Tratamiento de soporte respiratorio de la COVID-19. Papel de las unidades de cuidados respiratorios intermedios / COVID-19 respiratory support treatment. Role of the intermediate respiratory care units

El COVID-19 se relaciona con el desarrollo de un síndrome de distrés respiratorio, en muchos casos con insuficiencia respiratoria aguda grave. Ante la falta de disponibilidad o la ausencia de criterios para ingreso en las unidades de cuidados intensivos (UCI) de estos pacientes, los neumólogos han tenido que reinventar la indicación y el modo de uso de las terapias de soporte respiratorio no invasivo (TSRNI), y con ello las unidades de cuidados respiratorios intermedios atendidas por neumólogos. La presencia de estas unidades ha sido un factor determinante de la mortalidad por COVID-19, puesto que han permitido indicar ventilación mecánica no invasiva, presión positiva continua en vía aérea y/o terapia de alto flujo, además de la oxigenoterapia convencional, bajo estricta monitorización en un ambiente fuera de las UCI. Con esta revisión, nos hemos propuesto describir y analizar la evidencia disponible en cuanto al uso de las TSRNI en la COVID-19

COVID-19 leads to the development of a respiratory distress syndrome, in many cases including a severe hypoxemic respiratory failure. Due to the lack of Intensive Care Units (ICU) beds, or the absence of criteria to receive some patients, pulmonologists have had to rethink the indications and use of the noninvasive support respiratory therapies (NSRT), and the intermediate respiratory intensive care units (IRCU) managed by pulmonologists. The creation of these units has been a determinant factor of the mortality due to COVID-19, since support respiratory techniques like noninvasive mechanical ventilation, continuous airway positive pressure or high flow therapy, besides conventional oxygen therapy, have been indicated and strictly monitored even in the absence of an ICU room. In this paper, we attempt to describe and analyze the available evidence of the use of NSRT in patients with COVID-19

Evolución de pacientes con esclerosis lateral amiotrófica atendidos en una unidad multidisciplinar / Outcome of patients with amyotrophic lateral sclerosis attending in a multidisciplinary care unit

Introducción: La esclerosis lateral amiotrófica (ELA) es una enfermedad con muy mal pronóstico, con una mortalidad del 50% a los 18 meses tras el diagnóstico. Las unidades multidisciplinares pretenden mejorar la calidad de vida y la supervivencia de los enfermos de ELA. El objetivo de nuestro estudio es evaluar cada 3 meses la evolución de pacientes atendidos en la unidad de ELA desde el momento del diagnóstico y durante 24 meses. Material y métodos: Se realizó un estudio observacional prospectivo de pacientes atendidos en la unidad de ELA siguiendo una vía clínica desde el momento del diagnóstico y con revisiones trimestrales desde 2006 a 2010. La edad de inicio, el deterioro de la situación funcional (escala ALSFRS-r), el deterioro de la función respiratoria y la aparición de disfagia y de signos de depresión y/o de deterioro cognitivo fueron evaluados en relación con la localización inicial de los síntomas (bulbar [B], miembros superiores [MMSS], miembros inferiores [MMII]). Resultados: 42 pacientes (30V y 12M) fueron evaluados (edad media de inicio±desviación estándar de 57,97±14,56 años). Se encontró una distribución igual por localización de inicio de los síntomas (B 14 pacientes, MMSS 14, MMII 14). El deterioro funcional (B –26,89 pts.; MMSS –22,48 pts.; MMII –22,66 pts.), la necesidad de uso de BIPAP (B 64,28%; MMSS 35,71%, MMII 50%), la presencia de disfagia (B 85,71; MMSS 42.85; MMII 71.42%), de signos de depresión (B 78,57%, MMSS 35,71%; MMII 64,28%) y de deterioro cognitivo (B 42,85%; MMSS 21,42; MMII 35,71%) fue mayor a los 24 meses de evolución en los pacientes de inicio bulbar. No hubo diferencias en los datos de mortalidad (global 23,80%). Conclusiones: El tratamiento en unidades multidisciplinares no varía la evolución neurológica de la enfermedad pero favorece la aplicación de cuidados multidisciplinares e incrementa la supervivencia de los enfermos de ELA independientemente de su forma de inicio (AU)

