Fenotipos clínicos de la enfermedad pulmonar obstructiva crónica en los pacientes atendidos en el Hospital neumológico de La Habana / Clinical phenotypes of chronic obstructive pulmonary disease in patients treated at the Hospital Neumológico de La Habana

Introducción: La identificación de los fenotipos clínicos son claves en la modulación de la expresión clínica, para un tratamiento integrado de la EPOC. Objetivos: Caracterizar los fenotipos clínicos de la EPOC en los pacientes atendidos en el Hospital Neumológico Benéfico Jurídico. Métodos:Se realizó un estudio observacional descriptivo retrospectivo, en 172 pacientes con diagnóstico de EPOC, en el Hospital Neumológico Benéfico Jurídico durante el año 2017.Resultados: El 38,4 % de los pacientes tenían edad entre 70-79 años. Del total de pacientes, el 54,6 % eran del sexo masculino. El 52,9 % eran fumadores activos y el 41,3 % exfumadores. Aunque las diferencias no fueron significativas, la edad avanzada y el sexo masculino fueron más frecuentes en el fenotipo enfisematoso agudizador y agudizador bronquítico crónico. El tabaquismo activo fue más frecuente en el fenotipo enfisematoso agudizador. Todos los pacientes con el fenotipo agudizador bronquítico crónico tuvieron dos o más exacerbaciones, mientras que el enfisematoso agudizador se relacionó con una severidad grave de la EPOC (46,7 %). Conclusiones: El sexo masculino y la edad avanzada muestran una tendencia a relacionarse con el fenotipo enfisematoso agudizador y agudizador bronquítico crónico, mientras que el tabaquismo activo es más frecuente en el fenotipo enfisematoso agudizador. El fenotipo agudizador bronquítico crónico se relaciona con mayores exacerbaciones y el enfisematoso agudizador con una mayor severidad de la EPOC.

Introduction: The identification of clinical phenotypes are key in the modulation of clinical expression, for an integrated treatment of COPD. Objectives: To characterize the clinical phenotypes of COPD in patients treated at the Hospital Neumológico Benéfico Jurídico. Methods: A retrospective descriptive observational study was carried out in 172 patients with a diagnosis of COPD at the Hospital Neumológico Benéfico Jurídico in 2017. Results: 38.4 % of the patients were between 70-79 years of age. Of the total number of patients, 54.6 % were male. 52.9 % were active smokers and 41.3 % ex-smokers. Although the differences were not significant, advanced age and male sex were more frequent in the exacerbator emphysematous and chronic bronchial exacerbator phenotype. Active smoking was more frequent in the exacerbating emphysematous phenotype. All patients with the chronic bronchial exacerbator phenotype had two or more exacerbations, while exacerbation emphysematous was associated with severe severity of COPD (46.7 %). Conclusions: Male sex and advanced age show a tendency to be related to the exacerbating emphysematous phenotype and chronic bronchitis exacerbator, while active smoking is more frequent in the exacerbating emphysematous phenotype. The chronic bronchitis exacerbator phenotype is related to greater exacerbations and exacerbation emphysematous with a greater severity of COPD

Subfenótipos baseados em dados clínicos de beira-leito de pacientes críticos com COVID-19: um estudo de coorte / Bedside clinical data subphenotypes of critically ill COVID-19 patients: a cohort study

RESUMO Objetivo: Identificar apresentações mais graves de COVID-19. Métodos: Pacientes consecutivamente admitidos à unidade de terapia intensiva foram submetidos à análise de clusters por meio de método de explorações sequenciais Resultados: Analisamos os dados de 147 pacientes, com média de idade de 56 ± 16 anos e Simplified Acute Physiological Score 3 de 72 ± 18, dos quais 103 (70%) demandaram ventilação mecânica e 46 (31%) morreram na unidade de terapia intensiva. A partir do algoritmo de análise de clusters, identificaram-se dois grupos bem definidos, com base na frequência cardíaca máxima [Grupo A: 104 (IC95% 99 - 109) batimentos por minuto versus Grupo B: 159 (IC95% 155 - 163) batimentos por minuto], frequência respiratória máxima [Grupo A: 33 (IC95% 31 - 35) respirações por minuto versus Grupo B: 50 (IC95% 47 - 53) respirações por minuto] e na temperatura corpórea máxima [Grupo A: 37,4 (IC95% 37,1 - 37,7)ºC versus Grupo B: 39,3 (IC95% 39,1 - 39,5)ºC] durante o tempo de permanência na unidade de terapia intensiva, assim como a proporção entre a pressão parcial de oxigênio no sangue e a fração inspirada de oxigênio quando da admissão à unidade de terapia intensiva [Grupo A: 116 (IC95% 99 - 133) mmHg versus Grupo B: 78 (IC95% 63 - 93) mmHg]. Os subfenótipos foram distintos em termos de perfis inflamatórios, disfunções orgânicas, terapias de suporte, tempo de permanência na unidade de terapia intensiva e mortalidade na unidade de terapia intensiva (com proporção de 4,2 entre os grupos). Conclusão: Nossos achados, baseados em dados clínicos universalmente disponíveis, revelaram dois subfenótipos distintos, com diferentes evoluções de doença. Estes resultados podem ajudar os profissionais de saúde na alocação de recursos e seleção de pacientes para teste de novas terapias.

