Consenso multidisciplinar español sobre las características de los pacientes con asma grave en tratamiento con biológicos susceptibles de pasar a tratamiento domiciliario / Spanish multidisciplinary consensus on the characteristics of severe asthma patients on biologic treatment who are candidates for at-home administration

Antecedentes y objetivo Es bien sabido que las terapias biológicas reducen las exacerbaciones y mejoran el tratamiento del asma grave no controlada. La administración domiciliaria de biológicos ha aumentado durante la pandemia de COVID-19, pero aún no se han identificado las características de los pacientes con asma grave no controlada que pueden beneficiarse de la administración domiciliaria de terapia biológica. Materiales y métodos Este proyecto se basa en la metodología Delphi, diseñada para alcanzar un consenso entre expertos a través de un comité científico multidisciplinar que aborda las siguientes cuestiones: características clínicas, adherencia al tratamiento, capacidad de administración del paciente o cuidador, autocuidado del paciente, relación con el profesional sanitario, preferencias del paciente y acceso al hospital. Resultados Ciento treinta y un profesionales sanitarios (neumólogos, alergólogos, enfermeros y farmacéuticos hospitalarios) cumplimentaron las dos rondas de consenso del cuestionario Delphi. Se identificaron 14 ítems como características prioritarias, siendo los cinco primeros: 1. El paciente sigue las indicaciones/recomendaciones del equipo sanitario para controlar su enfermedad. 2. El paciente es capaz de detectar cualquier deterioro de su enfermedad y de identificar los factores desencadenantes de las exacerbaciones. 3. El paciente recibe tratamiento biológico y tiene una enfermedad estable sin riesgo vital. 4. El paciente se responsabiliza de su autocuidado y 5. el paciente tiene obligaciones laborales/educativas que le impiden acudir al hospital con regularidad (AU)

Background and objective Biologic therapies are known to reduce exacerbations and improve severe uncontrolled asthma management. The at-home administration of biologics has increased during the COVID-19 pandemic, but the characteristics of severe uncontrolled asthma patients who may benefit from at-home administration of biologic therapy have yet to be identified. Materials and methods This project is based on the Delphi method, designed to reach an expert consensus through a multidisciplinary scientific committee addressing the following questions: clinical characteristics, treatment adherence, patient or caregiver administration ability, patient self-care, relationship with the healthcare professional, patient preference, and access to the hospital. Results One hundred and thirty-one healthcare professionals (pulmonologists, allergists, nurses, and hospital pharmacists) completed two Delphi consensus questionnaires. Fourteen items were identified as priority characteristics, the first five being: 1. The patient follows the healthcare team's indications/recommendations to control their disease, 2. The patient is capable of detecting any deterioration in their disease and of identifying exacerbation triggers, 3. The patient receives biologic therapy and has stable disease with no vital risk, 4. The patient takes responsibility for their self-care, 5. The patient has occupational/educational obligations that prevent them from going to the hospital regularly. Conclusions Disease stability and control plus the ability to identify exacerbation triggers are the most important characteristics when opting for at-home administration for a patient with severe uncontrolled asthma on biologic therapy. These recommendations could be applicable in clinical practice (AU)

Spanish multidisciplinary consensus on the characteristics of severe asthma patients on biologic treatment who are candidates for at-home administration.

BACKGROUND AND OBJECTIVE: Biologic therapies are known to reduce exacerbations and improve severe uncontrolled asthma management. The at-home administration of biologics has increased during the COVID-19 pandemic, but the characteristics of severe uncontrolled asthma patients who may benefit from at-home administration of biologic therapy have yet to be identified. MATERIALS AND METHODS: This project is based on the Delphi method, designed to reach an expert consensus through a multidisciplinary scientific committee addressing the following questions: clinical characteristics, treatment adherence, patient or caregiver administration ability, patient self-care, relationship with the healthcare professional, patient preference, and access to the hospital. RESULTS: One hundred and thirty-one healthcare professionals (pulmonologists, allergists, nurses, and hospital pharmacists) completed two Delphi consensus questionnaires. Fourteen items were identified as priority characteristics, the first five being: 1. The patient follows the healthcare team's indications/recommendations to control their disease, 2. The patient is capable of detecting any deterioration in their disease and of identifying exacerbation triggers, 3. The patient receives biologic therapy and has stable disease with no vital risk, 4. The patient takes responsibility for their self-care, 5. The patient has occupational/educational obligations that prevent them from going to the hospital regularly. CONCLUSION: Disease stability and control plus the ability to identify exacerbation triggers are the most important characteristics when opting for at-home administration for a patient with severe uncontrolled asthma on biologic therapy. These recommendations could be applicable in clinical practice.

