Estudio de sobrevida a largo plazo en pacientes adultos con enfermedades respiratorias crónicas atendidos por infección respiratoria aguda por coronavirus SARS-CoV-2 / Study of long-term survival in adult patients with chronic respiratory diseases treated for acute respiratory infection by coronavirus SARS-CoV-2

La enfermedad respiratoria aguda por coronavirus SARS-CoV-2 (COVID-19) se ha convertido en un grave problema de salud pública a nivel mundial. Objetivos: Examinar el uso de recursos sanitarios, riesgo de complicaciones y muerte en pacientes adultos con enfermedades respiratorias crónicas atendidos por COVID-19. Métodos: Estudio clínico descriptivo prospectivo realizado en pacientes adultos atendidos por COVID-19 en la Red de Salud UC Christus entre el 1 de abril y 31 de diciembre de 2020. Resultados: Se evaluaron 2.160 pacientes adultos, edad: 47 ± 17 años (rango: 18-100), 51,3% sexo masculino, 43,8% tenía comorbilidades, especialmente hipertensión (23,2%), diabetes (11,7%) y enfermedades respiratorias crónicas: asma (5%), EPOC (1,4%) y enfermedad pulmonar difusa (EPD: 0,8%). Los pacientes adultos con enfermedades respiratorias crónicas tuvieron mayor riesgo de hospitalización y uso de oxígeno suplementario; sin embargo, la evolución de los pacientes asmáticos y la sobrevida a los doce meses fue similar a los pacientes sin comorbilidades atendidos por COVID-19, mientras que en los pacientes con EPOC y EPD la admisión a la unidad de paciente crítico y riesgo de muerte fueron más elevados. En el análisis multivariado, los principales predictores clínicos asociados al riesgo de muerte en el seguimiento a doce meses en pacientes adultos con COVID-19 fueron la edad y admisión al hospital, mientras que el asma fue un factor protector. Conclusión: Los pacientes asmáticos tuvieron bajo riesgo de complicaciones y muerte asociados a COVID-19; mientras que los pacientes con EPOC y EPD tuvieron mayor riesgo de complicaciones y muerte en el seguimiento a largo plazo.

The acute respiratory disease associated to coronavirus SARS-CoV-2 (COVID-19) has become a serious public health problem worldwide. Objectives: To examine the use of healthcare resources, risk of complications and death in adult patients with chronic respiratory diseases treated for COVID-19. Methods: Prospective descriptive clinical study conducted in adult patients treated for COVID-19 in the UC Christus Healthcare Network between April 1 and December 31, 2020. Results: 2,160 adult patients were evaluated, age: 47 ± 17 years-old (range: 18-100), 51.3% male, 43.8% had comorbidities, especially hypertension (23.2%), diabetes (11.7%), and chronic respiratory diseases: asthma (5%), COPD (1,4%) and interstitial lung disease (ILD: 0.8%). Adult patients with chronic respiratory diseases were at higher risk for hospitalization and use of supplemental oxygen; however, the evolution of asthmatic patients and survival at twelve months was similar to that of adult patients without comorbidities treated for COVID-19, while in patients with COPD and ILD admission to the critical care unit and risk of death were higher. In the multivariate analysis, the main clinical predictors associated to 12-month mortality risk in adult patients with COVID-19 were age and hospital admission, while asthma was a protective factor. Conclusion: Asthmatic patients had minor risk of complications and mortality associated with COVID-19; while patients with COPD and ILD had a significant higher risk of complications and 12-month mortality.

Predictores de mortalidad en pacientes con exacerbación de enfermedad pulmonar obstructiva crónica / Mortality predictors in patients with exacerbation of chronic obstructive pulmonary disease

RESUMEN Fundamento: La enfermedad pulmonar obstructiva crónica (EPOC) es un problema de salud y constituye la tercera causa de defunción en el mundo. La mortalidad es mayor en los pacientes que presentan exacerbaciones de esa enfermedad. Objetivo: Determinar los factores predictores de mortalidad en pacientes hospitalizados con exacerbación de EPOC en una institución hospitalaria del segundo nivel de atención en Cuba. Metodología: Se realizó un estudio transversal en el Hospital General Provincial Camilo Cienfuegos de Sancti Spíritus, durante dos años. Se incluyeron 335 pacientes. Las variables recogidas se agruparon en sociodemográficas, clínicas, enfermedades crónicas asociadas y estado del paciente al egreso. Se elaboró un árbol de decisión mediante el método Chaid exhaustivo, la variable dependiente fue la mortalidad por EPOC. Resultados: Predominaron los pacientes del sexo femenino (55.2 %), con 60 años o más (79 %) y con más de 4 exacerbaciones en el último año (53.1 %). El modelo del árbol de decisión tuvo una sensibilidad de 97 %, especificidad de 89.3 % y un porcentaje global de pronóstico correcto del 93.1 %. Se identificaron seis variables predictores de mortalidad: insuficiencia respiratoria aguda, diagnóstico de neumonía, no utilización de antitrombóticos, tromboembolismo pulmonar, edad mayor de 60 años y el hábito de fumar. Conclusiones: La probabilidad más alta de fallecer durante una exacerbación de EPOC se da entre los pacientes con insuficiencia respiratoria aguda, los que son diagnosticados con neumonía durante el ingreso, los que no realizan tratamiento antitrombótico y los que tienen más de 60 años de edad.

