Repercusiones pulmonares en pacientes con pectus excavatum: puesta al día / Pulmonary consequences on patients with pectus excavatum: update / Repercussões pulmonares em pacientes com pectus excavatum: atualização

El pectus excavatum (PEX) es una deformación de la pared torácica que obedece a una alteración de los cartílagos costales con el consiguiente hundimiento del esternón. Históricamente se clasificaba como un defecto únicamente estético o cosmético, sin embargo en los últimos años se han desarrollado nuevos métodos de estudio para la valoración de las repercusiones de esta patología, y existe cada vez más bibliografía que demuestra importantes repercusiones funcionales. Se realizó una puesta al día de las repercusiones pulmonares de la patología y análisis de los artículos más relevantes de los últimos años. Los síntomas respiratorios son frecuentes, estando presentes en más de la mitad de los pacientes. Se ha demostrado una disminución de la CVF, VEF1 y PEF25%-75%; así como la presencia de un patrón restrictivo y/o obstructivo, un aumento del VR y una alteración de la dinámica respiratoria. Se ha objetivado la afectación del PEX sobre la función pulmonar, determinando categóricamente que esta patología presenta una importante repercusión funcional.

Pectus excavatum (PEX) is a thoracic wall malformation due to an alteration of the costal cartilages with subsequent sinking of the sternum. Historically, it was considered a mere aesthetic or cosmetic defect, however, in recent years, new assessment methods have been developed to evaluate the repercussions of this pathology, and there is an increasing literature that demonstrates important functional consequences. We carried out an update of this pathology's pulmonary repercussions and analyzed the most relevant articles of the recent years. Respiratory symptoms are frequent, present in more than half of the patients. A decrease in FVC, FEV1 and PEF25%-75% has been shown; as well as the presence of a restrictive and/or obstructive pattern, an increase in RV and an alteration in respiratory dynamics. The affectation of PEX on pulmonary function has been objectified, and it has been determined categorically that this pathology has important functional consequences.

Pectus excavatum (PEX) é uma deformação da parede torácica devido a uma alteração das cartilagens costais com consequente afundamento do esterno. Historicamente, foi classificado como um defeito exclusivamente estético ou cosmético, porém, nos últimos anos, novos métodos de estudo foram desenvolvidos para avaliar as repercussões dessa patologia, e há uma literatura crescente que demonstra importantes repercussões funcionais. Foi realizada uma atualização das repercussões pulmonares da patologia e análise dos artigos mais relevantes dos últimos anos. Os sintomas respiratórios são frequentes, estando presentes em mais da metade dos pacientes. Foi demonstrada uma diminuição da CVF, VEF1 e PEF25-75%; bem como a presença de padrão restritivo e/ou obstrutivo, aumento do VD e alteração da dinâmica respiratória. A afetação do PEX na função pulmonar tem sido objetivada, determinando categoricamente que esta patologia apresenta importante repercussão funcional.

Lack of Kcnn4 improves mucociliary clearance in muco-obstructive lung disease.

Airway mucociliary clearance (MCC) is the main mechanism of lung defense keeping airways free of infection and mucus obstruction. Airway surface liquid volume, ciliary beating, and mucus are central for proper MCC and critically regulated by sodium absorption and anion secretion. Impaired MCC is a key feature of muco-obstructive diseases. The calcium-activated potassium channel KCa.3.1, encoded by Kcnn4, participates in ion secretion, and studies showed that its activation increases Na+ absorption in airway epithelia, suggesting that KCa3.1-induced hyperpolarization was sufficient to drive Na+ absorption. However, its role in airway epithelium is not fully understood. We aimed to elucidate the role of KCa3.1 in MCC using a genetically engineered mouse. KCa3.1 inhibition reduced Na+ absorption in mouse and human airway epithelium. Furthermore, the genetic deletion of Kcnn4 enhanced cilia beating frequency and MCC ex vivo and in vivo. Kcnn4 silencing in the Scnn1b-transgenic mouse (Scnn1btg/+), a model of muco-obstructive lung disease triggered by increased epithelial Na+ absorption, improved MCC, reduced Na+ absorption, and did not change the amount of mucus but did reduce mucus adhesion, neutrophil infiltration, and emphysema. Our data support that KCa3.1 inhibition attenuated muco-obstructive disease in the Scnn1btg/+ mice. K+ channel modulation may be a therapeutic strategy to treat muco-obstructive lung diseases.