Uso de biológicos para asma grave en otras indicaciones fuera de ficha técnica (off label) / Use of biologic agents for severe asthma in other indications that are off label

En la última década, hemos asistido a la introducción de los anticuerpos monoclonales para el tratamiento del asma grave, lo que ha supuesto una auténtica revolución en la vida de muchos de nuestros pacientes. Existen algunas patologías que a menudo, vemos asociadas al asma grave y con las que debemos hacer un adecuado diagnóstico diferencial como son: granulomatosis eosinofílica con poliangeitis (GEPA), síndromes hipereosinofílicos (SHE), neumonías eosinófilas crónicas (NEC) y aspergilosis broncopulmonar alérgica (ABPA) en las que se han probado dichos tratamientos con buenos resultados en la práctica clínica, pero cuya indicación se encuentra actualmente fuera de ficha técnica. Estas patologías suelen precisar para su control de tratamiento con corticoides sistémicos y/o inmunosupresores durante un tiempo prolongado, con los importantes efectos secundarios que conllevan. Las nuevas terapias están permitiendo un importante ahorro de corticoides sistémicos e incluso su retirada en muchos casos. Hemos realizado una revisión de estas enfermedades y de los resultados clínicos de dichos tratamientos biológicos en cada una. Otra situación en la que se dispone de nueva evidencia, es la utilización de biológicos para el asma alérgico grave durante el periodo de embarazo

In the last decade we have attended to the introduction of monoclonal antibodies for the treatment of severe asthma, which have supposed a real revolution in the lives of many of our patients. There are some pathologies that we often see associated with severe asthma and with which we must make an adequate differential diagnosis such as: eosinophilic granulomatosis with polyangiitis (EGPA), hypereosinophilic syndromes (HES), chronic eosinophilic pneumonia (cep) and allergic bronchopulmonary aspergillosis (ABPA). These treatments have been tested with good results in clinical practice, but being used off label. These pathologies usually require treatment with systemic corticosteroids and/or immunosuppressants for a long time producing important side effects. New therapies are allowing significant dose reduction of systemic corticosteroids and even their withdrawal in many cases. We have carried out a review of these diseases and the clinical results of biological treatments in each one of them. Another situation in which new evidence is available, is the use of biologicals for severe allergic asthma during pregnancy

Nuevos biológicos en el tratamiento del asma de control difícil / No disponible

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Tuberculosis pulmonar primaria en una paciente inmunocompetente con patrón clínico-radiológico de neumonía / No disponible

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Una paciente con asma en urgencias / A female patient with asthma in the emergency room

Mujer de 20 años, con intolerancia a antiinflamatorios no esteroideos. Madre y hermano asmáticos. No fumadora. Asma diagnosticada 2 años antes. Anosmia y síntomas de rinosinusitis. Varios ingresos hospitalarios previos por crisis, último hacía un mes, en UCI, sin precisar ventilación mecánica. Pruebas cutáneas negativas a aeroalérgenos. Mejor Peak-flow (PEF) personal: 450l/min. Tratamiento previo: salmeterol/fluticasona 50/500 1inh/12h y formoterol a demanda. Acude a urgencias en ambulancia por disnea de unas 24h de evolución con fiebre, expectoración y cefalea, por lo que había acudido a su médico, quien pautó metamizol y azitromicina. Regresa a la hora por trabajo respiratorio y saturación de O2: 89%. En la exploración física destaca: respiración abdominal, frecuencia respiratoria: 40rpm, saturación de O2: 92% con nebulización a 6lpm. PEF: 180l/min, taquicardia a 150lpm y sibilancias dispersas. Hemodinámicamente estable. Gasometría con O2 a 6lpm: pH 7,280; pCO2 45mmHg; pO2 66mmHg; HCO321,1mmol/l. Radiografía de tórax: sin consolidación(AU)