Abstract Objective: To identify more severe COVID-19 presentations. Methods: Consecutive intensive care unit-admitted patients were subjected to a stepwise clustering method. Results: Data from 147 patients who were on average 56 ± 16 years old with a Simplified Acute Physiological Score 3 of 72 ± 18, of which 103 (70%) needed mechanical ventilation and 46 (31%) died in the intensive care unit, were analyzed. From the clustering algorithm, two well-defined groups were found based on maximal heart rate [Cluster A: 104 (95%CI 99 - 109) beats per minute versus Cluster B: 159 (95%CI 155 - 163) beats per minute], maximal respiratory rate [Cluster A: 33 (95%CI 31 - 35) breaths per minute versus Cluster B: 50 (95%CI 47 - 53) breaths per minute], and maximal body temperature [Cluster A: 37.4 (95%CI 37.1 - 37.7)°C versus Cluster B: 39.3 (95%CI 39.1 - 39.5)°C] during the intensive care unit stay, as well as the oxygen partial pressure in the blood over the oxygen inspiratory fraction at intensive care unit admission [Cluster A: 116 (95%CI 99 - 133) mmHg versus Cluster B: 78 (95%CI 63 - 93) mmHg]. Subphenotypes were distinct in inflammation profiles, organ dysfunction, organ support, intensive care unit length of stay, and intensive care unit mortality (with a ratio of 4.2 between the groups). Conclusion: Our findings, based on common clinical data, revealed two distinct subphenotypes with different disease courses. These results could help health professionals allocate resources and select patients for testing novel therapies.

Fenótipos da DPOC: há interesse prático nesta avaliação? / COPD phenotypes: Is it interesting in clinical practice?

A doença pulmonar obstrutiva crônica é causa importante de mortalidade no mundo e está presente em 90-95% dos indivíduos que se expõem ao tabagismo. Há muito tem se discutido a heterogeneidade da doença, inicialmente subdividindo a expressão clínica em dois grandes grupos: "Pink puffer" e "Blow blooter". Recentemente, tem sido descrito diferentes fenótipos da doença subdividindo os pacientes em diversos grupos. Destacam-se como mais prevalentes o exacerbador, a síndrome de sobreposição asma/DPOC e o enfisema com hiperinsuflação. Entretanto, será que devemos, em consulta clínica, estar preocupados em classificar o nosso paciente nestes subgrupos? Essa pergunta é foco de grande discussão, mas à luz dos conhecimentos atuais essa subdivisão parece ser interessante para fins de decisão e escalonamento terapêutico, individualizando o tratamento com o objetivo de maior efetividade terapêutica.

Chronic obstructive pulmonary disease is an important cause of and in 90-95% of cases is associated smoking habit. The heterogeneity of the disease has long been discussed dividing the clinical expression of the disease into two major groups: Pink puffer and Blow blooter. Recently, different phenotypes of the disease have been described, subdividing the patients into several groups. The following stand out: Exacerbator, overlap asthma / COPD syndrome, emphysema with hyperinflation and others. However, is important for us to classify our patients in these subgroups? This question is a focus of great discussion, but the light of current knowledge this subdivision seems to be interesting to decide about which drug we will choose to achieve individual effectiveness.

