[Impact of a rescue program on the operability of patients with bronchogenic carcinoma and chronic obstructive pulmonary disease]. / Influencia de un programa de rescate en la decisión quirúrgica en pacientes con carcinoma broncogénico y EPOC.

OBJECTIVE: Bronchogenic carcinoma and chronic obstructive pulmonary disease (COPD) are strongly associated in our setting, occurring together in around 70% of cases. Approximately 60% of COPD patients who require resection for bronchogenic carcinoma are considered unfit for surgery because of seriously impaired lung function. The purpose of this study was to evaluate the extent to which a rescue program could improve lung function in COPD patients who had previously been considered unfit for surgery because of poor lung function. PATIENTS AND METHODS: The study enrolled COPD patients who had not been considered for surgical resection because they had a predicted postoperative forced expiratory volume in 1 second (FEV1) of less than 1 L. All of the patients participated in a 2-week rescue program that involved optimization of drug treatment (inhaled bronchodilators and/or corticosteroids) and intensive respiratory physiotherapy. Lung function was analyzed before and after the program. RESULTS: We evaluated 30 patients (26 men and 4 women) with a mean (SD) age of 66.7 (8.15) years and an initial FEV1 of 1.497 (0.27) mL (FEV1% of 55.7% [20.14%]). None of the patients had respiratory failure (PaO2 of 77.0 [9.4] mm Hg and PaCO2 of 41.6 [2.4] mm Hg). Twenty-four patients (80%) showed significant improvement in lung function (P< .001) after the program and were admitted for resection. Two wedge resections, 18 lobectomies, 2 pneumonectomies, and 2 exploratory thoracotomies were performed (based on oncologic indications). Nineteen of the 24 patients who underwent surgery had no complications. Two patients had prolonged air leaks, 1 empyema, and 1 hemothorax. One patient died from sepsis. CONCLUSIONS: A large number (80%) of COPD patients previously considered unfit for surgical resection because of seriously impaired lung function can be admitted for surgery following an intensive drug and respiratory physiotherapy rescue program.

[Benefits of a home-based pulmonary rehabilitation program for patients with severe chronic obstructive pulmonary disease]. / Beneficios de un programa de rehabilitación respiratoria domiciliaria en pacientes con EPOC grave.

OBJECTIVE: The benefits of a domiciliary program of pulmonary rehabilitation for patients with severe to very severe chronic obstructive pulmonary disease (COPD) are uncertain. We aimed to assess the short- and medium-term efficacy of such a program in this clinical setting. PATIENTS AND METHODS: Patients with severe COPD (stages III-IV, classification of the Global Initiative for Chronic Obstructive Lung Disease) and incapacitating dyspnea (scores 3-5, Medical Research Council [MRC] scale) were randomized to a control or domiciliary rehabilitation group. The 9-week supervised pulmonary rehabilitation program included educational sessions, respiratory physiotherapy, and muscle training in weekly sessions in the patient's home. We assessed the following variables at baseline, 9 weeks, and 6 months: lung function, exercise tolerance (3-minute walk test), dyspnea (MRC score), and health-related quality of life with the Chronic Respiratory Questionnaire (CRQ). RESULTS: Thirty-eight patients with a mean (SD) age of 68 (6) years were enrolled. The mean MRC score was 4 (0.8) and mean forced expiratory volume in 1 second was 29% of reference. Twenty-nine patients completed the study (6 months). Distance covered on the walk test increased significantly in the rehabilitation group (P=.001) and the difference was maintained at 6 months. Dyspnea also improved significantly with rehabilitation (P<.05), but the reduction was not evident at 6 months. Statistically significant improvements in symptoms related to 2 CRQ domains were detected between baseline and 9 weeks: dyspnea (3.1 [0.8] vs 3.6 [0.7]; P=.02) and fatigue (3.7 [0.8] vs 4.2 [0.9]; P=.002). A clinically relevant but not statistically significant change in mastery over disease was detected (from 4.3 to 4.9). All improvements were maintained at 6 months. CONCLUSIONS: Home-based pulmonary rehabilitation for patients with severe to very severe COPD and severe functional incapacity leads to improvements in exercise tolerance and health-related quality of life that are maintained at 6 months.

Continuous home oxygen therapy.

