Abordaje paliativo en enfermedades respiratorias avanzadas / Palliative Approach in Advanced Respiratory Diseases

Las enfermedades respiratorias crónicas avanzadas son prevalentes y producen deterioro de la calidad de vida, en particular la enfermedad pulmonar obstructiva crónica (EPOC), las enfermedades pulmonares intersticiales difusas (EPID) y las enfermedades neuromusculares progresivas con compromiso diafragmático (ENM). Quienes las padecen presentan síntomas persistentes que no son siempre adecuada-mente controlados por los tratamientos recomendados por las guías clínicas de mane-jo. El tratamiento paliativo de los síntomas persistentes es un punto relevante y suelen presentarse barreras para su implementación.Este artículo ofrece una revisión narrativa sobre una perspectiva latinoamericana acerca del rol de los cuidados paliativos en enfermedades respiratorias avanzadas.

Advanced chronic respiratory diseases are prevalent and cause deterioration in qual-ity of life, particularly chronic obstructive pulmonary disease (COPD), diffuse intersti-tial lung diseases (ILD) and progressive neuromuscular diseases with diaphragmatic involvement (NMD). Those who suffer from them usually present persistent symptoms that are not always adequately controlled by the treatments recommended by the clinical management guidelines. Palliative treatment of persistent symptoms is a relevant point, but the pal-liative approach usually presents barriers to its implementation.This article offers a narrative review over Latin American perspective on the role of pal-liative care in advanced respiratory diseases.

[Compliance with CPAP treatment in patients with obstructive sleep apneas during the COVID-19 pandemic in two hospitals in the Federal Capital] / Cumplimiento del tratamiento con CPAP en pacientes con apneas obstructivas del sueño durante la pandemia COVID-19 en dos hospitales de Capital Federal.

Introduction: CPAP therapy is the first line treatment for sleep apnea and its effectiveness depends on adherence. Face to face control and follow-up was limited due to the fact that our country was immersed in social isolation due to the COVID-19 pandemic as of March 2020. In order to assess whether CPAP adherence was maintained in patients with obstructive sleep apnea (OSA), in two hospitals during the COVID-19 pandemic and compare it with the pre-pandemic situation on a historical control basis in the city of Buenos Aires. Methods: Observational and retrospective study based on systematic data collection of adherence to CPAP and residual apnea-hypopnea index (AHI). For comparison, a historical control corresponding to the specular period (May to December of each year between 2016 and 2019) was used as a reference. Patients over 18 years ago with OSA on CPAP therapy more than 30 days of treatment were included. Patients with other chronic respiratory diseases requiring ventilation therapy (Bi-level, servo ventilation, volume-assured ventilation) were excluded. Results: 151 pre-pandemic patients and 127 from the pandemic period, respectively, were evaluated. Men 98 (65%) vs. 50 (60.3%) p: 0.9, age: 65.4 ± 11.9 vs. 63.6 ± 12.6 p: 0.22, body mass index 31.5 ± 5.0 vs. 31.2 ± 5.3 kg/m2 p: 0.6, respectively. In both centers, the most used treatment was fixed CPAP; 90 (59.6%) vs. 96 (75.6%) p: 0.005. There was an increase in compliance with it compared to the pre-pandemic period in minutes/night [341.4 95% CI 292.4 - 340.6 vs. 274.3 95% CI 208.5 - 267.4, p: 0.001] and residual AHI reduction [3.3 IC 95% 2.0 - 3.05 vs. 6.3 IC 95% 2.6 - 4.3 p: 0.006]. Conclusions: In the period of the COVID-19 pandemic, greater adherence to CPAP treatment was observed in patients with sleep apnea.

Introducción: La terapia con CPAP es el tratamiento de primera línea para la apnea del sueño y su eficacia depende de la adherencia. El control y seguimiento de forma presencial fue limitado debido a que nuestro país se vio inmerso en aislamiento social debido a la pandemia por COVID-19 a partir de marzo del 2020. Con el objeto de evaluar si se mantuvo la adherencia de la CPAP en pacientes con apnea obstructiva del sueño (AOS), en dos hospitales durante la pandemia COVID-19 y compararlo con la situación prepandemia sobre una base de control histórico de la ciudad de Buenos Aires. Métodos: Estudio observacional y retrospectivo basado en datos de recolección sistemática de adherencia a la CPAP e índice de apnea-hipopnea (IAH) residual. Para la comparación, se utilizó como referencia un control histórico correspondiente al periodo especular (mayo a diciembre de cada año entre el 2016 y 2019). Se incluyeron pacientes de más de 18 años de edad, con AOS con terapia con CPAP de más de 30 días de tratamiento. Se excluyeron pacientes con otras patologías respiratorias crónicas que requerían de terapias de ventilación (Bi-level, servo ventilación, ventilación con volumen asegurado). Resultados: Fueron evaluados 151 pacientes prepandemia y 127 del periodo pandemia respectivamente. Hombres 98 (65%) vs. 50 (60.3%) p: 0.9, edad de 65.4± 11.9 vs 63.6 ± 12.6 p: 0.22, índice de masa corporal 31.5 ± 5.0 vs. 31.2 ± 5.3 kg/m2 p: 0.6, respectivamente En ambos centros, el tratamiento más utilizado fue CPAP fijo; 90 (59.6%) vs. 96 (75.6%) p: 0.005. Existió un aumento en el cumplimiento del mismo en comparación al periodo prepandémico en minutos/noche [341.4 IC 95% 292.4 - 340.6 vs. 274.3 IC 95% 208.5 - 267.4, p: 0.001] y reducción del IAH residual [3.3 IC 95% 2.0 - 3.05 vs. 6.3 IC 95% 2.6 - 4.3 p: 0.006]. Conclusiones: En el periodo de pandemia COVID-19 se observó mayor adherencia al tratamiento con CPAP en pacientes con apneas del sueño.

