Recomendaciones ALAT para el uso de vacunas respiratorias. Guía de práctica clínica basada en evidencias / ALAT Recommendations for the Use of Respiratory VaccinesEvidence-Based Clinical Practice Guideline

Introducción: Las infecciones respiratorias son las enfermedades respiratorias con mayor mortalidad en el mundo. Las causadas por Streptococcus pneumoniae, virus de influenza, Bordetella pertussis, SARS-CoV-2 y el Virus Sincitial Respiratorio, cuentan hoy día con vacunas seguras y efectivas. Este documento representa una guía de práctica clínica (GPC) de la Asociación Latinoamericana de Tórax (ALAT), elaborada por iniciativa de los departamentos de enfermedades infecciosas y pediatría, con el objetivo de establecer recomendaciones sobre vacunas respiratorias, utilizando la evidencia disponible. Método: Se estableció un grupo de desarrollo de las guías conformado por cinco médicos responsables globales del proyecto, se crearon cinco subgrupos de trabajo, uno por cada vacuna, con expertos neumólogos de adulto, pediatras e infectólogos invitados, que generaron preguntas clínicas. Se trabajó con un grupo de expertos metodólogos que transformaron preguntas clínicas en preguntas PICO, seleccionándose nueve preguntas por método DELPHI. Luego, se utilizó el sistema GRADE (Grading of Recommendations Assessment, Development and Evaluation) para evaluar la evidencia disponible. Resultados: Se obtuvieron recomendaciones para población adulta y pediátrica de las vacunas de neumococo, influenza, tos ferina, COVID-19 y Virus Respiratorio Sincitial basadas en preguntas PICO. También se agregaron recomendaciones basadas en preguntas narrativas relacionadas al uso de vacunas respiratorias en población con enfermedades respiratorias crónicas como asma, EPOC y fibrosis pulmonar.

Introduction: Respiratory infections are the leading cause of respiratory disease-related mortality worldwide. Infections caused by Streptococcus pneumoniae, influenza virus, Bordetella pertussis, SARS-CoV-2 and Respiratory Syncytial Virus (RSV) now have safe and effective vaccines available.This document represents a Clinical Practice Guideline (CPG) by the Latin American Thoracic Association (ALAT), developed through the initiative of the departments of in-fectious diseases and pediatrics, with the goal of establishing recommendations on respiratory vaccines using the available evidence. Method: A guideline development group was established, composed of five lead physicians responsible for the overall project. Five working subgroups were created, one for each vaccine, involving invited experts in adult pulmonology, pediatrics, and infectious diseases, who formulated clinical questions. A group of expert methodologists then transformed these clinical questions into PICO questions, with nine questions selected using the DELPHI method. The GRADE (Grading of Recommendations Assessment, Development and Evaluation) system was then used to assess the available evidence. Results: Recommendations were obtained for the adult and pediatric populations for pneumococcal, influenza, pertussis, COVID-19 and Respiratory Syncytial Virus vaccines based on PICO questions. Additionally, recommendations based on narrative questions related to the use of respiratory vaccines in populations with chronic respiratory diseases such as asthma, COPD, and pulmonary fibrosis were included.

Cobertura para el diagnóstico y tratamiento de la apnea obstructiva del sueño en Latinoamérica: reporte del Foro Latinoamericano de Sociedades Respiratorias / Coverage for the Diagnosis and Treatment of Obstructive Sleep Apnea in Latin America: Report from the Latin American Forum of Respiratory Societies

Introducción: La Apnea Obstructiva del Sueño (AOS) es un problema de salud pública en Latinoamérica; una región que es heterogénea, con recursos diferentes y sistemas de salud diversos. El objetivo fue describir la información recabada por el Foro Latino-americano de Sociedades Respiratorias sobre el acceso y cobertura para los estudios diagnósticos y tratamiento con CPAP de los pacientes con AOS. Material y Métodos: A través de la Asociación Latinoamericana de Tórax (ALAT), se envió una encuesta a todas las sociedades miembros con preguntas sobre el acceso a diagnóstico, tratamiento y cobertura de seguros privados. Resultados: El foro contó con 15 países. Se reportó la existencia de 396 unidades formales de sueño, 82% privadas y 18% públicas; en 12 países el sistema de salud público (SSP) contrata unidades privadas para otorgar servicios. En todos los países se realiza tanto polisomnografía como poligrafía respiratoria para el diagnóstico. En 8 (53%) países, el SSP cubre el tratamiento con CPAP de la AOS (en Argentina, Guatemala y México esta cobertura es parcial); los seguros privados cubren AOS en 7/15 países. Conclusiones: En Latinoamérica, existen pocas unidades formales de sueño y la mayoría son privadas. Cerca de la mitad de los sistemas de salud pública no cubren su tratamiento y, en la mayoría de los casos, los seguros privados no ofrecen cobertura. Esto deja a nuestra población vulnerable a las complicaciones de la AOS, con un concomitante aumento de la morbimortalidad y costos en salud.