Oxygen therapy is defined as the therapeutic use of oxygen and consists of administering oxygen at higher concentrations than those found in room air, with the aim of treating or preventing hypoxia. This therapeutic intervention has been shown to increase survival in patients with chronic obstructive pulmonary disease (COPD) and respiratory failure. Although this concept has been extended by analogy to chronic respiratory failure caused by respiratory and non-respiratory diseases, continuous oxygen therapy has not been shown to be effective in other disorders. Oxygen therapy has not been shown to improve survival in patients with COPD and moderate hypoxaemia, nor is there consensus regarding its use during nocturnal desaturations in COPD or desaturations caused by effort. The choice of the oxygen source must be made on the basis of criteria such as technical issues, patient comfort and adaptability and cost. Flow must be adjusted to achieve appropriate transcutaneous oxyhaemoglobin saturation correction.

Oxigenoterapia continua domiciliaria / Continuous Home Oxygen Therapy

Se define como oxigenoterapia el uso terapéutico del oxígeno y consiste en su administración a concentraciones mayores de las que se encuentran en el aire ambiente, con la intención de tratar o prevenir las manifestaciones de la hipoxia. Esta medida terapéutica ha demostrado aumentar la supervivencia en los enfermos con enfermedad pulmonar obstructiva crónica (EPOC) e insuficiencia respiratoria. A pesar de que este concepto se ha extendido por analogía a la insuficiencia respiratoria crónica originada por otras enfermedades respiratorias y no respiratorias, la efectividad de la oxigenoterapia continua no está demostrada en otras entidades. La oxigenoterapia no se ha demostrado efectiva en términos de supervivencia en pacientes con EPOC e hipoxemia moderada. Tampoco hay consenso sobre su empleo durante las desaturaciones nocturnas en EPOC y durante las desaturaciones al esfuerzo. La elección de la fuente de oxígeno se debe realizar por criterios técnicos, de comodidad y adaptabilidad del paciente y de coste. Se debería ajustar el flujo para conseguir una adecuada corrección de la saturación transcutánea de oxihemoglobina

Oxygen therapy is defined as the therapeutic use of oxygen and consists of administering oxygen at higher concentrations than those found in room air, with the aim of treating or preventing hypoxia. This therapeutic intervention has been shown to increase survival in patients with chronic obstructive pulmonary disease (COPD) and respiratory failure. Although this concept has been extended by analogy to chronic respiratory failure caused by respiratory and non-respiratory diseases, continuous oxygen therapy has not been shown to be effective in other disorders. Oxygen therapy has not been shown to improve survival in patients with COPD and moderate hypoxaemia, nor is there consensus regarding its use during nocturnal desaturations in COPD or desaturations caused by effort. The choice of the oxygen source must be made on the basis of criteria such as technical issues, patient comfort and adaptability and cost. Flow must be adjusted to achieve appropriate transcutaneous oxyhaemoglobin saturation correction

Long-term oxygen therapy: are we prescribing appropriately?

Long-term oxygen therapy (LTOT) is the treatment proven to improve survival in chronic obstructive pulmonary disease (COPD) patients with chronic respiratory failure. It also appears to reduce the number of hospitalizations, increase effort capacity, and improve health-related quality of life. Standard LTOT criteria are related to COPD patients who have PaO2 < 60 mmHg, are in a clinical stable situation, and are receiving optimal pharmacological treatment. According to LTOT guidelines, oxygen should be prescribed for at least 18 hours per day although some authors consider 24 hours would be more beneficial. The benefits of LTOT depend on correction of hypoxemia. Arterial blood gases should be measured at rest. During exercise, an effort test should be done to assure adequate SaO2. During sleep, continuous monitoring of SaO2 and PaCO2 should be performed to confirm correction of SaO2 overnight. An arterial blood gas sample should be taken at awakening to assess PaCO, in order to prevent hypoventilation from the oxygen therapy. Several issues that need to be addressed are the use of LTOT in COPD patients with moderate hypoxemia, the efficacy of LTOT in patients who desaturate during exercise or during sleep, the optimal dosage of oxygen supplementation, LTOT compliance, and the LTOT prescription in diseases other than COPD.