ABSTRACT Background: Chronic obstructive pulmonary disease (COPD) is a health problem and the third cause of death in the world. Mortality is higher in patients who present exacerbations of this disease. Objective: To determine mortality predictors in hospitalized patients with exacerbation of COPD in a second care level hospital in Cuba. Methodology: A cross-sectional study was conducted at Camilo Cienfuegos Provincial General Hospital in Sancti Spíritus, for two years. 335 patients were included. The variables collected were grouped into sociodemographic, clinical, associated chronic diseases and patient status at discharge. A decision tree was developed using the exhaustive Chaid method, the dependent variable was mortality from COPD. Results: Female patients (55.2 %), 60 years or older (79 %) and with more than 4 exacerbations in the last year (53.1 %) predominated. The decision tree model had a sensitivity of 97 %, a specificity of 89.3 %, and an overall percentage of correct diagnosis of 93.1 %. Six variables that predicted mortality were identified: acute respiratory failure, diagnosis of pneumonia, non-use of antithrombotics, pulmonary thromboembolism, age over 60 years, and smoking. Conclusions: The highest probability of dying during an exacerbation of COPD occurs among patients with acute respiratory failure, those who are diagnosed with pneumonia during admission, those who do not receive antithrombotic treatment and those who are over 60 years of age.

Condición clínica, capacidad funcional, ansiedad/depresión y calidad de vida en pacientes con EPOC con diferentes rangos de edad / Clinical Condition, Functional Capacity, Anxiety or Depression, and Quality of Life in Patients with Chronic Obstructive Pulmonary Disease in Different Age Groups

Introducción: La enfermedad pulmonar obstructiva crónica genera una discapacidad progresiva en el sujeto que la padece a causa de la disnea frecuente, lo que conlleva a limitaciones y restricciones en la participación con el incremento de la edad, lo que finalmente le desencadena estados de ansiedad y depresión, secundarios a su condición clínica. Objetivo: Establecer las diferencias en la condición clínica, capacidad funcional, ansiedad/depresión y calidad de vida en un grupo de pacientes que se encuentran entre la prevejez, senectud y la ancianidad diagnosticados con enfermedad pulmonar obstructiva crónica. Métodos: Estudio descriptivo en pacientes con enfermedad pulmonar obstructiva crónica, quienes se dividieron en grupos edad. Se tuvieron en cuenta variables las clínicas: capacidad funcional, ansiedad/depresión y calidad de vida. Resultados: Se distribuyeron los pacientes en grupos de edad de la siguiente manera: 45-59 años (prevejez) n = 16; 60-79 años (senectud) n = 89; y 80 años y más (ancianidad) n = 24. Se vincularon mayor cantidad de hombres (61,3 por ciento), todos los grupos erar mayormente casados. Hubo diferencias significativas en la distacia recorrida siendo el grupo ancianidad quien presentó un peor resultado (235,25±106,8). La ansiedad y depresión no presentaron diferencias y la calidad de vida mostró mayor afección del dominio actividades. Conclusión: Los pacientes del grupo prevejez presentaron mejor desempeño en la capacidad funcional comparado con los grupos senectud y ansianidad. A su vez, la ansiedad y depresión es mayor en pacientes en prevejez, sin embargo, no resulta ser significativa entre los grupos(AU)

Introduction: Chronic obstructive pulmonary disease produces progressive disability in the person who presents the disease, because of frequent dyspnea, leading to limitations and restrictions in participation with age increase, which finally triggers anxiety and depression states secondary to their clinical condition. Objective: To establish the differences in clinical condition, functional capacity, anxiety or depression, and quality of life in a group of patients between late adulthood, senescence and old age diagnosed with chronic obstructive pulmonary disease. Methods: Descriptive study carried out in patients with chronic obstructive pulmonary disease, who were divided into age groups. Clinical variables were taken into account: functional capacity, anxiety or depression, and quality of life. Results: Patients were distributed into age groups as follows: 45-59 years (old age), n=16; 60-79 years (senescence); n=89; and 80 years and older (old age); n=24. There were significant differences in the distance traveled, with the old age group presenting the worst result (235.25±106.8). Anxiety or depression did not show differences, and quality of life showed greater repercussion in the activity domain. Conclusion: Patients in the late adulthood group presented better functional capacity compared to the senescence and old age groups. In turn, anxiety and depression were higher in patients in the late adulthood group; however, it was not significant between the groups(AU)

Avaliação da associação da aderência à oxigenoterapia domiciliar prolongada e marcadores clínicos e mortalidade em cinco anos em pacientes com a doença pulmonar obstrutiva crônica / Evaluation of the association of adherence to long-term home oxygen therapy and clinical markers and five-year mortality in patients with Chronic obstructive pulmonary disease

