Biliothorax in a patient with unresectable cholangiocarcinoma.

Biliothorax is a rare but serious condition, as the presence of bile is damaging and can lead to empyema. Here, we report a case of a 51-year-old man recently diagnosed with unresectable cholangiocarcinoma, admitted to the hospital for malignant obstructive jaundice. After interventional management of biliary obstruction, the patient developed a significant right pleural effusion compatible with biliothorax, successfully managed with pleural drainage and antibiotic therapy. Resolution was possible with a conservative approach: biliary decompression, chest tube drainage and antibiotics.

Features of Obstructive Sleep Apnea in Children with and without Comorbidities.

BACKGROUND: To compare the clinical and polysomnographic features of obstructive sleep apnea (OSA) in children with adenotonsillar hypertrophy (Group A) and comorbidities (Group B). METHODS: A five-year prospective study using nocturnal polysomnography before and after treatment. RESULTS: We included 168 patients: 121 in Group A and 47 in Group B, with differences in age (6.5 ± 3 vs. 8.6 ± 4 years; p < 0.001), body mass index (BMI) (18 ± 4 vs. 20 ± 7 kg/m2; p < 0.05), neck circumference (28 ± 4 vs. 30 ± 5 cm; p < 0.05), and obesity (17% vs. 30%; p < 0.05). Group B patients were more likely to have facial anomalies (p < 0.001), macroglossia (p < 0.01), dolichocephaly (p < 0.01), micrognathia (p < 0.001), and prognathism (p < 0.05). Adenotonsillectomy was performed in 103 Group A patients (85%) and 28 Group B patients (60%) (p < 0.001). In B, 13 children (28%) received treatment with continuous positive airway pressure (CPAP) and 2 (4%) with bilevel positive airway pressure (BiPAP), compared with 7 in Group A (6%) (p < 0.001). Maxillofacial surgery was more common in Group B (p < 0.01). Clinical and polysomnography parameters improved significantly in both groups after therapeutic intervention, though Group A showed better results. CONCLUSIONS: Obesity and facial anomalies are more frequent in childhood OSA patients with comorbidities, who often require combination therapy, such as ventilation and surgery.

Portopulmonary hypertension: Success with combined medical treatment.

Portopulmonary hypertension is an uncommon disease associated with high morbidity and mortality, so its early diagnosis and treatment are essential. We report here the case of a 57-year-old man with portopulmonary hypertension caused by chronic hepatosplenic schistosomiasis and also liver cirrhosis due to hepatitis C and alcoholism. As well as treating both diseases, portopulmonary hypertension was successfully managed with tadalafil and macitentan as maintenance therapy. This case reminds clinicians that pulmonary hypertension can be multifactorial, a good diagnosis and a multidisciplinary treatment can lead to improved prognosis.

Lung function and radiological findings 1 year after COVID-19: a prospective follow-up.

BACKGROUND: The coronavirus disease (COVID-19) pandemic has already affected more than 400 million people, with increasing numbers of survivors. These data indicate that a myriad of people may be affected by pulmonary sequelae of the infection. The aim of this study was to evaluate pulmonary sequelae in patients with bilateral COVID-19 pneumonia according to severity 1 year after hospital discharge. METHODS: COVID-FIBROTIC is a multicenter prospective observational cohort study for admitted patients with bilateral COVID-19 pneumonia. Pulmonary functional outcomes and chest computed tomography sequelae were analyzed 12 months after hospital discharge and we classified patients into three groups according to severity. A post hoc analysis model was designed to establish how functional test changed between groups and over time. A multivariable logistic regression model was created to study prognostic factors for lung diffusion impairment and radiological fibrotic-like changes at 12 months. RESULTS: Among 488 hospitalized patients with COVID-19 pneumonia, 284 patients had completed the entire evaluation at 12 months. Median age was 60.5 ± 11.9 and 55.3% were men. We found between-group differences in male sex, length of hospital stay, radiological involvement and inflammatory laboratory parameters. The functional evaluation of pulmonary sequelae showed that severe patients had statistically worse levels of lung diffusion at 2 months but no between group differences were found in subsequent controls. At 12-month follow up, however, we found impaired lung diffusion in 39.8% unrelated to severity. Radiological fibrotic-like changes at 12 months were reported in 22.7% of patients (102/448), only associated with radiological involvement at admission (OR: 1.55, 95% CI 1.06-2.38; p = 0.02) and LDH (OR: 0.99, 95% CI 0.98-0.99; p = 0.046). CONCLUSION: Our data suggest that a significant percentage of individuals would develop pulmonary sequelae after COVID 19 pneumonia, regardless of severity of the acute process. Trial registration clinicaltrials.gov NCT04409275 (June 1, 2020).

