Agreement between a simple dyspnea-guided treatment algorithm for stable COPD and the GOLD guidelines: a pilot study.

INTRODUCTION: Guidelines recommendations for the treatment of COPD are poorly followed. This could be related to the complexity of classification and treatment algorithms. The purpose of this study was to validate a simpler dyspnea-based treatment algorithm for inhaled pharmacotherapy in stable COPD, comparing its concordance with the current Global Initiative for Obstructive Lung Disease (GOLD) guideline. METHODS: We enrolled patients who had been diagnosed with COPD in three primary care facilities and two tertiary hospitals in Spain. We determined anthropometric data, forced expiratory volume in the 1st second (percent), exacerbations, and dyspnea based on the modified Medical Research Council scale. We evaluated the new algorithm based on dyspnea and exacerbations and calculated the concordance with the current GOLD recommendations. RESULTS: We enrolled 100 patients in primary care and 150 attending specialized care in a respiratory clinic. There were differences in the sample distribution between cohorts with 41% vs 26% in grade A, 16% vs 12% in grade B, 16% vs 22% in grade C, and 27% vs 40% in grade D for primary and respiratory care, respectively (P=0.005). The coincidence of the algorithm with the GOLD recommendations in primary care was 93% and 91.8% in the respiratory care cohort. CONCLUSION: A simple dyspnea-based treatment algorithm for inhaled pharmacotherapy of COPD could be useful in the management of COPD patients and concurs very well with the recommended schema suggested by the GOLD initiative.

Pulmonary Arterial Hypertension in Systemic Lupus Erythematosus: Prevalence and Predictors.

OBJECTIVE: Pulmonary arterial hypertension (PAH) prevalence has been reported to be between 0.5% and 17% in systemic lupus erythematosus (SLE). This study assessed PAH prevalence and predictors in an SLE cohort. METHODS: The Borg dyspnea scale, DLCO, N-terminal pro-brain natriuretic peptide (NT-proBNP), and Doppler echocardiographic (DE) were performed. An echocardiographic Doppler exercise test was conducted in selected patients. When DE systolic pulmonary arterial pressure was ≥ 45 mmHg or increased during exercise > 20 mmHg, a right heart catheterization was performed. Hemodynamic during exercise was measured if rest mean pulmonary arterial pressure was < 25 mmHg. RESULTS: Of the 203 patients with SLE, 152 were included. The mean age was 44.9 ± 12.3 years, and 94% were women. Three patients had known PAH. The algorithm diagnosed 1 patient with chronic thromboembolic pulmonary hypertension and 5 with exercise-induced pulmonary artery pressure increase (4 with occult left diastolic dysfunction). These patients had significantly more dyspnea, higher NT-proBNP, and lower DLCO. CONCLUSION: These data confirm the low prevalence of PAH in SLE. In our cohort, occult left ventricular diastolic dysfunction was a frequent diagnosis of unexplained dyspnea. Dyspnea, DLCO, and NT-proBNP could be predictors of pulmonary hypertension in patients with SLE.

Prevalencia de enfermedad pulmonar obstructiva crónica en las Islas Canarias / Prevalence of Chronic Obstructive Pulmonary Disease in the Canary Islands

Introducción: La prevalencia de la enfermedad pulmonar obstructiva crónica (EPOC) varía considerablemente entre las diferentes áreas geográficas estudiadas. En España hay 2 estudios epidemiológicos que muestran una prevalencia entre el 9 y el 10% en población mayor de 40 años. No obstante, ninguno de ellos ha incluido a las Islas Canarias, región de interés por sus características climáticas y su alta prevalencia de tabaquismo. Material y métodos: A partir de una muestra poblacional de 596.478 personas se seleccionó una muestra aleatorizada de 1.353 individuos entre 40 y 70 años. Los participantes rellenaron un cuestionario y posteriormente realizaron una espirometría con test de broncodilatación si existía obstrucción. Se diagnosticó EPOC cuando el cociente FEV1/FVC después de la broncodilatación era menor de 0,70. Resultados: La prevalencia de EPOC fue del 7,3% (IC 95%: 5,5-9,5), siendo mayor en varones que en mujeres (8,7% vs. 6,3%, p = 0,134). La tasa de tabaquismo fue del 29,4% (IC 95%: 25,4-33,1), también mayor en los varones que en las mujeres (35,1% vs 25,4%, p < 0,001). La prevalencia de EPOC estratificada según la gravedad de la obstrucción, en base a los criterios GOLD, fue del 16% en el grupo I , del 69,9% en el II , del 10,4% en el III y del 3,3% en el IV . El infradiagnóstico fue del 71,6% y el infratratamiento, del 63,5%. Conclusiones: A pesar de tener una de las tasas de tabaquismo más altas de España, la prevalencia de EPOC en las Islas Canarias es menor que en la mayoría de las zonas españolas estudiadas

