Soporte telemático de autogestión para pacientes con apnea obstructiva del sueño en tratamiento con CPAP: aspectos metodológicos y resultados preliminares del ensayo clinico telesas / Telematic self-management support for patients with obstructive sleep apnea under CPAP treatment: methodological aspects and preliminary results of the telesas clinical trial

Objetivo: Comprobar si un programa de telemedicina mejora el cumplimiento con CPAP, alcanzando un uso de, al menos, 4 horas al día en el 90% de los pacientes. Realizamos un estudio piloto para comprobar la viabilidad de un proyecto multicéntrico en el que perfeccionaremos dicho programa. Metodología: Pacientes con AOS severa poco sintomáticos en tratamiento con CPAP fueron randomizados a seguimiento habitual o seguimiento habitual más un programa de telemedicina durante 6 meses. Dentro de este programa, las variables de telemonitorización, la aparición de efectos secundarios y la presencia de sueño reparador eran analizadas para generar alarmas e instrucciones al paciente para la autogestión precoz de los problemas presentados con la CPAP. Resultados: 60 pacientes fueron randomizados, 33 al grupo intervención y 27 al grupo control, sin diferencias significativas en las variables basales. El 80% eran hombres con un rango de edad entre los 24 y 75 años. Solo hubo un abandono en el grupo control. Conclusiones: El uso de nuestro programa de telemedicina no ha supuesto ningún problema para los pacientes incluidos a pesar de la horquilla amplia de edad, siendo viable el desarrollo de un estudio a mayor escala con una herramienta de telemedicina perfeccionada. (AU)

Basis: poor compliance with CPAP is a problem at a clinical and research level, assuming the expected results are not achieved. The benefits of using telemedicine in obstructive sleep apnea (OSA) are inconclusive, with its positive effect on compliance being the most consistent in the literature. Objective: to check if a telemedicine program improves compliance with CPAP, reaching use of at least 4 hours a day in 90% of patients. We carried out a pilot study to verify the viability of a multicenter project in which we will perfect this program. Method: patients with severe OSA with few symptoms on CPAP treatment were randomized to usual follow-up or usual follow-up plus a telemedicine program for 6 months. Within this program, the telemonitoring variables, the appearance of side effects and the presence of restorative sleep were analyzed to generate alarms and instructions to the patient for early self-management of the problems presented with CPAP. Preliminary results: 60 patients were randomized, 33 to the intervention group and 27 to the control group, with no significant differences in the baseline variables. 80% were men with an age range between 24 and 75 years. There was only one dropout in the control group. Conclusions: the use of our telemedicine program has not posed any problems for the included patients despite the wide age range, making it feasible to develop a larger-scale study with an improved telemedicine tool. (AU)

Sumario de las recomendaciones y puntos clave del Consenso de las Sociedades Científicas Españolas (SEPAR, SEMICYUC, SEMES; SECIP, SENeo, SEDAR, SENP) para la utilización de la ventilación no invasiva y terapia de alto flujo con cánulas nasales en el paciente adulto, pediátrico y neonatal con insuficiencia respiratoria aguda grave / Summary of recommendations and key points of the consensus of Spanish scientific societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the use of non-invasive ventilation and high-flow oxygen therapy with nasal cannulas in adult, pediatric, and neonatal patients with severe acute respiratory failure

El soporte respiratorio no invasivo (SRNI) comprende 2 modalidades de tratamiento, la ventilación mecá-nica no invasiva (VMNI) y la terapia de alto flujo con cánulas nasales (TAFCN) que se aplican en pacientes adultos, pediátricos y neonatales con insuficiencia respiratoria aguda (IRA). Sin embargo, el grado de acuerdo entre las distintas especialidades sobre el beneficio de estas técnicas en diferentes escenarios clínicos es controvertido. El objetivo del presente consenso fue elaborar una serie de recomendaciones de buena práctica clínica para la aplicación de soporte no invasivo en pacientes con IRA, avaladas por todas las sociedades científicas involucradas en el manejo del paciente adulto y pediátrico/neonatal con IRA. Para ello se contactó con las diferentes sociedades implicadas, quienes designaron a su vez a un grupo de 26 profesionales con suficiente experiencia en su aplicación. Se realizaron 3 reuniones presenciales para consensuar las recomendaciones (hasta un total de 71) fundamentadas en la revisión de la literatura y en la actualización de la evidencia disponible en relación con 3 categorías: indicaciones, monitorización yseguimiento del SRNI. Finalmente, se procedió a votación telemática de cada una de las recomendaciones, por parte de los expertos de cada sociedad científica implicada. Para la clasificación del grado de acuerdo se optó por un sistema analógico de clasificación fácil e intuitivo de usar, y que expresara con claridad si el procedimiento relacionado con el SRNI debía hacerse, podía hacerse o no debía hacerse. (AU)