RESUMO Objetivo Avaliar a relação entre a adesão à oxigenoterapia domiciliar prolongada (ODP) e a mortalidade em pacientes com doença pulmonar obstrutiva crônica (DPOC) e insuficiência respiratória crônica e suas características clínicas. Métodos Análise retrospectiva longitudinal de 254 pacientes com DPOC e insuficiência respiratória crônica no período de 2008 a 2016. No início do estudo, avaliamos o diagnóstico, valores espirométricos, gasometria arterial, hemograma, oximetria de pulso, composição corporal e questionários de saúde (dispnéia, qualidade). vida, ansiedade e depressão). Para a análise de adesão referida ao ODP, foram incluídos 199 pacientes, divididos de acordo com a prescrição de oxigênio: 12h/dia (G1), 15h/dia (G2) e 24h/dia (G3). As causas e datas da morte foram estudadas durante o período de cinco anos. Resultados Em cinco anos, identificamos 124 óbitos (62,3%). Não houve diferença significativa na mortalidade entre os grupos de adesão (p = 0,75) e não encontramos diferenças nos parâmetros clínicos avaliados. A prescrição de ODP não foi associada à mortalidade (p = 0,07). Na análise de regressão de Cox, não houve associação entre mortalidade e não adesão ao ODP (HR: 0,75; IC95%: 0,21-2,70). O risco de mortalidade aumentou no G3 em comparação ao G1 (HR: 7,16; IC 95%: 1,44-35,38) e naqueles com maior escore de depressão (HR: 1,35; IC: 1,14-1,59). Conclusão Não foi encontrada associação entre adesão à ODP e mortalidade em pacientes com DPOC e insuficiência respiratória. Não houve diferenças clínicas entre os grupos de adesão.

ABSTRACT Objective Assess the relationship between adherence to long-term oxygen therapy (LTOT) with mortality in patients with chronic obstructive pulmonary disease (COPD) and chronic respiratory failure and their clinical features. Methods Longitudinal retrospective analysis of 254 patients with COPD and chronic respiratory failure from 2008 to 2016. At baseline, we evaluated the diagnosis, spirometry values, arterial blood gas analysis, blood count, pulse oximetry, body composition and health questionnaires (dyspnea, quality of life, anxiety and depression). For referred adherence analysis to LTOT we included 199 patients, divided according to prescription of oxygen: 12h/day (G1), 15h/day (G2) and 24h/day (G3). The cause of death and dates were studied over the five-year period. Results In five years we identified 124 deaths (62.3%). No significant difference was found in mortality between the adherence groups (p=0.75) nor did we find differences in the clinical parameters evaluated. LTOT prescription was not associated with mortality (p=0.07). In Cox regression analysis, there was no association between mortality and non-adherence to LTOT (HR: 0.75; IC95%: 0.21-2.70). The risk of mortality was increased in G3 compared with G1 (HR: 7.16; IC 95%: 1.44-35.38) and in those with a higher depression score (HR: 1.35; IC: 1.14-1.59). Conclusion No association was found between LTOT adherence and mortality in patients with COPD and respiratory failure. There were no clinical differences between the adherence groups.

La enfermedad pulmonar obstructiva crónica es un problema de salud / Chronic obstructive pulmonary disease is a health problem

RESUMEN La enfermedad pulmonar obstructiva crónica se caracteriza por una limitación crónica al flujo aéreo poco reversible y asociada en particular al humo de tabaco. Se trata de una enfermedad infradiagnosticada y con una elevada morbimortalidad, lo que implica un problema de salud pública de gran magnitud. Constituye la cuarta causa de muerte en los países del Caribe y se prevé que su prevalencia siga en aumento, lo que representa un elevado costo sanitario. En Cuba la enfermedad pulmonar obstructiva crónica constituye la quinta causa de muerte con una tendencia ascendente en los próximos años, por lo que es un problema de salud, del que no se excluye la provincia de Matanzas, como causa de ingresos frecuentes en sus unidades de atención al grave, las cuales en ocasiones presentan una evolución desfavorable. Entre los factores de riesgo que incrementan esta entidad se encuentran el tabaquismo y la contaminación ambiental, que aumentan la morbilidad por esta entidad con complicaciones que prolongan la estadía hospitalaria y elevan la mortalidad (AU).

SUMMARY Chronic obstructive pulmonary disease is characterized by the chronic limitation of the airflow, almost irreversible and mainly associated to tobacco smoke. It is an underdiagnosed disease with a high morbimortality, meaning a health problem of high magnitude. It is the fourth cause of death in the Caribbean countries and it is expected its prevalence will still increase, representing a high sanitary cost. In Cuba, it is the fifth cause of death with an increasing tendency in the next years, being a health problem because it causes frequent admissions in the Seriously-ill Care Units, frequently having an unfavorable evolution. The province of Matanzas is not excluded from this. Smoking and environmental pollution are among the risk factors favoring this entity, increasing this entity morbidity with complications that make hospital staying longer and mortality higher (AU).