Lung Function, Radiological Findings and Biomarkers of Fibrogenesis in a Cohort of COVID-19 Patients Six Months After Hospital Discharge / Función pulmonar, hallazgos radiológicos y biomarcadores de la fibrogénesis en una cohorte de pacientes de COVID-19 seis meses después del alta

Introduction Impairment in pulmonary function tests and radiological abnormalities are a major concern in COVID-19 survivors. Our aim is to evaluate functional respiratory parameters, changes in chest CT, and correlation with peripheral blood biomarkers involved in lung fibrosis at two and six months after SARS-CoV-2 pneumonia. Methods COVID-FIBROTIC (clinicaltrials.gov NCT04409275) is a multicenter prospective observational cohort study aimed to evaluate discharged patients. Pulmonary function tests, circulating serum biomarkers, chest radiography and chest CT were performed at outpatient visits. Results In total, 313, aged 61.12±12.26 years, out of 481 included patients were available. The proportion of patients with DLCO<80% was 54.6% and 47% at 60 and 180 days. Associated factors with diffusion impairment at 6 months were female sex (OR: 2.97, 95%CI 1.74–5.06, p=0.001), age (OR: 1.03, 95% CI: 1.01–1.05, p=0.005), and peak RALE score (OR: 1.22, 95% CI 1.06–1.40, p=0.005). Patients with altered lung diffusion showed higher levels of MMP-7 (11.54±8.96 vs 6.71±4.25, p=0.001), and periostin (1.11±0.07 vs 0.84±0.40, p=0.001). 226 patients underwent CT scan, of whom 149 (66%) had radiological sequelae of COVID-19. In severe patients, 68.35% had ground glass opacities and 38.46% had parenchymal bands. Early fibrotic changes were associated with higher levels of MMP7 (13.20±9.20 vs 7.92±6.32, p=0.001), MMP1 (10.40±8.21 vs 6.97±8.89, p=0.023), and periostin (1.36±0.93 vs 0.87±0.39, p=0.001). Conclusion Almost half of patients with moderate or severe COVID-19 pneumonia had impaired pulmonary diffusion six months after discharge. Severe patients showed fibrotic lesions in CT scan and elevated serum biomarkers involved in pulmonary fibrosis.

Introducción El deterioro de la función pulmonar en las pruebas correspondientes y las alteraciones radiológicas son las preocupaciones principales en los supervivientes de la COVID-19. Nuestro objetivo fue evaluar los parámetros de la función respiratoria, los cambios en la TC de tórax y la correlación con los biomarcadores en sangre periférica involucrados en la fibrosis pulmonar a los 2 y a los 6 meses tras la neumonía por SARS-CoV-2. Métodos El ensayo COVID-FIBROTIC (clinicaltrials.gov NCT04409275) es un estudio de cohortes multicéntrico, prospectivo y observacional cuyo objetivo fue evaluar los pacientes dados de alta. Se realizaron pruebas de función pulmonar, detección de biomarcadores en plasma circulante y radiografía y TC de tórax durante las visitas ambulatorias. Resultados En total 313 pacientes, de 61,12±12,26 años, de los 481 incluidos estuvieron disponibles. La proporción de pacientes con DLCO<80% fue del 54,6 y del 47% a los 60 y 180 días. Los factores que se sociaron a la alteración de la difusión a los 6 meses fueron el sexo femenino (OR: 2,97; IC del 95%: 1,74-5,06; p=0,001), la edad (OR: 1,03; IC del 95%: 1,01-1,05; p=0,005) y la puntuación RALE más alta (OR: 1,22; IC del 95%: 1,06-1,40; p=0,005). Los pacientes con alteración de la difusión pulmonar mostraron niveles más altos de MMP-7 (11,54±8,96 frente a 6,71±4,25; p=0,001) y periostina (1,11±0.07 frente a 0,84±0,40; p=0,001). Se le realizó una TC a 226 pacientes de los cuales 149 (66%) presentaban secuelas radiológicas de la COVID-19. En los pacientes graves, el 68,35% mostraban opacidades en vidrio esmerilado y el 38,46%, bandas parenquimatosas. Los cambios fibróticos tempranos se asociaron a niveles más altos de MMP7 (13,20±9,20 frente a 7,92±6,32; p=0,001), MMP1 (10,40±8,21 frente a 6,97±8,89; p=0,023), y periostina (1,36±0,93 frente a 0,87±0,39; p=0,001). Conclusión Casi la mitad de los pacientes con neumonía moderada o grave por COVID-19 presentaba alteración de la difusión pulmonar 6 meses después del alta. Los pacientes graves mostraban lesiones fibróticas en laTC y un aumento de los biomarcadores séricos relacionados con la fibrosis pulmonar

Lung Function, Radiological Findings and Biomarkers of Fibrogenesis in a Cohort of COVID-19 Patients Six Months After Hospital Discharge.