Introduction: The prevalence of chronic obstructive pulmonary disease (COPD) varies significantly among the different geographical areas reported. In Spain, two epidemiological studies have shown a prevalence of 9-10% in the population aged over 40. However, neither of these studies included the Canary Islands, which are of interest due to their climatic conditions and high incidence of smoking. Materials and methods: A random group of 1353 subjects aged between 40 and 70 years was selected from a sample population of 596 478 individuals. Participants completed a questionnaire and then performed spirometry with bronchodilator testing if obstruction was observed. COPD was diagnosed when the post-bronchodilator FEV1/FVC ratio was less than 0.70. Results: The prevalence of COPD was 7.3% (95%CI: 5.5-9.5) and was higher in males than in females (8.7% vs 6.3%, P = .134). The incidence of smoking was 29.4% (95%CI: 25.4-33.1) and was also higher in males than in females (35.1% vs 25.4%, P < 0.001). The prevalence of COPD stratified by severity of obstruction, according to the GOLD criteria, was 16% in group I, 69.9% in group II, 10.4% in group III and 3.3% in group IV. 71.6% of the subjects were underdiagnosed and 63.5% undertreated. Conclusions: Despite having one of the highest rates of smoking in Spain, the prevalence of COPD in the Canary Islands is lower than in most of the Spanish regions studied

Prevalence of chronic obstructive pulmonary disease in the Canary Islands.

INTRODUCTION: The prevalence of chronic obstructive pulmonary disease (COPD) varies significantly among the different geographical areas reported. In Spain, two epidemiological studies have shown a prevalence of 9-10% in the population aged over 40. However, neither of these studies included the Canary Islands, which are of interest due to their climatic conditions and high incidence of smoking. MATERIALS AND METHODS: A random group of 1,353 subjects aged between 40 and 70years was selected from a sample population of 596,478 individuals. Participants completed a questionnaire and then performed spirometry with bronchodilator testing if obstruction was observed. COPD was diagnosed when the post-bronchodilator FEV1/FVC ratio was less than 0.70. RESULTS: The prevalence of COPD was 7.3% (95%CI: 5.5-9.5) and was higher in males than in females (8.7% vs. 6.3%, P=.134). The incidence of smoking was 29.4% (95%CI: 25.4-33.1) and was also higher in males than in females (35.1% vs 25.4%, P<.001). The prevalence of COPD stratified by severity of obstruction, according to the GOLD criteria, was 16% in groupi, 69.9% in groupii, 10.4% in groupiii and 3.3% in groupiv. 71.6% of the subjects were underdiagnosed and 63.5% undertreated. CONCLUSIONS: Despite having one of the highest rates of smoking in Spain, the prevalence of COPD in the Canary Islands is lower than in most of the Spanish regions studied.

Prevalence of sensitization to Blomia tropicalis among young adults in a temperate climate.

BACKGROUND: There are no previous population-based studies assessing the prevalence of Blomia tropicalis (BT). This investigation analyzes the prevalence of sensitization to BT and its contribution to asthma and related diseases among young adults in the Canary Islands. MATERIAL AND METHODS: From a random sample of 9506 adults, aged between 20 and 44, who had previously answered a short respiratory questionnaire, a further 20% random sample was drawn. All participants filled in an extensive questionnaire, and they underwent spirometry and bronchial hyperresponsiveness (BHR) test and skin testing to several allergens as well as the determination of total IgE and specific IgE. RESULTS: The prevalence of positive skin tests to BT was 13.8% (95% confidence interval [CI] 10.6-17.9%) and that of BT-specific IgE 17.9% (95% CI 14.2-24.5%). Sensitization to BT (positive skin tests or positive specific IgE) was 20.9% (95% CI 16.9-25.5%). Most of the subjects sensitized to BT were also sensitized to Dermatophagoides pteronissimus; however, only 7% displayed monosensitization to BT. Among subjects who exhibited BHR, sensitization to BT reached 46.7% (95% CI 32.7-60.9%), among those with asthma 50% (95% CI 26.8-73.2%), in subjects with rhinitis 37.2% (95% CI 28.1-47.6%), and in those suffering from dermatitis 25.9% (95% CI 18.7-34.5%). A strong association of BT sensitization with BHR and asthma before and after 15 years was found. CONCLUSION: The prevalence of sensitization to BT among young adults in the Canary Islands is high, and it displays a close relationship with allergic respiratory diseases and dermatitis.