Introduction: Amyotrophic lateral sclerosis (ALS) is a disease with very poor prognosis, and a mortality of 50% at 18 months after diagnosis. Multidisciplinary units attempt to improve the quality of life and survival of patients with ALS. The aim of this study is to evaluate every 3 months, over a 24-month period, the outcome of patients treated at the ALS unit since the time of diagnosis. Material and methods: We performed a prospective observational study of patients treated in the ALS unit following a clinical pathway since the time of diagnosis with quarterly reviews from 2006 to 2010. The age of onset, functional impairment (ALSFRS-r), impairment of respiratory function, dysphagia and signs of depression and/or cognitive impairment were evaluated in relation to the initial location symptoms (bulbar [B], upper limbs [UL], lower limbs [LL]). Results: A total of 42 patients (30 males and 12 females) were evaluated (mean age at onset of 57.97years old, SD 14.56). There was an even distribution by location of onset of symptoms (B 14 patients, UL 14, LL 14.) Functional impairment (B –26,89 points, UL –22,48 points, LL –22,66 points), the need for use of BIPAP (B 64.28%; UL 35.71%; LL 50%), the presence of dysphagia (B 85.71; UL 42.85; LL 71.42%), signs of depression (B 78.57%; UL 35.71%; LL 64.28%) and cognitive impairment (B 42.85%; UL 21.42; LL 35.71%) was higher at 24 months of progression in patients with bulbar onset. There was no difference in mortality data (23.80% overall). Conclusions: The treatment in multidisciplinary units does not change the neurological progression of the disease, but increases the survival of ALS patients regardless of their initial onset, emphasising the use of multidisciplinary care (AU)

Outcome of patients with amyotrophic lateral sclerosis attending in a multidisciplinary care unit.

INTRODUCTION: Amyotrophic lateral sclerosis (ALS) is a disease with very poor prognosis, and a mortality of 50% at 18 months after diagnosis. Multidisciplinary units attempt to improve the quality of life and survival of patients with ALS. The aim of this study is to evaluate every 3 months, over a 24-month period, the outcome of patients treated at the ALS unit since the time of diagnosis. MATERIAL AND METHODS: We performed a prospective observational study of patients treated in the ALS unit following a clinical pathway since the time of diagnosis with quarterly reviews from 2006 to 2010. The age of onset, functional impairment (ALSFRS-r), impairment of respiratory function, dysphagia and signs of depression and/or cognitive impairment were evaluated in relation to the initial location symptoms (bulbar [B], upper limbs [UL], lower limbs [LL]). RESULTS: A total of 42 patients (30 males and 12 females) were evaluated (mean age at onset of 57.97 years old, SD 14.56). There was an even distribution by location of onset of symptoms (B 14 patients, UL 14, LL 14.) Functional impairment (B -26,89 points, UL -22,48 points, LL -22,66 points), the need for use of BIPAP (B 64.28%; UL 35.71%; LL 50%), the presence of dysphagia (B 85.71; UL 42.85; LL 71.42%), signs of depression (B 78.57%; UL 35.71%; LL 64.28%) and cognitive impairment (B 42.85%; UL 21.42; LL 35.71%) was higher at 24 months of progression in patients with bulbar onset. There was no difference in mortality data (23.80% overall). CONCLUSIONS: The treatment in multidisciplinary units does not change the neurological progression of the disease, but increases the survival of ALS patients regardless of their initial onset, emphasising the use of multidisciplinary care.

Aspergilosis pulmonar invasiva debido a Aspergillus terreus en un paciente inmunocompetente con enfermedad pulmonar obstructiva crónica / Invasive pulmonary aspergillosis due to Aspergillus terrus in an immunocompetent patient with chronic obstructive pulmonary disease

En los últimos años se ha observado con más frecuencia la presencia de aspergilosis invasiva en pacientes con enfermedad pulmonar obstructiva crónica (EPOC). En ciertas ocasiones esta se debe a la especie Aspergillus terreus, que presenta ciertas características propias como son su rareza para producir infección invasiva pulmonar, su alta mortalidad y su resistencia a antifúngicos. Presentamos el caso de un paciente inmunocompetente con EPOC que cursó con clínica de infección respiratoria de mala evolución, causada por una aspergilosis invasiva por Aspergillus terreus (AU)

The frequency of invasive aspergillosis in chronic obstructive pulmonary disease patients has been observed more frequently in recent years. It is sometimes due to the species of Aspergillus terreus, which has some characteristic features such as it being a rare cause of this invasive disease, its high mortality and its resistance to antifungal agents. We report the case of invasive aspergillosis in a non-immunosuppressed patient with COPD who had a complicated respiratory infection caused by Aspergillus terreus (AU)

Relationship between the upper airway and obstructive sleep apnea-hypopnea syndrome in morbidly obese women.