Sarcopenia, lung disease and mortality: a secondary analysis of the CRELES study / Sarcopenia, doença pulmonar e mortalidade: uma análise secundária do estudo CRELES

AIM: Chronic obstructive pulmonary disease (COPD) is a pro-inflammatory condition leading to wasting states such as sarcopenia. We aimed to describe the effect of COPD and sarcopenia on mortality in Costa Rican older adults in the Costa Rican Longevity and Healthy Aging Study (CRELES). METHOD: This is a secondary analysis of the CRELES, a cohort study consisting of three waves of interviews. For the current study, data from the first and third waves were used. The dependent variable was survival status. COPD and sarcopenia were independent variables. Bivariate analyses were used to compare mortality curves for each group. Association with 3-year mortality was tested with Cox regression models, and hazard ratios (HR) with 95% confidence intervals (CI) were estimated as a measure of the strength of association. RESULTS: Of a total of 2704 participants, 54.29% (n = 1468) were women. Overall mortality was 9.05%. Sarcopenic older adults had the strongest association with mortality (HR = 2.65; 95%CI, 1.81­3.90; p < 0.001), followed by those with both COPD and sarcopenia (HR = 2.59; 95%CI, 1.37­4.92; p = 0.003). The weakest association with mortality was found in patients with neither COPD nor sarcopenia. CONCLUSIONS: The synergistic effect of sarcopenia and COPD has been shown to independently increase mortality in older patients. Our results may be applicable to both Latin American residents and subjects of Hispanic descent living in developed countries. Sarcopenia should be assessed in all patients with COPD since the latter is not a disease limited to the lungs, but rather a systemic disease.

OBJETIVO: A doença pulmonar obstrutiva crônica (DPOC) é uma condição pró-inflamatória que conduz a estados de perda como a sarcopenia. Nosso objetivo foi descrever o efeito da DPOC e da sarcopenia sobre a mortalidade em idosos costa-riquenhos do estudo Costa Rican Longevity and Healthy Aging Study (CRELES). MÉTODO: Esta é uma análise secundária do CRELES, um estudo de coorte composto por três ondas de entrevistas. Para o presente estudo, foram utilizados dados da primeira e terceira ondas. A variável dependente foi o status de sobrevida. DPOC e sarcopenia foram variáveis independentes. Foram realizadas análises bivariadas para comparar as curvas de mortalidade para cada grupo. Testou-se a associação à mortalidade em 3 anos com modelos de regressão de Cox, e razões de risco (HR) com intervalos de confiança (IC) de 95% foram estimadas como medida da força da associação. RESULTADOS: De um total de 2704 participantes, 54,29% (n = 1468) eram mulheres. A mortalidade geral foi 9,05%. Idosos sarcopênicos apresentaram a associação mais forte à mortalidade (HR = 2,65; IC95%, 1,81­3,90; p < 0,001), seguidos por aqueles com DPOC e sarcopenia (HR = 2,59; IC95%, 1,37­4,92; p = 0,003). A associação mais fraca à mortalidade foi encontrada em pacientes sem DPOC e sarcopenia. CONCLUSÕES: Demonstrou-se que o efeito sinérgico da sarcopenia e da DPOC aumenta de forma independente a mortalidade em pacientes idosos. Nossos resultados podem ser aplicáveis a residentes latino-americanos e a descendentes de hispânicos que vivem em países desenvolvidos. A sarcopenia deve ser avaliada em todos os pacientes com DPOC, visto que esta não é uma doença limitada aos pulmões, mas sim uma doença sistêmica.

Single-center study comparing short and mid-term results of evar in old and young populations

Abstract Objective: The purpose of this study was to compare the operative mortality rate and outcomes of endovascular aneurysm repair (EVAR) between young and geriatric people in a single center. Methods: Eighty-five patients with abdominal aortic aneurysms who underwent EVAR between January 2012 and September 2016 were included. Outcomes were compared between two groups: the young (aged < 65 years) and the geriatric (aged ≥ 65 years). The primary study outcome was technical success; the secondary endpoints were mortality and secondary interventions. The mean follow-up time was 36 months (3-60 months). Results: The study included 72 males and 13 females with a mean age of 71.08±8.6 years (range 49-85 years). Of the 85 patients analyzed, 18 (21.2%) were under 65 years old and 67 patients (78.8%) were over 65 years old. There was no statistically significant correlation between chronic disease and age. We found no statistically significant difference between aneurysm diameter, neck angle, neck length, or right and left iliac angles. The secondary intervention rate was 7% (six patients). The conversion to open surgery was necessary for only one patient and only three deaths were reported (3.5%). There was no statistically significant difference in the mortality and reintervention rates between the age groups. The three deaths occurred only in the geriatric group and two died secondary to rupture. Kidney failure was observed in three patients in the geriatric group (4.5%). Conclusion: Our single-center experience shows that EVAR can be used safely in both young and geriatric patients.