INTRODUCTION: Impairment in pulmonary function tests and radiological abnormalities are a major concern in COVID-19 survivors. Our aim is to evaluate functional respiratory parameters, changes in chest CT, and correlation with peripheral blood biomarkers involved in lung fibrosis at two and six months after SARS-CoV-2 pneumonia. METHODS: COVID-FIBROTIC (clinicaltrials.gov NCT04409275) is a multicenter prospective observational cohort study aimed to evaluate discharged patients. Pulmonary function tests, circulating serum biomarkers, chest radiography and chest CT were performed at outpatient visits. RESULTS: In total, 313, aged 61.12 ± 12.26 years, out of 481 included patients were available. The proportion of patients with DLCO < 80% was 54.6% and 47% at 60 and 180 days. Associated factors with diffusion impairment at 6 months were female sex (OR: 2.97, 95%CI 1.74-5.06, p = 0.001), age (OR: 1.03, 95% CI: 1.01-1.05, p = 0.005), and peak RALE score (OR: 1.22, 95% CI 1.06-1.40, p = 0.005). Patients with altered lung diffusion showed higher levels of MMP-7 (11.54 ± 8.96 vs 6.71 ± 4.25, p = 0.001), and periostin (1.11 ± 0.07 vs 0.84 ± 0.40, p = 0.001). 226 patients underwent CT scan, of whom 149 (66%) had radiological sequelae of COVID-19. In severe patients, 68.35% had ground glass opacities and 38.46% had parenchymal bands. Early fibrotic changes were associated with higher levels of MMP7 (13.20 ± 9.20 vs 7.92 ± 6.32, p = 0.001), MMP1 (10.40 ± 8.21 vs 6.97 ± 8.89, p = 0.023), and periostin (1.36 ± 0.93 vs 0.87 ± 0.39, p = 0.001). CONCLUSION: Almost half of patients with moderate or severe COVID-19 pneumonia had impaired pulmonary diffusion six months after discharge. Severe patients showed fibrotic lesions in CT scan and elevated serum biomarkers involved in pulmonary fibrosis.

INTRODUCCIÓN: El deterioro de la función pulmonar en las pruebas correspondientes y las alteraciones radiológicas son las preocupaciones principales en los supervivientes de la COVID-19. Nuestro objetivo fue evaluar los parámetros de la función respiratoria, los cambios en la TC de tórax y la correlación con los biomarcadores en sangre periférica involucrados en la fibrosis pulmonar a los 2 y a los 6 meses tras la neumonía por SARS-CoV-2. MÉTODOS: El ensayo COVID-FIBROTIC (clinicaltrials.gov NCT04409275) es un estudio de cohortes multicéntrico, prospectivo y observacional cuyo objetivo fue evaluar los pacientes dados de alta. Se realizaron pruebas de función pulmonar, detección de biomarcadores en plasma circulante y radiografía y TC de tórax durante las visitas ambulatorias. RESULTADOS: En total 313 pacientes, de 61,12 ± 12,26 años, de los 481 incluidos estuvieron disponibles.La proporción de pacientes con DLCO < 80% fue del 54,6 y del 47% a los 60 y 180 días.Los factores que se asociaron a la alteración de la difusión a los 6 meses fueron el sexo femenino (OR: 2,97; IC del 95%: 1,74-5,06; p = 0,001), la edad (OR: 1,03; IC del 95%: 1,01-1,05; p = 0,005) y la puntuación RALE más alta (OR: 1,22; IC del 95%: 1,06-1,40; p = 0,005). Los pacientes con alteración de la difusión pulmonar mostraron niveles más altos de MMP-7 (11,54 ± 8,96 frente a 6,71 ± 4,25; p = 0,001) y periostina (1,11 ± 0.07 frente a 0,84 ± 0,40; p = 0,001). Se le realizó una TC a 226 pacientes de los cuales 149 (66%) presentaban secuelas radiológicas de la COVID-19. En los pacientes graves, el 68,35% mostraban opacidades en vidrio esmerilado y el 38,46%, bandas parenquimatosas. Los cambios fibróticos tempranos se asociaron a niveles más altos de MMP7 (13,20 ± 9,20 frente a 7,92 ± 6,32; p = 0,001), MMP1 (10,40 ± 8,21 frente a 6,97 ± 8,89; p = 0,023), y periostina (1,36 ± 0,93 frente a 0,87 ± 0,39; p = 0,001). CONCLUSIÓN: Casi la mitad de los pacientes con neumonía moderada o grave por COVID-19 presentaba alteración de la difusión pulmonar 6 meses después del alta. Los pacientes graves mostraban lesiones fibróticas en laTC y un aumento de los biomarcadores séricos relacionados con la fibrosis pulmonar.