BACKGROUND: The authors studied changes in the upper airway in morbidly obese women and the relationship to sleep apnea-hypopnea syndrome (OSAS). METHODS: Patients underwent a cardiorespiratory polygraphic study, respiratory function test (spirometry, plethysmography, maximum inspiratory pressures and arterial blood gas analysis), and computed tomographic studies of the upper airway. RESULTS: 40 morbidly obese women being evaluated for bariatric surgery (mean age 39.6 +/- 9.6 years old, BMI 48.7 +/- 5.6 kg/m2) were studied. 37 women had OSAS, and 14 had severe OSAS. Results on respiratory function tests were normal. BMI and weight had a positive correlation with apnea-hypopnea index (AHI), apnea index (AI), desaturation index (DI), lowest oxygen saturation and CT90. Uvula diameter had a negative correlation with FEV1, FVC, VC IN and a positive correlation with TLC. Retropharynx soft tissue at the retropalatal level had a negative correlation with FEV1, FVC and VC IN. The oropharynx area at maximal inspiration (total lung capacity) obtained a negative correlation with the AHI (r = - 0.423, P = 0.044), AI (r = - 0.484, P = 0.042) and DI (r = - 0.484, P = 0.019). CONCLUSIONS: Prevalence of OSAS in morbidly obese women is very high. Our results show the significant correlation between BMI and AHI in morbidly obese women. Uvula diameter and retropharynx soft tissue are the upper airway parameters with higher relationship with pulmonary function. A reduction in the cross-sectional area of the airway at the level of the oropharynx could be related to the severity of OSAS in morbidly obese women.

Síndrome de la cimitarra / Scimitar syndrome

No disponible

[Vascular tumors arising in the chest wall: 25 years' experience]. / Experiencia de 25 años en tumores vasculares de la pared torácica.

Seventy-three interventions for chest wall tumors were performed at our hospital from 1978 through 2003. Six (8.2%) tumors were vascular. Four of them were soft tissue tumors, and two involved bone. The histologic diagnoses were hemangioendothelioma (1), low-grade angiosarcoma (1), and hemangioma (4). The diagnosis was established after surgery in all cases except one that had been previously diagnosed during an attempted resection before the patient came to our hospital. Fine needle aspiration carried out in 4 patients was inconclusive in all cases. Complete tumor resection with a margin greater than 3 cm was performed in each patient. Embolization followed by ligation of the intercostal vessels was performed prior to tumor resection in 1 patient with arteriovenous fistula and diffuse angiomatosis. Chest wall reconstruction after tumor removal was carried out using autologous tissues except in 1 case in which a Marlex mesh (CR Bard Inc., Burlington, USA) and a metallic prosthesis was inserted to prevent deformity in the lower costal arch. All patients have been followed and have survived with no evidence of recurrence after follow up ranging from 2 to 25 years.

Experiencia de 25 años en tumores vasculares de la pared torácica / Vascular tumors arising in the chest wall: 25 years' experience

En el período de 1978 a 2003 realizamos 73 intervenciones en tumores de la pared del tórax, de los cuales 6 eran tumores vasculares, un 8,2%. Cuatro eran tumores de partes blandas y 2 tenían afectación ósea. El diagnóstico histológico fue de 4 hemangiomas, un hemangioendotelioma y un angiosarcoma de bajo grado. En todos el diagnóstico se estableció tras la cirugía, excepto en un caso que había sido diagnosticado previamente en un intento de resección antes de llegara nuestro servicio. A 4 enfermos se les realizó una punción-aspiración con aguja fina, que no fue concluyente en ningún caso. Se practicó resección completa del tumor en todos los pacientes, con un margen superior a 3 cm. En un enfermo con fístula arteriovenosa y angiomatosis difusa se practicó embolización con posterior ligadura quirúrgica de los vasos intercostales antes de la resección tumoral. La reconstrucción parietal del defecto tras la extirpación del tumor se llevó a cabo con tejidos propios, excepto en un caso en que utilizamos placa de Marlex y prótesis metálica para evitar la deformidad de la arcada costal inferior. Hemos realizado seguimiento de todos los enfermos, que en la actualidad están vivos y sin signos de recidiva, entre2 y 25 años tras la cirugía

Seventy-three interventions for chest wall tumors were performed at our hospital from 1978 through 2003. Six(8.2%) tumors were vascular. Four of them were soft tissue tumors, and two involved bone. The histologic diagnoses were hemangio endothelioma (1), low-grade angio sarcoma (1),and hemangioma (4). The diagnosis was established after surgery in all cases except one that had been previously diagnosed during an attempted resection before the patient came to our hospital. Fine needle aspiration carried out in 4 patients was inconclusive in all cases. Complete tumor resection with amargin greater than 3 cm was performed in each patient. Embolization followed by ligation of the intercostal vessels was performed prior to tumor resection in 1 patient with arterio venous fistula and diffuse angiomatosis. Chest wall reconstruction after tumor removal was carried out using autologous tissues except in 1 case in which a Marlex mesh(CR Bard Inc., Burlington, USA) and a metallic prosthesis was inserted to prevent deformity in the lower costal arch. All patients have been followed and have survived with no evidence of recurrence after follow up ranging from 2 to 25 years