Sildenafil to improve respiratory rehabilitation outcomes in COPD: a controlled trial.

Pulmonary hypertension is a serious complication of chronic obstructive pulmonary disease (COPD) that currently has no established pharmacological treatment. This study aimed to assess whether concomitant treatment with sildenafil would enhance the results of pulmonary rehabilitation in patients with COPD and increased pulmonary arterial pressure (PAP). In this double-blind, randomised controlled trial patients received 20 mg sildenafil or placebo three times daily and underwent pulmonary rehabilitation for 3 months. The primary end-point was the gain in the cycle endurance time at a constant work-rate. Secondary end-points included performance in the incremental exercise test, 6-min walk distance and quality of life. 63 patients with severe COPD and moderately increased PAP were randomised. Cycle endurance time increased by 149 s (95% CI 26-518 s) in the sildenafil group and by 169 s (95% CI 0-768 s) in the placebo group (median change difference -7 s, 95% CI -540-244 s; p=0.77). Gains in the incremental exercise test, 6-min walk distance and quality of life at the end of the study did not differ between groups. Measurements of arterial oxygenation and adverse events were similar in both groups. In patients with severe COPD and moderately increased PAP, concomitant treatment with sildenafil does not improve the results of pulmonary rehabilitation in exercise tolerance.

Evolution of the SEFH's "Proyecto 2020" in a Hospital Pharmacy Department.

OBJECTIVE: To describe the evolution of our Pharmacy Service in relation to the  objectives of Proyecto 2020 (Project 2020) of the Sociedad Española  Farmacia Hospitalaria (Spanish Society of Hospital Pharmacy), to identify weak  points, and to implement improvement actions to achieve the set  objectives. METHOD: A 10-year prospective observational study. We analysed the initial  situation of the Pharmacy Service and conducted follow-up reassessments. We  developed a questionnaire comprising the 28 goals of the five strategic focus  reas (blocks) of the project based on a 4-level quantitative classification of  these goals: level A, implementation in all areas (3 points); level B,  mplementation in some areas (2 points); level C, not implemented, but  formally discussed (1 point); or level D, not addressed (0 points). After each  assessment, we identified the goals with the lowest scores and determined  which improvement actions needed to be implemented. After each assessment,  the targets with lower score were identified and improvement  actions needed to be implemented were decided. Results: The initial assessment was conducted in 2010. The overall score was  42/84 and the highest score (7/9) related to the block scientific evidence. The  follow-up reassessments (2014, 2019) and the final one (2020) showed an  overall gradual increase in level A scores (18% vs 53%) and a  decrease in  level C (43% vs 4%) and D objectives (14% vs 4%). All blocks improved their  score, obtaining a final score of 68/84 (31% increase). A total of 18 weak  points were identified and appropriate improvement actions were implemented,  which included automation, quality management, the creation  of multidisciplinary working groups, the prevention of medication errors, the  incorporation of intelligent pumps or therapeutic drug monitoring among other  solutions. CONCLUSIONS: Projects promoted by scientific societies help to prioritize improvement actions in health organizations that contribute to  improve their quality. Follow up conducted within Project 2020 has led to  improvements in all blocks and positive impacts on the quality of  pharmaceutical practice.