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied. (AU)

Summary of recommendations and key points of the consensus of Spanish scientific societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the use of non-invasive ventilation and high-flow oxygen therapy with nasal cannulas in adult, pediatric, and neonatal patients with severe acute respiratory failure.

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

Summary of recommendations and key points of the consensus of Spanish scientific societies (SEPAR, SEMICYUC, SEMES; SECIP, SENEO, SEDAR, SENP) on the use of non-invasive ventilation and high-flow oxygen therapy with nasal cannulas in adult, pediatric, and neonatal patients with severe acute respiratory failure. / Sumario de las recomendaciones y puntos clave del Consenso de las Sociedades Científicas Españolas (SEPAR, SEMICYUC, SEMES; SECIP, SENeo, SEDAR, SENP) para la utilización de la ventilación no invasiva y terapia de alto flujo con cánulas nasales en el paciente adulto, pediátrico y neonatal con insuficiencia respiratoria aguda grave.

Non-invasive respiratory support (NIRS) in adult, pediatric, and neonatal patients with acute respiratory failure (ARF) comprises two treatment modalities, non-invasive mechanical ventilation (NIMV) and high-flow nasal cannula (HFNC) therapy. However, experts from different specialties disagree on the benefit of these techniques in different clinical settings. The objective of this consensus was to develop a series of good clinical practice recommendations for the application of non-invasive support in patients with ARF, endorsed by all scientific societies involved in the management of adult and pediatric/neonatal patients with ARF. To this end, the different societies involved were contacted, and they in turn appointed a group of 26 professionals with sufficient experience in the use of these techniques. Three face-to-face meetings were held to agree on recommendations (up to a total of 71) based on a literature review and the latest evidence associated with 3 categories: indications, monitoring and follow-up of NIRS. Finally, the experts from each scientific society involved voted telematically on each of the recommendations. To classify the degree of agreement, an analogue classification system was chosen that was easy and intuitive to use and that clearly stated whether the each NIRS intervention should be applied, could be applied, or should not be applied.

Effectiveness of different treatments in obesity hypoventilation syndrome.

Obesity hypoventilation syndrome (OHS) is an undesirable consequence of obesity, defined as daytime hypoventilation, sleep disorder breathing and obesity; during the past few years the prevalence of extreme obesity has markedly increased worldwide consequently increasing the prevalence of OHS. Patients with OHS have a lower quality of life and a higher risk of unfavourable cardiometabolic consequences. Early diagnosis and effective treatment can lead to significant improvement in patient outcomes; therefore, such data has noticeably raised interest in the management and treatment of this sleep disorder. This paper will discuss the findings on the main current treatment modalities OHS will be discussed.

Clinical Consensus Recommendations Regarding Non-Invasive Respiratory Support in the Adult Patient with Acute Respiratory Failure Secondary to SARS-CoV-2 infection. / Recomendaciones de consenso respecto al soporte respiratorio no invasivo en el paciente adulto con insuficiencia respiratoria aguda secundaria a infección por SARS-CoV-2.