Vitamin D deficiency is independently associated with mortality among critically ill patients

OBJECTIVE: Studies suggest an association between vitamin D deficiency and morbidity/mortality in critically ill patients. Several issues remain unexplained, including which vitamin D levels are related to morbidity and mortality and the relevance of vitamin D kinetics to clinical outcomes. We conducted this study to address the association of baseline vitamin D levels and vitamin D kinetics with morbidity and mortality in critically ill patients. METHOD: In 135 intensive care unit (ICU) patients, vitamin D was prospectively measured on admission and weekly until discharge from the ICU. The following outcomes of interest were analyzed: 28-day mortality, mechanical ventilation, length of stay, infection rate, and culture positivity. RESULTS: Mortality rates were higher among patients with vitamin D levels <12 ng/mL (versus vitamin D levels >12 ng/mL) (32.2% vs. 13.2%), with an adjusted relative risk of 2.2 (95% CI 1.07-4.54; p< 0.05). There were no differences in the length of stay, ventilation requirements, infection rate, or culture positivity. CONCLUSIONS: This study suggests that low vitamin D levels on ICU admission are an independent risk factor for mortality in critically ill patients. Low vitamin D levels at ICU admission may have a causal relationship with mortality and may serve as an indicator for vitamin D replacement among critically ill patients. .

Low serum levels of alpha1 anti-trypsin (α1-AT) and risk of airflow obstruction in non-primary α1-AT-deficient patients with compensated chronic liver disease.

BACKGROUND: Alpha1 anti-trypsin (α1-AT), a serine protease inhibitor synthesized in the liver, is a major circulating antiprotease that provides defense against proteolytic damage in several tissues. Its deficiency is associated with airflow obstruction. The present study aimed to explore the role of α1-AT as a biomarker of airflow performance in chronic liver disease (CLD). MATERIAL/METHODS: Serum α1-AT levels and lung function (spirometry) were evaluated in non-primary α1-AT-deficient, alcoholic CLD patients without evident respiratory limitations. RESULTS: Thirty-four patients with airflow obstruction (n=11), airflow restriction (n=12), and normal airflow (n=11, age-matched controls) were eligible. α1-AT was decreased in the airflow obstruction group. ROC-cutoff α1-AT=24 mg/dL effectively discriminated airflow obstruction (AUC=0.687) and was associated with a 10-fold higher risk (p=0.0007). CONCLUSIONS: Lower α1-AT increased the risk of airflow obstruction in CLD patients without primary α1-AT deficiency.

Obstructive lung disease in children with idiopathic scoliosis.

OBJECTIVE: To measure the prevalence of obstructive lung disease (OLD) among patients undergoing preoperative pulmonary assessment for idiopathic scoliosis. STUDY DESIGN: This was a retrospective, descriptive review from clinical data in a tertiary care pediatric hospital in the US. Patients (n = 176) with idiopathic scoliosis with Cobb angles of ≥ 40 degrees who performed acceptable and repeatable preoperative pulmonary function testing were included. The primary outcome measure was the forced expiratory volume in the first second (FEV1)/forced vital capacity (FVC) ratio. RESULTS: The prevalence of OLD (low FEV1/FVC ratio) was 39% (68/176 patients). In multivariate modeling, radiographic measures were poor predictors of pulmonary function outcomes of FVC (r(2) 0.06), FEV1 (r(2) 0.05), FEV1/FVC ratio (r(2) 0.08), and total lung capacity (r(2) 0.06). CONCLUSIONS: OLD is common in patients with idiopathic scoliosis. We recommend preoperative pulmonary function testing for patients with idiopathic scoliosis under consideration for spinal fusion surgery.

Relationship between insulin-like growth factor I levels, early insulin treatment, and clinical outcomes of very low birth weight infants.

OBJECTIVES: Insulin regulates the secretion of insulin-like growth factor I (IGF-I) in the newborn, and low levels of IGF-I have been linked to neonatal morbidity. As part of the Neonatal Insulin Replacement Therapy in Europe Trial, we investigated the impact of early insulin treatment on IGF-I levels and their relationship with morbidity and growth. STUDY DESIGN: Prospective cohort analyses of data collected as part of an international randomized controlled trial. Blood samples (days 1, 3, 7, and 28), were taken for IGF-I bioassay from 283 very low birth weight infants (<1500 g). RESULTS: Early insulin treatment led to a late increase in IGF-I levels between day 7 and 28 (P = .028). In the first week of life IGF-I levels were lower in infants with early hyperglycemia; mean difference -0.10 µg/L (95% CI -0.19, -0.02, P = .02). Lower levels of IGF-I at day 28 were independently associated with an increased risk of chronic lung disease, OR 3.23 (95% CI, 1.09-9.10), and greater IGF-I levels were independently associated with better weight gain, 0.10 kg (95% CI, 0.03-0.33, P = .02). CONCLUSIONS: Early intervention with insulin is related to increased IGF-I levels at 28 days. Low IGF-I levels are associated with hyperglycemia, increased morbidity, and reduced growth. Increasing IGF-I levels may improve outcomes of very low birth weight infants.