OBJETIVO: Describir la evolución de nuestro Servicio de Farmacia con respecto  a los objetivos del Proyecto 2020 de la Sociedad Española de Farmacia  Hospitalaria, la identificación de puntos débiles y la implementación de  acciones de mejora dirigidas a alcanzar los objetivos planteados.Método: Estudio observacional prospectivo de 10 años de duración. Se analizó  la situación basal y se realizaron reevaluaciones de seguimiento y de  situación final. Se elaboró un cuestionario que contemplaba los 28 objetivos de  los cinco bloques del proyecto basándose en cuatro niveles según si el  objetivo estaba implantado en todas las áreas (A), implantado en algunas  áreas (B), si se había debatido formalmente pero no estaba implantado (C) o si  no se había considerado (D). Para la evaluación cuantitativa se asignaron 3  puntos a los objetivos de nivel A, 2 puntos a los de nivel B, 1 punto a los de  nivel C y 0 puntos a los de nivel D. Tras cada evaluación se identificaron los  puntos débiles (los de menor puntuación) y se decidieron acciones de mejora a  implementar. RESULTADOS: En 2010 se realizó la evaluación inicial obteniendo una  puntuación de 42/84, siendo el bloque de evidencia científica el de mayor puntuación (7/9). En las diferentes evaluaciones de seguimiento (2014,  2019) y final (2020) se observó un incremento gradual de los objetivos de  nivel A  (18% versus 53%) y una reducción de los objetivos de nivel C (43%  versus 4%) y D (14% versus 4%). Todos los bloques mejoraron, obteniendo  una puntuación global final de 68/84 (31% de incremento). Se identificaron 18  puntos débiles y se implementaron sus correspondientes acciones de  mejora, incluyendo robotización, gestión de la calidad, creación de grupos de  trabajo multidisciplinares, prevención de errores de medicación,  implementación de bombas inteligentes o la monitorización farmacocinética,  entre otras. CONCLUSIONES: La adherencia a proyectos promovidos por sociedades científicas ayudan a priorizar acciones de mejora en las  organizaciones sanitarias que contribuyen a mejorar la calidad de las mismas.  En nuestro Servicio de Farmacia, el seguimiento del Proyecto 2020 ha  conllevado una mejora en todos los bloques, lo que repercute positivamente en  la calidad de la práctica farmacéutica.

Predicting nocturnal hypoventilation in hypercapnic chronic obstructive pulmonary disease patients undergoing long-term oxygen therapy.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) patients are very sensitive to changes in pulmonary mechanics and central ventilation control during sleep and may develop significant gas exchange alterations with increased hypoxemia and hypercapnia. Oxygen therapy improves nocturnal desaturation but can worsen hypoventilation. OBJECTIVES: To analyze the prevalence of nocturnal hypoventilation (NHV) in hypercapnic COPD patients and to determine predictive factors for this phenomenon. METHODS: This was a prospective multicenter study which enrolled 80 clinically stable COPD patients with hypercapnic respiratory failure who fulfilled the conventional criteria for long-term oxygen therapy (LTOT). All patients had undergone pulmonary function testing, blood gas analysis, and respiratory polygraphy. Arterial blood gas samples were obtained while patients were awake and during sleep. NHV was considered when an increase in PaCO2 >10 mm Hg was observed in any nocturnal arterial blood gas sample as compared to the awake levels. RESULTS: Seventeen patients (21%) developed NHV. NHV was associated with the values of BMI, hemoglobin, hematocrits, DLCO, and PaO2 reached after oxygen administration. In the logistic regression analysis BMI (OR 1.26, 95% CI 1.068-1.481; p = 0.006) and the diurnal increase of PaO2 after O2 (OR 0.89, 95% CI 0.807-0.972; p = 0.010) were the variables that best discriminated with a sensitivity of 82% and a specificity of 78%. CONCLUSIONS: NHV is a relatively common finding in stable hypercapnic COPD patients undergoing LTOT and it is related to a higher BMI and lower PaO2 after oxygen administration.

Telerehabilitation Programme as a Maintenance Strategy for COPD Patients: A 12-Month Randomized Clinical Trial.

BACKGROUND: There is uncertainty regarding efficacy of telehealth-based approaches in COPD patients for sustaining benefits achieved with intensive pulmonary rehabilitation (PR). RESEARCH QUESTION: To determine whether a maintenance pulmonary telerehabilitation (TelePR) programme, after intensive initial PR, is superior to usual care in sustaining over time benefits achieved by intensive PR. STUDY DESIGN AND METHODS: A multicentre open-label pragmatic parallel-group randomized clinical trial was conducted. Two groups were created at completion of an 8-week intensive outpatient hospital PR programme. Intervention group (IG) patients were given appropriate training equipment and instructed to perform three weekly training sessions and send performance data through an app to a web-based platform. Patients in the control group (CG) were advised to exercise regularly (usual care). RESULTS: Ninety-four patients (46 IG, 48 CG) were randomized. The analysis of covariance showed non-significant improvements in 6-min walk distance [19.9m (95% CI -4.1/+43.8)] and Chronic Respiratory Disease Questionnaire - Emotion score [0.4 points (0-0.8)] in the IG. Secondary linear mixed models showed improvements in the IG in Short Form-36 mental component summary [9.7, (4.0-15.4)] and Chronic Respiratory Disease Questionnaire - Emotion [0.5, (0.2-0.9)] scores, but there was no association between compliance and outcomes. Acute exacerbations were associated with a marginally significant decrease in 6-minute walk distance of 15.8m (-32.3/0.8) in linear models. CONCLUSIONS: The TelePR maintenance strategy was both feasible and safe but failed to show superiority over usual care, despite improvements in some HRQoL domains. Acute exacerbations may have an important negative influence on long-term physical function. CLINICALTRIALS. GOV IDENTIFIER: NCT03247933.