Coronavirus disease 2019 (COVID-19) is a respiratory tract infection caused by a newly emergent coronavirus, that was first recognized in Wuhan, China, in December 2019. Currently, the World Health Organization (WHO) has defined the infection as a global pandemic and there is a health and social emergency for the management of this new infection. While most people with COVID-19 develop only mild or uncomplicated illness, approximately 14% develop severe disease that requires hospitalization and oxygen support, and 5% require admission to an intensive care unit. In severe cases, COVID-19 can be complicated by the acute respiratory distress syndrome (ARDS), sepsis and septic shock, and multiorgan failure. This consensus document has been prepared on evidence-informed guidelines developed by a multidisciplinary panel of health care providers from four Spanish scientific societies (Spanish Society of Intensive Care Medicine [SEMICYUC], Spanish Society of Pulmonologists [SEPAR], Spanish Society of Emergency [SEMES], Spanish Society of Anesthesiology, Reanimation, and Pain [SEDAR]) with experience in the clinical management of patients with COVID-19 and other viral infections, including SARS, as well as sepsis and ARDS. The document provides clinical recommendations for the noninvasive respiratory support (noninvasive ventilation, high flow oxygen therapy with nasal cannula) in any patient with suspected or confirmed presentation of COVID-19 with acute respiratory failure. This consensus guidance should serve as a foundation for optimized supportive care to ensure the best possible chance for survival and to allow for reliable comparison of investigational therapeutic interventions as part of randomized controlled trials.

Supervivencia global a largo plazo en el cáncer de pulmón. Análisis de una serie de 610 pacientes no seleccionados / Overall long-term survival in lung cancer analyzed in 610 unselected patients

INTRODUCCIÓN Y OBJETIVOS: Muchos estudios sobre la supervivencia en el cáncer de pulmón se refieren a subgrupos de pacientes seleccionados por diferentes criterios que suelen influir favorablemente en la estimación del pronóstico. El objetivo de este trabajo es conocer la supervivencia global de los pacientes diagnosticados en nuestro medio. PACIENTES Y MÉTODOS: De 694 pacientes diagnosticados de cáncer de pulmón en nuestro centro en el período 1991-1998, se incluyó en el estudio a 610 (88 por ciento) con datos de supervivencia. Se analizaron la edad, el sexo, la estirpe histológica, estadios, tumor, nódulos, metástasis (TNM), tratamiento aplicado bienio diagnóstico y su relación con la supervivencia. RESULTADOS: Se incluyó en el estudio a 596 varones y a 14 mujeres, con una mediana de edad de 67 años. En cuanto a la estirpe del cáncer de pulmón, 141 eran microcíticos, 447 no microcíticos y 22 de otra estirpe. Se operó a 118 pacientes (19,3 por ciento). El 6,4 por ciento de los casos de cáncer de pulmón microcítico y el 40,5 por ciento de los no microcíticos recibieron sólo tratamiento sintomático. Éste fue más frecuente en mayores de 70 años (52,5 por ciento) y menos habitual durante el último bienio (1997-1998; 19 por ciento). La supervivencia a los 5 años del grupo total fue del 7,9 por ciento (del 2,8 por ciento para los microcíticos y del 9,4 por ciento para los no microcíticos). Los mayores de 70 años tuvieron peor supervivencia. Hubo diferencias significativas entre los sucesivos estadios TNM clínico, salvo entre IIIA y IIIB. Los diagnosticados en el período 1997-1998 tuvieron mejor supervivencia (un 40,8 por ciento al año y un 11,2 por ciento a los 5 años). CONCLUSIONES: La supervivencia observada, similar a la de otros países europeos, es pobre porque la tasa de resecciones quirúrgicas es baja dado el alto porcentaje de estadios avanzados (AU)

[Overall long-term survival in lung cancer analyzed in 610 unselected patients]. / Supervivencia global a largo plazo en el cáncer de pulmón. Análisis de una serie de 610 pacientes no seleccionados.

INTRODUCTION AND OBJECTIVES: Many studies of lung cancer survival are carried out in patients selected for certain features that usually influence prognosis favorably. The objective of this study was to assess the overall survival of unselected patients with a diagnosis of lung cancer in our practice. PATIENTS AND METHODS: We studied 610 patients for whom survival information was available, a population comprising 88% of the 694 with lung cancer diagnosed in our hospital from 1991 through 1998. The variables analyzed for their correlation with survival were age, sex, histology, tumor-node-metastasis (TNM) stage, treatment, and time of diagnosis (with patients grouped by 2-year periods). RESULTS: The cases of 596 men and 14 women with a mean age of approximately 67 years were studied. Small cell tumors were found in 141, non-small cell tumors in 447, and other tissue types in 22. Surgical excision was carried out on 118 (19.3%), and treatment was confined to control of symptoms for 6.4% of the patients with small cell tumors and 40.5% of those with non-small cell cancer. Symptomatic treatment alone was more common for patients older than 70 years (52.5%) and less common during the last 2 years of the study period (1997-1998: 19%). Overall 5-year survival was 7.9% (2.8% in small cell cancer and 9.4% in non-small cell cancer). Survival rates were lower in patients over 70 years of age. Significant differences in survival were seen for successive TNM stages, with the exception of IIIA and IIIB. The 1997-1998 period saw better survival rates, at 40.8% after 1 year and 11.2% after 5 years. CONCLUSIONS: The survival rates in lung cancer patients in our hospital practice are low because the rate of surgical resections is low owing to the high percentage of cases found in advanced stages. Our observations are similar to those reported from other European countries.

