Deshabituación tabáquica con vareniclina según dosis en distintas patologías / Tobacco cessation with varenicline according to dosage in different pathologies

Objetivos: el objetivo principal fue evaluar la eficacia de Vareniclina a mitad de dosis, comparada con la habitual, en la Unidad de Tabaquismo del Hospital Universitario Virgen Macarena. Los objetivos secundarios fueron valorar: -la influencia de comorbilidades respiratorias, cardiovasculares y psiquiátricas, así como el consumo de otras drogas -la evolución de la escala hospitalaria de ansiedad/ depresión (HADS). Métodos: ensayo clínico prospectivo, aleatorizado, a 2 grupos, con una 1ª visita médica y soporte cognitivoconductual durante un año. Se emplearon pautas cortas (2 meses) a dosis de 1 mg/12h vs 0,5 mg/12h. Resultados: la tasa de abstinencia a un año fue del 46,5% con 1 mg vs 46,4% con 0,5 mg, p = 1,0. Los pacientes con síndrome metabólico (n = 27) presentaron mejor abstinencia (74,1% vs 42,3%, p = 0,01). Aquellos con EPOC (n = 162, 33,5%) también dejaron de fumar más (52,5% vs 43,5%, p = 0,067). Sin embargo, el asma bronquial (n = 41) suponía más dificultad para dejar de fumar (26,8% vs 49,1%, p = 0,005). De los 109 previamente diagnosticados de ansiedaddepresión, un 41,3% dejó de fumar vs un 49% (p = 0,154), observándose una tendencia a mejor abstinencia con la dosis reducida (44,3% vs 37,5% con la dosis estándar, p = 0,094). En cuanto a la evolución de los parámetros psiquiátricos, se realizó el HADS al comienzo, a los 3 meses y al año, objetivándose una reducción >50%, incluso más llamativa en el subgrupo de adicción a drogas

Aims: the main aim of the trial was to evaluate the efficacy of low dose Varenicline, compared to the standard dose, at the Stop-Smoking Clinic of the Virgen Macarena University Hospital. The secondary aims were to evaluate: -the influence of respiratory, cardiovascular and psychiatric diseases, as well as consumption of other drugs -the evolution of hospital anxiety/depression scale (HADS). Methods: randomized parallel-group controlled trial, with a baseline visit and 6 follow-ups during 1 year. Patients were randomized either to 1 mg or 0.5 mg (both twice daily during 8 weeks). Results: abstinence rates at 1 year were 46.5% with 1 mg vs. 46.4% with 0.5 mg (p = 1.0) Patients with metabolic syndrome (n = 27) had better quit rates than those without this condition (74,1% vs 42,3%, p = 0,01).Patients with chronic obstructive pulmonary disease (COPD) (n = 162, 33,5%) were more successful in quitting smoking than those who did not have this disease (52,5% vs 43,5%, p = 0,067). However, having bronchial asthma (n = 41) was related to having more difficulties in stopping smoking (26,8% vs 49,1%, p = 0,005). From the 109 patients previously diagnosed with anxiety and depression disorder, 41,3% stopped smoking vs 49% of those who did not have this condition (p = 0,154). There was a tendency to better results with the low dose (44,3% vs 37,5% with the standard dose, p = 0,094). Regarding to the evolution of the psychiatric parameters, there was a reduction of more than 50% of the HADS score from the start of the program to the end of the follow-up year

Cambios en actividad física tras un programa de rehabilitación respiratoria en EPOC / Changes in physical activity after a COPD respiratory rehabilitation program

INTRODUCCIÓN: la inactividad es un hallazgo permanente en los pacientes EPOC y tiene clara implicación pronóstica, asociándose con un aumento de la morbimortalidad. Sin embargo, aún no disponemos de estrategias eficaces para aumentar el nivel de actividad física de nuestros pacientes. El objetivo del trabajo fue evaluar el impacto de un programa de rehabilitación respiratoria (RR) en el nivel de actividad física en EPOC, medido por acelerómetro. MÉTODO: estudio longitudinal, prospectivo y randomizado en 2 grupos: control y de intervención, con programa de RR mixto de 12 semanas (3 sesiones/semana) con seguimiento a 3 meses. Se midió actividad física mediante acelerómetro, de forma basal y a los 3 meses en ambos grupos. RESULTADOS: n: 36 (RR 19 vs control 17). La mayoría hombres, con edad media de 64 ± 3,6 en RR y 64,9 ± 10,1 en control, con una obstrucción grave (RR 45,5 ± 15,9% vs control 33,8 ± 7,3%) y un consumo acumulado de tabaco significativamente mayor en el grupo control (RR 49 vs control 65,4 paq/año). Basalmente, los sujetos de ambos grupos eran sedentarios. Tras finalizar el programa de entrenamiento, no se encontraron diferencias significativas en las variables de actividad física analizadas en ninguno grupo. En cuanto a tolerancia al ejercicio, el grupo de rehabilitación presentó mejores resultados que el control (PM6M: RR 478 ± 33,6 m vs control 367,7 ± 106 m, p 0,01/Submáximo: RR 1.231,1 ± 640,4 vs control 390 ± 155 seg, p 0,01. CONCLUSIONES: en nuestro trabajo, un programa específico de rehabilitación respiratoria mejora la tolerancia al ejercicio de los pacientes, pero el beneficio en cuanto actividad física continúa siendo controvertido