Sleep hypoventilation due to increased nocturnal oxygen flow in hypercapnic COPD patients.

UNLABELLED: This study shows the risks and benefits of increasing the nocturnal oxygen flow in hypercapnic COPD patients undergoing LTOT, as recommended by some COPD treatment guidelines to avoid nocturnal desaturation. BACKGROUND AND OBJECTIVE: Several COPD treatment guidelines recommend increasing oxygen flow during sleep to avoid nocturnal desaturation. However, such an increase could have deleterious clinical and gas exchange effects. The objective of this study was to evaluate short-term gas exchange alterations produced by increasing the nocturnal oxygen flow rate. METHODS: Thirty-eight COPD patients with chronic hypercapnic respiratory failure were evaluated. In a cross-over study, patients were randomly assigned to receive the daytime oxygen flow rate on one night and an additional litre on the alternate night. Nocturnal pulse oximetry and arterial blood gases at awakening were measured, in each patient, on two consecutive days. RESULTS: The administration of 1 L more oxygen during the night resulted in improved parameters of nocturnal oxygenation (oxygen pulse oximetry saturation-SpO2; percentage of sleep time spent at SpO2<90%-CT90; PaO2 at awakening). Nevertheless, such an increase in oxygen flow during the night was also associated with greater hypercapnia and acidosis (p<0.05) the next morning. CONCLUSIONS: The increase of oxygen flow in severe COPD patients with established daytime hypercapnia improved nocturnal oxygenation but it also led to greater hypercapnia and respiratory acidosis at awakening in a considerable proportion of these patients.

Clinical outcomes of expiratory muscle training in severe COPD patients.

UNLABELLED: The most common symptoms in chronic obstructive pulmonary disease (COPD) patients are breathlessness and exercise limitation. Although both general and inspiratory muscle training have shown clinical benefits, the effects of specific expiratory muscle training remain controversial. OBJECTIVE: To investigate the effects of expiratory training on lung function, exercise tolerance, symptoms and health-related quality of life in severe COPD patients. METHODS: Sixteen patients (FEV(1), 28+/-8% pred.) were randomised to either expiratory muscle or sham training groups, both completing a 5-week programme (30 min sessions breathing through an expiratory threshold valve 3 times per week) (50% of their maximal expiratory pressure (MEP) vs. placebo, respectively). Lung function, exercise capacity (bicycle ergometry and walking test), and clinical outcomes (dyspnoea and quality of life (St. George Respiratory Questionnaire (SGRQ)) were evaluated both at baseline and following the training period. RESULTS: Although lung function remained roughly unchanged after training, exercise capacity, symptoms and quality of life significantly improved. The improvement in both walking distance and the SGRQ score significantly correlated with changes in MEP. CONCLUSION: Our results confirm that a short outpatient programme of expiratory training can improve symptoms and quality of life in severe COPD patients. These effects could be partially explained by changes in expiratory muscle strength.

[Oxygen-conserving devices: a forgotten resource]. / Sistemas de ahorro de oxígeno. Una realidad olvidada.

Oxygen-conserving devices include transtracheal catheters, reservoir cannulas, and demand oxygen delivery systems. They are designed to extend the amount of time portable oxygen cylinders will last and correct hypoxemia with a lower flow of oxygen. Transtracheal catheters increase the fraction of inspired oxygen by delivering oxygen directly to the trachea, bypassing the dead space of the oropharynx and improving the efficiency of the upper airway as a reservoir. Reservoir cannulas increase the fraction of inspired oxygen at the beginning of the inspiratory phase. Demand oxygen delivery systems have a valve that is activated during inspiration, meaning that oxygen is only delivered during this stage of the respiratory cycle. Each system has advantages and disadvantages arising from differing design features. Prescription should be based on individual tests in all cases to ensure optimal oxygen delivery during rest, exercise, and sleep.

