[Consensus document for severe asthma in adults. 2022 update]. / Documento de consenso de asma grave en adultos. Actualización 2022.

Severe asthma is a heterogeneous syndrome with several clinical variants and often represents a complex disease requiring a specialized and multidisciplinary approach, as well as the use of multiple drugs. The prevalence of severe asthma varies from one country to another, and it is estimated that 50% of these patients present a poor control of their disease. For the best management of the patient, it is necessary a correct diagnosis, an adequate follow-up and undoubtedly to offer the best available treatment, including biologic treatments with monoclonal antibodies. With this objective, this consensus process was born, which began in its first version in 2018, whose goal is to offer the patient the best possible management of their disease in order to minimize their symptomatology. For this 2020 consensus update, a literature review was conducted by the authors. Subsequently, through a two-round interactive Delphi process, a broad panel of asthma experts from SEPAR and the regional pulmonology societies proposed the recommendations and conclusions contained in this document.

[Spanish asthma patients' beliefs about health and medicines: validation of 2 questionnaires]. / Creencias sobre la salud y los medicamentos en la población asmática española. Validación de 2 instrumentos para su medida.

OBJECTIVE: We translated 2 health beliefs questionnaires-an instrument based on the health belief model (HBM) containing 19 items in 6 domains and the Beliefs About Medicines Questionnaire (BMQ) containing 18 items divided into a general and a specific section-and then administered and validated them in a group of Spanish patients with asthma. PATIENTS AND METHODS: In 2 clinical visits data were collected on 126 patients with stable asthma of different levels of severity. At the first visit, the patients underwent spirometry and were asked questions about sociodemographic factors and clinical history. At the second visit, they completed the State-Trait Anxiety Inventory, the Beck Depression Inventory, and the Spanish versions of the HBM and BMQ, which had been previously translated and backtranslated. RESULTS: The BMQ had adequate internal consistency and content validity but the HBM replicated just 4 of the 6 domains present in the original questionnaire. The reformulated HBM (measuring 4 domains) accounted for 48% of the variance and had Cronbach #a levels ranging from 0.63 to 0.75. The 2 questionnaires showed interactions between a) negative beliefs about medicines and asthma and b) awareness of the need for medication and trust in physician and pessimism. Correlations were also found between negative beliefs and anxiety and depression and between awareness of the need for medication and disease severity. Finally, low educational level, female sex, and greater duration of asthma were correlated with beliefs that disease control was driven by chance. CONCLUSIONS: The reformulated HBM and the BMQ have satisfactory measurement properties and assess similar but not identical aspects of beliefs and value judgments about health and medicine in individuals with asthma. These beliefs were correlated to different degrees with the clinical, sociodemographic, and psychologic variables studied.

[Contribution of exhaled nitric oxide measurements to abbreviated bronchial challenge test protocols]. / Aportaciones del óxido nítrico exhalado a los procedimientos abreviados de las pruebas de provocación bronquial.

OBJECTIVE: The bronchial challenge test is commonly used to diagnose asthma but it is a tedious, time-consuming procedure. Although in recent years, several shortened methods have been proposed, it has been shown that they can give rise to exaggerated bronchoconstriction. The aims of the present study were a) to determine the frequency of exaggerated bronchoconstriction in patients with asthma following the application of a shortened bronchial challenge test, and b) to determine if the fraction of exhaled nitric oxide (FENO) can be used to predict the onset of exaggerated bronchoconstriction. PATIENTS AND METHODS: We performed a prospective study of 210 patients with asthma in whom FENO levels were measured in accordance with the abbreviated protocol recommended by the European Respiratory Society (ERS). Exaggerated bronchoconstriction was defined as a decrease of more than 20% in forced expiratory volume in 1 second after the first challenge, after a skipped dose, or after administration of saline. A receiver operating characteristic (ROC) curve was generated to determine the best FENO cutoff value for predicting exaggerated bronchoconstriction. The pretest probability of developing exaggerated bronchoconstriction was also calculated using Bayes' theorem. RESULTS: The frequency of exaggerated bronchoconstriction in our series was 30%. Patients who developed exaggerated bronchoconstriction had significantly higher FENO levels than those who did not (32.6 vs 16.2 parts per billion [ppb]). The chosen FENO cutoff of 19.5 ppb had a sensitivity of 80%, a specificity of 77%, and a negative predictive value of 88%. The area under the ROC curve was 0.83 (95% confidence interval, 0.77-0.89). CONCLUSIONS: The abbreviated bronchial challenge test recommended by the ERS led to exaggerated bronchoconstriction in 30% of the patients studied. FENO measurements could possibly be used to identify patients at increased risk of exaggerated bronchoconstriction. The shortened challenge test can be performed safely in individuals with a FENO of <19.5 ppb.