INTRODUCTION: inactivity is a permanent finding in COPD patients and it has clear prognostic implications associated with an increase in morbidity-mortality rate. Nevertheless, we do not have effective strategies to increase physical activity in our patients. The objective of this work was to assess the impact of a respiratory rehabilitation (RR) program on the physical activity level of COPD patients, measured with an accelerometer. METHOD: longitudinal, prospective and randomized study in two groups: control and intervention group, with a mixed, 12-week (3 weekly sessions) RR program with three month follow-up. Physical activity was measured with an accelerometer, baseline measurement and after three months in both groups. RESULTS: n: 36 (RR 19 vs control 17). Most of the participants were men, with a mean age of 64 ± 3.6 in RR y 64.9 ± 10,1 in the control group, with serious obstruction (RR 45.5 ± 15.9% vs control 33.8 ± 7.3%) and accumulated tobacco consumption that was significantly higher in the control group (RR 49 vs Control 65.4 pack/yr.). In basal metabolism terms, the subjects in both groups were sedentary. Upon concluding the training program, no significant differences were found in the variables for physical activity analyzed in either group. In terms of exercise tolerance, the rehabilitation group presented better results than the control group. (PM6M: RR 478 ± 33.6 m vs Control 367.7 ± 106 m, p 0.01/Submaxim: RR 1,231.1 ± 640.4 vs 390 ± 155 sec., p 0.01. CONCLUSIONS: this study shows that a respiratory rehabilitation program improves tolerance to exercise in patients, but the benefits of physical activity continue to be controversial

Efecto de la obstrucción de la vía aérea en la medición de la fracción de óxido nítrico exhalado / Effect of airway obstruction when testing exhaled nitric oxide fractionfeno

INTRODUCCIÓN: numerosos trabajos han intentado ver la aplicabilidad de la FeNO para el diagnóstico o para el control y regulación del tratamiento en el asma bronquial. Dado que el significado real de los valores de la FeNO en relación a la obstrucción bronquial sigue siendo incierto, intentar esclarecer esta circunstancia tiene un enorme interés en la práctica clínica diaria. MATERIAL Y MÉTODO: se realizó un estudio de corte trasversal de pacientes diagnosticados de asma leve-moderada, según criterios de la GEMA 2009, durante 9 meses. Se recogieron datos de control de asma (ACQ), FeNO basal, espirometría basal (FEV1), test de metacolina (PD20) y tras broncodilatación. En un subgrupo de pacientes se realizaron espirometrías seriadas. RESULTADOS: Se analizaron 48 asmáticos. La puntuación de ACQ fue de 1,7 ± 0,3 (0,7 - 2) puntos. El FEV1 basal fue 2,93 ± 0,8 (92 ± 16%). Al final del test de la metacolina, tanto el FEV1 como el FeNO caían significativamente respecto a los basales. Los pacientes que estaban en tratamiento con corticoides inhalados tenían unas cifras de FeNO menores que los que estaban sin corticoides: 21,4 ± 10 ppb, frente a 50,2 ± 29 ppb; p0,001. Se encontró una correlación significativa entre la disminución de FeNO, expresado en % del basal y la disminución de FEV1, expresado tanto en cifras absolutas como en % (R = 0,52 y 0,583, respectivamente). Se diseñó una curva ROC, recodificando la variable de disminución de FeNO en dos grupos, según disminuyesen más o menos de un 10% (área bajo la curva de 0,928, p < 0,001). Considerando como punto de corte un 18% de disminución de FEV1, se obtuvo una sensibilidad del 85% y una especificidad del 87%. No se encontraron diferencias en el subgrupo donde se realizaron maniobras espirométricas repetidas. CONCLUSIONES: Existe una afectación de la medida de la FeNO tras las variaciones agudas del calibre bronquial, con pruebas de metacolina y tras broncodilatadores, utilizando sistemas portátiles con sensor electroquímico, debiendo valorarse el impacto de estos hallazgos en el seguimiento de los pacientes asmáticos