[Risk factors for mortality in chronic obstructive pulmonary disease]. / Factores de riesgo de mortalidad en la EPOC.

OBJECTIVE: Although the factors predictive of survival in patients with chronic obstructive pulmonary disease (COPD) have been widely studied, full consensus has yet to be reached. The objective of this study was to further clarify how lung function parameters, exercise tolerance, and quality of life influence survival in patients with COPD. PATIENTS AND METHODS: This prospective study included 60 patients diagnosed with COPD. At the start of the study, patients underwent respiratory function tests, exercise testing, and 6-minute walk test. They also answered a chronic respiratory disease questionnaire to measure health-related quality of life. Follow-up lasted 7 years. RESULTS: Five of the 60 patients withdrew from the study. Twenty-six of the remaining 55 patients (47%) died during the study. Univariate Cox regression analysis showed a correlation between survival and age, degree of obstruction, inspiratory capacity, carbon monoxide diffusing capacity, and peak exercise tolerance. No correlation was found between survival and body mass index, PaO2, PaCO2, total lung capacity, residual volume, maximal respiratory pressures, 6-minute walk distance, or health-related quality of life. Age, degree of obstruction (measured as the ratio of forced expiratory volume in 1 second to forced vital capacity after administration of bronchodilator), and maximum minute ventilation in the exercise test were introduced initially in the multivariate Cox stepwise regression analysis, but only maximum minute ventilation remained in the final model (relative risk, 0.926; P< .001). CONCLUSIONS: Our findings show that peak exercise tolerance is the best predictor of survival in patients with COPD.

Heart failure induced by itraconazole. / Insuficiencia cardíaca secundaria a tratamiento con itraconazol.

INTRODUCTION AND OBJECTIVE: Itraconazole is an antifungal imidazole used for the treatment of aspergillosis. Evidence supporting the association between itraconazole and the onset of congestive heart failure (CHF) is limited and is based on cases reported after drug market release. CASE REPORT: We report the case of a 76-year-old man with hypertension and COPD GOLD D who experienced heart failure after receiving a new line of treatment with itraconazole. The patient's symptoms resolved completely after the drug's withdrawal and initiation of treatment with diuretic therapy. Using validated algorithms, we concluded that there was a probable association between itraconazole and the onset of CHF. CONCLUSIONS: The association between the administration of itraconazole and the onset of CHF is difficult to prove. Further observational studies are needed to assess this association. However, based on the available evidence, we should consider this possible adverse effect and even contraindicate this treatment in patients with a structural heart disease.

Evolución del Proyecto 2020 de la Sociedad Españolade Farmacia Hospitalaria en un Servicio de FarmaciaHospitalaria / Evolution of the SEFH’s “Proyecto 2020” in a Hospital Pharmacy Department

Objetivo: Describir la evolución de nuestro Servicio de Farmacia conrespecto a los objetivos del Proyecto 2020 de la Sociedad Española deFarmacia Hospitalaria, la identificación de puntos débiles y la implementaciónde acciones de mejora dirigidas a alcanzar los objetivos planteados.Método: Estudio observacional prospectivo de 10 años de duración.Se analizó la situación basal y se realizaron reevaluaciones de seguimientoy de situación final. Se elaboró un cuestionario que contemplabalos 28 objetivos de los cinco bloques del proyecto basándose en cuatroniveles según si el objetivo estaba implantado en todas las áreas (A),implantado en algunas áreas (B), si se había debatido formalmente pero noestaba implantado (C) o si no se había considerado (D). Para la evaluacióncuantitativa se asignaron 3 puntos a los objetivos de nivel A, 2 puntos a losde nivel B, 1 punto a los de nivel C y 0 puntos a los de nivel D. Tras cadaevaluación se identificaron los puntos débiles (los de menor puntuación) yse decidieron acciones de mejora a implementar.Resultados: En 2010 se realizó la evaluación inicial obteniendo una puntuaciónde 42/84, siendo el bloque de evidencia científica el de mayorpuntuación(7/9). En las diferentes evaluaciones de seguimiento (2014, 2019)y final (2020) se observó un incremento gradual de los objetivos de nivel A (18% versus 53%) y una reducción de los objetivos de nivel C (43% versus 4%)y D (14% versus 4%). Todos los bloques mejoraron, obteniendo una puntuaciónglobal final de 68/84 (31% de incremento). Se identificaron 18 puntosdébiles y se implementaron sus correspondientes acciones de mejora, incluyendorobotización, gestión de la calidad, creación de grupos de trabajomultidisciplinares, prevención de errores de medicación, implementación debombas inteligentes o la monitorización farmacocinética, entre otras.

