

Since morbidity, mortality and socioeconomic costs from Chronic Obstructive Pulmonary Disease (COPD) are widely increasing, a group of respiratory medicine specialists was summoned by the AAMR to update basic knowledge on COPD and to issue recommendations for its prevention, diagnosis and treatment. The authors review the definition of COPD together with current knowledge on pathophysiology. Clinical presentation, functional evaluation and imaging are summarized. Early diagnosis through pulmonary function tests -mainly spirometry- and the role of smoking cessation are stressed. Smoking cessation strategies are described as well as pharmacological and non-pharmacological treatment. Long acting bronchodilators are considered the first pharmacological option for treatment due to its effectiveness and patient compliance. Inhaled corticosteroids are indicated in combination with long-acting bronchodilators in patients who present persistent airway obstruction associated with frequent exacerbations since they reduce their number although further studies are needed to confirm their cost/benefit. Annual influenza vaccination is recommended in all patients. In the non-pharmacological section, surgery for emphysema is suggested in very specific cases. Respiratory rehabilitation is a useful tool for patients with daily activities limitation. Long-term oxygen therapy at home improves survival in patients with severe chronic hypoxemia. Non-invasive home ventilation in chronic patients has limited indications in specific subgroups. Acute exacerbations should be aggressively treated with bronchodilators, oxygen, antibiotics, corticosteroids and eventually mechanical ventilation, as invasive as not invasive respiratory support. The importance of public education as well as of individual patients and their families is deemed essential in the prevention and treatment of the disease.(AU)