Beneficios de un programa de rehabilitación respiratoria domiciliaria en pacientes con EPOC grave / Benefits of a home-based pulmonary rehabilitation program for patients with severe Chronic Obstructive Pulmonary Disease

Objetivo: Los beneficios de la rehabilitación respiratoria domiciliaria (RRD) en pacientes con enfermedad pulmonar obstructiva crónica (EPOC) de grado grave-muy grave son controvertidos. Nuestro objetivo ha sido evaluar la eficacia a corto y medio plazo de un programa de RRD en pacientes con EPOC grave. Pacientes y métodos: Se trata de un estudio prospectivo y aleatorizado en pacientes con EPOC grave (estadios III y IV de la clasificación GOLD) y disnea invalidante --puntuación de 3 a 5 en la escala del Medical Research Council (MRC)--, distribuidos en grupo control y grupo RRD. El programa de rehabilitación respiratoria fue de 9 semanas y consistía en educación, fisioterapia respiratoria y entrenamiento muscular con supervisión semanal en domicilio. Evaluamos en situación basal, a las 9 semanas y a los 6 meses la función pulmonar, la capacidad de ejercicio (prueba de la marcha de 3 min), la disnea (MRC) y la calidad de vida relacionada con la salud, determinada con el Chronic Respiratory Questionnaire (CRQ). Resultados: Participaron en el estudio 38 pacientes, con una edad media ± desviación estándar de 68 ± 6 años (puntuación MRC: 4 ± 0,8; volumen espiratorio forzado en el primer segundo: 29% del valor de referencia), y 29 completaron el seguimiento a los 6 meses. En el grupo RRD se incrementó significativamente la distancia recorrida en la prueba de la marcha de 3 min (p = 0,001), resultado que se mantuvo a los 6 meses. La disnea mejoró significativamente tras la RRD (p < 0,05), pero dicha mejoría desapareció a los 6 meses. Se observó una mejoría clínica y estadísticamente significativa en 2 dominios del CRQ, el de disnea (3,1 ± 0,8 frente a 3,6 ± 0,7; p = 0,02) y el de fatiga (3,7 ± 0,8 frente a 4,2 ± 0,9; p = 0,002), y tan sólo clínica (4,3 frente a 4,9) en el control de la enfermedad, mejorías que se mantuvieron a los 6 meses. Conclusiones: La RRD en pacientes con EPOC grave-muy grave y alta incapacidad funcional aporta beneficios en la calidad de vida relacionada con la salud y la capacidad de ejercicio, que pueden mantenerse hasta los 6 meses

Objective: The benefits of a domiciliary program of pulmonary rehabilitation for patients with severe to very severe chronic obstructive pulmonary disease (COPD) are uncertain. We aimed to assess the short- and medium-term efficacy of such a program in this clinical setting. Patients and methods: Patients with severe COPD (stages III-IV, classification of the Global Initiative for Chronic Obstructive Lung Disease) and incapacitating dyspnea (scores 3-5, Medical Research Council [MRC] scale) were randomized to a control or domiciliary rehabilitation group. The 9-week supervised pulmonary rehabilitation program included educational sessions, respiratory physiotherapy, and muscle training in weekly sessions in the patient´s home. We assessed the following variables at baseline, 9 weeks, and 6 months: lung function, exercise tolerance (3-minute walk test), dyspnea (MRC score), and health-related quality of life with the Chronic Respiratory Questionnaire (CRQ). Results: Thirty-eight patients with a mean (SD) age of 68 (6) years were enrolled. The mean MRC score was 4 (0.8) and mean forced expiratory volume in 1 second was 29% of reference. Twenty-nine patients completed the study (6 months). Distance covered on the walk test increased significantly in the rehabilitation group (P=.001) and the difference was maintained at 6 months. Dyspnea also improved significantly with rehabilitation (P<.05), but the reduction was not evident at 6 months. Statistically significant improvements in symptoms related to 2 CRQ domains were detected between baseline and 9 weeks: dyspnea (3.1 [0.8] vs 3.6 [0.7]; P=.02) and fatigue (3.7 [0.8] vs 4.2 [0.9]; P=.002). A clinically relevant but not statistically significant change in mastery over disease was detected (from 4.3 to 4.9). All improvements were maintained at 6 months. Conclusions: Home-based pulmonary rehabilitation for patients with severe to very severe COPD and severe functional incapacity leads to improvements in exercise tolerance and health-related quality of life that are maintained at 6 months