Long-term cardiopulmonary function after thoracic sympathectomy: comparison between the conventional and simplified techniques.

OBJECTIVE: We sought to compare the long-term effects of conventional and simplified thoracic sympathectomy on cardiopulmonary function. METHODS: We performed a prospective and randomized study of 32 patients with diagnoses of primary hyperhidrosis who were candidates for either conventional or simplified thoracic sympathectomy. Patients were randomized according to the type of procedure: conventional thoracic sympathectomy (18 patients) and simplified thoracic sympathectomy (14 patients). Before surgical intervention, forced spirometry, body plethysmography, measurement of the diffusing capacity of the lung for carbon monoxide (DLCO), and exercise tests were carried out in all patients. These evaluations were performed again 1 year after the procedure to assess the long-term effects of sympathectomy. RESULTS: Lung function tests revealed a significant decrease in forced expiratory volume in 1 second (FEV(1)) and forced expiratory flow between 25% and 75% of vital capacity (FEF(25%-75%)) in both groups (FEV(1) of -6.3% and FEF(25%-75%) of -9.1% in the conventional thoracic sympathectomy group and FEV(1) of -3.5% and FEF(25%-75%) of -12.3% in the simplified thoracic sympathectomy group). DLCO and heart rate at rest and maximal values after exercise were also significantly reduced in both groups (DLCO of -4.2%, DLCO corrected by alveolar volume of -6.1%, resting heart rate of -11.8 beats/min, and maximal heart rate of -9.5 beats/min in the conventional thoracic sympathectomy group and DLCO of -3.9%, DLCO corrected by alveolar volume of -5.2%, resting heart rate of -10.7 beats/min, and maximal heart rate of -17.6 beats/min in the simplified thoracic sympathectomy group). Airway resistance increased significantly in the group of patients undergoing conventional thoracic sympathectomy (+13%). Despite all these changes, the patients remained asymptomatic. No significant differences were found between the conventional and simplified thoracic sympathectomy groups. CONCLUSIONS: Simplified and conventional thoracic sympathectomy resulted in a long-term reduction in FEV(1), FEF(25%-75%), DLCO, and resting and maximal heart rate, as well as a mild but significant increase in airway resistance in the conventional thoracic sympathectomy group, without any clinical consequence to the patient. These changes were unrelated to the level of transection of the thoracic sympathetic chain.

Long-term inhaled nitric oxide plus phosphodiesterase 5 inhibitors for severe pulmonary hypertension.

BACKGROUND: Inhaled nitric oxide (iNO) is a potent pulmonary vasodilator, but therapeutic experience in patients with severe pulmonary hypertension is scarce. METHODS: Eleven patients with severe pulmonary hypertension, 6 due to pulmonary arterial hypertension and 4 due to chronic thromboembolic disease, were selected for iNO therapy. A phosphodiesterase type 5 inhibitor (PDE5i) was added in cases of clinical worsening. In this study we evaluate the clinical effectiveness and safety of long-term treatment with iNO either alone or combined with a PDE5i. RESULTS: After 1 month of iNO administration, improvements were observed in World Health Organization functional class, Borg scale (p = 0.003), brain natriuretic peptide levels (p = 0.002) and 6-minute walk test (p = 0.003). After 6 months of treatment, 7 patients had clinical deterioration that was reversed upon adding a PDE5i. One of these patients died in Month 8 and another underwent pulmonary transplantation in Month 9. The clinical condition of the remaining 9 patients was unchanged after 1 year. A second right catheterization showed improvement in mean pulmonary arterial pressure (66 +/- 15 mm Hg to 56 +/- 18 mm Hg; p = 0.01), pulmonary vascular resistance (1,234 +/- 380 dyn/s/cm(5) to 911 +/- 410 dyn/s/cm(5); p = 0.008) and cardiac index (2.0 +/- 0.4 liters/min/m(2) to 2.5 +/- 0.4 liters/min/m(2); p = 0.04). There was no significant increase in methemoglobin, no worsening of pulmonary function and no sudden withdrawal syndrome. CONCLUSIONS: We suggest that iNO therapy alone or in combination with a PDE5i could be a therapeutic alternative for severe pulmonary hypertension.

Avances terapéuticos en el asma / Therapeutic advances in asthma

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[Intrathoracic gossypiboma interpreted as bronchogenic carcinoma. Another false positive with positron emission tomography]. / Textiloma intratorácico interpretado como carcinoma broncogénico. Otro falso positivo de la tomografía por emisión de positrones.