Heterogeneidad en los fenotipos inflamatorios de los pacientes con EPOC: rol del recuento celular diferencial en esputo / Heterogeneity of Inflammatory Phenotypes In Copd Patients: Role of Differential Cell Counting in Sputum

El tabaquismo es la principal causa de la EPOC, sin embargo, factores como la edad de diagnóstico, la historia previa de asma, exacerbaciones, predisposición genética y otros influirían en el desarrollo de la enfermedad. Esto estaría relacionado con los fenotipos de pacientes con EPOC, los cuales tendrían diferentes respuestas a los corticoides inhalados (CI). Recientemente, ha sido propuesto que los eosinófilos serían potenciales biomarcadores predictores de buena respuesta a los CI. Con la hipótesis de que la presencia de eosinófilos en esputo podría constituir una estrategia para diferenciar fenotipos de pacientes con EPOC, evaluamos los perfiles celulares infamatorios en muestras de esputo inducido en pacientes con EPOC no exacerbados. Para esto, se reclutaron 20 pacientes con EPOC moderado a severo que concurren al gimnasio de rehabilitación respiratoria, los cuales fueron agrupados en eosinofílicos (n: 8, cuando presentaron más de 3% de eosinófilos en la muestra de esputo inducido) o no eosinofílicos (n: 9). Se descartaron 3 muestras por contaminación con células epiteliales. Si bien no se observaron diferencias significativas en los test de función pulmonar o de marcha de 6 minutos, los pacientes con eosinoflia presentaron ligeramente mayor reversibilidad luego del broncodilatador. Además, tuvieron mayor eosinofilia periférica, mayores valores de FeNO y mejor calidad de vida (medida por cuestionarios) que los pacientes no eosinofílicos. El esputo inducido es una técnica no invasiva, económica, que representaría una herramienta útil para conocer los diferentes fenotipos inflamatorios en pacientes con EPOC.

Smoking is the major cause of COPD; however factors such as age, previous history of asthma, exacerbations, and genetic predisposition could infuence the development of the disease. This could be related with the phenotypes of COPD patients, who would have different responses to inhaled corticosteroids (ICs). Recently, it has been suggested that eosinophils are potential biomarkers that contribute to predict good response to ICs. To test the hypothesis that the presence of eosinophils in sputum could be useful to characterize different phenotypes of COPD patients, we assessed the infammatory cell profles in induced sputum samples from not exacerbated COPD patients. 20 patients with moderate to severe COPD, attending a pulmonary rehabilitation gym, were grouped into eosinophilic (8 patients who presented more than 3% eosinophils in the induced sputum sample) or neutrophilic (9 patients who had more than 60% neutrophils). Only 3 patients were excluded due to contamination of the sputum with epithelial cells. Although there were no-signifcant differences in the pulmonary function tests or the 6-minute walk, the patients with eosinophilia showed higher responsiveness to bronchodilator therapy. Besides this group presented an increase of peripheral eosinophils, higher FeNO and better quality of life (measured by questionnaires) compared with the neutrophilic patients. Induced sputum is an economic non-invasive technique and would be a useful tool to know different infammatory phenotypes in COPD patients.

Diagnóstico de asma en el niño: [revisión] / Diagnosis of asthma in children: [review]

El asma es una enfermedad crónica inflamatoria de las vías aéreas, caracterizado por obstrucción aérea, la cual puede ser total o parcialmente reversible con o sin terapia específica. La inflamación de la vía aérea es el resultado de la interacción entre varias células, elementos celulares y citocinas. En individuos susceptibles, la inflamación aérea puede causar broncoespasmo recurrente o persistente, lo cual genera síntomas como dificultad respiratoria, falta de aliento, sensación de opresión torácica y tos. El asma infantil cuenta con varios fenotipos clínicos y diferentes estrategias terapéuticas. El diagnóstico de asma en niños necesita de un examen físico y una revisión adecuada de la historia médica actual y pasada. El diagnóstico del asma requiere de estudios especializados y descartar otras posibles causas.

Asthma is a chronic inflammatory disorder of the airway pathways characterized by an obstruction of airflow, which may be completely or partially reversed with or without specific therapy. Airway inflammation is the result of interactions between various cells, cellular elements and cytokines. In susceptible individuals, airway inflammation may cause recurrent or persistent broncho spasm, which causes symptoms including wheezing, breathlessness, chest tightness, and cough. Childhood asthma includes several different clinical phenotypes with different management strategies.The diagnosis of asthma in children requires a careful review of the child's current and past medical history, family history and a physical examination. Specialized testing is sometimes needed to diagnose asthma and to rule out other possible causes.