La edad y el uso de máscara oronasal se asocian con menor calidad en la titulación con CPAP autoajustable en domicilio en pacientes sin adaptación / Age and Oronasal Mask are Associated with Lower Quality in Automatic CPAP Titration at Home in Patients without Previous Adaptation

Introducción: se considera aceptable (TitAcept) una prueba con CPAP automático en domicilio (APAP) cuando su uso es ≥ a 4 horas/noche y el índice de apneas residuales (IAHr) ≤ 10 eventos/hora (AASM). Sin embargo, todas las variables relacionadas con la calidad de este procedimiento no se conocen completamente. Objetivo: evaluar la cali-dad de la titulación con APAP en el domicilio. Material y métodos: estudio retrospectivo en pacientes "naïve" de CPAP. El criterio de TitAcept seleccionó dos grupos y la regresión logística múltiple identificó predictores de prueba no aceptables. Resultados: incluimos 1325 TitAcept; 941 hombres (71%), edad: 57 ± 12,4 años, IMC: 32,3 ± 8,8 kg/m2, IAH: 34,2 ± 19 ev/h. La titulación alcanzó 3,4 ± 3,5 noches, adherencia: 379 minutos/noche; pre-sión efectiva: 8,7 ± 1,7 cm H2O, IAHr; 3,1 ± 2,4 ev/h y fugas 16,1 ± 8,7 litros/min. Fueron predictores; edad ≥ 50 años; OR: 1,62 (IC95%: 1,23-3,46), p: 0.0005 y máscara orona-sal; OR: 2,49 (IC95%: 1,79-3,46), p: 0.0001. Conclusiones: una significativa proporción de pacientes que realizaron una titulación no vigilada con APAP en domicilio no alcan-zaron criterios de calidad adecuada. La edad ≥ 50 años y el uso de máscara oronasal se asocian con menor calidad en la prueba, de acuerdo a criterios preestablecidos. (AU)

Introduction: automated CPAP (APAP) titration at home is considered acceptable (Tit-Accept) when its device is used ≥ 4 hours/night and the residual apnea index (AHIr) es ≤ 10 events/hour (AASM). However, all the variables related to quality of this procedure are not fully known. Objective: to assess the quality of the titration with APAP at home.Material and Methods: retrospective study in CPAP "naïve" patients. The TitAccept criteri-on selected two groups and multiple logistic regression identified predictors of non-ac-ceptable titration. Results: we included 1325 TitAccept; 941 men (71%), age: 57 ± 12.4 years, BMI: 32.3 ± 8.8 kg/m2, baseline AHI: 34.2 ± 19 ev/h. The titration reached 3.4 ± 3.5 nights, adherence: 379 minutes/night; effective pressure: 8.7 ± 1.7 cmH2O, AHIr; 3.1 ± 2.4 ev/h and leaks 16.1 ± 8.7 liters/min. The predictors were; age ≥ 50 years; OR: (AU)

Hipoxemia y el riesgo de hipertensión arterial en apnea obstructiva del sueño / Hypoxemia and the Hypertension Risk in Obstructive Sleep Apnea

Hay poca información sobre el rol de la hipoxemia como factor de riesgo de hipertensión arterial (HTA) en pacientes con apnea obstructiva del sueño. El objetivo de este estudio fue evaluar la hipoxemia como factor de riesgo independiente de HTA en un modelo de trabajo basado en pacientes reales examinados en una unidad de sueño. Métodos: estudio retrospectivo. Modelo predictivo mediante regresión logística múltiple para establecer la relación entre HTA y edad, sexo, índice de masa corporal (IMC), índice de apneas e hipopneas por hora de registro (IAH) y tiempo de saturación de oxígeno debajo de 90% (T90 > 3%). Resultados: incluimos 3854 pacientes (edad mediana 55 años), predominio varones (61.5%). Según el modelo, las variables asociadas con HTA fueron: edad (OR 3.27 ­ 3.29, IC95% 2.83 ­ 3.80, p < 0.0001), sexo masculino (OR 1.35, IC95% 1.17 ­ 1.56, p < 0.001), obesidad (OR 1.83, IC95% 1.59 ­ 2.11, p < 0.0001), IAH ≥ 15 eventos por hora (OR 1.22, IC95% 1.05 ­ 1.43, p < 0.01) y T90 ≥ 3% (OR 1.56 ­ 1.57, IC95% 1.32 ­ 1.84, p < 0.0001). Conclusiones: en una población clínica con sospecha de apnea obstructiva del sueño, la hipoxemia (T90 ≥ 3%) se asoció con hipertensión arterial. (AU);

There is limited information about the role of hypoxemia degree as a risk factor for hypertension (HTN) in patients with obstructive sleep apnea (OSA). The objective of this study is to assess hypoxemia as an independent risk factor for HTN in a work model based on real-life patients examined at sleep unit. Methods: this retrospective study consisted of a predictive model using multiple logistic regression to establish the relationship between HTN and age, sex, body mass index (BMI), apnea/hypopnea index (AHI) and time below SO2 ≤ 90% (T90 ≥ 3%). Results: we included 3.854 patients (median age: 55 years), mostly men (61.5%). According to the model, the variables that were significantly associated with HTN were: age (OR: 3.27 ­ 3.29, CI95% 2.83 ­ 3.80, p < 0.0001), male sex (OR 1.35, CI95% 1.17 ­ 1.56, p < 0.001), Obesity (OR 1.83, CI95% 1.59 ­ 2.11, p < 0.0001), AHI > 15 events per hour (OR 1.22, CI95% 1.05 ­ 1.43, p < 0.01) and T90 ≥ 3% (OR 1.56 ­ 1.57, CI95% 1.32 ­ 1.84, p < 0.0001). Conclusion: in a clinical population of subjects suspected of OSA, nocturnal hypoxemia measure as T90 ≥ 3% was associated with HTN. (AU);

Independent association between hypoxemia and night sweats in obstructive sleep apnea.