Clinical and Epidemiological Features of Tuberculous Pleural Effusion in Alicante, Spain.

We aimed to (1) evaluate the incidence of tuberculous pleural effusion (TPE) over 25 years in our centre; (2) measure the yield of different diagnostic techniques; (3) compare TPE features between immigrant and native patients. Retrospective study of patients who underwent diagnostic thoracentesis and pleural biopsy in our hospital between 1995 and 2020. TPE was diagnosed in 71 patients (65% natives, 35% immigrants). Onset was acute in 35%, subacute in 26% and prolonged in 39%. Radiological features were atypical in 42%. Thoracentesis specimens were lymphocyte-predominant in 84.5% of patients, with elevated adenosine deaminase in 75% of patients. Diagnostic yield of pleural biopsy was 78%. Compared with native patients, more immigrants had previous contact with TB (54% vs. 17%, p = 0.001), prior TB (21% vs. 4%, p < 0.02) and atypical radiological features (58% vs. 34%, p < 0.03). TPE incidence was six times higher in the immigrant population (6.7 vs. 1.1 per 100,000 person-years, p < 0.001). TPE has an acute onset and sometimes atypical radiological features. Pleural biopsy has the highest diagnostic yield. Reactivation, prior contact with TB, atypical radiological features, complications, and positive microbiology results are more common in immigrant patients.

Cutaneous Metastases of Solid Tumors: Demographic, Clinical, and Survival Characteristics.

BACKGROUND: Cutaneous metastasis (CM), while uncommon, is usually an indicator of poor prognosis. With cancer patients living longer, the incidence of CM has increased, which justifies its analysis. OBJECTIVES: The objective of this study was to carry out a descriptive study of CM diagnosed for 18 years in a dermatology department of a tertiary care hospital and to assess the epidemiological, clinical, and histological variables that condition them, as well as data on their survival and prognosis. METHODS: We performed a descriptive study of cases of CM diagnosed over 18 years in the dermatology department of a tertiary referral hospital analyzing the following variables: patient age and sex, site of primary neoplasm, pathochronology, survival time, histological findings, immunohistochemical markers, the anatomical area affected, the clinical appearance of the metastasis, therapeutic plan, and existence of metastases in other regions. We checked normal distribution using the Kolmogorov-Smirnov test and then compared the quantitative variables using the Student's t-test (unpaired samples), Mann-Whitney test (non-normal distribution), analysis of variance (ANOVA; for more than two groups), and categorical variables using the chi-square or Fisher's exact test. RESULTS: We included 37 cases (20 men and 17 women), of whom 32 had died. The mean age was 62 ± 15 years. CM detection was defined early in 8% of cases, synchronous in 32%, and metachronous in 60%. The most frequent primary tumor sites were lungs (24%), breasts (21%), and bladders (11%). Most metastases were solitary. The most frequent locations for CM were the scalp, trunk, armpits, and groin. Most lesions had a nodular presentation (81%). Squamous cell carcinoma and adenocarcinoma showed the same frequency in lung cancer CM. Breast cancer leading to CM was the most common invasive ductal carcinoma. The most aggressive cases, with the worst survival, originated in lung neoplasms. Therapeutic management for most patients involved surgery in combination with other procedures. The only difference detected between the lung and breast cancer CM was the predominance of lung tumors in men (89%) and breast tumors in women compared with metastases from other sites; breast cancer CM manifested more frequently as plaques and less frequently as nodules (p < 0.05) and was less frequently associated with multisystemic metastasis. In lung cancer CM, time from tumor diagnosis to CM occurrence was shorter (p < 0.01) and multisystemic metastasis was more frequent than in CM of other tumors. CONCLUSIONS: CM tends to affect patients aged above 60 years and arises predominantly from lung cancer in men and breast cancer in women. The most typical locations are the chest and scalp, and the appearance is usually nodular. Survival after CM detection is low, particularly in lung cancer CM.