Objective: To describe the evolution of our Pharmacy Service in relationto the objectives of Proyecto 2020 (Project 2020) of the SociedadEspañola Farmacia Hospitalaria (Spanish Society of Hospital Pharmacy),to identify weak points, and to implement improvement actions to achievethe set objectives.Method: A 10-year prospective observational study. We analysed theinitial situation of the Pharmacy Service and conducted follow-up reassessments.We developed a questionnaire comprising the 28 goals of thefive strategic focus areas (blocks) of the project based on a 4-level quantitativeclassification of these goals: level A, implementation in all areas(3 points); level B, implementation in some areas (2 points); level C, notimplemented, but formally discussed (1 point); or level D, not addressed(0 points). After each assessment, we identified the goals with the lowestscores and determined which improvement actions needed to be implemented.After each assessment, the targets with lower score were identifiedand improvement actions needed to be implemented were decided.Results: The initial assessment was conducted in 2010. The overall scorewas 42/84 and the highest score (7/9) related to the block scientific evidence.The follow-up reassessments (2014, 2019) and the final one (2020)showed an overall gradual increase in level A scores (18% vs 53%) and a decrease in level C (43% vs 4%) and D objectives (14% vs 4%). All blocksimproved their score, obtaining a final score of 68/84 (31% increase).A total of 18 weak points were identified and appropriate improvementactions were implemented, which included automation, quality management,the creation of multidisciplinary working groups, the prevention ofmedication errors, the incorporation of intelligent pumps or therapeutic drugmonitoring among other solutions.

Impact of pulmonary rehabilitation on psychosocial morbidity in patients with severe COPD.

STUDY OBJECTIVE: To assess the effect of pulmonary rehabilitation (PR) on psychosocial morbidity, functional exercise capacity, and health-related quality of life (HRQL) in patients with severe COPD. DESIGN: A prospective, randomized, controlled trial with blinding of outcome assessment and data analysis. SETTING: A tertiary-care respiratory service. PATIENTS: Forty patients (mean age, 65 +/- 8 years [+/- SD]) with severe chronic flow limitation (FEV(1), 35 +/- 13%) without respiratory failure (Pao(2), 72 +/- 9 mm Hg; Paco(2), 42 +/- 5 mm Hg) were randomized either to a control group or to a PR group (PRG). INTERVENTIONS: Sixteen weeks of PR that included breathing retraining and exercise. MEASUREMENTS: At baseline and 16 weeks, we evaluated psychosocial morbidity using two questionnaires (the Millon Behavior Health Inventory [MBHI] and the Revised Symptom Checklist [SCL-90-R]) and measured 6-min walk distance (6WMD) and HRQL using the Chronic Respiratory Questionnaire (CRQ). RESULTS: We found differences in favor of the PRG in the following MBHI domains: introversive, forceful, and sensitive personality styles (all p

Telerehabilitation Programme as a Maintenance Strategy for COPD Patients: A 12-Month Randomized Clinical Trial / Programa de telerrehabilitación como estrategia de mantenimiento para pacientes con EPOC: un ensayo clínico aleatorizado de 12 meses