[Impact of baseline and induced dyspnea on the quality of life of patients with COPD]. / Importancia de la disnea basal e inducida en la calidad de vida de los pacientes con EPOC.

OBJECTIVE: Dyspnea is the main symptom of chronic obstructive pulmonary disease (COPD) and as such is an important determinant of health-related quality of life. It is, however, weakly correlated to severity of obstruction and there is little information available on how it exercises its effect on health-related quality of life. The aims of this study were to identify the determinants of baseline dyspnea and to ascertain how that factor influences the health-related quality of life of patients with COPD. PATIENTS AND METHODS: A total of 101 patients with COPD were studied. Tests included full lung function assessment, the bronchial provocation test (n=70), and the 6-minute walk test. The following variables were measured: Baseline dyspnea, bronchoconstriction-induced dyspnea, exertional dyspnea, health-related quality of life, and levels of anxiety and depression. RESULTS: Determinants of baseline dyspnea were anxiety (explained variance, 17%), maximal inspiratory pressure (4%), and PaO2 (4%). In patients with mild to moderate COPD (forced expiratory volume in 1 second, >50% of predicted), the main determinant of health-related quality of life was anxiety (explained variance, 43%). Other determinants were the number of meters walked in the 6-minute-walk test, age, and Baseline dyspnea (variance explained by both factors, 26%). Baseline dyspnea and bronchoconstriction-induced dyspnea were both identified as independent determinants of health-related quality of life (on the activity and impact subscales of the St George's Respiratory Questionnaire, respectively). The main determinant of health-related quality of life in patients with severe COPD (forced expiratory volume in 1 second, < or =50% of predicted) was baseline dyspnea. Finally, the main determinants of anxiety were exertional dyspnea (variance, 42%) and baseline dyspnea (6%). CONCLUSIONS: Anxiety is the main determinant of health-related quality of life in patients with COPD, and it is triggered mainly by baseline dyspnea and exertional dyspnea.

[Assessment of patient satisfaction and preferences with inhalers in asthma with the FSI-10 Questionnaire]. / Satisfacción y preferencia del paciente asmático por los dispositivos de inhalación. Aplicación del FSI-10.

BACKGROUND AND OBJECTIVE: Lack of adherence to inhaled corticosteroid therapy is common in patients with asthma, and it has been suggested that allowing patients to choose their own inhalers would resolve this problem. The FSI-10 (Feeling of Satisfaction with Inhaler) is a self-completed questionnaire to assess patient opinions regarding ease or difficulty of use, portability, and usability of devices for delivery of inhaled corticosteroids. The aim of this study was to define the measurement properties of the FSI-10 questionnaire and to use this inventory to compare satisfaction and preferences of patients with asthma regarding 3 different devices for delivery of inhaled corticosteroids: Turbuhaler, Accuhaler, and Novolizer. PATIENTS AND METHODS: We performed a multicenter, prospective, observational study in 112 stable asthmatic patients (64 women; mean [SD] age, 37 [22] years) treated on a regular basis with inhaled corticosteroids. The use of the devices was explained to the patients and the order in which they should be used in each case was randomly assigned. The devices were used for 7-day periods and at the end of each the FSI-10 questionnaire was completed for the device used. Once the protocol was completed, patients stated their preference for the different devices used. RESULTS: The FSI-10 was easily understood and rapidly completed, and it exhibited acceptable measurement properties. Factor analysis showed that the measure was unidimensional. Although acceptance of all 3 devices assessed was reasonable, the FSI-10 questionnaire detected significant differences between them: Turbuhaler and Novolizer scored higher than Accuhaler on a number of questions. This preference is partly explained by Turbuhaler having been the device that was commonly used by the patients prior to the study. However, the highest scoring and most often preferred inhaler in patients under 16 years of age was the Novolizer, even though the Turbuhaler had also usually been used by those patients prior to the study. CONCLUSIONS: The FSI-10 is a useful instrument for assessing the degree of satisfaction of asthmatic patients regarding available inhalation devices. It is easy to understand and complete, and able to identify differences in patient satisfaction with the different inhalers.