INTRODUCTION: several studies have tried to implementFeNOfor diagnosis or to control and regulate bronchial asthma treatments. Given that the significance of FeNO values regardingbronchial obstruction continues to be uncertain, clarifying this circumstance is extremely interesting for daily clinical practice. MATERIAL AND METHOD: across-sectional study was carried out with patients who were diagnosed with mild to moderate asthma, in keeping with the GEMA 2009 criteria, for 9 months. Asthma control data was collected (ACQ), basal FeNO, basal spirometry (FEV1), methacholine test (PD20) and post-bronchodilation. In a sub-group of patients, serial spirometry was carried out. RESULTS: 48 asthmatic patients were analyzed. The ACQ score was 1.7 ± 0.3 (0.7 - 2) points. Basal FEV1 was 2.93 ± 0.8 (92 ± 16%). Upon concluding the methacholine test, both FEV1 andFeNOfell significantly with regards to basal values. Patients treated with inhaled corticosteroids had lower FeNOlevels thanthose not oncorticosteroids: 21.4 ± 10 ppb, compared to 50.2 ± 29 ppb; p < 0.001. A significant correlation was seen between the decrease in FeNO, expressed in percentage of basal values, and the decrease of FEV1, expressed both in absolute values as well as in percentages, R = 0.52 and 0.583, respectively). A ROC (receiver operative curve) analysis was performed, recoding the decreased variable for FeNOinto two groups, based on a reduction of more or less than 10% (area under the curve was 0.928, p <0.001).A 18% cutoff for FEV1 decline had a 85% sensitivity and 87% specificity. No differences were found in the sub-group where repeated spirometrictests were performed. CONCLUSIONS: there is anaffectationwhen measuring FeNOafter acute variations of the bronchial caliber, with methacholine tests and after bronchodilators, using portable systems with electrochemical sensors. The impact of these findings for the follow-up of asthmatic patients must be assessed

Evolución de los niveles de ansiedad y depresión tras un programa de abandono del tabaco en pacientes psiquiátricos y factores relacionados / Progression of anxiety and depression in a program to stop smoking among psychiatric patients and related factors

La relación entre tabaquismo y patología psiquiátrica está bien establecida. Estos pacientes suponen un reto por presentar mayor riesgo de recaídas y empeoramiento de su enfermedad de base tras dejar de fumar. Nuestro objetivo fue valorar la influencia de un programa de abandono del tabaco en el estado emocional de un grupo de pacientes psiquiátricos. MÉTODO: se realizó un estudio de cohortes observacional y prospectivo de pacientes psiquiátricos que acudieron a dejar de fumar mediante programa combinado de tratamiento farmacológico y psicológico cognitivo-conductual. Se midió la presencia de síntomas de ansiedad y depresión utilizando el cuestionario HADS al inicio, al mes y los tres meses de dejar de fumar. RESULTADOS: la ansiedad y la depresión presentaron mejoría significativa y progresiva a lo largo del tratamiento (ansiedad basal 11,3 ± 4,5; ansiedad 1 mes 7,1 ± 3,7; ansiedad 3 meses 5,3 ± 3,5; p < 0,05 / depresión basal 7,4 ± 4,8; depresión 1 mes 4,2 ± 3,6; depresión 3 meses 3 ± 2,9; p < 0,05). La tasa de abstinencia, que fue de 53,2% no se vio afectada por los niveles basales de ansiedad y depresión. CONCLUSIONES: los niveles de ansiedad y depresión evolucionan de forma favorable durante el programa, alcanzándose buenos resultados

The relationship between smoking and psychiatric conditions has been firmly established. These patients are a real challenge as they are at a greater risk of relapse and their condition may worsen once they have stopped smoking. Our objective was to assess the influence of a program to stop smoking on the emotional state of a group of psychiatric patients. METHOD: an observational and prospective cohort study was carried out with a group of psychiatric patients who participated in a program to stop smoking that combined pharmacological and cognitive-behavioral psychological treatments. The presence of anxiety and depression was measured using the HADS (Hospital Anxiety and Depression Scale) questionnaire at the onset of the program; it was repeated after one month and then three months after they stopped smoking. RESULTS: anxiety and depression showed significant and progressive improvement throughout the treatment (basal anxiety 11.3 ± 4.5; anxiety at 1 month 7.1 ± 3.7; anxiety at 3 months 5.3 ± 3.5; p < 0.05 / basal depression 7.4 ± 4.8; depression at 1 month 4.2 ± 3.6; depression at 3 months 3 ± 2.9; p < 0.05). The abstinence rate, which was 53.2%, was not affected by the basal level of anxiety and depression. CONCLUSIONS: the levels of anxiety and depression progressed favorably throughout the program, to attain good result