Background: There is uncertainty regarding efficacy of telehealth-based approaches in COPD patients for sustaining benefits achieved with intensive pulmonary rehabilitation (PR).Research question: To determine whether a maintenance pulmonary telerehabilitation (TelePR) programme, after intensive initial PR, is superior to usual care in sustaining over time benefits achieved by intensive PR.Study design and methods: A multicentre open-label pragmatic parallel-group randomized clinical trial was conducted. Two groups were created at completion of an 8-week intensive outpatient hospital PR programme. Intervention group (IG) patients were given appropriate training equipment and instructed to perform three weekly training sessions and send performance data through an app to a web-based platform. Patients in the control group (CG) were advised to exercise regularly (usual care).Results: Ninety-four patients (46 IG, 48 CG) were randomized. The analysis of covariance showed non-significant improvements in 6-min walk distance [19.9m (95% CI ∧4.1/+43.8)] and Chronic Respiratory Disease Questionnaire • Emotion score [0.4 points (0•0.8)] in the IG. Secondary linear mixed models showed improvements in the IG in Short Form-36 mental component summary [9.7, (4.0•15.4)] and Chronic Respiratory Disease Questionnaire • Emotion [0.5, (0.2•0.9)] scores, but there was no association between compliance and outcomes. Acute exacerbations were associated with a marginally significant decrease in 6-minute walk distance of 15.8m (∧32.3/0.8) in linear models. (AU)

Contexto previo: Existe incertidumbre con respecto a la eficacia de los enfoques basados en telesalud en pacientes con enfermedad pulmonar obstructiva crónica (EPOC) para mantener los beneficios logrados con la rehabilitación pulmonar (RP) intensiva.Pregunta de investigación: Determinar si un programa de telerrehabilitación pulmonar de mantenimiento (TeleRP), después de una RP inicial intensiva, es superior a la atención habitual para mantener en el tiempo los beneficios logrados por la RP intensiva.Diseño del estudio y métodos: Se realizó un ensayo clínico aleatorizado, pragmático, abierto, multicéntrico, de grupos paralelos. Se crearon 2 grupos al finalizar un programa de RP intensiva en rèc)gimen ambulatorio de 8 semanas de duración. A los pacientes del grupo de intervención (GI) se les proporcionó el equipo de entrenamiento apropiado y se les instruyó para realizar 3 sesiones de entrenamiento semanales y enviar los datos de rendimiento a travèc)s de una aplicación a una plataforma web. Se aconsejó a los pacientes del grupo de control (GC) que hicieran ejercicio regularmente (cuidado habitual).Resultados: Se aleatorizaron 94 pacientes (46 GI, 48 GC). El análisis de covarianza mostró mejoras no significativas en la distancia en la prueba de marcha de 6min (19,9m [IC 95%: ∧4,1/+43,8]) y el cuestionario de enfermedad respiratoria crónica-factor emocional (0,4 puntos [0-0,8]) en el GI. Los modelos lineales mixtos secundarios mostraron mejoras en el GI en las puntuaciones de la sección mental del SF-36 (9,7 [4,0-15,4]) y el cuestionario de enfermedad respiratoria crónica-factor emocional (0,5 puntos [0,2-0,9]), pero no se demostró asociación entre el cumplimiento y los resultados. Las exacerbaciones agudas se asociaron con una disminución marginalmente significativa en la distancia en la prueba de la marcha de 6min de 15,8m (∧32,3/0,8) en los modelos lineales.

Effects of 8-week, interval-based inspiratory muscle training and breathing retraining in patients with generalized myasthenia gravis.