Gossypibomas from inflammatory reactions to textile foreign bodies are a rare postoperative complication and are easily confused with neoplastic processes because of their diversity of symptoms and radiographic signs. Positron emission tomography (PET) is seldom used to diagnose gossypibomas and PET findings can result in false positives for a diagnosis of neoplastic disease. We describe the case of a 56-year-old man in whom PET findings showed an intrathoracic mass suggesting a tumor. The final diagnosis was gossypiboma, identified 23 years after pneumothorax surgery.

Textiloma intratorácico interpretado como carcinoma broncogénico. Otro falso positivo de la tomografía por emisión de positrones / Intrathoracic gossypiboma interpreted as bronchogenic carcinoma: another false positive with positron emission tomography

Los textilomas, reacciones inflamatorias contra cuerpos extraños de tipo textil, representan una complicación posquirúrgica poco frecuente. La diversidad de síntomas y signos radiológicos con que se manifiestan contribuye a que su diagnóstico se confunda con un proceso de tipo neoplásico. Los hallazgos descritos con la tomografía por emisión de positrones (PET), técnica poco habitual en el manejo diagnóstico de esta entidad, pueden condicionar falsos positivos neoplásicos. Describimos el caso de un varón de 56 años, que 23 años después de una cirugía de neumotórax presentó una masa intratorácica indicativa de neoplasia en la PET, cuyo diagnóstico final fue de textiloma

Gossypibomas from inflammatory reactions to textile foreign bodies are a rare postoperative complication and are easily confused with neoplastic processes because of their diversity of symptoms and radiographic signs. Positron emission tomography (PET) is seldom used to diagnose gossypibomas and PET findings can result in false positives for a diagnosis of neoplastic disease. We describe the case of a 56-year-old man in whom PET findings showed an intrathoracic mass suggesting a tumor. The final diagnosis was gossypiboma, identified 23 years after pneumothorax surgery

Anticuerpos monoclonales en la terapéutica neumológica / Therapeutic use of monoclonal antibodies in pneumology

La tecnología desarrollada en los últimos 20 años con los anticuerpos monoclonales, inicialmente para su uso como marcadores de laboratorio, ha llevado recientemente a la creación de una nueva serie de fármacos de vanguardia, altamente selectivos. En la actualidad las publicaciones médicas de mayor prestigio están informando, con gran profusión, de sus resultados clínicos. Dentro de la neumología, sólo uno de estos fármacos –el omalizumab (Xolair®)– ha sido autorizado para el tratamiento del asma, aunque se han publicado diversos estudios con otros anticuerpos monoclonales que inciden en las vías etiopatogénicas del asma. La investigación de estos fármacos en el carcinoma de pulmón está menos desarrollada, pero no es menos prometedora. En esta revisión se analizan los fundamentos del tratamiento con anticuerpos monoclonales y se actualiza la investigación que se está desarrollando en el campo de la neumología (AU)

The technology developed in the last 20 years with monoclonal antibodies, initially for their use as laboratory markers, has led to the recent creation of a novel series of highlyselective drugs. Currently, a large number of publications in high-prestige medical journals are reporting the results of the clinical use of these drugs. Within pneumology, only one of these drugs – omalizumab (Xolair®) – has been authorized for the treatment of asthma, although several studies of other monoclonal antibodies that affect the etiopathogenic pathways of asthma have been published. Research into the use of these drugs in lung cancer is less well developed but no less promising. The present review analyzes the bases for monoclonal antibody therapy and provides an update on the research being carried out in the field of pneumology (AU)

Usefulness of cephalometry in sparing polysomnography of patients with suspected obstructive sleep apnea.

The aim of this investigation was to evaluate the contribution of cephalometry to a statistical model integrating clinical, physical, and oximetric variables, to reduce demands for polysomnographies. Two hundred and twenty-five consecutive patients that had been referred to the sleep clinic for suspected obstructive sleep apnea (OSA) were studied. The clinical assessment of all patients consisted of a sleep related questionnaire, the Epworth sleepiness scale, and a physical examination. In addition, they all underwent spirometry, cephalometry, and a full polysomnography. The clinical variables related with OSA were questions concerning witnessing of apneas by bed partners, intensity of snoring, a history of hypertension, and nocturia. A significant relation was also found with score on the Epworth scale, sex, age, body mass index, neck and waist circumferences, total number and frequency of oxygen desaturations, and the lowest oxygen saturation value. Significant cephalometric measurements were: the linear distance from gonion to gnathion, from the hyoid bone to the mandibular plane, and from the posterior nasal spine to the tip of the soft palate, and the thickness of the uvula as well. A statistical model was built to estimate a patient's probability of having OSA based on clinical variables, physical examination, pulse oximetry, and cephalometry. The validation of this model demonstrated a remarkable ability in reducing the number of polysomnographic studies. We conclude that cephalometry combined with clinical variables, physical examination, and nocturnal oximetry is useful in the diagnosis of OSA and enables the sparing of a considerable number of polysomnographies.