Effectiveness and safety of pirfenidone for idiopathic pulmonary fibrosis.

OBJECTIVES: To assess the long-term effectiveness of pirfenidone in idiopathic pulmonary fibrosis (IPF) treatment and to establish its adverse effects profile. METHODS: Retrospective observational study in patients with IPF who initiated treatment with pirfenidone between 2011 and 2016. We collected demographic variables (age, sex); date of first and last treatment; reason for discontinuation; pulmonary function measures (forced vital capacity (FVC), carbon monoxide diffusion capacity (DLCO), and 6 min walk test (6MWT)) at treatment initiation (baseline) and at 1, 2 and 3 year follow-up; adherence to pirfenidone treatment; recorded adverse effects; and mortality. RESULTS: Thirty-one patients treated with pirfenidone were included; mean±SD age was 69±8 years, 74% were men, and 59% had a smoking history. Mean baseline values were: FVC 2.43±0.66 L (61.8±12.1%); DLCO 46.1±19.4%; and 6MWT 334±125 m. Median duration of treatment was 14±13 months, and treatment was discontinued in 58% of patients. The most frequently observed adverse effects were gastrointestinal disturbances and photosensitivity. Twenty (65%) patients were evaluated at 1 year, when mean FVC was 2.41±0.86 L (64.7±20.3%); DLCO 50.8±26.8%; and 6MWT 341±139 m. At 2 years' follow-up, 11 patients (36%) who were still taking pirfenidone were evaluated. Mean FVC was 2.34±0.79 L (66.2±14.7%); DLCO 50.0±28.3%; and 6MWT 265±121 m. At 3 years, five patients were still taking the treatment. Mean FVC was 2.71±0.84 L (71.0±24.7%); DLCO 52.6±26.7%; and 6MWT 286±139 m. Nineteen per cent of patients were non-adherent to treatment. CONCLUSIONS: Pirfenidone seems to be effective for long-term control of IPF despite substantial variability in response among individual patients. The most frequent adverse effects were digestive and cutaneous, prompting in some cases a reduction in dose or even discontinuation of the treatment.

Home Respiratory Polygraphy is Useful in the Diagnosis of Childhood Obstructive Sleep Apnea Syndrome.

The utility of home respiratory polygraphy (HRP) was assessed as an alternative to polysomnography (PSG) in the diagnosis of childhood obstructive sleep apnea syndrome (OSAS). PSG was indicated only in patients with concomitant disease or where HRP results were questionable. The follow-up period was 1 year. We recorded clinical and anthropometric data, physical examination findings, respiratory variables, severity level and choice of therapy. We assessed 121 children, 70 boys and 51 girls, with mean age 7 ± 4 years, mean body mass index (BMI) 19 ± 5 kg/m2, and mean BMI percentile 62 ± 38%. We included 104 HRP and 24 PSG recordings. Of the latter, 7 were preceded by HRP (false negatives) and 17 were indicated as the first-choice method owing to concomitant disease. Of the initial HRP recordings, 93% were technically valid. All technically valid HRPs and 96% of PSGs resulted in a diagnosis of OSAS (apnea-hypopnea index 9.5 ± 9.1/h). Thirty-three percent of cases were moderate and 22% severe. Apnea-hypopnea index showed no correlation with BMI or BMI percentile. Adenotonsillectomy was indicated in 93 patients (77%), conservative treatment in 17 (14%), and conservative treatment combined with CPAP/BiPAP in 11 (9%). There were no significant differences between children diagnosed by HRP and by PSG in terms of treatment choice. The prevalence of OSAS in our sample was 96.7%. In conclusion, when the probability of OSAS is high, HRP is usually sufficient for diagnosing the syndrome and establishing therapy in children. PSG is advisable in complex or questionable cases.

Utility of Flexible Bronchoscopy for Airway Foreign Bodies Removal in Adults.