Introduction: Obstructive Sleep Apnea (OSA) is a public health problem in Latin America, which is a heterogeneous region, with different resources and diverse health systems. The objective was to describe the information collected by the Latin American Forum of Respiratory Societies on access and coverage for diagnostic studies and CPAP treatment of patients with OSA. Methods: Through the Latin American Thorax Association (ALAT, Spanish acronym), a survey was sent to all member societies with questions about access to diagnosis, treatment, and private insurance coverage. Results: The forum included 15 countries. The existence of 396 sleep medicine units was reported, 82% private and 18% public; in 12/15 countries the public health system (PHS) contracts private units to provide services. In all countries, both polysomnography and respiratory polygraphy are performed to make the diagnosis. In only 8 (53%) countries the PHS covers the treatment of OSA (in Argentina, Guatemala and Mexico this coverage is partial); private insurance coverage is in 7/15 countries.Conclusions: In Latin America there are few formal sleep units and most are private. About half of public health systems do not cover their treatment and, in most cases, private insurance does not offer coverage. This leaves our population vulnerable to the complications of OSA, with a concomitant increase in morbidity, mortality and health costs.

Función pulmonar en post COVID-19

Introduction: Infection by SARS-CoV-2 affects multiple organs, but the lung is the most affected organ and can have sequelae. The diagnosis of sequelae includes: medical history, physical examination, chest radiography and/or tomography, and pulmonary function tests (spirometry, carbon monoxide diffusing capacity, 6-minute walk test, and lung volumes). The objective of this study was to describe lung function in post COVID-19 patients at the Center for Diagnosis and Treatment of Respiratory Diseases CEDITER. Methodology: We conducted a descriptive, retrospective, and cross-sectional study of patients over 18 years of age, with a history of SARS-CoV-2 infection, who had undergone any pulmonary function tests and were found in the CEDITER database, from March 2020 to December 2021. Results: 246 cases were included, of which 57.7% were male and 43.3% were female. The mean age was 50.8 years with a standard deviation of 13.2. 46.1% had a body mass index (BMI) between 30 and 39.9, classified as obesity. 207 spirometries were analyzed, of which 34.3% were abnormal. Out of the 236 carbon monoxide diffusion tests, 53% showed mild to moderate decreases. Conclusions: The pulmonary function test that was most affected was carbon monoxide diffusion (DLCO), in a predominantly male population, with overweight or obesity, and with a mean age of 50 years. (provisto por Infomedic International)

Introducción: La infección por el SARS-CoV-2 afecta a múltiples órganos, pero el pulmón es el órgano más afectado y puede tener secuelas. El diagnóstico de secuelas incluye: la historia clínica, el examen físico, radiografía y/o tomografía del tórax, y pruebas de función pulmonar (espirometría, capacidad de difusión de monóxido de carbono, caminata de 6 minutos y los volúmenes pulmonares). El objetivo de este estudio fue describir la función pulmonar en pacientes post COVID-19 en el Centro de Diagnóstico y Tratamiento de las Enfermedades Respiratorias CEDITER. Metodología: Realizamos un estudio descriptivo, retrospectivo y transversal, de pacientes mayores de 18 años, con historia de infección por SARS CoV-2, que tuviesen alguna de las pruebas de función pulmonar y se encontrara en la base de datos de CEDITER, entre marzo del 2020 a diciembre 2021. Resultados: Se incluyeron 246 casos, de los cuales el 57.7 % correspondieron al sexo masculino y 43.3 % al femenino. La media de edad fue de 50.8 años con DS de 13.2. El 46.1 % tenía un índice de masa corporal (IMC) entre 30 y 39.9, clasificada como obesidad. Se analizaron 207 espirometrías, de las cuales el 34.3 % fueron anormales. De las 236 pruebas de difusión de monóxido de carbono, el 53% mostraron disminución entre leve a moderada. Conclusiones La prueba de función pulmonar que resultó ser la más afectada fue la difusión de monóxido de carbono (DLCO), en una población mayoritariamente del sexo masculino, con sobrepeso u obesidad y con una media de edad de 50 años. (provided by Infomedic International)

Rate of severe exacerbations, healthcare resource utilisation and clinical outcomes in patients with COPD in low-income and middle-income countries: results from the EXACOS International Study.