Valoración clínico-funcional según fenotipo exacerbador en pacientes con enfermedad pulmonar obstructiva crónica / Clinical-functional assessment based On exacerbating phenotype in patients With chronic obstructive pulmonary disease

OBJETIVO: Las exacerbaciones de la enfermedad pulmonar obstructiva crónica (EPOC) inciden negativamente en la evo-lución y pronóstico de la misma, habiéndose demostrado que los exacerbadores frecuentes (Ex-F) presentan un deterioro mayor y más rápido de la función pulmonar, peor calidad de vida, mayor grado de inflamación y una tasa de mortalidad más elevada. Nuestro objetivo fue determinar si existían di-ferencias en parámetros clínicos y funcionales en función del número de exacerbaciones de los pacientes. MATERIAL Y MÉTODO: Estudio observacional, prospectivo, con selección consecutiva de pacientes EPOC. Se clasificó a los pacientes en dos grupos según el número de exacerbaciones en el año previo: no frecuente (Ex-NF) (<2 exacerbaciones-año) y frecuente (Ex-F) (≥2 exacerbaciones-año). Se analiza-ron datos epidemiológicos, clínicos (escalas de disnea, índi-ce de consumo tabáquico, cuestionarios de calidad de vida y ansiedad-depresión) y parámetros funcionales (espirometría, prueba de la marcha de 6 minutos (PM6M) y prueba de es-fuerzo cardiopulmonar (PECP) máxima y submáxima), así como los recursos sanitarios utilizados y la incidencia de neu-monía en cada uno de los grupos. RESULTADOS: Se incluyeron 108 pacientes, de los cuales 54 eran Ex-F. Este grupo presentó un mayor consumo tabáquico, mayor impacto en las escalas de medición de la disnea, peores resultados en los cuestionarios de calidad de vida y ansiedad-depresión. Este grupo también presentó un mayor deterioro funcional, medido mediante FEV1, y nivel de gravedad de las exacerbaciones (p < 0,05), salvo en sus ingresos en unidad de cuidados intensivos (UCI). Sin embargo no se encontraron di-ferencias en las pruebas de esfuerzo realizadas, ni una mayor incidencia de neumonías en este grupo. CONCLUSIONES: A pesar de encontrar diferencias estadística-mente significativas en distintos parámetros clínicos y fun-cionales asociadas al fenotipo exacerbador, la capacidad de esfuerzo parece independiente del número de exacerbaciones previas, al menos en este tipo de pacientes

OBJECTIVE: Exacerbations of chronic obstructive pulmonary disease (COPD) impact negatively on its development and prognostics; frequent exacerbations (Ex-F) have proven to cause greater and faster deterioration of lung function, worse quality of life, greater degree of inflammation and a higher death rate. Our objective was to determine whether or not there were differences in clinical and functional parameters depending on the number of exacerbations in the patients. MATERIAL AND METHOD: An observational, prospective study, with consecutive selection of COPD patients classified into two groups according to the number of exacerbations during the previous year: not frequent (Ex-NF) (< 2 exacerbations-year) and frequent (Ex-F) (≥2 exacerbations -year). Epidemio-logical data was analyzed, as was clinical information (dyspnea scales, tobacco consumption index, quality of life question-naires and anxiety-depression) and functional parameters (spi-rometry, 6-minute walking test (6MWT) and maximum and sub-maximum cardiopulmonary exercise testing (CPET), in addition to the healthcare resources used and the incidence of pneumonia in each group. RESULTS: 108 patients were included in the study, of which 54 were Ex-F. This group presented higher tobacco consump-tion, higher impact on the dyspnea scales, worse results in the quality of life questionnaires and anxiety-depression. This group also presented greater functional deterioration mea-sured by FEV1, and in the seriousness of the exacerbations (p < 0.05); except for admission to intensive care unit (ICU). Nevertheless there were no differences in the exercise testing performed, nor was there a greater incidence of pneumonia in this group. CONCLUSIONS: Despite statistically significant differences for the various clinical and functional parameters associated with the exacerbating phenotype, exercise/stress capacity appears to be independent of the number of previous exacerbations, at least in this type of patient

Efectos de diferentes estrategias de entrenamiento al ejercicio sobre parámetros antropométricos según el fenotipo del paciente con EPOC / Effects of different exercise training strategies on anthropometric parameters according to the prenotype of the patient with EPOC