Foreign body aspiration is relatively infrequent in adults. Airway foreign bodies (AFBs) can be removed by flexible bronchoscopy (FB) or rigid bronchoscopy (RB). We performed a retrospective analysis of FBs performed in our centre over a 25 year period, focusing on the procedures that revealed an AFB during the examination stage. We recorded demographic data, clinical characteristics and radiological and bronchoscopic findings. During the study period, 12,588 FBs were performed in adults. Airway foreign bodies were identified in 32 of these cases, giving a prevalence of 0.25%. The most frequent clinical presentation was cough, sputum and fever. The most frequent radiological findings were alveolar infiltrates and atelectasis. In 94% of cases, AFBs were removed successfully by FB; RB was necessary in only 6% of cases. There were no FB-related complications. The most common AFB location was the right bronchial tree (69%). We classified AFBs as organic (85%: animal 57%; vegetable 28%), inorganic (6%) and iatrogenic (9%). Bronchial infection occurred in 51% of cases, and Actinomyces spp. was the most common causal microorganism. In conclusion, AFBs are a rare entity with nonspecific clinical presentation, most AFBs were organic, and FB is a safe and effective method for AFB removal.

Argon plasma coagulation for management of hemoptysis in endobronchial metastasis from soft-tissue sarcoma.

Hemoptysis is a manifestation of a wide variety of diseases. Endobronchial metastases from nonpulmonary neoplasms are unusual. Among these causes, soft-tissue sarcoma is also discretely rare and scarcely documented. Argon plasma coagulation is a useful tool for the interventional pulmonologist that can allow control of bleeding from these lesions. Here we report a case of hemoptysis from an endobronchial metastasis of soft-tissue sarcoma. Argon plasma coagulation of the bleeding lesion was performed successfully.

Non-invasive ventilation in obesity hypoventilation syndrome without severe obstructive sleep apnoea.

BACKGROUND: Non-invasive ventilation (NIV) is an effective form of treatment in patients with obesity hypoventilation syndrome (OHS) who have concomitant severe obstructive sleep apnoea (OSA). However, there is a paucity of evidence on the efficacy of NIV in patients with OHS without severe OSA. We performed a multicentre randomised clinical trial to determine the comparative efficacy of NIV versus lifestyle modification (control group) using daytime arterial carbon dioxide tension (PaCO2) as the main outcome measure. METHODS: Between May 2009 and December 2014 we sequentially screened patients with OHS without severe OSA. Participants were randomised to NIV versus lifestyle modification and were followed for 2 months. Arterial blood gas parameters, clinical symptoms, health-related quality of life assessments, polysomnography, spirometry, 6-min walk distance test, blood pressure measurements and healthcare resource utilisation were evaluated. Statistical analysis was performed using intention-to-treat analysis. RESULTS: A total of 365 patients were screened of whom 58 were excluded. Severe OSA was present in 221 and the remaining 86 patients without severe OSA were randomised. NIV led to a significantly larger improvement in PaCO2 of -6 (95% CI -7.7 to -4.2) mm Hg versus -2.8 (95% CI -4.3 to -1.3) mm Hg, (p<0.001) and serum bicarbonate of -3.4 (95% CI -4.5 to -2.3) versus -1 (95% CI -1.7 to -0.2 95% CI)  mmol/L (p<0.001). PaCO2 change adjusted for NIV compliance did not further improve the inter-group statistical significance. Sleepiness, some health-related quality of life assessments and polysomnographic parameters improved significantly more with NIV than with lifestyle modification. Additionally, there was a tendency towards lower healthcare resource utilisation in the NIV group. CONCLUSIONS: NIV is more effective than lifestyle modification in improving daytime PaCO2, sleepiness and polysomnographic parameters. Long-term prospective studies are necessary to determine whether NIV reduces healthcare resource utilisation, cardiovascular events and mortality. TRIAL REGISTRATION NUMBER: NCT01405976; results.

Association between Obstructive Sleep Apnea and Community-Acquired Pneumonia.

BACKGROUND: We hypothesized that obstructive sleep apnea (OSA) can predispose individuals to lower airway infections and community-acquired pneumonia (CAP) due to upper airway microaspiration. This study evaluated the association between OSA and CAP. METHODS: We performed a case-control study that included 82 patients with CAP and 41 patients with other infections (control group). The controls were matched according to age, sex and body mass index (BMI). A respiratory polygraph (RP) was performed upon admission for patients in both groups. The severity of pneumonia was assessed according to the Pneumonia Severity Index (PSI). The associations between CAP and the Epworth Sleepiness Scale (ESS), OSA, OSA severity and other sleep-related variables were evaluated using logistic regression models. The associations between OSA, OSA severity with CAP severity were evaluated with linear regression models and non-parametric tests. FINDINGS: No significant differences were found between CAP and control patients regarding anthropometric variables, toxic habits and risk factors for CAP. Patients with OSA, defined as individuals with an Apnea-Hypopnea Index (AHI) ≥10, showed an increased risk of CAP (OR = 2·86, 95%CI 1·29-6·44, p = 0·01). Patients with severe OSA (AHI≥30) also had a higher risk of CAP (OR = 3·18, 95%CI 1·11-11·56, p = 0·047). In addition, OSA severity, defined according to the AHI quartile, was also significantly associated with CAP (p = 0·007). Furthermore, OSA was significantly associated with CAP severity (p = 0·0002), and OSA severity was also associated with CAP severity (p = 0·0006). CONCLUSIONS: OSA and OSA severity are associated with CAP when compared to patients admitted to the hospital for non-respiratory infections. In addition, OSA and OSA severity are associated with CAP severity. These results support the potential role of OSA in the pathogenesis of CAP and could have clinical implications. This link between OSA and infection risk should be explored to investigate the relationships among gastroesophageal reflux, silent aspiration, laryngeal sensory dysfunction and CAP. TRIAL REGISTRATION: ClinicalTrials.gov NCT01071421.