PURPOSE: To assess the relationship between hypoxemia during polysomnography (PSG) and patient-reported night sweats (NS). METHODS: This retrospective observational study included adult patients who completed a standardized sleep questionnaire and the Epworth Sleepiness Scale (ESS) before PSG. RESULTS: We included 1397 patients (41% women). The median age was 52 years, 80% had obstructive sleep apnea (OSA) defined as an apnea-hypopnea index (AHI) ≥ 5, and 35% were obese. A total of 245 patients (17.5%) reported NS. Their prevalence was higher among patients with OSA compared to controls (18.9% vs. 12.2%, p < 0.01). In the bivariate analysis, the variables associated with NS were BMI, AHI, hypoxemia (T90 ≥ 2.5% of total recording time plus minimum SO2 < 85%), frequent body movements or awakenings, nightmares, excessive daytime sleepiness (Epworth > 10), nocturia, cardiovascular events, and the use of sedatives or antidepressants. In the multivariate model, the independent predictors of NS were BMI (OR: 1.47, CI 95%: 1.07-2.01, p = 0.016), hypoxemia (OR: 1.87, CI 95%: 1.37-2.60, p = 0.0001), nightmares (OR: 2.60, CI 95%: 1.73-3.80, p < 0.0001), frequent body movements and awakenings (OR: 1.57, CI 95%: 1.16-2.11, p = 0.003 and OR: 1.54, CI 95%: 1.13-2.08, p = 0.005, respectively), and excessive daytime sleepiness (OR: 1.65, CI 95%: 1.24-2.20, p = 0.0007). CONCLUSIONS: In patients with OSA, night sweats were significantly and independently associated with a higher hypoxic burden.

Proposal of a diagnostic algorithm based on the use of pulse oximetry in obstructive sleep apnea.

PURPOSE: The aims of this study were to assess the cut-off values for oxygen desaturation index ≥ 3% (ODI3) to confirm obstructive sleep apnea (OSA) in subjects undergoing polysomnography (PSG) and home-based respiratory polygraphy (RP), and to propose an algorithm based on pulse oximetry (PO) for initial management of patients with suspected OSA. METHODS: This was an observational, cross-sectional, retrospective study. ODI3 was used to classify subjects as healthy (no OSA = AHI < 5 or < 15 events/h) or unhealthy (OSA = AHI ≥ 5 or ≥ 15 events/h). On the PSG or experimental group (Exp-G), we determined ODI3 cut-off values with 100% specificity (Sp) for both OSA definitions. ODI3 values without false positives in the Exp-G were applied to a validation group (Val-G) to assess their performance. A strategy based on PO was proposed in patients with suspected OSA. RESULTS: In Exp-G (PSG) 1141 patients and in Val-G (RP) 1141 patients were included. In Exp-G, ODI3 > 12 (OSA = AHI ≥ 5) had a sensitivity of 69.5% (CI95% 66.1-72.7) and Sp of 100% (CI95% 99-100), while an ODI3 ≥ 26 had a 53.8% sensitivity (CI95% 49.3-58.2) and Sp of 100% (CI95% 99.4-100) for AHI ≥ 15. A high pretest probability for OSA by Berlin questionaire (≥ 2 categories) had a lower diagnostic performance than by STOP-BANG questionnaire ≥ 5 points (AHI ≥ 5: 0.856 vs. 0.899, p < 0.001; AHI ≥ 15: 0.783 vs. 0.807, p 0.026). CONCLUSION: We propose the initial use of PO at home in cases of moderate-to-high pretest probability of OSA. This algorithm considers PO as well as RP and PSG for more challenging cases or in case of doubt.

The Cervical Fat Tissue Volume is a Predictor for Moderate to Severe OSA.

Objective Obstructive sleep apnea (OSA) is a disorder characterized by recurrent pharyngeal obstruction during sleep, in which upper airway anatomy plays a key role in its pathogenesis. The aim of this study was to describe whether the quantification of cervical fat tissue volume (CFTV) obtained by Computed Tomography (CT)cephalometry is related to the severity of OSA. Methods Retrospective study between 2018 and 2020 in those patients > 18 years old, with diagnosis of OSA who performed a volumetric cephalometric imaging. Three-dimensional reconstruction of the images was performed and CFTV was measured. Results 91 patients were included in this study of which: without OSA (n: 7), mild (n: 19), moderate (n: 39) and severe OSA (n: 26). We observed a progressive increase of CFTV related to OSA severity has been observed (without OSA: 58.9 ml (47.9-87.5), mild: 59.1ml (48.4-78.3), moderate: 71 ml (42.6-127.1) and severe OSA 103.6 ml (81-153); p < 0.01); nevertheless, no differences were found in the airway volume and neck area. It was showed a significant correlation between CFTV and OSA indicators: AHI, ODI and T90 (Sp r: 0.48; 0.38 and 0.36; p < 0.01 respectively). CFTV cut-off value to discriminate AHI >15 ev/h with best sensitivity-specificity relationship was 64.1 ml with an area under the curve of 0.6 ± 0.06. Multivariate analysis showed that CFTV is a predictor for moderate to severe OSA (OR:3.05, IC95%: 1.14-8.17). Conclusion Cervical fat quantification by CT cephalometry correlates with OSA severity in adults. Fat volume > 64.1 ml increased more than three times the risk of OSA moderate to severe.