Supervivencia en una cohorte de pacientes con enfermedad pulmonar obstructiva crónica acorde a la clasificación GOLD 2017 / Survival in a cohort of patients with chronic obstructive pulmonary disease according to GOLD 2017 classification

Hasta el momento, no existe información sobre la evolución de los pacientes con enfermedad pulmonar obstructiva crónica (EPOC) de acuerdo con la nueva clasificación GOLD 2017. El objetivo de este estudio fue determinar, en una cohorte de pacientes con EPOC seguidos por veinte años, la influencia del cambio a la nueva clasificación en resultados de supervivencia por grupos y su asociación con otras variables como comorbilidades. Se evaluaron enfermos con EPOC (definición GOLD 2017) con seguimiento desde enero de 1996 a diciembre de 2016. Se usaron estadísticas convencionales y análisis de supervivencia de Log- Rank (Mantel-Cox). Se analizaron 354 pacientes: edad 66.5 ± 8.4, 66.7% hombres; ex-tabaquistas: 74.2% (56 paquetes-año); índice de Charlson 4.1 ± 1.7. A los 20 años, estaban vivos 219 (62%) y fallecidos 135 (38%), con un seguimiento de 28 meses (12-54.7). En el análisis uni y multivariado, el sexo masculino y la edad se asociaron a mayor mortalidad. Teniendo en cuenta solo la espirometría, a peor grado de obstrucción al flujo aéreo, la supervivencia es menor. Con la clasificación ABCD 2017, la peor supervivencia se encuentra en el grupo D y solo en este grupo es independiente del nivel de deterioro del VEF1 (p = 0.005). La nueva clasificación ABCD es predictora de mortalidad solo si está asociada a la función pulmonar.

Until now, there is no information on the evolution of patients with chronic obstructive pulmonary disease (COPD) according to the new GOLD classification. The objective of this study was to determine, in a cohort of patients with COPD followed by twenty years, the impact of the change to the new classification: survival by groups and their association with other variables such as comorbidities. COPD patients (GOLD 2017 definition) were evaluated with follow-up since January 1996 to December 2016. Conventional statistics and Log-Rank survival analysis (Mantel-Cox) were used. We analyzed 354 patients: age 66.5 ± 8.4, 66.7% men. Former smokers 74.2% (56 pack-year). Charlson index 4.1 ± 1.7. At the end of study 219 (62%) were alive and 135 (38%) died. The follow-up was 28 months (12-54.7). In the univariate and multivariate analysis, male sex and age were associated with higher mortality. Considering only the spirometry, to a worse degree of airflow obstruction, corresponded a lower survival. With the ABCD 2017 classification, the worst survival was observed in group D. Only in this group, survival is independent of the level of deterioration of FEV1 (p = 0.005). The new ABCD classification is a mortality predictor, only if it is associated to pulmonary function.

Enfermedad pulmonar obstructiva crónica en pacientes ingresados en unidades de atención al grave. Cárdenas / Chronic obstructive pulmonary diseases in in-patients of the intensive care unit. Cárdenas

RESUMEN Introducción: la enfermedad pulmonar obstructiva crónica es infradiagnosticada y presenta una elevada morbimortalidad. Constituye la sèptima causa de muerte en Cuba. En la Unidad de Cuidados Intensivos, del Hospital General Docente "Julio M. Aristegui" de Cárdenas, provincia de Matanzas, resulta una causa de ingresos frecuentes, con evolución desfavorable que prolonga la estadía y elevan la mortalidad. Objetivo: determinar el comportamiento de esta enfermedad en Unidad de Cuidados Intensivos. Materiales y métodos: se realizó un estudio descriptivo, longitudinal y retrospectivo, en la Unidad de Cuidados Intensivos del Hospital General Docente "Julio M. Aristegui", de Cárdenas, durante el periodo de enero del 2015 a diciembre del 2016. El universo fue los pacientes ingresados por la enfermedad pulmonar obstructiva crónica. Las variables estudiadas fueron: sexo, edad, factores de riesgo, diagnóstico al ingreso, complicaciones, estadía, destino al egreso. Resultados: predominó el grupo etáreo de 65-74 años y el sexo masculino. El factor de riesgo más significativo fue el tabaquismo. La estadía y el número de días ventilados fue de 20-30 días. La gran mayoría de los pacientes fallecieron en la Unidad de Cuidados Intensivos. Conclusiones: La enfermedad pulmonar obstructiva crónica, por sus factores de riesgo y complicaciones, conlleva al cuidado hospitalario del paciente en Unidades de Cuidados Intensivos (AU).

ABSTRACT Introduction: the chronic obstructive pulmonary disease is under diagnosed and shows a high morbimortality. It is the fifth cause of death in Cuba. It is a frequent cause of admission in the Intensive Care Unit of the Teaching General Hospital "Julio M. Aristegui" of Cardenas, province of Matanzas, with an unfavorable evolution extending the staying and increasing mortality. Objective: to determine this disease behaviour in an intensive care unit. Materials and methods: a retrospective, longitudinal, descriptive study was carried out in the Intensive Care Unit of the General Teaching Hospital "Julio Aristegui" of Cardenas during the period January 2015- December 2016. The universe was the patients admitted due to chronic obstructive pulmonary disease. The studied variables were sex, age, risk factors, diagnosis at the admission, complications, staying, and destination at discharge. Results: the 65-74 years-old age group and male sex predominated. The most significant risk factor was tobacco smoking. Staying and number of days under ventilation were 20-30 days. Most of the patients died in the Intensive Care Unit. Conclusions: the chronic obstructive pulmonary disease, due to its risk factors and complications, leads to the hospital care of the patient in intensive care units (AU).