Técnicas complementarias a la ventilación mecánica domiciliaria. Año SEPAR 2014 / Complementary Home Mechanical Ventilation Techniques. SEPAR Year 2014

La ventilación mecánica domiciliaria (VMD) precisa técnicas complementarias para optimizar el tratamiento, que son revisadas en el presente trabajo. El manejo de las secreciones respiratorias es muy importante, ya que muchos pacientes, particularmente cuando descienden los flujos de tos, precisan la aplicación de técnicas manuales o asistidas para el manejo de secreciones, técnicas de tos asistida (manual o mecánica) y aspiración mecánica de secreciones. Si se aplica la VMD de forma invasiva, el buen manejo de la cánula de traqueostomía es esencial para su éxito. Las alteraciones durante el sueño pueden estar presentes en estos pacientes, siendo un aspecto a valorar, estudiadas mediante polisomnografía o poligrafía respiratoria, que además ayudan a identificar las asincronías entre el paciente y el ventilador. Otras técnicas que pueden ser requeridas en pacientes con VMD son la fibrobroncoscopia o el soporte nutricional (especialmente si se requiere la colocación de una sonda de gastrostomía). La monitorización de la VMD aporta información sobre la efectividad del tratamiento aplicado. Existen varios métodos para ello, como pueden ser la pulsioximetría, la capnografía o los programas internos de los ventiladores. Finalmente, se revisa la importancia de la percepción subjetiva del paciente, ya que puede tener potencial influencia en el éxito de la VMD

This is a review of the different complementary techniques that are useful for optimizing home mechanical ventilation (HMV). Airway clearance is very important in patients with HMV and many patients, particularly those with reduced peak cough flow, require airway clearance (manual or assisted) or assisted cough techniques (manual or mechanical) and suctioning procedures, in addition to ventilation. In the case of invasive HMV, good tracheostomy cannula management is essential for success. HMV patients may have sleep disturbances that must be taken into account. Sleep studies including complete polysomnography or respiratory polygraphy are helpful for identifying patient-ventilator asynchrony. Other techniques, such as bronchoscopy or nutritional support, may be required in patients on HMV, particularly if percutaneous gastrostomy is required Information on treatment efficacy can be obtained from HMV monitoring, using methods such as pulse oximetry, capnography or the internal programs of the ventilators themselves. Finally, the importance of the patient’s subjective perception is reviewed, as this may potentially affect the success of the HMV

Complementary home mechanical ventilation techniques. SEPAR Year 2014.

This is a review of the different complementary techniques that are useful for optimizing home mechanical ventilation (HMV). Airway clearance is very important in patients with HMV and many patients, particularly those with reduced peak cough flow, require airway clearance (manual or assisted) or assisted cough techniques (manual or mechanical) and suctioning procedures, in addition to ventilation. In the case of invasive HMV, good tracheostomy cannula management is essential for success. HMV patients may have sleep disturbances that must be taken into account. Sleep studies including complete polysomnography or respiratory polygraphy are helpful for identifying patient-ventilator asynchrony. Other techniques, such as bronchoscopy or nutritional support, may be required in patients on HMV, particularly if percutaneous gastrostomy is required. Information on treatment efficacy can be obtained from HMV monitoring, using methods such as pulse oximetry, capnography or the internal programs of the ventilators themselves. Finally, the importance of the patient's subjective perception is reviewed, as this may potentially affect the success of the HMV.