A 20-year-old woman, with intolerance to non-steroid anti-inflammatory drugs (NSAIDs) who was diagnosed of asthma 2 years earlier. Both her mother and brother were asthmatic. Non-smoker. Anosmia and rhinosinusitis symptoms. Several hospitalizations for asthmatic attacks, the last one, one month before in the ICU that did not require mechanical ventilation. Skin tests negative to aeroallergens. Better personal PEF: 450l/min. Previous treatment: salmeterol/fluticasone 50/500 1inh/12h. and formoterol p.r.n. She came to the emergency room by ambulance due to evolution of fever, expectoration and headache after having gone to her physician, who had prescribed metamizole and azithromycin. She returned at one hour due to difficult breathing and Sat O2 89%. The physical examination showed abdominal breathing, 40rpm and Sat O2 92% with nebulizer at 6bpm, PEF: 180l/min, tachycardia at 150bpm, generalized wheezing. Hemodynamically stable. Blood gases with O2 to 6bpm: 7.28pH, 45 pCO2, 66pO2, 21.1HCO3, Chest X-ray: no consolidations(AU)

[A female patient with asthma in the emergency room]. / Una paciente con asma en urgencias.

A 20-year-old woman, with intolerance to non-steroid anti-inflammatory drugs (NSAIDs) who was diagnosed of asthma 2 years earlier. Both her mother and brother were asthmatic. Non-smoker. Anosmia and rhinosinusitis symptoms. Several hospitalizations for asthmatic attacks, the last one, one month before in the ICU that did not require mechanical ventilation. Skin tests negative to aeroallergens. Better personal PEF: 450 l/min. Previous treatment: salmeterol/fluticasone 50/500 1 inh/12h. and formoterol p.r.n. She came to the emergency room by ambulance due to evolution of fever, expectoration and headache after having gone to her physician, who had prescribed metamizole and azithromycin. She returned at one hour due to difficult breathing and Sat O(2) 89%. The physical examination showed abdominal breathing, 40 rpm and Sat O(2) 92% with nebulizer at 6 bpm, PEF: 180 l/min, tachycardia at 150 bpm, generalized wheezing. Hemodynamically stable. Blood gases with O(2) to 6 bpm: 7.28 pH, 45 pCO(2), 66pO(2), 21.1 HCO(3), Chest X-ray: no consolidations.

Selección bibliográfica: asma / Screening of bibliography: asthma

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Asma de control difícil: factores predisponentes y factores agravantes / Difficult to control asthma: predisposing and aggravating factors

El concepto de asma de control difícil engloba a todos aquellos pacientes con asma insuficientemente o mal controlada, a pesar de seguir una estrategia terap¨¦utica apropiada, una vez se ha comprobado el cumplimiento de esta, se han descartado otras enfermedades y controlados los factores agravantes de la enfermedad. Los factores que contribuyen a que el asma sea refractaria al tratamiento no son bien conocidos. Algunos estudios establecen asociaciones d¨¦biles entre determinadas alteraciones gen¨¦ticas y varios factores ambientales. Se ha descrito que mutaciones del gen IL-4 y su receptor parecen tener relaci¨®n con la p¨¦rdida de funci¨®n pulmonar y con episodios de asma de riesgo vital. Tambi¨¦n se han relacionado con la gravedad del asma factores implicados en el remodelado de la v¨ªa a¨¦rea as¨ª como mutaciones de los receptores para los glucocorticoides y los ¦Â2-adren¨¦rgicos. Por otra parte se han asociado con la gravedad del asma diversos factores ambientales como la exposici¨®n continua a al¨¦rgenos, tabaquismo, intolerancia a antiinflamatorios no esteroideos (AINE) e infecciones. Estudios multic¨¦ntricos como el estudio ENFUMOSA y el estudio TENOR nos han ayudado a comprender en parte esta enfermedad (AU)