Enfermedad Pulmonar Obstructiva Crónica en el Siglo XXI - Optimismo basado en evidencia / Chronic Obstructive Pulmonary Disease in the 21st Century - Evidence-based optimism

There are increasingly more data on the prevalence and distribution of Chronic Obstructive Pulmonary Disease (COPD) from around the world. COPD is predicted to be the third most frequent cause of death in the world by 2020. COPD is mainly caused by chronic tobacco smoking, which induces important changes in both the airways and lung parenchyma. COPD is a progressive, disabling condition that ultimately ends in respiratory failure and death. Is a multicomponent disease, there is evidence that systemic inflammation and extrapulmonary effects are also common in COPD, although the association between systemic inflammation and systemic manifestations of COPD is still not entirely clear. COPD has been associated with a nihilistic attitude. On the basis of current evidence, this nihilistic attitude is totally unjustified. The disease must be viewed through the lens of a new paradigm: COPD is not only preventable but also treatable. The past decade has witnessed great progress in COPD research. New drugs have been developed and tested and a growing base of scientific evidence now documents the efficacy of various therapies for symptoms and exacerbations. It is clear that many patients with COPD can benefit from aggressive management, with a decrease in the frequency of hospitalizations and improvements in symptoms and quality of life. In addition, basic and clinical scientists have now identified cells, mechanisms, and molecules that appear to play key roles in disease pathogenesis. Additional novel treatments are on the horizon and the advent of newer and more effective therapies will lead to a decline in the contribution of this disease to poor world health. The good news about COPD is to increase awareness of the disease. COPD is now viewed under a new paradigm as preventable and treatable.

Variables clínicas y funcionales asociadas al riesgo de muerte en el seguimiento a largo plazo en pacientes con enfermedad pulmonar obstructiva crónica / Clinical and functional variables associated to long-term mortality in COPD patients

Background: Identifying risk factors for long-term mortality in patients with chronic obstructive pulmonary disease (COPD) could improve their clinical management. Aim: To examine the clinical variables associated to long-term mortality in a cohort of COPD patients. Patients and Methods: A clinical and respiratory functional assessment, chest computed tomography and clinical follow up for five years was carried out in 202 COPD patients aged 66 ± 9 years (59% males), active or former smokers of 10 or more pack-years. Results: Thirty four percent of patients were active smokers, consuming 46 ± 23 packs/year, 86% had comorbidities, especially chronic cardiovascular and metabolic diseases. Forty-six patients died in the five years follow-up (5-year mortality was therefore 22.8%). In the univariate analysis, the main risk factors associated to long-term mortality were an older age, male sex, dyspnea severity, severe exacerbation risk, chronic respiratory failure, magnitude of lung emphysema, airflow obstruction and lung hyperinflation, reduction of thigh muscle cross-sectional area and physical activity limitation. In the multivariate analysis, the three independent risk factors for long-term mortality were dyspnea severity, chronic hypoxemia and exercise limitation measured with the six minutes' walk test. Conclusions: Systematic clinical assessment allowed to identify the main risk factors associated with long-term mortality in patients with COPD, which could be used in planning preventive and management programs aimed at the high-risk population.

Tendências de mortalidade por doença pulmonar obstrutiva crônica no Rio de Janeiro e em Porto Alegre, 1980-2014 / Tendencias en la mortalidad por enfermedad pulmonar obstructiva crónica en Rio de Janeiro y Porto Alegre, Brasil, 1980-2014 / Trends in mortality from chronic obstructive pulmonary disease in Rio de Janeiro and Porto Alegre, Brazil, 1980-2014

Objetivo: analisar o efeito da idade, período e coorte de nascimento (APC) na mortalidade por doença pulmonar obstrutiva crônica (DPOC) nos municípios de Porto Alegre, RS, e Rio de Janeiro, RJ, Brasil, entre 1980 e 2014. Métodos: estudo de séries temporais com dados corrigidos do Sistema de Informações sobre Mortalidade (SIM); o efeito APC foi estimado por regressão de Poisson, em relação à coorte de 1935. Resultados: o risco relativo (RR) de morte por DPOC para os homens foi decrescente na coorte de nascimento mais recente (1970-1974), em Porto Alegre (RR=0,39; IC95% 0,32;0,48) e no Rio de Janeiro (RR=0,42; IC95% 0,38;0,48); para mulheres, no Rio de Janeiro observou-se aumento do risco relativo para as coortes mais recentes (RR=1,41; IC95% 1,20;1,67). Conclusão: entre os homens, houve a diminuição do risco por morte por DPOC, enquanto para as mulheres houve aumento do risco no Rio de Janeiro.