Seminoma con afectación bronquial y síndrome de vena cava superior: una asociación excepcional / Seminoma with Bronchial Involvement and Superior Vena Cava Syndrome: A Rare Combination

Se describe el caso de un varón de 45 años que ingresó con signos clínicos de un síndrome de vena cava superior (SVCS), destacando en la exploración edema en esclavina y gran circulación colateral en el cuello y en la región anterosuperior torácica, así como una gran masa testicular. La fibrobroncoscopia mostró una lesión endobronquial tumoral, cuyo diagnóstico histopatológico fue de seminoma, con las mismas características que la biopsia testicular. Se inició tratamiento con cirugía, quimioterapia y radioterapia, presentando gran mejoría clínica. Señalamos la importancia de considerar el SVCS como entidad relacionada con procesos neoplásicos menos frecuentes, como son los tumores germinales

We describe the case of a 45-year-old male who was admitted with clinical signs of superior vena cava syndrome (SVCS). Physical examination showed collar of Stokes and extensive collateral circulation in the neck and anterosuperior thoracic region, as well as a large testicular mass. Fibrobronchoscopy revealed an endobronchial tumor, histopathologically diagnosed as seminoma, with the same characteristics as the testicular biopsy. Treatment was initiated with surgery, chemotherapy and radiotherapy, resulting in a major clinical improvement. We indicate the importance of considering SVCS as an entity related with less common neoplasms such as germ cell tumors

Seminoma with bronchial involvement and superior vena cava syndrome: a rare combination.

We describe the case of a 45-year-old male who was admitted with clinical signs of superior vena cava syndrome (SVCS). Physical examination showed collar of Stokes and extensive collateral circulation in the neck and anterosuperior thoracic region, as well as a large testicular mass. Fibrobronchoscopy revealed an endobronchial tumour, histopathologically diagnosed as seminoma, with the same characteristics as the testicular biopsy. Treatment was initiated with surgery, chemotherapy and radiotherapy, resulting in a major clinical improvement. We indicate the importance of considering SVCS as an entity related with less common neoplasms such as germ cell tumours.

Effectiveness of three sleep apnea management alternatives.

RATIONALE: Home respiratory polygraphy (HRP) may be a cost-effective alternative to polysomnography (PSG) for diagnosis and treatment election in patients with high clinical probability of obstructive sleep apnea (OSA), but there is conflicting evidence on its use for a wider spectrum of patients. OBJECTIVES: To determine the efficacy and cost of OSA management (diagnosis and therapeutic decision making) using (1) PSG for all patients (PSG arm); (2) HRP for all patients (HRP arm); and (3) HRP for a subsample of patients with high clinical probability of being treated with continuous positive airway pressure (CPAP) and PSG for the remainder (elective HRP arm). METHODS: Multicentric study of 366 patients with intermediate-high clinical probability of OSA, randomly subjected to HRP and PSG. We explored the diagnostic and therapeutic decision agreements between the PSG and both HRP arms for several HRP cutoff points and calculated costs for equal diagnostic and/or therapeutic decision efficacy. RESULTS: For equal diagnostic and therapeutic decision efficacy, PSG arm costs were 18% higher than HRP arm costs and 20% higher than elective HRP arm costs. HRP arm costs tended to be lower than elective HRP arm costs, and both tended to be lower than PSG arm costs if patient costs were omitted. CONCLUSION: Home respiratory polygraphy is a less costly alternative than polysomnography for the diagnosis and therapeutic decision making for patients with suspected obstructive sleep apnea. We found no advantage in cost terms, however, in using home respiratory polygraphy for all patients or home respiratory polygraphy for the most symptomatic patients and polysomnography for the rest.

The use of ambulatory strategies for the diagnosis and treatment of obstructive sleep apnea in adults.

Obstructive sleep apnea (OSA) is a highly prevalent disorder associated with complications such as arterial hypertension, coronary heart disease, cerebrovascular disease and traffic accidents. Patients with untreated OSA consume more financial and healthcare resources and have higher mortality than those treated properly. The resources allocated for OSA are insufficient in some countries for such a prevalent disorder. This has given rise to a significant public health problem and a search for alternative strategies based on the ambulatory management. In the diagnostic process, portable monitors have been evaluated. Continuous positive airway pressure is the most effective treatment in OSA, but other forms of treatments have also been used (weight loss, oral appliances, surgery and so on). Ambulatory monitoring of the therapeutic modalities has been evaluated to enhance the care process and reduce costs compared with the conventional approach, without sacrificing efficiency. This review aims to highlight the most important advances in this field, analyzing the results of the main works to date, in order to assess the current situation and future research needs.