Perfil farmacológico del omalizumab / Pharmacological profile of omalizumab

Después de varias décadas de investigación en biología celular y molecular, se ha logrado un gran avance en el conocimiento de la patogenia del asma. Hoy se conoce, en gran parte, la secuencia de las reacciones biológicas que ponen en marcha los rasgos fenotípicos del asma: la obstrucción al flujo aéreo, la inflamación y la hiperrespuesta bronquial. Este conocimiento ha permitido señalar a la inmunoglobulina (Ig) E como una de las dianas a neutralizar, ya que es un componente inicial en los complejos procesos inflamatorios del asma. El omalizumab, un anticuerpo monoclonal humanizado, consigue bloquear la IgE libre y mejorar enfermedades alérgicas como la rinitis y el asma. En esta revisión, se analizan los fundamentos del tratamiento con anticuerpos monoclonales y se actualiza la acción del omalizumab desde el punto de vista farmacológico y clínico (AU)

After several decades of research in cell and molecular biology, a great step forward has been made in our knowledge of the pathogenesis of asthma. Today, the sequence of biological reactions that lead to the phenotypic features of asthma are largely known: airflow obstruction, inflammation and bronchial hyperreactivity. This knowledge has allowed us to identify IgE as one of the targets to be neutralized as it is an initial component in the complex inflammatory processes of asthma. Omalizumab, a humanized monoclonal antibody, blocks free IgE and has a beneficial effect on allergic diseases such as rhinitis and asthma. The present review analyzes the basic principles of therapy with monoclonal antibodies and provides an update of the action of omalizumab from the pharmacological and clinical points of view (AU)

Long-term inhaled nitric oxide plus dipyridamole for pulmonary arterial hypertension.

Inhaled nitric oxide (iNO) has been shown to be a potent and selective vasodilator in pulmonary arterial hypertension (PAH). However, the clinical experience in prolonged treatment is limited. We assess the safety and effectiveness of long-term administration of iNO in severe PAH. Two female patients were admitted to our hospital because of severe dyspnea (World Health Organization functional class IV) and hypoxemia. They were diagnosed with PAH (primary and secondary to congenital heart disease) and treated with iNO for 2 years. The delivery system consisted of an NO tank of 800 ppm, a modified gas-pulsing device, and nasal cannulas. On iNO treatment the patients showed remarkable improvement of symptoms, oxygenation and 6-min walk distance. After 16 months the patients began to experience a progressive rebound of symptoms. A phosphodiesterase type 5 inhibitor (dipyridamole) was added to iNO. This intervention proved useful in improving clinical deterioration and hemodynamics. This is the first study reporting 2-year iNO therapy in 2 patients with primary and secondary pulmonary hypertension. The combination of dipyridamole with iNO augments the pulmonary vasodilatation and may be useful in managing PAH.

Long-term pulmonary function after thoracic sympathectomy.

BACKGROUND: The purpose of this study was to evaluate the long-term and midterm effects of thoracic sympathectomy on pulmonary function and to assess the influence of the sympathetic nervous system on bronchomotor tone. METHODS: Thirty-seven consecutive patients were diagnosed with primary hyperhidrosis requiring thoracic sympathectomy and were included in this study. Spirometry and methacholine challenge testing were performed before and 3 months after surgery. To assess the long-term effects of the intervention, another spirometric study was performed 1 year later. RESULTS: Spirometry 3 months after surgery showed a significant decrease in the forced vital capacity (-5.2%), the forced expiratory volume in the first second (-6.1%), and the forced expiratory flow between 25% and 75% of vital capacity (-5.1%). Whereas methacholine challenge testing before surgery was positive in 3 subjects (2 of whom were asthmatic), it was positive in 6 patients after the procedure; differences were not statistically significant. After 12 months, forced vital capacity started recovering, and forced expiratory volume in the first second and forced expiratory flow rate 25% to 75% showed a sustained and significant reduction (-2.8% and -11.2%, respectively); however, patients remained asymptomatic. CONCLUSIONS: We conclude that thoracic sympathectomy generates a mild, although significant, impairment of the bronchomotor tone, with no clinical consequences. These results suggest that the sympathetic nervous system is involved in pulmonary bronchomotor tone.