INTRODUCTION: The EXAcerbations of Chronic obstructive lung disease (COPD) and their OutcomeS (EXACOS) International Study aimed to quantify the rate of severe exacerbations and examine healthcare resource utilisation (HCRU) and clinical outcomes in patients with COPD from low-income and middle-income countries. METHODS: EXACOS International was an observational, cross-sectional study with retrospective data collection from medical records for a period of up to 5 years. Data were collected from 12 countries: Argentina, Brazil, Chile, Colombia, Costa Rica, Dominican Republic, Guatemala, Hong Kong, Mexico, Panama, Russia and Taiwan. The study population comprised patients ≥40 years of age with COPD. Outcomes/variables included the prevalence of severe exacerbations, the annual rate of severe exacerbations and time between severe exacerbations; change in lung function over time (measured by the forced expiratory volume in 1 s (FEV1)); peripheral blood eosinophil counts (BECs) and the prevalence of comorbidities; treatment patterns; and HCRU. RESULTS: In total, 1702 patients were included in the study. The study population had a mean age of 69.7 years, with 69.4% males, and a mean body mass index of 26.4 kg/m2. The mean annual prevalence of severe exacerbations was 20.1%, and 48.4% of patients experienced ≥1 severe exacerbation during the 5-year study period. As the number of severe exacerbations increased, the interval between successive exacerbations decreased. A statistically significant decrease in mean (SD) FEV1 from baseline to post-baseline was observed in patients with ≥1 severe exacerbation (1.23 (0.51) to 1.13 (0.52) L; p=0.0000). Mean BEC was 0.198 x109 cells/L, with 64.7% of patients having a BEC ≥0.1 x109 cells/L and 21.3% having a BEC ≥0.3 x109 cells/L. The most common comorbidity was hypertension (58.3%). An increasing number of severe exacerbations per year was associated with greater HCRU. DISCUSSION: The findings presented here indicate that effective treatment strategies to prevent severe exacerbations in patients with COPD remain a significant unmet need in low-income and middle-income countries.

Effect of Altitude on Respiratory Functional Status in COVID-19 Survivors: Results from a Latin American Cohort-FIRCOV.

Laura Gochicoa-Rangel, Santiago C. Arce, Carlos Aguirre-Franco, Wilmer Madrid-Mejía, Mónica Gutiérrez-Clavería, Lorena Noriega-Aguirre, Patricia Schonffeldt-Guerrero, Agustín Acuña-Izcaray, Arturo Cortés-Telles, Luisa Martínez-Valdeavellano, Federico Isaac Hernández-Rocha, Omar Ceballos-Zúñiga, Rodrigo Del Rio Hidalgo, Sonia Sánchez, Erika Meneses-Tamayo, and Iván Chérrez-Ojeda; and on Behalf of the Respiratory Physiology Project in COVID-19 (FIRCOV). Effect of altitude on respiratory functional status in COVID-19 survivors: results from a Latin American Cohort-FIRCOV. High Alt Med Biol 24:37-48, 2023. Persistent symptoms and lung function abnormalities are common in COVID-19 survivors. Objectives: To determine the effect of altitude and other independent variables on respiratory function in COVID-19 survivors. Methods: Analytical, observational, cross-sectional cohort study done at 13 medical centers in Latin America located at different altitudes above sea level. COVID-19 survivors were invited to perform pulmonary function tests at least 3 weeks after diagnosis. Results: 1,368 participants (59% male) had mild (20%), moderate (59%), and severe (21%) disease. Restriction by spirometry was noted in 32%; diffusing capacity of the lung for carbon monoxide (DLCO) was low in 43.7%; and 22.2% walked less meters during the 6-minute walk test (6-MWT). In multiple linear regression models, higher altitude was associated with better spirometry, DLCO and 6-MWT, but lower oxygen saturation at rest and during exercise. Men were 3 times more likely to have restriction and 5.7 times more likely to have a low DLCO. Those who had required mechanical ventilation had lower DLCO and walked less during the 6-MWT. Conclusions: Men were more likely to have lower lung function than women, even after correcting for disease severity and other factors. Patients living at a higher altitude were more likely to have better spirometric patterns and walked farther but had lower DLCO and oxygen saturation.