Influencia de un programa de rescate en la decisión quirúrgica en pacientes con carcinoma broncogénico y EPOC / Impact of a rescue program on the operability of patients with bronchogenic carcinoma and chronic obstructive pulmonary disease

Objetivo: La asociación entre carcinoma broncogénico y enfermedad pulmonar obstructiva crónica (EPOC) se sitúa en torno al 70% en nuestro medio. Aproximadamente un 60% de los pacientes con dichos diagnósticos son rechazados para cirugía de resección del carcinoma broncogénico debido a la intensa alteración de su función pulmonar. El objetivo del presente trabajo es evaluar el efecto de un programa de rescate en la mejoría de la función pulmonar de pacientes con EPOC y previamente descartados para cirugía por la alteración de su función pulmonar. Pacientes y métodos: Se incluyó en el estudio a pacientes con EPOC descartados inicialmente porque se había calculado que su volumen espiratorio forzado en el primer segundo (FEV1) tras la intervención quirúrgica sería menor de 1 l. Todos ellos participaron en un programa de rescate de 2 semanas de duración que incluía: optimización del tratamiento farmacológico (broncodilatadores inhalados y/o corticoides) y fisioterapia respiratoria intensiva. Se analizó la función pulmonar antes y después del programa. Resultados: Se evaluó a 30 pacientes (26 varones y 4 mujeres) con una edad media ± desviación estándar de 66,7 ± 8,15 años y FEV1 inicial de 1,497 ± 0,27 ml (FEV1%: 55,7 ± 20,14 l), que no presentaban insuficiencia respiratoria (presión arterial de oxígeno: 77,0 ± 9,4 mmHg; presión arterial de anhídrido carbónico: 41,6 ± 2,4 mmHg). Tras el programa 24 pacientes (80%) pudieron ser aceptados para la resección propuesta al objetivarse una mejoría significativa en la función pulmonar (p < 0,001). Se realizaron 2 resecciones en cuña, 18 lobectomías, 2 neumonectomías y 2 toracotomías exploradoras (por criterios oncológicos). De los 24 pacientes a los que se intervino, en 19 no hubo complicaciones, 2 presentaron fugas aéreas mantenidas, hubo un caso de empiema pleural y otro de hemotórax. Un paciente falleció por sepsis. Conclusiones: El diseño de un programa intensivo farmacológico y de fisioterapia respiratoria permite rescatar para cirugía a un número alto (80%) de los pacientes con EPOC a los que inicialmente se descarta por una alteración importante de la función pulmonar

Objective: Bronchogenic carcinoma and chronic obstructive pulmonary disease (COPD) are strongly associated in our setting, occurring together in around 70% of cases. Approximately 60% of COPD patients who require resection for bronchogenic carcinoma are considered unfit for surgery because of seriously impaired lung function. The purpose of this study was to evaluate the extent to which a rescue program could improve lung function in COPD patients who had previously been considered unfit for surgery because of poor lung function. Patients and methods: The study enrolled COPD patients who had not been considered for surgical resection because they had a predicted postoperative forced expiratory volume in 1 second (FEV1) of less than 1 L. All of the patients participated in a 2-week rescue program that involved optimization of drug treatment (inhaled bronchodilators and/or corticosteroids) and intensive respiratory physiotherapy. Lung function was analyzed before and after the program. Results: We evaluated 30 patients (26 men and 4 women) with a mean (SD) age of 66.7 (8.15) years and an initial FEV1 of 1.497 (0.27) mL (FEV1% of 55.7% [20.14%]). None of the patients had respiratory failure (PaO2 of 77.0 [9.4] mm Hg and PaCO2 of 41.6 [2.4] mm Hg). Twenty-four patients (80%) showed significant improvement in lung function (P<.001) after the program and were admitted for resection. Two wedge resections, 18 lobectomies, 2 pneumonectomies, and 2 exploratory thoracotomies were performed (based on oncologic indications). Nineteen of the 24 patients who underwent surgery had no complications. Two patients had prolonged air leaks, 1 empyema, and 1 hemothorax. One patient died from sepsis. Conclusions: A large number (80%) of COPD patients previously considered unfit for surgical resection because of seriously impaired lung function can be admitted for surgery following an intensive drug and respiratory physiotherapy rescue program

Serie 2: EPOC y músculos periféricos / Serie 2: Chronic obstructive pulmonary disease and peripheral muscles

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