Performance of the NOSE Questionnaire in Mask Selection for Home CPAP Titration.

Introduction Many patients abandon CPAP treatment because they find the mask uncomfortable. Therefore, specialists may benefit from the predictive value of airway assessment tools. Objective To identify nasal ventilation failure through the Nasal Obstruction Symptom Evaluation (NOSE) scale in patients with obstructive sleep apnea (OSA) who undergo home-based auto-adjusting CPAP titration and to determine whether there is a correlation between NOSE score and the type of mask selected. Materials and Methods In this prospective correlational study, the NOSE scale was used in terms of mask selection and titration indicators. Patients were classified based on their NOSE score: > or < 50. Results We included 303 patients; 226 men (74.5%), BMI: 33.2 ± 6.1 kg/m 2 , neck circumference (cm): 42.8 ± 3.6 and Epworth (ESS) score: 9.2 ± 5.6, mild OSA: 12 (3.9%), moderate OSA: 127 (41.9%), and severe OSA: 164 (54.1%). The mean NOSE score was 24.3 ± 22.8 and 42 patients (13.8%) had NOSE scores > 50. Indicators for both groups were: compliance (5.9 ± 1.3 vs. 5.8 ± 1.4 hours) p: 0.41, therapeutic pressure (9.1 ± 2.0 vs. 8.8 ± 1.6 cm of H 2 O) p: 0.23, residual AHI (2.3 ± 1.8 vs. 2.8 ± 2.6 events/hour) p: 0.25, and leaks (20.5 ± 10.6 vs. 21.3 ± 10.7 liters/minute) p: 0.64. According to adjusted multiple regression, a NOSE of > 50 was not a predictor of mask selection. Conclusions A > 50 NOSE score was not a predictor of mask selection, and it was not correlated to titration performance.

[Life care of a cohort of patients with home chronic ventilatory support]. / Trayectoria vital de pacientes con soporte ventilatorio crónico domiciliario.

INTRODUCTION: Home mechanical ventilation in chronic respiratory failure improves quality of life and decreases hospitalizations. In order to know clinical characteristics, resource consumption and survival, we proposed an analysis of the vital trajectory during six years. METHODS: Descriptive and retrospective study. Information was obtained from the clinical history of the day hospital program. Kaplan Meier type survival curves were made. We included 100 patients, 57% men, age 65 ± 13 years and body mass index of 29.1 ± 8.6 kg/m2. Thirty had chronic obstructive pulmonary disease (COPD), 23 had amyotrophic lateral sclerosis, 18 obesity hypoventilation syndrome, other neuromuscular diseases in 16 cases, diaphragmatic dysfunction in 10, and chest wall restriction in 3 patients. Ninety-eight received non-invasive ventilation and two invasive cases through tracheostomy. 80% used spontaneous-timed mode (S/T); 14.6%, spontaneous (S); 4% average volume-assured pressure support ventilation (AVAPS) and 1.3% control pressure. Non-invasive compliance was: 7.8 ± 2.6 hours/day. RESULTS: After the start of home ventilation, hospitalizations were reduced (0.2, SD: 0.38 vs. 0.5 SD: 0.5, p < 0.001) and days of hospitalization per episode (5.14, SD: 17.7 vs. 10.45 SD: 16.69, p < 0.001). Median survival was two years with a better vital prognosis in COPD (3 years on average) vs. neuromuscular disease (< 2 years) p < 0.05. CONCLUSIONS: patients with home mechanical ventilation showed a reduction in the days of hospitalization after starting ventilation. Better survival was observed in COPD in relation to neuromuscular disease.

Introducción: La ventilación mecánica domiciliaria en insuficiencia respiratoria crónica, mejora calidad de vida y disminuye hospitalizaciones. Para conocer características clínicas, consumo de recursos y supervivencia, propusimos un análisis de la trayectoria vital durante seis años. Métodos: Estudio descriptivo y retrospectivo. Se obtuvo información de la historia clínica del programa de hospital de día. Se confeccionaron curvas de supervivencia tipo Kaplan Meier. Incluimos 100 pacientes, 57% hombres, edad 65 ± 13 años e índice de masa corporal de 29.1 ± 8.6 kg/m2. Treinta tenían enfermedad pulmonar obstructiva crónica (EPOC), 23 esclerosis lateral amiotrófica, 18 síndrome obesidad hipoventilación, otras enfermedades neuromusculares (ENM) en 16 casos, disfunción diafragmática en 10 y restricción por caja torácica en 3 pacientes. Noventa y ocho recibieron ventilación no invasiva y en dos casos invasiva mediante traqueostomía. El 80% utilizó modo spontaneous-timed (S/T); 14.6%, spontaneous (S); 4% average volume-assured pressure support ventilation ("AVAPS") y 1.3% presión control. El cumplimiento en no invasiva fue: 7.8 ± 2.6 horas/día. Resultados: Luego del inicio de la ventilación domiciliaria se redujeron las hospitalizaciones (0.2, DS: 0.38 vs. 0.5 DS: 0.5, p < 0.001) y los días de internación por episodio (5.14, DS: 17.7 "vs." 10.45 DS: 16.69, p < 0.001). La supervivencia media fue de dos años con mejor pronóstico vital en EPOC (3 años de media) vs. enfermedad neuromuscular (< 2 años) p < 0.05. Conclusiones: los pacientes con ventilación mecánica domiciliaria mostraron reducción de los días de hospitalización luego de comenzado el soporte ventilatorio. Se observó mejor supervivencia en EPOC en relación a enfermedad neuromuscular.