OBJETIVO: Analizar el efecto sobre dos parámetros antropométricos de la aplicación de distintas modalidades de entrenamiento al ejercicio en un grupo de pacientes con enfermedad pulmonar obstructiva crónica (EPOC), categorizados según su fenotipo (con o sin predominio de enfisema). METODOLOGIA: 64 pacientes con EPOC estable (edad media de 64,1 ± 6,8 años) que presentan obstrucción moderada severa al flujo aéreo, realizaron un programa de entrenamiento al ejercicio, aleatoriamente distribuidos en tres grupos: resistencia (n=21; entrenamiento aeróbico en bicicleta al 70% de su VO2 máximo inicial), fuerza (n=22; cinco ejercicios de levantamiento de pesas al 70-85% del test 1 RM inicial, incluyendo grupos musculares de MMSS y MMII) y mixto (n=21; combinación de los anteriores).Se subdividieron en pacientes EPOC con predominio de enfisema(n=32) o sin enfisema (n=32) según criterios clínicos, funcionales y radiológicos. Inicialmente y tras 12 semanas de entrenamiento se midieron los cambios en el peso y en el índice de masa corporal (IMC) como parámetros antropométricos. RESULTADOS: Los pacientes EPOC sin enfisema cuyo entrenamiento incluía ejercicios de tipo aeróbico (grupos resistencia y mixto) experimentaron una disminución del IMC (-0,43 ± 1,45 y -0,82 ± 1,04; p<0,05) y del peso (-0,96 ± 4,15 y -2,44 ± 2,96 kg). Los EPOC tipo enfisema cuyo entrenamiento incluía ejercicios de fuerza (fuerza y mixto) presentaron un aumento del IMC (0,42 ± 0,50 y 0,35± 1,04; p<0,05) y del peso (0,91 ± 1,08 y 1,25 ± 2,83 kg; p<0,05). CONCLUSIONES: Distintas estrategias de entrenamiento alejercicio producen efectos diferentes sobre índices antropométricos en pacientes con EPOC, dependiendo del fenotipo que presenten (AU)

OBJECTIVE: To analyse the effect of the application of different modes of exercise training on two anthropometric parameters in a group of patients with chronic obstructive pulmonary disease (COPD), categorised according to their phenotype (with or without predominance of emphysema). METHODOLOGY: Sixty-four patients with stable COPD (average age of 64.1 ± 6.8 years) that presented moderate-severe air flow obstruction, undertook an exercise training programme, randomly distributed in three groups: resistance (n=21; aerobicbicycle training to 70% of their initial maximum VO2), strength(n=22; five weight raising exercises to 70-85% of the initial 1-RMtest, including arm and leg muscle groups) and mixed (n=21; combination of the previous). They were subdivided into COPD patients with predominance of emphysema (n=32) or without emphysema (n=32) according to clinical, functional and radiological criteria. The changes in weight and body mass index (BMI) were measured as anthropometric parameters initially, and after12 weeks of training. RESULTS: COPD patients without emphysema whose training included aerobic type exercises (resistance and mixed groups) experienced a reduction of BMI (-0.43 ± 1.45 and -0.82 ± 1.04;p<0.05) and weight (-0.96 ± 4.15 and – 2.44 ± 2.96 kg). The COPD patients with emphysema whose training included strength exercises (strength and mixed) displayed an increase in BMI (0.42 ± 0.50and 0.35 ± 1.04; p<0.05) and weight (0.91 ± 1.08 and 1.25 ± 2.83 kg; p<0.05). CONCLUSIONS: Different exercise training strategies produce different effects on anthropometric indices in patients with COPD, depending on the phenotype they present (AU)

Neumomediastino y asma bronquial / Pneumomediastinum and bronchial asthma

Se considera el neumomediastino como una complicación pocofrecuente de una crisis de asma y en general como un hecho banaly sin gran repercusión en la gravedad de dicha situación clínica.Sin embargo en nuestra experiencia, el neumomediastino noparece tan excepcional en el asma bronquial, muestra un fenotipode presentación bastante homogéneo de asmáticos jóvenes, incumplidoresde tratamiento y con hábito de uso de drogas inhaladas.Además en ocasiones se presenta con características de gravedadtales como hipoxemia severa, necesidad de atención en cuidadosintensivos e incluso de ventilación mecánica

Pneumomediastinum is considered to be an uncommon complicationof an asthma crisis and in general, something trivial, withoutany major repercussions in the seriousness of this clinical problem.However in our experience, pneumomediastinum does notseem that exceptional in bronchial asthma. It presents a standardphenotype in young asthma patients, as well as in those who fail tocomplete their treatment and in those who inhale drugs. In somecases, it presents serious characteristics such as severe hypoxemia, the need for intensive care and even mechanical ventilation (AU)

[Distribution of pulmonologists and chest surgeons in Spain]. / Distribución de neumólogos y cirujanos torácicos en España.