Tabacosis, un cambio de terminología para un aumento de conciencia / Tabacosis, a change in therminology for an increase increase in consciousness

Ante la ausencia de definición categórica de la Real Academia Española, tenemos que la Enfermedad Pulmonar Obstructiva Crónica (EPOC) es prevenible y tratable, con afectación sistémica extrapulmonar, donde el componente pulmonar se caracteriza por limitación al flujo del aire que no es completamente reversible y es progresivo. Esta es probablemente una de la definiciones médicas con mayor cantidad de posiciones e intereses encontrados y es que, indudable y lastimosamente, las siglas EPOC, fueron del gremio médico, no tiene mayor significancia, pues diariamente se encuentra gran cantidad de pacientes portadores de esta patología, que no tiene noción real de su padecimiento, el cual con mucho costo es aclarado por el médico tratante, debido a lo engorroso de su significado, variedad de síntomas y múltiples patologías causadas. Estas vicisitudes, en cuanto a la patología causal de EPOC, son las que la han convertido en el "cajón" donde se colocan diversas neumopatías que no tienen un origen específico, sin importar si presenta o no obtrucción al flujo aéreo; además, estos inconvenientes sobre terminología, hacen dificultosa la realización de búsquedas bibliográcas, por la poca acogida que ha tenido el término.

[Pulmonary tuberculosis: association between extent of the residual pulmonary lesion and alteration in the lung function]. / Tuberculose pulmonar: associação entre extensão de lesão pulmonar residual e alteração da função pulmonar.

OBJECTIVE: To describe alterations in spirometric variables and its disturbances and to study the existence of a relationship between extent of the residual lung lesion at the end of treatment for tuberculosis and alteration of the lung function measured by spirometry. METHODS: Analyzed were 96 patients with diagnosis of pulmonary tuberculosis, treated in three health centers in the metropolitan area of Recife, from January, 2003 to November, 2005. Patients of both genders, 15 years of age or older were included, whose chest x-rays at end of the treatment were classified according to criteria of the National Tuberculosis Association (NTA) for extent of lung lesion. Patients replied to a questionnaire at the beginning of the survey, and were submitted to spirometry after conclusion of treatment. RESULTS: Of the 96 patients, 89.6% presented with radiographic sequels. About 54% had moderate to severe sequels. These radiographic alterations correspond to 24.6% and 73.8% respectively of alterations in the pulmonary function. CONCLUSION: The large number of residual radiographic lesionss (89.6%) and breathing dysfunction (66,7%) identified in this survey call attention to the fact that treatment of a patient with pulmonary tuberculosis must not be restricted to bacteriological healing of the disease. Identification of the residual lung lesions and of the breathing dysfunction in patients who conclude treatment will promote early actions to treat these sequels, improving the quality of life of these patients.

Tuberculose pulmonar: associação entre extensão de lesão pulmonar residual e alteração da função pulmonar / Pulmonary tuberculosis: association between extent of the residual pulmonary lesion and alteration in the lung function

OBJETIVO: Descrever as alterações nas variáveis da espirometria e seus distúrbios; estudar a existência de associação entre a extensão da lesão pulmonar residual ao final do tratamento da tuberculose e a alteração da função pulmonar aferida pela espirometria. MÉTODOS: Estudou-se uma série de 96 pacientes com diagnóstico de tuberculose pulmonar, atendidos em três unidades de saúde de Região Metropolitana do Recife, durante o período de janeiro de 2003 a novembro de 2005. Foram analisados pacientes de ambos os sexos, com idade a partir de 15 anos, cujas radiografias do tórax do final do tratamento foram classificadas pelo critério da National Tuberculosis Association (NTA). Os pacientes responderam questionário, no início da pesquisa, e foram submetidos à prova de função pulmonar, após o término do tratamento. RESULTADOS: Dos 96 pacientes estudados, concluímos que 89,6 por cento apresentavam seqüelas radiográficas; 54 por cento apresentavam seqüelas moderadas a graves. Estas alterações radiográficas correspondiam a 24,6 por cento e 73,8 por cento, respectivamente, de alterações na função pulmonar. CONCLUSÃO: Foram identificadas 89,6 por cento de lesões residuais radiográficas, enquanto 66,7 por cento das disfunções respiratórias alertam para o fato de que a assistência ao paciente com tuberculose pulmonar não deve se restringir apenas à cura baciloscópica da doença. A identificação de lesões pulmonares residuais e disfunções respiratórias em pacientes que concluem o tratamento da tuberculose permitirão instituir medidas precoces de tratamento dessas seqüelas para uma melhor qualidade de vida.