Factors associated with lung function decline in adult patients with stable non-cystic fibrosis bronchiectasis.

BACKGROUND: Bronchiectasis remains a major public health problem, but factors influencing its natural history are not well characterized. The objective of our study was to explore modifiable and nonmodifiable factors associated with lung function decline in a clinical cohort of patients with stable non-cystic fibrosis (CF) bronchiectasis. METHODS: Seventy-six stable adult patients (mean age, 69.9 years; 48.7% men) with bronchiectasis were included. The diagnosis of bronchiectasis was established in all cases by high-resolution CT scanning. Baseline data were collected on clinical history, symptoms, disease extension, treatment, sputum volume, microbiological aspects, laboratory findings, and exacerbations. All patients were invited to attend the clinic every 6 months for 24 months to conduct full spirometry and microbiological analysis of sputum, and to report the number of exacerbations. RESULTS: Overall, the group experienced a rate of decline of lung function (FEV1) of 52.7 mL per year. Independent factors associated with an accelerated decline of lung function were chronic colonization with Pseudomonas aeruginosa (PA) [odds ratio (OR), 30.4; 95% confidence interval (CI), 3.8 to 39.4; p=0.005], more frequent severe exacerbations (OR, 6.9; 95% CI, 2.3 to 10.5; p=0.014), and more systemic inflammation (OR, 3.1; 95% CI, 1.9 to 8.9; p=0.023). Regrettably, none of the long-term treatment strategies evaluated, including the use of long-acting inhaled bronchodilators, inhaled or oral steroids, oxygen therapy, secretion clearance maneuvers, or antibiotics had a significant effect on FEV1 decline. CONCLUSION: Chronic colonization by PA, severe exacerbations, and systemic inflammation are associated with disease progression in non-CF bronchiectasis.

[Bronchiectasis in the elderly. Study of serum levels of immunoglobulin G subclasses]. / Bronquiectasias en pacientes mayores de 65 años. Estudio de los valores séricos de las subclases de inmunoglobulina G.

BACKGROUND AND OBJECTIVE: To analyze the serum levels of immunoglobulin G (IgG) subclasses in a broad range of elderly patients with bronchiectasis. PATIENTS AND METHOD: Data were collected from all patients who had a high-resolution chest computerized axial tomography diagnosis of bronchiectasis in our center. We gathered data related to case history, respiratory symptoms, forced spirometry, general laboratory tests, immunoglobulin concentration (including IgG subclasses), Mantoux test, sputum culture and staining, paranasal sinus X-rays/computerized axial tomography, and a specific etiologic evaluation based on the available clinical evidence. RESULTS: A total of 128 patients were included -mean age (standard deviation): 71.6 (5.1) years; range: 65-88; 44.5% males- and 20.3% of them had chronic sputum colonization with Pseudomonas aeruginosa. 28.1% cases had a post-infectious nature and in 40.6% the etiology was unknown. Sixteen patients (12.5%) had decreased levels of at least one of the sIgG compared to normal values. The most frequent deficiency corresponded to IgG2 levels. These subjects showed a characteristic profile of bronchiectasis with an increased lung extension of the disease (p = 0.02); greater presence of cylindrical and diffuse bronchiectasis (p = 0.02 and 0.01, respectively), greater percentage of an unknown etiology (p = 0.004); greater presence of paranasal sinus X-ray abnormalities (p = 0.004) and increased number of past repeated upper airway infections (p = 0.03). CONCLUSIONS: Decreased serum levels of IgG subclasses might be associated with a characteristic profile of bronchiectasis in elderly patients in whom other etiologies have been ruled out.

El asma en las personas mayores también existe / Asthma Exists in Older People too

No disponible

[Translated article] Asthma Exists in Older People too / El asma en las personas mayores también existe

No disponible

Inhaled steroids improve quality of life in patients with steady-state bronchiectasis.