OBJECTIVE: To study the real situation of respiratory medicine specialists and chest surgeons in the Spanish health service. SUBJECTS AND METHOD: Using the database of the secretary of the Spanish Society of Respiratory Medicine and Chest Surgery (SEPAR) for 1999, we gathered data on 326 Spanish hospitals. We were thus able to ascertain the level of staffing of respiratory medicine and chest surgery departments. The results were expressed as simple percentages showing distribution by age, duties and geographic area. The number of specialists per 100,000 inhabitants in each community was also calculated based on population data provided by the National Statistics Institute for 1997. RESULTS: We studied 1,786 physicians or surgeons (1,245 pneumologists, 185 surgeons and 356 from other specialties). The mean age was 41 9 years for pneumologists, 44 10 years for surgeons and 51 8 years for the others. We observed unequal distribution by geographic area, with a high of 6.66 pneumologists and 0.9 surgeons per 100,000 inhabitants in Asturias and Madrid, respectively and a low of 1.4 pneumologists per 100,000 inhabitants in Murcia and 0 surgeons in Extremadura. CONCLUSIONS: Specialist coverage by pneumologists and chest surgeons is inadequate in many provinces and communities in Spain. The professional market is not saturated, indicating that future specialists can look forward to market demand.

Distribución de neumólogos y cirujanos torácicos en España / Distribution of pulmonologists and chest surgeons in Spain

OBJETIVOS: Conocer la situación real de los especialistas en neumología y cirugía torácica en el marco de la red sanitaria pública española. SUJETOS Y MÉTODO: Teniendo en cuenta la base de datos de la Secretaría de la SEPAR del año 1999, se recopiló información de 326 hospitales españoles. Se pudo obtener, así, la composición de las plantillas de las secciones o servicios de neumología y cirugía torácica de los mismos. Los resultados se expresaron como proporciones simples en lo referente a su distribución por edades, cargos y autonomías. Además, se calcularon las tasas por 100.000 habitantes en cada comunidad (datos de población según el Instituto Nacional de Estadística del año 1997). RESULTADOS: Se evaluó un total de 1.786 médicos (1.245 neumólogos, 185 cirujanos y 356 pertenecientes a otras especialidades). La edad media fue de 41 ñ 9 años para los neumólogos, 44 ñ 10 años en el grupo de cirujanos y 51 ñ 8 años en el resto. La distribución por comunidades autónomas fue desigual, encontrándose un máximo de 6,66 neumólogos y 0,9 cirujanos/100.000 habitantes en Asturias y Madrid, respectivamente, y un mínimo de neumólogos en Murcia y de cirujanos torácicos en Extremadura (1,4 y 0/100.000 habitantes, respectivamente). CONCLUSIONES: La situación de las especialidades de neumología y cirugía torácica es deficitaria en muchas provincias y comunidades autónomas de nuestra geografía. En este sentido, el mercado profesional no está saturado, por lo que parece haber unas buenas perspectivas laborales para los futuros especialistas. (AU)

Inspiratory muscle training in patients with COPD: effect on dyspnea, exercise performance, and quality of life.

OBJECTIVE: The aim of the study was to assess the effect of target-flow inspiratory muscle training (IMT) on respiratory muscle function, exercise performance, dyspnea, and health-related quality of life (HRQL) in patients with COPD. PATIENTS AND METHODS: Twenty patients with severe COPD were randomly assigned to a training group (group T) or to a control group (group C) following a double-blind procedure. Patients in group T (n = 10) trained with 60 to 70% maximal sustained inspiratory pressure (SIPmax) as a training load, and those in group C (n = 10) received no training. Group T trained at home for 30 min daily, 6 days a week for 6 months. MEASUREMENTS: The measurements performed included spirometry, SIPmax, inspiratory muscle strength, and exercise capacity, which included maximal oxygen uptake (VO(2)), and minute ventilation (VE). Exercise performance was evaluated by the distance walked in the shuttle walking test (SWT). Changes in dyspnea and HRQL also were measured. RESULTS: Results showed significant increases in SIPmax, maximal inspiratory pressure, and SWT only in group T (p < 0.003, p < 0.003, and p < 0.001, respectively), with significant differences after 6 months between the two groups (p < 0.003, p < 0.003, and p < 0.05, respectively). The levels of VO(2) and VE did not change in either group. The values for transitional dyspnea index and HRQL improved in group T at 6 months in comparison with group C (p < 0.003 and p < 0.003, respectively). CONCLUSIONS: We conclude that targeted IMT relieves dyspnea, increases the capacity to walk, and improves HRQL in COPD patients.