Latin American Registry of Idiopathic Pulmonary Fibrosis (REFIPI): Clinical Characteristics, Evolution and Treatment

Introduction: Idiopathic pulmonary fibrosis (IPF) is a progressive, irreversible and frequently fatal disease. Currently there are national and multinational registries in Europe, United States, Australia and China to better understand the magnitude of the problem and the characteristics of the IPF patients. However, there are no national or regional registries in Latin America, so the objective of this study was to carry out a Latin American registry that would allow the identification of IPF patients in our region. Methodology: A system consisting of 3 levels of control was designed, ensuring that patients met the diagnostic criteria for IPF according to international guidelines ATS/ERS/ALAT/JRS 2011. Demographic, clinical, serological, functional, tomographic, histological and treatment variables were recorded through a digital platform. Results: 761 IPF patients from 14 Latin American countries were included for analysis, 74.7% were male, with a mean age of 71.9+8.3 years. In general there was a long period of symptoms before definitive diagnosis (median 1 year). In functional tests, an average reduction of FVC (70.9%) and DLCO (53.7%) was detected. 72% received at least one antifibrotic drug (pirfenidone or nintedanib) and 11.2% of the patients had an acute exacerbation, of which 38 (45.2%) died from this cause. Conclusions: Like other registries, we found that there is difficulty in the recognition and excessive delay in the diagnosis of IPF in Latin America. Most of the patients in REFIPI received antifibrotics; these were well tolerated and associated with fewer adverse events than those reported in clinical trials. (AU)

Presión positiva en vía aérea y cánula de alto flujo en el tratamiento de insuficiencia respiratoria por COVID-19, en unidades de cuidados respiratorios especiales, de dos hospitales de referencia en la República de Panamá

Introducción: En Panamá, así como en otras partes del mundo como España e Italia, se crearon Unidades de Cuidados Respiratorios Especiales para brindar soporte no invasivo a pacientes con insuficiencia respiratoria por neumonía por SARS-COV-2. En este trabajo se describen las características demográfica y clínicas de los pacientes que utilizaron ventilación no invasiva y/o cánula de alto flujo.  Material y métodos: El diseño del estudio fue prospectivo, observacional y descriptivo en dos hospitales de referencia en Panamá. Los pacientes firmaron un consentimiento informado y se procedió a llenar un cuestionario diario sobre las características demográficas y variables clínicas diarias.  Resultados: Se logró recolectar datos de 173 paciente, 60.69% correspondió al sexo masculino y se encontraban en una media de edad de 59 años, la comorbilidad más común fue la hipertensión arterial. El 88.75% de los pacientes tuvieron un NEWS 2 por arriba de 5 que indicaba mayor vigilancia por riesgo medio de paciente crítico, tanto la VMNI como el CAF tuvieron buenos resultados, 60% y 80% respectivamente. Conclusión: Nuestro estudio nos da luces sobre las características de los pacientes con insuficiencia respiratoria que requirieron dispositivos no invasivos y nos permite observar la evolución de estos en un contexto donde los recursos son limitados para terapia en cuidados intensivos. (provisto por Infomedic International)

Introduction: In Panama, as in other parts of the world, Special Respiratory Care Units were created to provide non-invasive support to patients with respiratory failure due to SARS-COV-2 pneumonia. In this work, the demographic and clinical characteristics of the patients who used non-invasive ventilation and/or high-flow cannula are described. Material and method: The study design was prospective, observational and descriptive in two Reference Hospitals in Panama. The patients signed an informed consent and proceeded to fill out a daily questionnaire on demographic characteristics and daily clinical variables. Results: We included 173 patients, 60.69% were male and had a mean age of 59 years, and the most common comorbidity was hypertension. In the evaluation of the risks, the 88.75% had a NEWS 2 above 5 that indicated greater vigilance due to the medium risk of a critical patient, both NIV and HFC had good results in 60% and 80% respectively. Conclusion: Our study sheds light on the characteristics of patients with respiratory failure who required non-invasive devices and allows us to observe their evolution in a context where resources are limited for intensive care therapy. (provided by Infomedic International)

Latin American Registry of Idiopathic Pulmonary Fibrosis (REFIPI): Clinical Characteristics, Evolution and Treatment.