[Sleepy drivers have a high frequency of traffic accidents related to respiratory effort-related arousals]. / Los conductores somnolientos tienen alta frecuencia de accidentes de tráfico asociados a exceso de RERA.

INTRODUCTION: Respiratory effort-related arousals (RERA) are secondary to subtle obstructions of the upper airway during sleep and can appear in the absence of a predominance of apneas and hypopneas, causing excessive daytime sleepiness. Analyzing the possible consequences of these new respiratory events is of increasing interest. Habitually sleepy drivers are at high risk of having traffic accidents related to sleep disorders (apneas, hypopneas and RERA). OBJECTIVE: The aim of this study was to determine whether excess RERA alone is an independent risk factor among sleepy drivers. METHOD: We studied 40 habitually sleepy drivers and 23 age- and sex-matched controls selected from a sample of 4,002 automobile drivers. We surveyed sleep habits, daytime sleepiness and traffic accidents. Sleep studies of esophageal pressure were performed. RESULTS: The sleepy drivers with apneas (apnea/hypopnea index > 10) had a higher 5-year accident rate (0.33 0.50) than did control drivers (0.004 0.21; p < 0.05). However, a high RERA index, but not sleep apnea, was an independent risk factor among the habitually sleepy drivers. The adjusted odds ratio (OR) for a RERA index > or = 10 was 7.6 (confidence interval [CI], 1.2 to 48); for a RERA index > or = 15, the OR was 17 (CI 1.5 to 91). CONCLUSIONS: The high risk of traffic accidents among sleepy drivers is mainly determined by the presence of RERA rather than the presence of apneas and hypopneas. These findings verify the importance of identifying RERA in routine sleep laboratory studies.

Los conductores somnolientos tienen alta frecuenciade accidentes de tráfico asociados a exceso de RERA / Sleepy drivers have a high frequency of traffic accidents related to respiratory effort-related arousals

INTRODUCCIÓN: Los RERA (respiratory effort-related arousal) son secundarios a sutiles obstrucciones de la vía aérea superior durante el sueño, pueden aparecer sin predominio de apneas e hipopneas y causan somnolencia diurna excesiva. El análisis de las potenciales consecuencias de estos nuevos acontecimientos respiratorios tiene hoy un interés creciente. Los conductores habitualmente somnolientos tienen un riesgo alto de sufrir accidentes de tráfico asociados a trastornos respiratorios durante el sueño (apneas más hipopneas más RERA). OBJETIVO: El objetivo de este trabajo es determinar si exclusivamente el exceso de RERA es un factor independiente de riesgo de accidentes en los conductores somnolientos. MÉTODO: Estudiamos a 40 conductores habitualmente somnolientos y 23 controles (conductores no somnolientos) pareados por edad y sexo, y ambos extraídos de una muestra de 4.002 conductores de vehículos. Se estudiaron datos sobre hábitos de sueño, somnolencia diurna, accidentes de tráfico y se realizaron estudios de sueño con medida de presión esofágica. RESULTADOS: Los conductores somnolientos con apneas de sueño tienen una tasa de accidentes en 5 años mayor que los controles (índice de apneas-hipoapneas [IAH] > 10; 0,33 ñ 0,50 frente a 0,004 ñ 0,21 en los controles; p < 0,05), pero sólo el exceso de RERA y no el de apneas de sueño fue un factor independiente de riesgo de accidentes en conductores somnolientos. La odds ratio (OR) ajustada para un índice de RERA 10 fue de 7,6 (intervalo de confianza [IC] del 95 por ciento, 1,2-48) y para un índice de RERA 15 fue de 17 (IC, 1,5-91).CONCLUSIONES: El alto riesgo de accidentes de tráfico de los conductores somnolientos viene principalmente determinado por la presencia de RERA más que por la presencia de apneas e hipopneas de sueño. Estos datos ratifican la importancia y la necesidad de identificar RERA en la práctica habitual de los laboratorios de sueño (AU)

[Diagnostic utility of carcinoembryonic antigen, neuron-specific enolase and squamous cell carcinoma antigen in malignant pleural effusion]. / Utilidad del antígeno carcinoembrionario, enolasa neuroespecífica y antígeno de células escamosas (en líquido pleural y suero) en el diagnóstico del derrame pleural maligno.