[Role of dyspnea in quality of life of the patient with chronic obstructive pulmonary disease]. / Papel de la disnea en la calidad de vida del paciente con enfermedad pulmonar obstructiva crónica.

OBJECTIVE: To analyze the correlation between quality of life and 1) lung function parameters at rest and during exercise, and 2) mean baseline dyspnea measured on two scales--Mahler's baseline dyspnea index (BDI/TDI) and the Medical Research Council (MRC) scale. We sought to observe the factor or factors having the greatest impact on the quality of life of such patients. MATERIAL AND METHODS: Fifty-five patients diagnosed of COPD in stable phase of disease participated. Al underwent lung function testing at rest and during exercise (shuttle walking test with increasing loads and an exercise cycle test). Quality of life was assessed on the validated Spanish translation of the Chronic Respiratory Disease Questionnaire, which refers specifically to COPD. Baseline dyspnea was measured using Mahler's BDI/TDI and the MRC scale. RESULTS: Mean patient age was 63 +/- 9.5 years and FEV1 was 40 +/- 16.9%. Overall quality of life and each sub-item correlated significantly with mean dyspnea on both scales (BDI/TDI and MRC). Effort was weakly correlated and function parameters at rest were unrelated. Multiple correlation analysis showed that baseline dyspnea (BDI/TDI) was the most important predictor of quality of life. CONCLUSIONS: Dyspnea, particularly when expressed as BDI/TDI but also as measured on the MRC scale, correlates more highly with quality of life than does any other parameter. This indicates that dyspnea has greater impact than other factor on quality of life and that BDI/TDI provides a good baseline assessment of dyspnea in COPD patients.

[Comparative study of the efficacy of 2 respiratory physiotherapy protocols for patients with cystic fibrosis]. / Estudio comparativo de la eficacia de dos protocolos de fisioterapia respiratoria en pacientes con fibrosis quística.

OBJECTIVE: To compare the short-term efficacy of two respiratory physiotherapy protocols on sputum clearance, lung function and symptoms in patients with cystic fibrosis. Treatment A consisted of diaphragm breathing with incentive spirometry and postural drainage. Treatment B consisted of diaphragm breathing with positive expiratory pressure (PEP-mask) and postural drainage. METHODS: Twenty-seven cystic fibrosis patients in stable condition followed both protocols (A and B) in random order on different days separated by at least 48 hours. After each treatment session the amount of sputum removed was weighed. Lung function variables (FVC, FEV1, FEV1%, MMEFwt-75, MVV and PEF) were measured pre- and posttreatment. PEF was measured with a peak flow meter. The patients later recorded PEF every hour at home and filled in a questionnaire on frequency and intensity of coughing, sputum characteristics, chest discomfort and dyspnea. RESULTS: During treatment A with incentive spirometry, 14.6 +/- 13.7 g of sputum was removed, whereas 9.8 +/- 10.2 g was eliminated during treatment B (p < 0.05). The differences in PEF after treatments A and B in comparison with baseline values were +19.3 l/min and -0.2 l/min, respectively (p < 0.01). PEF stayed high during the afternoon, in comparison with baseline, with treatment A (p < 0.02). After treatment B, no changes in PEF in comparison with baseline were observed (p = 0.49). Neither treatment led to significant differences in symptoms reported on the clinical questionnaire. CONCLUSIONS: Respiratory physiotherapy with incentive spirometry significantly increases sputum clearance in cystic fibrosis patients, with no immediate repercussions on lung function or symptoms.

[Reproducibility of a shuttle walking test in patients with chronic obstructive pulmonary disease]. / Reproducibilidad de un test de paseo de carga progresiva (shuttle walking test) en pacientes con enfermedad pulmonar obstructiva crónica.