STUDY OBJECTIVE: To assess the effect of interval-based inspiratory muscle training (IMT) combined with breathing retraining (BR) in patients with generalized myasthenia gravis (MG) in a partial home program. DESIGN: A randomized controlled trial with blinding of outcome assessment. SETTING: A secondary-care respiratory clinic. PATIENTS: Twenty-seven patients with generalized MG were randomized to a control group or a training group. INTERVENTIONS: The training group underwent interval-based IMT associated with BR (diaphragmatic breathing [DB] and pursed-lips breathing [PLB]) three times a week for 8 weeks. The sessions included 10 min each of DB, interval-based IMT, and PLB. Interval-based IMT consisted of training series interspersed with recovery time. The threshold load was increased from 20 to 60% of maximal inspiratory pressure (P(Imax)) over the 8 weeks. MEASUREMENTS AND RESULTS: Lung function, respiratory pattern, respiratory muscle strength, respiratory endurance, and thoracic mobility were measured before and after the 8 weeks. The training group improved significantly compared to control group in P(Imax) (p = 0.001), maximal expiratory pressure (P(Emax)) [p = 0.01], respiratory rate (RR)/tidal volume (V(T)) ratio (p = 0.05), and upper chest wall expansion (p = 0.02) and reduction (p = 0.04). Significant differences were seen in the training group compared to baseline P(Imax) (p = 0.001), P(Emax) (p = 0.01), maximal voluntary ventilation (p = 0.02), RR/V(T) ratio (p = 0.003), Vt (p = 0.02), RR (p = 0.01), total time of RR (p = 0.01), and upper chest wall expansion (p = 0.005) and reduction (p = 0.005). No significant improvement was seen in lower chest wall or lung function. CONCLUSIONS: The partial home program of interval-based IMT associated with BR is feasible and effective in patients with generalized MG. Improvements in respiratory muscle strength, chest wall mobility, respiratory pattern, and respiratory endurance were observed.

Acute physiologic effects of nasal and full-face masks during noninvasive positive-pressure ventilation in patients with acute exacerbations of chronic obstructive pulmonary disease.

OBJECTIVE: To assess the efficacy of and patient tolerance for nasal and full-face masks during noninvasive positive-pressure ventilation (NPPV) with patients suffering acute exacerbations of chronic obstructive pulmonary disease. SETTING: A respiratory medicine ward of a referral hospital. METHODS: Fourteen patients were randomized to 2 groups. Seven used nasal masks and 7 used full-face masks. We used a portable ventilator and recorded arterial blood gases and indices of respiratory muscle effort before and after 15 min of NPPV. Patient tolerance was scored as follows: no tolerance (mask had to be withdrawn before the study period ended) = 0 points; poor tolerance (patient complained of discomfort from the ventilation devices but nevertheless remained compliant) = 1 point; fair tolerance (patient seemed uncomfortable but did not complain) = 2 points; excellent tolerance (patient felt better than before beginning NPPV) = 3 points. RESULTS: The groups were comparable in clinical and pulmonary function variables at baseline. NPPV improved both arterial blood gases and the indices of respiratory effort, with no significant differences between the groups. During NPPV the group that used full-face mask had a greater decrease in respiratory rate, but no other differences. NPPV was well tolerated in both groups. CONCLUSIONS: In patients suffering acute exacerbations of chronic obstructive pulmonary disease NPPV improves arterial blood gases and respiratory effort indices regardless of the type of mask used.

Are daytime arterial blood gases a good reflection of nighttime gas exchange in patients on long-term oxygen therapy?

OBJECTIVE: Compare nighttime and daytime arterial blood gas values in patients undergoing long-term oxygen therapy (LTOT). METHODS: We studied 39 LTOT patients with chronic airflow limitation. Oxygen from an oxygen concentrator was administered via nasal prongs until daytime blood oxygen saturation (measured via pulse oximetry [S(pO2)]) was > or = 90%. Arterial blood samples were drawn at 6:00 PM, while the subject breathed room air, and also during oxygen administration at night (3:00 AM), early in the morning (7:00 AM), and at noon. S(pO2) was measured throughout the night. RESULTS: Mean patient age was 70 +/- 7 yr. All patients suffered severe chronic airflow limitation (mean forced expiratory volume in the first second 28 +/- 9% of predicted). The mean oxygen flow administered was 1.41 +/- 0.6 L/min. Mean overnight S(pO2) was 92 +/- 2.5%, with 21.5 +/- 28% of recording time under 90%. There were statistically significant differences between P(aO2), P(aCO2), and pH obtained at 3:00 AM and noon and between 7:00 AM and noon, while the patients breathed the same oxygen concentration. The differences between the 3:00 and 7:00 AM values were not significant. In 23 patients (59%) we observed a P(aCO2) increase > 10 mm Hg and/or a pH decrease to < 7.33 during that period, indicating poor response to LTOT. CONCLUSIONS: Daytime arterial blood gas measurements do not reflect nighttime gas exchange. However, samples taken early in the morning (7:00 AM) do seem to reflect arterial blood gases during the night and can therefore be used for setting and monitoring nighttime oxygen flow.