Trayectoria vital de pacientes con soporte ventilatorio crónico domiciliario / Life care of a cohort of patients with home chronic ventilatory support

Resumen Introducción: La ventilación mecánica domiciliaria en insuficiencia respiratoria crónica, mejora calidad de vida y disminuye hospitalizaciones. Para conocer características clínicas, consumo de recursos y supervivencia, propusimos un análisis de la trayectoria vital durante seis años. Métodos: Estudio descriptivo y retrospectivo. Se obtuvo información de la historia clínica del programa de hospital de día. Se confeccionaron curvas de supervivencia tipo Kaplan Meier. Incluimos 100 pacientes, 57% hombres, edad 65 ± 13 años e índice de masa corporal de 29.1 ± 8.6 kg/m2. Treinta tenían enfermedad pulmonar obstructiva crónica (EPOC), 23 esclerosis lateral amiotrófica, 18 síndrome obesidad hipoventilación, otras enfermedades neuromus culares (ENM) en 16 casos, disfunción diafragmática en 10 y restricción por caja torácica en 3 pacientes. Noventa y ocho recibieron ventilación no invasiva y en dos casos invasiva mediante traqueostomía. El 80% utilizó modo spontaneous-timed (S/T); 14.6%, spontaneous (S); 4% average volume-assured pressure support ventilation ("AVAPS") y 1.3% presión control. El cumplimiento en no invasiva fue: 7.8 ± 2.6 horas/día. Resultados: Luego del inicio de la ventilación domiciliaria se redujeron las hospitalizaciones (0.2, DS: 0.38 vs. 0.5 DS: 0.5, p < 0.001) y los días de internación por episodio (5.14, DS: 17.7 "vs." 10.45 DS: 16.69, p < 0.001). La supervivencia media fue de dos años con mejor pronóstico vital en EPOC (3 años de media) vs. enfermedad neuromuscular (< 2 años) p < 0.05. Conclusiones: los pacientes con ventilación mecánica domiciliaria mostraron reducción de los días de hospitalización luego de comenzado el soporte ventilatorio. Se observó mejor supervivencia en EPOC en relación a enfermedad neuromuscular.

Abstract Introduction: Home mechanical ventilation in chronic respiratory failure improves quality of life and decreases hospitalizations. In order to know clinical characteristics, resource consumption and survival, we pro posed an analysis of the vital trajectory during six years. Methods: Descriptive and retrospective study. Information was obtained from the clinical history of the day hospital program. Kaplan Meier type survival curves were made. We included 100 patients, 57% men, age 65 ± 13 years and body mass index of 29.1 ± 8.6 kg/m2. Thirty had chronic obstructive pulmonary disease (COPD), 23 had amyotrophic lateral sclerosis, 18 obesity hypoventilation syndrome, other neuromuscular diseases in 16 cases, diaphragmatic dysfunction in 10, and chest wall restriction in 3 patients. Ninety-eight received non-invasive ventilation and two invasive cases through tracheostomy. 80% used spontaneous-timed mode (S/T); 14.6%, spontaneous (S); 4% average volume-assured pressure support ventilation (AVAPS) and 1.3% control pressure. Non-invasive compliance was: 7.8 ± 2.6 hours/day. Results: After the start of home ventilation, hospitalizations were reduced (0.2, SD: 0.38 vs. 0.5 SD: 0.5, p < 0.001) and days of hospitalization per episode (5.14, SD: 17.7 vs. 10.45 SD: 16.69, p < 0.001). Median survival was two years with a better vital prognosis in COPD (3 years on average) vs. neuromuscular disease (< 2 years) p < 0.05. Conclusions: patients with home mechanical ventilation showed a reduction in the days of hospitalization after starting ventilation. Better survival was observed in COPD in relation to neuromuscular disease.

Ventilación no invasiva en sala de hospitalización general / Non-Invasive Ventilation in a Regular Hospital Ward

Introducción: La experiencia clínica ha permitido la ventilación no invasiva fuera de unidades críticas. Describimos el perfil clínico y evolución de pacientes que recibieron ventilación no invasiva en sala general. Material y métodos: Estudio retrospectivo en pacientes con soporte ventilatorio du rante un año en un hospital general. Resultados: Se utilizó ventilación no invasiva en 43 pacientes, 67,4% con hipercap nia. La relación hombre/mujer fue 1:1. La edad y el IMC fueron 68,3 ± 12,4 años y 30,1 ± 12,3 kg/m2 y los diagnósticos principales, enfermedad pulmonar obstructiva crónica, enfermedad neuromuscular y obesidad-hipoventilación. Un tercio inició la ventilación no invasiva en la unidad de cuidados intensivos, y dos tercios usaban ventilación no invasiva en domicilio antes del ingreso por exacerbación de la enfermedad pulmonar obstructiva crónica (39,5%) o progresión de la enfermedad (14%). La estancia hospi talaria fue 12,1 ± 7 d (14 ± 9 en supervivientes y 5,7 ± 3 en pacientes fallecidos). La gasometría arterial al ingreso reveló PaCO2: 52,7 ± 13,7 mmHg; PaO2: 72,2 ± 16,2 mmHg y pH de 7,36 ± 0,08. Se halló pH < 7,35 en el 18,6% y PaCO2 > 45 en el 57,4%. La PaCO2 al alta fue menor (46,1 ± 4,6; p > 0,05). El modo ST se utilizó en 34 (79%) pacientes. El período de ventilación fue 12,7 ± 10,2 días con uso de 6,9 ± 3,1 h/d. Un tercio recibió cuidados paliativos (13,9% de mortalidad). Tres pacientes (7%) fueron transferidos a la unidad de cuidados intensivos por deterioro clínico y treinta y cinco egresaron con ventilación crónica (94,6%). Conclusiones: Hubo escasas transferencias a la unidad de cuidados intensivos. La mortalidad hospitalaria fue baja y los que fallecieron tenían instrucciones anticipadas.