OBJECTIVE: To describe alterations in spirometric variables and its disturbances and to study the existence of a relationship between extent of the residual lung lesion at the end of treatment for tuberculosis and alteration of the lung function measured by spirometry. METHODS: Analyzed were 96 patients with diagnosis of pulmonary tuberculosis, treated in three health centers in the metropolitan area of Recife, from January, 2003 to November, 2005. Patients of both genders, 15 years of age or older were included, whose chest x-rays at end of the treatment were classified according to criteria of the National Tuberculosis Association (NTA) for extent of lung lesion. Patients replied to a questionnaire at the beginning of the survey, and were submitted to spirometry after conclusion of treatment. RESULTS: Of the 96 patients, 89.6 percent presented with radiographic sequels. About 54 percent had moderate to severe sequels. These radiographic alterations correspond to 24.6 percent and 73.8 percent respectively of alterations in the pulmonary function. CONCLUSION: The large number of residual radiographic lesionss (89.6 percent) and breathing dysfunction (66,7 percent) identified in this survey call attention to the fact that treatment of a patient with pulmonary tuberculosis must not be restricted to bacteriological healing of the disease. Identification of the residual lung lesions and of the breathing dysfunction in patients who conclude treatment will promote early actions to treat these sequels, improving the quality of life of these patients.

La relación entre el asma y la enfermedad pulmonar obstructiva crónica / The relation between the asthma and chronic respiratory pulmonary disease

Asma y enfermedad pulmonar obstructiva crónica (EPOC) son enfermedades pulmonares comunes con semejanza y diferencias. Estudios genéticos recientes han dado información importante acerca de los múltiples loci susceptibles para cada enfermedad. Estudios del genoma han mostrado resultados similares en al menos una región crosomal en ambas enfermedades, así como también evidencia la interacción con factores ambientales (por ejemplo, el fumado activo en los pacientes con EPOC, o el pasivo en aquellos con asma). Existen pocos estudios recientes acerca del remodelamiento de la vía aérea y su importancia en pacientes asmáticos persistentes crónicos, lo que podría explicar de cierta forma la progresión de estas personas a enfermedades pulmonares obstructivas crónicas.

Importancia del cálculo de la diferencia alveolo. Artrial de oxigeno en la enfermedad pulmonar obstructiva crónica (EPOC) en la altura / Importance of the calculation of the difference alveolo. Artrial of I oxygenate in the pulmonary disease obstructiva chronicle (EPOC) in altura

Es un trabajo descriptivo realizado en el Instituto Boliviano de Biología de Altura, en la ciudad de La Paz, que aplica el cálculo del gradiente alveoloarterial de oxígeno (P(A-a)02), en la altura, para valorar la alteración de la Relación Ventilación Perfusión (V/Q), principal alteración funcional en la mayoría de las patologías englobadas en la Enfermedad Pulmonar Obstructiva Crónica (EPOC). El gradiente alveoloarterial de oxigeno a una presión barométrica de 495 mmHg es de 6,5 mmHg. Se estudiaron 111 pacientes con diagnóstico de EPOC, EPI, Asma Ocupacional y apnea del sueño, de los que se reviso las historias clínicas, y sus gasometríasd de pacientes, patologías en las que la alteración funcional principal, esta en la relacion V/Q. De cada uno de ellos se analizó su gasometría arterial en reposo y en hiperoxia y se calculo el gradiente alveoloarterial de óxigeno a partir de la gasometría en reposo. El cálculo del gradiente alveiolo arterial de Oxígeno nospermite evaluar con presión la alteración de la relación ventilación perfusión en pacintes con EPOC, EPI, Apnea de Sueño y Asma Ocupacional. Es cálculo es sencillo, que evita tener que someter al paciente a técnicas invasivas (preuba de la hiperoxia). Permite valorar y analizar las alteraciones del intecambio gaseoso, y de la relación V/Q en pacientes de UTI o sometidos a una ventilación mecánica.