Objetivo: analizar el efecto de la edad período y cohorte de nacimiento (EPOC) en las ciudades de Porto Alegre, RS, y Río de Janeiro, RJ, Brasil, entre 1980 y 2014. Métodos: estudio de series temporales con datos corregidos del Sistema de Informaciones sobre Mortalidad (SIM); el efecto APC fue estimado por regresión de Poisson, en relación a la cohorte de 1935. Resultados: el riesgo relativo (RR) de muerte para los hombres por EPOC fue disminuyendo en la cohorte de nacimiento más reciente (1970-1974), en Porto Alegre (RR=0,39; IC95% 0,32;0,48) y Rio de Janeiro (RR=0,42; IC95% 0,38;0,48); para las mujeres, en Río de Janeiro hubo un aumento del riesgo de muerte por EPOC para las cohortes más recientes (RR=1,41; IC95% 1,20;1,67). Conclusión: entre los hombres, hubo reducción del riesgo de muerte por EPOC, mientras que entre las mujeres de Rio de Janeiro hubo un aumento del riesgo.

Objective: to analyze age-period-cohort (APC) effects on mortality from chronic obstructive pulmonary disease (COPD) in the municipalities of Porto Alegre, RS, and Rio de Janeiro, RJ, Brazil, between 1980 and 2014. Methods: this was a time series study using corrected Mortality Information System (SIM) data; APC effects were estimated by Poisson regression, in relation to the 1935 cohort. Results: relative risk (RR) of death due to COPD for males decreased in the most recent birth cohort (1970-1974) in Porto Alegre (RR=0.39; 95%CI 0.32;0.48) and Rio de Janeiro (RR=0.42; 95%CI 0.38;0.48); while among women an increase in risk of death due to COPD was observed in Rio de Janeiro in more recent cohorts (RR=1.41; 95%CI 1.20;1.67). Conclusion: risk of death due to COPD decreased among men, while risk among women in Rio de Janeiro increased.

Long-term efficacy of a rural community-based integrated intervention for prevention and management of chronic obstructive pulmonary disease: a cluster randomized controlled trial in China's rural areas

This study aimed to assess the efficacy of a rural community-based integrated intervention for early prevention and management of chronic obstructive pulmonary disease (COPD) in China. This 18-year cluster-randomized controlled trial encompassing 15 villages included 1008 patients (454 men and 40 women in the intervention group [mean age, 54 ± 10 years]; 482 men and 32 women in the control group [mean age, 53 ± 10 years]) with confirmed COPD or at risk for COPD. Villages were randomly assigned to the intervention or the control group, and study participants residing within the villages received treatment accordingly. Intervention group patients took part in a program that included systematic health education, smoking cessation counseling, and education on management of COPD. Control group patients received usual care. The groups were compared after 18 years regarding the incidence of COPD, decline in lung function, and mortality of COPD. COPD incidence was lower in the intervention group than in the control group (10% vs 16%, <0.05). A decline in lung function was also significantly delayed in the intervention group compared to the control group of COPD and high-risk patients. The intervention group showed significant improvement in smoking cessation compared with the control group, and smokers in the intervention group had lower smoking indices than in the control group (350 vs 450, <0.05). The intervention group also had a significantly lower cumulative COPD-related death rate than the control group (37% vs 47%, <0.05). A rural community-based integrated intervention is effective in reducing the incidence of COPD among those at risk, delaying a decline in lung function in COPD patients and those at risk, and reducing mortality of COPD.

Hospitalización diurna como modelo de atención de salud en pacientes adultos inmunocompetentes con neumonía adquirida en la comunidad / Respiratory day hospital care for immunocompetent adult patients with community-acquired pneumonia

Background: Day hospitals can reduce health care costs without increasing the risks of patients with lower respiratory tract infection. Aim: To report the experience of a respiratory day hospital care delivered to adult patients with community-acquired pneumonia (CAP) in a public hospital. Material and Methods: During the fall and winter of 2011 and 2012, adult patients with CAP of intermediate risk categories were assessed in the emergency room, their severity was stratified according to confusion, respiratory rate, blood pressure, 65 years of age or older (CRB-65) score and the Chilean CAP Clinical Guidelines, and were admitted to the respiratory day hospital. Results: One hundred seventeen patients aged 67 ± 16 years, (62% females) with CAP were attended in the respiratory day hospital. Ninety percent had comorbidities, especially chronic obstructive pulmonary disease in 58%, heart disease in 32%, diabetes in 16% and asthma in 13%. Their most important risk factors were age over 65 years in 60%, comorbidities in 88%, failure of antibiotic treatment in 17%, loss of autonomy in 21%, vital sign abnormalities in 60%, mental confusion in 5%, multilobar CAP in 23%, pleural effusion in 15%, hypoxemia in 41% and a serum urea nitrogen over 30 mg/dL in 16%. Patients stayed an average of seven days in the day hospital with oxygen, hydration, chest physiotherapy and third-generation cephalosporins (89%) associated with quinolones (52%) or macrolides (4%). Thirteen patients required noninvasive ventilation, eight patients were hospitalized because of clinical deterioration and three died in hospital. Conclusions: Day hospital care reduced hospital admission rates of patients with lower respiratory tract infections.