Introduction: Clinical experience has allowed the use of non-invasive ventilation out side the acute-care setting. We describe the clinical profile and evolution of patients who received non-invasive ventilation in a regular ward. Materials and methods: Retrospective study in patients with ventilatory support for one year in a general hospital. Results: Non-invasive ventilation was delivered to 43 patients, 67.4% of which had hy percapnia. The male/female ratio was 1:1. Age and BMI (Body Mass Index) were 68.3 ± 12.4 years and 30.1 ± 12.3 kg/m2, and the main diagnoses were chronic obstructive pulmonary disease, neuromuscular disease and obesity-hypoventilation. One third of patients began non-invasive ventilation in the Intensive Care Unit, and two thirds had been using non-invasive ventilation at their homes before being admitted with exacerba tion of chronic obstructive pulmonary disease (39.5%) or disease progression (14%). Hospital length of stay was 12.1 ± 7 d (14 ± 9 in survivors and 5.7 ± 3 in deceased patients). Arterial blood gas analysis on admission showed: PaCO2 (partial pressure of arterial carbon dioxide), 52.7 ± 13.7 mmHg; PaO2 (partial pressure of arterial oxygen), 72.2 ± 16.2 mmHg, and pH, 7.36 ± 0.08. A pH level < 7.35 was found in 18.6%, and PaCO2 > 45 in 57.4%. PaCO2 values upon discharge were lower (46.1 ± 4.6; p > 0.05). The ST (spontaneous-timed) mode was used in 34 patients (79%). The ventilation period was 12.7 ± 10.2 days, using 6.9 ± 3.1 h/d. One third of patients received palliative care (13.9% of mortality). Three patients (7%) were transferred to the Intensive Care Unit due to clinical decline, and thirty-five were discharged with chronic ventilation (94.6%). Conclusions: there were few referrals to the Intensive Care Unit. Hospital mortality was low, and patients who died had advance directives.

Documento internacional de consenso sobre apnea obstructiva del sueño / International Consensus Document on Obstructive Sleep Apnea

El objetivo principal de este documento internacional de consenso sobre apnea obstructiva del sueño es proporcionar unas directrices que permitan a los profesionales sanitarios tomar las mejores decisiones en la asistencia de los pacientes adultos con esta enfermedad según un resumen crítico de la literatura más actualizada. El grupo de trabajo de expertos se ha constituido principalmente por 17 sociedades científicas y 56 especialistas con amplia representación geográfica (con la participación de 4 sociedades internacionales), además de un metodólogo experto y un documentalista del Centro Cochrane Iberoamericano. El documento consta de un manuscrito principal, con las novedades más relevantes, y una serie de manuscritos online que recogen las búsquedas bibliográficas sistemáticas de cada uno de los apartados del documento internacional de consenso. Este documento no cubre la edad pediátrica ni el manejo del paciente en ventilación mecánica crónica no invasiva (que se publicarán en sendos documentos de consenso aparte). Palabras clave: Apnea obstructiva del sueño Diagnóstico Tratamiento

The main aim of this international consensus document on obstructive sleep apnea is to provide guidelines based on a critical analysis of the latest literature to help health professionals make the best decisions in the care of adult patients with this disease. The expert working group was formed primarily of 17 scientific societies and 56 specialists from a wide geographical area (including the participation of 4 international societies), an expert in methodology, and a documentalist from the Iberoamerican Cochrane Center. The document consists of a main section containing the most significant innovations and a series of online manuscripts that report the systematic literature searches performed for each section of the international consensus document. This document does not discuss pediatric patients or the management of patients receiving chronic non-invasive mechanical ventilation (these topics will be addressed in separate consensus documents). Keywords: Obstructive sleep apnea Diagnosis Treatment

International Consensus Document on Obstructive Sleep Apnea. / Documento internacional de consenso sobre apnea obstructiva del sueño.

The main aim of this international consensus document on obstructive sleep apnea is to provide guidelines based on a critical analysis of the latest literature to help health professionals make the best decisions in the care of adult patients with this disease. The expert working group was formed primarily of 17 scientific societies and 56 specialists from a wide geographical area (including the participation of 4 international societies), an expert in methodology, and a documentalist from the Iberoamerican Cochrane Center. The document consists of a main section containing the most significant innovations and a series of online manuscripts that report the systematic literature searches performed for each section of the international consensus document. This document does not discuss pediatric patients or the management of patients receiving chronic non-invasive mechanical ventilation (these topics will be addressed in separate consensus documents).