To analyze the reproducibility of the shuttle walking test (SWT) in comparison to the six min walking test in patients with chronic obstructive pulmonary disease (COPD). The stress tests were performed by 13 patients diagnosed of COPD with moderate-to-severe air flow obstruction (FEV1 45.85 +/- 18.82% of theoretical values). Each patient performed the SWT six times (twice a week over three consecutive weeks). The 6 min walking test was performed an equal number of times. At baseline and at the end of both types of test, heart rate and degree of dyspnea (on a modified version of Borg's scale) were recorded, as well as the level reached and the number of meters walked. No significant differences in distance walked, heart rate or degree of dyspnea were found for the six SWTs performed. The interclass correlation coefficients for the aforementioned parameters were 0.875, 0.879 and 0.896, respectively; the variation coefficient for distance covered ranged between -10.7% and 10.2%. In the six min walking test significant differences were seen between distance walked in the first two tests and the other four tests. The variation co-efficient ranged between 11.4% and 17.5%. The SWT is a reproducible stress test in which the patient must exert progressively greater effort. The low degree of variability observed assures that the level of effort attained is steady and consistent.

[Comparison of a shuttle walking test with an exertion test with cycloergometer in patients with COPD]. / Comparación de un test de paseo de carga progresiva (shuttle walking test) con una prueba de esfuerzo en cicloergómetro en pacientes con EPOC.

To validate a shuttle walking test in a group of patients with COPD, comparing responses to those produced by a conventional stress test limited by symptoms on the cycle ergometer, and to analyze the relation between the shuttle walking test and maximal effort parameters. We enrolled 20 patients with COPD, mean age 60 years (SD 7), FEV1/46.6% (SD 19.2) of theoretical value and FEV1/FVC% 47.3% (SD 11.2). All the patients underwent a maximal effort test on the cycle ergometer, determination of initial dyspnea by applying Mahler's baseline dyspnea index, and a quality of life questionnaire specific to COPD the Chronic Respiratory Disease Questionnaire). To compare the responses of patients to the two tests, we analyzed heart rate, dyspnea and lactic acid at the end of each test. To see the relations between the two tests, we examined distance walked and maximal effort parameters. The relation between the walking test and lung function parameters at rest, initial dyspnea and quality of life were also analyzed. No statistically significant differences were found for heart rate [128.2 (SD 19.8) versus 131.6 (SD 12.9)], dyspnea 17.1 (SD 1.78) versus 7.24 (SD 2.64)] or lactic acid [5.24 (SD 2.34) versus 6.19 (SD 2.12)] at the end of the tests. Distance covered on the shuttle walking test correlated significantly with V'O2ml/min/Kgmax (r = 0.71), as well as with the remaining parameters of maximal effort. There was only a slight relation between lung function at rest and quality of life. The COPD patient's cardiovascular, metabolic and subjective responses to the shuttle walking test are similar to those of the cycle ergometer test, and oxygen consumption is significantly correlated. The shuttle walking test gives a valid estimate of the functional capacity of COPD patients.

[Abdominal respiratory muscle activity in patients with stable chronic obstructive pulmonary disease]. / Actividad de la musculatura espiratoria abdominal en pacientes con enfermedad pulmonar obstructiva crónica estable.

With the purpose of defining the pattern of abdominal respiratory muscle activity in patients with chronic obstructive pulmonary disease (COPD), we studied the electromyogram of the rectus abdominis (RA), the external oblique (EO) and transversus (TM) muscles in 14 patients with different degrees of airways obstruction (FEV1: 41 +/- 12%; FEV1/FVC: 45 +/- 10%; RV: 198 +/- 38%; PaO2: 75.8 +/- 12 y PaCO2: 41.4 +/- 5.7 mmHg). The EMG was obtained by insertion of bipolar electrodes guided by an ultrasound image of the abdominal wall to locate the position of the muscles. The measurements were recorded in supine decubitus position in 5 situations: a) breathing at tidal volume; b) slow expiration until RV; c) with inspiratory load; d) with expiratory load, and e) during relaxed breathing with the arms raised. Recordings were also made in the same situations with 10 patients sitting. Eight patients presented phasic expiratory activity during relaxed breathing (TM activity alone or accompanied by EO). We found no significant differences in degree of hyperinflation or in arterial gases between patients with phasic expiratory activity and those without. There were significant differences between these 2 groups, however, as to degree of airways obstruction, for absolute values of FEV1 (p < 0.02) and in raw values (p < 0.04). Slow breathing until RV recruited muscular activity in 13 patients; the muscles did not operate in unison, however, with TM acting first. Recruitment was also observed when inspiratory and expiratory loads were placed, although in this case the 3 muscles acted simultaneously. Phasic activity was observed in only 2 patients for recordings made with arms raised, at which time there was greater tonic muscle activity. The phasic activity pattern recorded when patients were sitting was very similar to that obtained in supine position. In summary, some patients with stable COPD have phasic expiratory activity of the abdominal muscles when resting. These muscles do not appear to act as a unit and this phasic expiratory activity is related to severity of upper airways obstruction.