The concept of difficult-to-control asthma covers all those patients with insufficiently or poorly controlled asthma who, in spite of having followed an appropriate therapeutic strategy, and after having verified its compliance, other diseases have been ruled out and aggravating factors of the disease controlled. The factors that contribute to making asthma refractory to treatment are not well known. Some studies establish weak associations between certain genetic alterations and several environmental factors. It has been described that mutations of the IL-4 gene and its receptor seem to have a relationship with loss of pulmonary function and with life-threatening asthma episodes. They have also been related with the severity of the asthma factors involved in airway remodeling and mutations of glucocorticoids and beta 2-adrenergic receptors. On the other hand, different environmental factors such as continuing exposure to allergens, tobacco smoke, intolerance to NSAIDs and infections have been associated with the severity of asthma. Multicenter study such as the ENFUMOSA study and the TENOR study have partially helped us to understand this disease (AU)

Asma bronquial / Bronchial asthma

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Tratamiento del asma: diferentes estrategias. ¿Cuál escoger? / Asthma treatment: different strategies. Which one should be chosen?

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Anticuerpo monoclonal anti-IgE en el tratamiento del asma / Anti-IgE monoclonal antibody in asthma treatment

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[Pleural empyema associated with endobronchial lipoma]. / Empiema pleural asociado a lipoma endobronquial.

Bronchial benign tumors comprise fewer than 4% of pulmonary neoplasms. Endobronchial lipoma is an extremely rare benign neoplasm accounting for only 0.1% to 0.5% of all lung tumors. Clinical symptoms of lipoma depend on the location of the tumor, the severity of bronchial obstruction, and the functional and anatomical effects on the parenchyma distal to the obstruction. Computed axial tomography usually reveals the adipose composition of the lipomatous tumor. We report the case of an 83-year-old man diagnosed with community-acquired pneumonia that led to complications: pleural empyema caused by Haemophilus influenzae infection and atelectasis of the right middle and lower lobes secondary to a lipomatous endobronchial obstruction. Removal of the bronchial lipoma was performed by laser resection.

Empiema pleural asociado a lipoma endobronquial / Pleural empyema associated with endobronchial lipoma

Los tumores benignos broncopulmonares representan menos del 4% de las neoplasias de origen pulmonar. El lipoma endobronquial es una neoplasia benigna extremadamente rara, cuya incidencia oscila entre el 0,1 y el 0,5% de todos los tumores del pulmón. Los síntomas clínicos dependen de su localización, del grado de obstrucción bronquial y de las consecuencias morfofuncionantes de dicha obstrucción sobre el parénquima distal. La tomografía axial computarizada suele poner de manifiesto el contenido adiposo del tumor. Presentamos el caso clínico de un varón de 83 años diagnosticado de neumonía adquirida en la comunidad, que se complicó con un empiema pleural por Haemophilus influenzae y atelectasia de lóbulos medio e inferior derecho, secundaria a obstrucción endobronquial por lipoma. Se realizó extirpación del lipoma bronquial mediante fotorresección con láser

Bronchial benign tumors comprise fewer than 4% of pulmonary neoplasms. Endobronchial lipoma is an extremely rare benign neoplasm accounting for only 0.1% to 0.5% of all lung tumors. Clinical symptoms of lipoma depend on the location of the tumor, the severity of bronchial obstruction, and the functional and anatomical effects on the parenchyma distal to the obstruction. Computed axial tomography usually reveals the adipose composition of the lipomatous tumor. We report the case of an 83-year-old man diagnosed with community-acquired pneumonia that led to complications: pleural empyema caused by Haemophilus influenzae infection and atelectasis of the right middle and lower lobes secondary to a lipomatous endobronchial obstruction. Removal of the bronchial lipoma was performed by laser resection