Evaluación respiratoria y manejo de pacientes con obesidad candidatos a procedimientos quirúrgicos y cirugía bariátrica / Respiratory evaluation and management of obese patients who are candidates for surgical procedures and bariatric surgery

En el seno de la Sección de Sueño, Oxigenoterapia y Asistencia Ventilatoria de la Asociación Argentina de Medicina Respiratoria, se planteó el desarrollo de sugerencias para la exploración respiratoria del paciente con obesidad y definiciones sobre el manejo perioperatorio en cirugía bariátrica y procedimientos quirúrgicos electivos (cirugía no bariátrica). Esta iniciativa se basó en la necesidad de contar con lineamientos adaptados a la realidad local y discutida por expertos que se desempeñan en la realidad coyuntural cotidiana de nuestro país. La agenda se inició en agosto de 2020 en un grupo de revisión de la bibliografía y redacción. Revisores de diferentes provincias argentinas efectuaron una extensa valoración de la evidencia. Luego, un comité editorial realizo una revisión crítica del documento. Finalmente, todo el grupo debatió las sugerencias que se exponen como puntos clave. Este documento exhorta a cirujanos y clínicos a trabajar junto a especialistas respiratorios en la evaluación del riesgo, definición de la aptitud operatoria y corrección de trastornos funcionales y apneas del sueño. La cirugía en individuos con obesidad y la cirugía bariátrica, son procedimientos a los que se arriba luego de una evaluación exhaustiva de la situación clínica y funcional. La tarea multidisciplinaria y el tratamiento de las anormalidades detectadas pueden disminuir los riesgos perioperatorios. Pacientes con obesidad que requieren cirugía electiva con anestesia general deben ser evaluados mediante pruebas objetivas para confirmar la presencia de apneas del sueño y estar adecuadamente tratados con CPAP.

Within the Sleep, Oxygen Therapy and Ventilatory Assistance Section of the Argentine Association of Respiratory Medicine, we de velopment of recommendations for the respiratory exploration of patients with obesity and definitions on perioperative management in bariatric surgery and elective surgical procedures (surgery non bariatric). This initiative was based on the need to have guidelines adapted to the local reality and discussed by experts who work in the daily conjunctural reality of our country. The schedule was started in August 2020 in a literature review group. Reviewers from different Argentine provinces carried out an extensive assessment of the evidence. Then, an editorial committee performed a critical review of the document. Finally, the whole group discussed the suggestions that are presented as key points. This document encourages surgeons and clinicians to work close to respiratory specialists in assessing risk, defining operative competence, and revise functional disorders and sleep apnea. Surgery in obese individuals and bariatric surgery are procedures that are reached after a detailed evaluation about clinical and functional situation. The multidisciplinary team and the treatment of detected abnormalities can reduce perioperative risks. Obese patients who require elective surgery with general anesthesia should be evaluated by objective tests to confirm the presence of sleep apnea and be adequately treated with CPAP.

Contribution of pulse oximetry in relation to respiratory flow events in a home-based approach aimed at diagnosing obstructive sleep apnea.

OBJECTIVE: To compare pulse oximetry with manual analysis against all signals of respiratory polygraphy. MATERIAL AND METHODS: This retrospective study estimated sensitivity (S), specificity (Sp) and positive/negative likelihood ratio (LR+/-) of the oxygen desaturation index (ODI-test) and apnea-hypopnea index (AHI-reference). RESULTS: 3854 patients (61.5% men) were included. Age, BMI, Epworth sleepiness scale and AHI were: 55 years (44-65), 30.9kg/m2 (27-36), 7 points (4-11), and 14 events/hour (6-25), respectively. 18% showed an AHI <5 events/hour, 34% = 5 and <15, 27% = or > 15 and < 30, and 31% > 30. The S, Sp, and LR+/- of ODI for AHI = 5 events/hour was 93%, 92%, 12 and 0.08 with an accuracy of 93%. For AHI = 15 events/hour, the values were: S 94%, Sp 94%, LR+ 15 and LR- 0.06 and 94% accuracy (r(2) Spearman: 0.92). CONCLUSION: In a population at a high risk for OSA, home-based pulse oximetry had a diagnostic accuracy > 90% when is compared against all respiratory signals obtained from simplified home sleep testing.

Relation between inflammatory markers and severity of the apnea and hypopnea sleep syndrome / [Relación entre marcadores inflamatorios y severidad del síndrome de apnea e hipopnea del sueño]

INTRODUCCION: Intermittent chronic hypoxia produced during obstructive sleep apneas (OSA) leads to oxidative stress, and consequently to a state of systemic inflammation. There are no biomarkers that assess the degree of inflammation and are related to the severity of this disease. The red cell distribution amplitude and the ultrasensitive reactive C protein are sensitive to the systemic inflammation generated by oxidative stress. We intend to correlate the reactive C protein and red cell distribution amplitude values ​​with the degree of severity of OSA. METHODS: An observational, prospective, analytical study was performed. OSA patients participated. Spearman's correlation coefficient was used to estimate the correlation between red cell distribution amplitude and reactive C protein with OSA severity according to apnea hypopnea index (AHI). RESULTS: 95 patients participated, of which 79 were men. Only 10 (10.5%) patients presented normal BMI. The correlations between AHI with reactive C protein and red cell distribution amplitude were weak (r = 0.17; p = 0.1066 and r = 0.06; p = 0.5867, respectively). The correlations between T90 with reactive C protein and red cell distribution amplitude were also weak (r = 0.16; p = 0.1331 and r = 0.24; p = 0.0202, respectively). An association was found between red cell distribution amplitude greater than 14 and severe OSA (p = 0.0369) and with T90 greater than 10% (p = 0.0168). CONCLUSIONS: Although the correlations between AHI and T90 with reactive C protein and red cell distribution amplitude were weak, it was found that severe patients, presented higher values ​​of red cell distribution amplitude and higher T <90. This association could not be tested with reactive C protein.