INTRODUCTION: Idiopathic pulmonary fibrosis (IPF) is a progressive, irreversible and frequently fatal disease. Currently there are national and multinational registries in Europe, United States, Australia and China to better understand the magnitude of the problem and the characteristics of the IPF patients. However, there are no national or regional registries in Latin America, so the objective of this study was to carry out a Latin American registry that would allow the identification of IPF patients in our region. METHODOLOGY: A system consisting of 3 levels of control was designed, ensuring that patients met the diagnostic criteria for IPF according to international guidelines ATS/ERS/ALAT/JRS 2011. Demographic, clinical, serological, functional, tomographic, histological and treatment variables were recorded through a digital platform. RESULTS: 761 IPF patients from 14 Latin American countries were included for analysis, 74.7% were male, with a mean age of 71.9+8.3 years. In general there was a long period of symptoms before definitive diagnosis (median 1 year). In functional tests, an average reduction of FVC (70.9%) and DLCO (53.7%) was detected. 72% received at least one antifibrotic drug (pirfenidone or nintedanib) and 11.2% of the patients had an acute exacerbation, of which 38 (45.2%) died from this cause. CONCLUSIONS: Like other registries, we found that there is difficulty in the recognition and excessive delay in the diagnosis of IPF in Latin America. Most of the patients in REFIPI received antifibrotics; these were well tolerated and associated with fewer adverse events than those reported in clinical trials.

Fibrosis pulmonar idiopática. Características clínicas de un registro en Panamá. 2017-2020

Introducción: La fibrosis pulmonar idiopática es una enfermedad rara, asociada al envejecimiento, con una alta tasa de mortalidad entre los 2.5 a 3 años. El diagnóstico se realiza con la sospecha clínica y la confirmación del patrón de neumonía intersticial usual, en tomografía del tórax o en biopsia pulmonar; el tratamiento actual se basa en fármacos anti fibróticos. Material y método: Se llevó a cabo un estudio descriptivo y prospectivo tipo registro, de pacientes con fibrosis pulmonar idiopática, que estuviesen en seguimiento por médicos especialistas en neumología en 4 consultorios privados de la ciudad de Panamá entre el 2017 y el 2020. Resultado: Se evaluaron 32 pacientes, edad media de 69 años (rango 53 ­ 91); 18/32 (56.3%) fueron masculinos, y de estos, 16/18 (88.9%) eran fumadores. Los crepitantes tipo velcro subescapulares se encontraron en 29/32 (90.6%). El patrón de neumonía intersticial usual en tomografía se encontró en 30/32 (93.7%), y 2/32 (6.3%) en biopsia. Los medicamentos anti fibróticos fueron usados en 6/32 (18.6%); el 50% usó nintedanib y el 50% pirfenidona. Fallecieron 4/32 (12.5%) pacientes en el periodo de estudio. Conclusión: La fibrosis pulmonar idiopática es frecuente en mayores de 50 años, principalmente varones, con historial de tabaquismo y reflujo gastroesofágico. Los crepitantes tipo velcro subescapulares son un hallazgo frecuente. El diagnóstico se realizó en su mayoría con tomografía de tórax de alta resolución; la difusión de monóxido de carbono y la saturación en la caminata de 6 minutos son las pruebas funcionales más alteradas. Menos de un tercio de los pacientes recibe tratamiento con anti fibróticos. (provisto por Infomedic International)

Introduction: Idiopathic pulmonary fibrosis is a rare disease, associated with aging, with a high mortality rate between 2.5 to 3 years. Diagnosis is made with clinical suspicion and confirmation of the usual interstitial pneumonia pattern in chest tomography or lung biopsy; current treatment is based on antifibrotic drugs. Methods: A descriptive and prospective registry-type study was carried out on patients with idiopathic pulmonary fibrosis who were being followed up by pulmonology specialists in 4 private practices in Panama City between 2017 and 2020. Results: 32 patients were evaluated, mean age 69 years (range 53 - 91); 18/32 (56.3%) were male, and of these, 16/18 (88.9%) were smokers. Subscapularis velcro-type crackles were found in 29/32 (90.6%). The usual interstitial pneumonia pattern on CT was found in 30/32 (93.7%), and 2/32 (6.3%) on biopsy. Antifibrotic drugs were used in 6/32 (18.6%); 50% used nintedanib and 50% pirfenidone. Four/32 (12.5%) patients died during the study period. Conclusion: Idiopathic pulmonary fibrosis is frequent in patients older than 50 years, mainly males, with a history of smoking and gastroesophageal reflux. Subscapular Velcro-like crackles are a frequent finding. Diagnosis was mostly made with high-resolution chest CT; carbon monoxide diffusion and 6-minute walk saturation are the most altered functional tests. Less than one third of patients receive treatment with antifibrotic drugs. (provided by Infomedic International)