Desvinculación de la asistencia ventilatoria mecánica prolongada a las 72 horas de respiración espontánea

El objetivo del presente trabajo fue describir la población que ingresó en un centro de desvinculación de la ventilación mecánica y rehabilitación (CDVMR) en asistencia ventilatoria mecánica invasiva (AVMi), analizar su evolución y determinar los predictores de fracaso de la desvinculación de la AVMi. Se revisaron las historias clínicas de 763 pacientes que ingresaron en el servicio de Cuidados Respiratorios, en el período comprendido entre mayo 2005 y enero 2012, se seleccionaron 372 con traqueotomía y AVMi. Se analizaron diferentes variables como posibles predictores de desvinculación. La media de edad fue 69 años (DS 14.7), 57% fueron hombres. La mediana de días de internación en la unidad de terapia intensiva (UTI) fue de 33 (rango intercuartilo-RQ 26-46). El 86% de los ingresados a UTI fue por causa médica. Durante la internación en el CDVMR lograron desvincularse el 50%; mediana de días de desvinculación, 13 (RQ 5-38). La edad fue predictor de fracaso de desvinculación. Al estudiar a la subpoblación con desvinculación parcial, se sumó el antecedente de EPOC como predictor. Si bien un 25% de los pacientes falleció o requirió derivación a un centro de mayor complejidad antes de 2 semanas de internación, más de la mitad de los pacientes lograron ser desvinculados definitivamente de la AVMi; esto podría sustentar la atención de pacientes críticos crónicos en CDVMR en la Argentina, ya que los pacientes internados en estos centros tienen buena expectativa de desvinculación, a pesar de las altas chances de desarrollar complicaciones.

The aim of this study was to describe the population admitted to a weaning center (WC) to receive invasive mechanical ventilation (MV), analyze their evolution and identify weaning failure predictors. The medical records of 763 patients admitted to the respiratory care service in the period between May 2005 and January 2012 were reviewed; 372 were selected among 415 tracheotomized and mechanically ventilated. Different variables were analyzed as weaning failure predictors. The mean age of patients admitted was 69 years (SD 14.7), 57% were men. The median length of hospitalization in ICU was 33 days (IQR 26-46). Admission to ICU was due to medical causes in 86% of cases. During hospitalization in WC 186 (50%) patients achieved the successful weaning at a median of 13 days (interquartile range-IQR 5-38). A predictor of weaning failure was age. When we studied the subpopulation with partial disconnection of mechanical ventilation, we found a history of COPD and ageas predictors. Although 25% of the patients died, or required referral to a center of major complexity before 2 weeks of hospitalization, more than half of the patients were able to be removed permanently from the invasive mechanical ventilation (MV), this could support the care of chronic critical patients in MV and rehabilitation centers in Argentina because patients in these centers have a chance of weaning from MV, despite the high chances of developing complications.

Mortality trends due to chronic obstructive pulmonary disease in Brazil / Tendências de mortalidade por doença pulmonar obstrutiva crônica no Brasil

Objective: the purpose of this study was to update and analyze data on mortality trend due to chronic obstructive pulmonary disease (COPD) in Brazil. Methods: initially, the specific COPD mortality rates were calculated from 1989 to 2009 using data collected from DATASUS (Departamento de Informática do SUS - Brazilian Health System Database). Then, the polynomial regression models from the observed functional relation were estimated based on mortality coefficients and study years. Results: we verified that the general mortality rates due to COPD in Brazil showed an increasing trend from 1989 to 2004, and then decreased. Both genders showed the same increasing tendencies until 2004 and decreased thereafter. The age group under 35 years old showed a linear decreasing trend. All other age groups showed quadratic tendencies, with increases until the years of 1998-1999 and then decreasing. The South and Southeast regions showed the highest COPD mortality rates with increasing trends until the years 2001-2002 and then decreased. The North, Northeast and Central-West regions showed lower mortality rates but increasing trend. Conclusion: this is the first report of COPD mortality stabilization in Brazil since 1980. .

Objetivo: o objetivo deste artigo foi de atualizar e analisar a tendência da mortalidade por doença pulmonar obstrutiva crônica (DPOC) no Brasil. Métodos: inicialmente, foram calculadas as taxas de mortalidade específica por DPOC entre 1989 e 2009 por meio do Departamento de Informática do SUS (Datasus). Depois, foram estimados os modelos de regressão polinomial a partir da relação funcional entre as taxas de mortalidade e os anos de estudo. Resultados: verificou-se que as taxas de mortalidade geral por DPOC no Brasil mostraram uma tendência de aumento de 1998 até 2004 e, depois, uma diminuição. Essa mesma tendência de aumento até 2004 e, em seguida, diminuição semelhante para ambos os sexos. A faixa etária abaixo de 35 anos mostrou tendência de queda linear, enquanto as outras faixas etárias mostraram tendências quadráticas com aumento entre os anos de 1998 e 1999 e, após, queda. As regiões Sul e Sudeste mostraram as taxas de mortalidade mais altas com tendências crescentes até os anos de 2001 e 2002 e, após, decrescentes. As regiões Norte, Nordeste e Centro - Oeste mostraram taxas de mortalidade mais baixas, mas com tendência de elevação. Conclusão: este é o primeiro relato de estabilização da mortalidade por DPOC no Brasil desde 1980. .