INTRODUCCION: La hipoxia crónica intermitente producida durante las apneas obstructivas del sueño (AOS) conduce a estrés oxidativo, y consecuentemente a un estado de inflamación sistémica. No se dispone de biomarcadores que evalúen el grado de inflamación y se relacionen con la severidad de esta enfermedad. La amplitud de distribución eritrocitaria (ADE) y la Proteína C Reactiva ultrasensible (PCRus), son sensibles a la inflamación sistémica generada por el estrés oxidativo. Pretendemos correlacionar los valores de PCR y ADE con el grado de severidad de AOS. METODOS: Se realizó un estudio observacional, prospectivo, analítico. Participaron pacientes con AOS. Para estimar la correlación entre el ADE y PCR con la gravedad del SAOS según IAH se utilizó el coeficiente de correlación de Spearman. RESULTADOS: Participaron 95 pacientes, de los cuales 79 fueron hombres. Solo 10 (10.5%) pacientes presentaron IMC normal. Las correlaciones entre IAH con PCR y ADE fueron débiles (r=0,17; p=0,1066 y r=0.06; p=0.5867, respectivamente). También fueron débiles las correlaciones entre T90 con PCR y ADE (r=0,16; p=0,1331 y r=0,24; p=0,0202, respectivamente). Se encontró una asociación entre ADE mayor a 14 y AOS severo (p=0.0369) y entre ADE mayor a 14 y T90 mayor al 10% (p=0.0168). CONCLUSIONES: Si bien las correlaciones entre IAH y T90 con PCR y ADE fueron débiles, se halló que los pacientes severos, presentaron mayores valores de ADE y mayor T<90. Esta asociación no pudo ser probada con la PCR.

Cumplimiento e intolerancias durante el tratamiento con presión positiva en las vías aéreas Perfil de consultas externas en una unidad de sueño

Resumen Introducción: El tratamiento con presión positiva puede generar efectos adversos. Para conocer el perfil de cumplimiento e intole rancias analizamos conductas instituidas por kinesiólogos de una Unidad de Sueño. Material y Métodos: Estudio retrospectivo, trasversal y observacional. Se incluyeron pacientes > 18 años con presión positiva derivados a la consulta kinésica. Resultados: Durante cuatro años se evaluaron 244 pacientes; 165 hombres (67%), edad; 65.7 ± 11.6 años, IMC (kg/m2) 31.0 ± 5.4, de los cuales 61% utilizaba CPAP fija, 29% autoajustable, 8% dispositivos binivelados, máscaras nasales 147 (60%), oronasales 52 (21%); almohadillas 37 (15%) y termohumidificador 92 (36%). Los motivos de consultas fueron; control de la terapia (239; 61%), intolerancias (67; 17%) y calibración (51; 13%). El cumplimiento (horas/noche) fue de 4.61 ± 2.1 con un % de noches > 4 horas de 67 ± 36 %. No hallamos diferencias de cumplimiento entre primer y segundo año (4.5 vs. 5.0 horas/noche) p > 0.13, aunque este fue mayor a partir de 600 días de uso de la terapia (p < 0.05). 141 pacientes (57%) presentaban dificultades siendo más frecuentes las fugas (19%) o intolerancias a la máscara (10%). Un (97%) de los pacientes resolvieron intolerancias con 194 conductas; demostración de máscaras (94; 48%), calibración (44; 22%), educación (45; 23%), titulación (13; 6%) y derivación al neumonólogo (14; 7%). Conclusiones: Dos terceras partes de los pacientes cumplen el tratamiento con presión positiva y la mitad presenta intolerancias. La consulta kinésica especializada puede contribuir a la identificación y resolución de dificultades durante la terapia.

Patient Intolerance and Compliance with Positive Airway Pressure Treatment Outpatient Consultations Profile in a Sleep Unit

Abstract Introduction: Treatment with positive pressure may cause adverse effects. In order to know the compliance and intolerance profile, we analyzed the behaviors established by physiotherapists of a Sleep Unit. Materials and Methods: Observational, retrospective, cross-sectional study. We included patients older than 18 years with positive pressure referred to the kinesiological consultation. Results: 244 patients were evaluated during four years: 165 men (67%), age 65.7 ± 11.6 years, BMI (Body Mass Index) 31.0 ± 5.4 (kg/m2), 61% of which used fixed CPAP (Continuous Positive Airway Pressure), 29% auto-adjusting CPAP, 8% bilevel devices, 147 (60%) nasal masks, 52 (21%) oronasal masks; 37 pads (15%), and 92 (36%) thermohumidifiers. Reasons for consultation were: therapy control, 239 (61%); intolerance, 67 (17%), and calibration, 51 (13%). Compliance (hours/night) was 4.61 ± 2.1, with a percentage of nights > 4 hours of 67 ± 36%. We didn't find any difference in the com pliance of the first and the second year (4.5 vs. 5.0 hours/night) p > 0.13, but the value was higher after 600 days of therapy (p < 0.05). 141 patients (57%) showed some complications, the most frequent being leaks (19%) or intolerance to the masks (10%). 97% of the patients resolved the intolerance with 194 behaviors: explanation of how to use the mask, 94 (48%); calibration, 44 (22%); information, 45 (23%); titration, 13 (6%), and referral to the pulmonologist, 14 (7%). Conclusions: Two thirds of the patients complied with the positive pressure treatment and half of the patients showed intolerance. The specialized kinesiological consultation can contribute to the identification and resolution of difficulties that may arise during therapy.