Ambulatory adaptation to noninvasive ventilation in restrictive pulmonary disease: a randomized trial with cost assessment.

BACKGROUND: Home mechanical ventilation is usually initiated in hospital. However, cost-effectiveness of inpatient set up has never been compared to outpatient adaptation in a randomized design. A Prospective, multicenter, non-inferiority trial was conducted comparing the effectiveness of adaptation to noninvasive mechanical ventilation (NIMV) performed in the ambulatory or hospital setting in patients with chronic respiratory failure secondary to restrictive thoracic disease, obesity-hypoventilation syndrome or neuromuscular disease. METHODS: The study included 53 candidates for NIMV, randomized to ambulatory adaptation (AA) (n = 27) or hospital adaptation (HA) (n = 26). The patients' characteristics were recorded before establishing ventilation and at 1 and 6 months after. The main outcome variable was PaCO2 decrease at 6 months following initiation of NIMV. The direct costs of the two interventions were compared. RESULTS: Before starting NIMV, PaCO2 was 50.4 ± 6.8 mmHg in the AA group and 50.3 ± 5.7 mmHg in the HA group. At 6 months of NIMV use, a significant improvement in PaCO2 relative to baseline was found in both groups: mean (95% CI) PaCO2 decrease was 4.9 (2.3; 7.4) mmHg in AA and 3.3 (1.4; 5.1) mmHg in HA. The direct calculated cost was 1500 euros per patient in AA and 2692 euros per patient in HA. CONCLUSIONS: Adaptation to NIMV in the ambulatory setting is not inferior to hospital adaptation in terms of therapeutic equivalence in stable patients with chronic respiratory failure secondary to restrictive thoracic disease, obesity-hypoventilation syndrome or neuromuscular disease. Outpatient adaptation may represent a cost saving for the healthcare system. CLINICAL TRIAL: Identifier number NCT00698958 at www.clinicaltrials.gov.

Probable hipocalemia secundaria al tratamiento con ceftolozano/tazobactam: a propósito de 3 casos / Hypokalaemia probably associated with ceftolozane/tazobactam treatment: Three case reports

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[Relationship between expiratory muscle dysfunction and dynamic hyperinflation in advanced chronic obstructive pulmonary disease]. / Relación entre disfunción de los músculos espiratorios e hiperinflación dinámica en la EPOC avanzada.

BACKGROUND AND OBJECTIVES: Dynamic hyperinflation (DH) and expiratory flow limitation (EFL) are physiologically linked and seem to be involved in the genesis of dyspnea and the quality of life (QL) impairment in chronic obstructive pulmonary disease (COPD). Advanced COPD patients often show expiratory muscles dysfunction that could be involved in DH development. AIM: Study the relationships between expiratory muscle dysfunction and DH, and their association with dyspnea and QL, in advanced COPD. PATIENTS AND METHODS: In 25 patients we measured lung function, exercise capacity (incremental ergometry and walking test), EFL and end-expiratory lung volume (EELV) at rest and during exercise, respiratory muscles strength and endurance, dyspnea and QL (Saint George Respiratory Questionnaire, SGRQ). RESULTS: The patients (mean FEV(1)=31% predicted) showed a moderate decrease of respiratory muscles strength and endurance. Nineteen patients exhibited EFL at rest and 24 at 70% of maximal workload (W(max)). The EELV increased from rest to 70% W(max) (9% of predicted FVC). At 70% W(max) EELV correlated inversely with the EFL amount (rho=-0.42), the inspiratory and expiratory muscles endurance (rho=-0.43 and -0.42 respectively) and y VO(2max) (rho=-0.52). The EELV increase from resting to 70% W(max) correlated with dyspnea (rho=0.53) and the amount of EFL at 70%W(max) with the activity score of SGRQ. The FEV(1,) expiratory muscles endurance and LFE amount were independent predictors of EELV at 70% W(max). CONCLUSIONS: In advanced COPD a poorer expiratory muscles endurance is related with higher DH during exercise (and lower EFL), which is correlated with higher dyspnea and worse QL.