We evaluated the diagnostic utility of the carcinoembryonic antigen (CEA), neuron-specific enolase (NSE) and squamous cell carcinoma antigen (SCC Ag.) in malignant pleural effusion (MPE). CEA, NSE and SCC Ag, blood and pleural levels were quantified by enzyme immunoassay (EIA) in 85 patients with pleural effusions: 35 non malignant pleural effusions, and 50 MPE; 42 with lung carcinoma (LC), and 8 with extrapulmonary carcinoma. The sensitivity and specificity was compared to cytological results of the pleural fluid. The sensitivities of CEA7 NSE and SCC Ag. (in pleural fluid) were 59.5%, 48.7% and 16.7% respectively in patients with LC (specificity higher than 90%). Using a combination with CEA and NSE, the sensitivity reached 80.9% (specificity, 91.4%). The cytology of pleural fluid was positive in 45.2%. The pleural/blood ratios did not improve the diagnostic performance. In patients with extrapulmonary carcinoma, the sensitivity of these tumor markers was lower. The combination of CEA and NSE pleural levels is useful in the diagnostic approach to the patient with pleural effusion. A high level of NSE is suggestive of small cell lung cancer (SCLC).

Nasal intermittent positive pressure ventilation. Analysis of its withdrawal.

Nasal intermittent positive pressure ventilation (NIPPV) applied during sleep has been demonstrated to be useful in the treatment of restrictive thoracic diseases (RTD). The purpose of this study was to evaluate the repercussions of a withdrawal period from NIPPV of 15 days. This would be sufficient time for patients to go on trips without the respirator. It was hypothesized that once daytime improvement was achieved and was stable, it could be maintained for this period of time. Five volunteer patients with severe RTD who had been receiving treatment with nocturnal NIPPV for at least 2 months before and who had improved at least 5 mm Hg in daytime PO2 and PCO2 were included in the study. No significant differences were disclosed clinically or with arterial blood gas levels, spirometry results, lung volumes, airway resistances, or maximal muscle pressures 15 days following the withdrawal. However, in the sleep studies, a severe worsening of gas exchange was observed, mainly during rapid eye movement (REM) sleep, as well as a trend toward a more disturbed sleep pattern and more important alterations in cardiac rhythm. Consequently, withdrawing the treatment with nocturnal NIPPV cannot be recommended, at least for this particular removal period. Moreover, alterations in daytime gas exchange were found to originate in those produced during REM sleep through the blunting of the respiratory center to CO2. The NIPPV obstructs this mechanism, preventing the deterioration of gas exchange during sleep.

Meaning and diagnostic value of determining the lysozyme level of pleural fluid.

We determined the levels of lysozyme in pleural fluid and serum in 141 patients with the following different causes for their pleural effusions: tuberculosis; neoplasias; transudates; parapneumonic, not complicated; empyemas; and miscellaneous. The lysozyme level of the pleural fluid and the ratio of that level over the serum level of lysozyme (PL/SL ratio) was meaningfully increased in patients with empyema (p less than 0.01). The groups with tuberculous and neoplastic effusions showed significant differences in the PL/SL ratio (p less than 0.01). The existence of a raised PL/SL ratio suggested important local synthesis of lysozyme, and it came up in empyemas and tuberculosis, unlike the other groups. Excluding the patients with empyemas, a PL/SL ratio of 1.2 showed a sensitivity of 100 percent, specificity of 94.9 percent, positive predictive value of 94.7 percent, negative predictive value of 100 percent, and accuracy of 97.3 percent for the diagnosis of tuberculous pleural effusion. All of this suggests that the determination of the lysozyme level can be an easy method of great usefulness in the initial diagnosis of pleural effusions.