Relação entre o fluxo gastroesofágico e doença pulmonar obstrutiva crônica / Relationship between gastroesophageal reflux disease and chronic obstrutive pulmonary disease

Refluxo gastroesofágico patológico é entidade frequente na população geral. Ocorre associada a queixas digestivas e extradigestivas como cardíacas, respiratórias e otorrinolaringológicas assim como na forma assintomática. Embora a correlação de RGE com doenças respiratórias tenha tido relatos frequentes , o mesmo não ocorreu com DPOC .Foram estudados 29 pacientes ambulatoriais portadores de DPOC através de questionário, pHmetria esofágica distal e proximal durante 24 hs e medidas de função pulmonar. Encontrou-se 57 por cento de RGE patológicos proximais e distais. Significância estatistíca (p < 0,05) foi observada entre o Indice de Massa Corpórea (IMC) e RGE proximal. Concluiu-se que o RGE patológico foi expressivo em DPOC e não houve correlação entre as queixas otorrinolaringológicas e RGE proximal como relatado na literatura.Pathological gastroesophageal reflux is a very frequent condition among general population.It can be found in assimptomatic patients or related to digestive, cardiac, respiratory and otorhinolaringological complains.Although there were many reports concerning to respiratory diseases and GERD ,the relationship between GERD and COPD is not well established. 29 out patients with COPD were studied. Questionnaires were answered, esophageal distal and proximal pHmonitorings were performed during 24 hours as well as respiratory functional tests. Proximal and distal pathological refluxes were registered in 57 per cent of all patients. Statistical significance (p < 0.05) was observed concerning to proximal pathological reflux and body mass index. COPD has a high prevalence of GERD. Otorhinolaringological symptoms were not correlated to proximal reflux as previously reported...

Edema pulmonar postobstructivo: reporte de 3 casos / Postobstructive pulmonary edema: report 3 cases

El edema pulmonar postobstructivo (EPPO) es una complicación postoperatoria cuyo manejo adecuado depende de un diagnóstico etiológico correcto. El EPPO se clasifica en dos tipos. El tipo I es secundario a la obstrucción aguda de la vía aérea superior. Por su parte, el tipo II ocurre luego de corregir quirúrgicamente una obstrucción crónica de la vía aérea. Fisiopatológicamente, el mecanismo que explica el cuadro es una disminución marcada de la presión intersticial en el nivel pericapilar pulmonar resultante de la inspiración forzada. Lo anterior produce fuga capilar y el consecuente edema de pulmón. El manejo de este cuadro requiere de soporte respiratorio que incluye ventilación mecánica e incluso presión positiva al final de la espiración (PEEP). El pronóstico es muy bueno si el diagnóstico es correcto y oportuno. Se reportan 3 casos que ilustran la entidad, su diagnóstico y manejo. Descriptores: Edema pulmonar postobstructivo, complicación postoperatoria.

Agentes físicos en el tratamiento de la enfermedad pulmonar obstructiva crónica / Physical agents in the treatment of chronic obstructive pulmonary disease

Se hizo una revisión bibliográfica relacionada con el efecto de los agentes físicos sobre la enfermedad pulmonar obstructiva crónica. Se observó que los agentes de mayor influencia positiva sobre esta afección fueron: el calor infrarrojo, el ultrasonido, la diatermia, la ultra alta frecuencia, la magnetoterapia, el láser y el masaje vibratorio. En experiencias obtenidas en la aplicación fisioterapéutica de estos agentes, se ha comprobado beneficios en la conductancia aérea intrapulmonar

Correlation between respiratory function tests and evolution time in asthmatic patients.

A transversal and prospective study was performed to demonstrate a relationship between the evolution time of asthma episodes and alterations observed in the respiratory function tests (RFT) during asymptomatic periods. Asthmatic patients (n = 80) of both sexes, were studied, we investigated the evolution time of the asthmatic episodes and performed RFTs in the patients during their asymptomatic periods. Respiratory patterns were classified as normal, obstructive, or mixed (obstructive-restrictive), and a Spearman correlation test was performed. Twenty nine patients were male and fifty one female. All were between 5 and 49 years of age. Of the total number of patients, 13.7% fell into a normal pattern, 57.5% into an obstructive pattern and 28.7% in a mixed pattern. In the groups showing the shortest evolution time, the obstructive pattern was more common (75% of patients with less than 5 years of evolution time and 53.8% with an evolution time between five and ten years). The mixed pattern was more common in patients with more years suffering asthma (16.6% in the group of patients having 5 or less years of evolution and 50% in the group with more than 20 years). We found a Spearman value of 0.7, and we can conclude that there is more pulmonary damage associated to a longer evolution period of bronchial asthma.