BACKGROUND: The effects of inhaled steroids upon the quality of life of patients with bronchiectasis remain unknown. STUDY OBJECTIVE: To analyze the effect of inhaled fluticasone propionate (FP) for 6 months upon the clinical, functional, microbiological and outcome parameters of patients with steady-state bronchiectasis not due to cystic fibrosis, and its repercussions for patient health-related quality of life (HRQoL). DESIGN: Prospective, randomized, double-blind (for effective doses) study. PATIENTS AND INTERVENTIONS: The diagnosis of bronchiectasis was made by high-resolution computed tomography. Ninety-three patients (mean age: 68.5 [8.4]) were randomized to receive 250 microg bid, 500 microg bid or no treatment with inhaled FP for 6 months. Data were collected at baseline and at 1, 3 and 6 months after the start of treatment. HRQoL was assessed using the validated Spanish version of the St. George's Respiratory Questionnaire. RESULTS: The group administered FP 1000 microg daily showed significant improvement in dyspnea (1.03 [2.1]-1.24 [2.2] points; P = 0.01-0.04), sputum production (P = 0.001), days without cough (P = 0.02) and short-acting beta-2 agonists used (P = 0.01) from the first month of treatment, with no changes in pulmonary function, number or severity of exacerbations, or microbiological profile of the sputum. As a result, an improvement in HRQoL was seen in this group after 3 months of treatment (45.4 [14.2] vs. 40.5 [13.9]; P = 0.01). CONCLUSIONS: Inhalatory FP 500 microg bid is effective from the first month of treatment for controlling the symptoms of patients with steady-state bronchiectasis-thus ensuring a significant improvement in HRQoL.

Quality-of-life determinants in patients with clinically stable bronchiectasis.

STUDY OBJECTIVE: To determine the most important variables influencing health-related quality of life (HRQL) in patients with clinically stable bronchiectasis (SB). DESIGN: Cross-sectional study. PATIENTS AND INTERVENTIONS: A total of 86 patients (mean age, 69.5 years; SD, 8.9 years; 64% male) with SB were included. Data were collected on general patient characteristics, symptoms, laboratory findings, the extent of bronchiectasis, functional variables, medication in acute or stable phases, and the number of exacerbations. All patients completed the St. George Respiratory Questionnaire (SGRQ). Univariate and multivariate analyses were performed to identify the variables significantly influencing HRQL in these patients. RESULTS: Different clinical parameters (sputum, dyspnea, cough, and wheezing), spirometric variables, and laboratory parameters (fibrinogen), as well as the extent of bronchiectasis, medication, and the number of exacerbations were significantly correlated to the total questionnaire score, although only dyspnea (r2 = 0.43, p < 0.0001), FEV1 (r2 = 0.33, p < 0.0001), and daily sputum production (r2 = 0.2, p < 0.004) were independently correlated to the total score, globally explaining 55% of the total score variability. Systemic steroid treatment of exacerbations (r2 = 0.17, p < 0.028) and the habitual presence of coughing (r2 = 0.22, p < 0.004) and wheezing (r2 = 0.16, p < 0.013) were in turn independently correlated to the activity and symptoms subscales, respectively. CONCLUSION: Dyspnea, FEV1, and sputum production are the strongest conditioning factors of HRQL in patients with clinically SB.

Guidelines for severe uncontrolled asthma.

Since the publication, 9 years ago, of the latest SEPAR (Spanish Society of Pulmonology and Thoracic Surgery) Guidelines on Difficult-to-Control Asthma (DCA), much progress has been made in the understanding of asthmatic disease. These new data need to be reviewed, analyzed and incorporated into the guidelines according to their level of evidence and recommendation. Recently, consensus documents and clinical practice guidelines (CPG) addressing this issue have been published. In these guidelines, specific mention will be made of what the previous DCA guidelines defined as "true difficult-to-control asthma". This is asthma that remains uncontrolled after diagnosis and a systematic evaluation to rule out factors unrelated to the disease itself that lead to poor control ("false difficult-to-control asthma"), and despite an appropriate treatment strategy (Spanish Guidelines for the Management of Asthma [GEMA] steps 5 and 6): severe uncontrolled asthma. In this respect, the guidelines propose a revised definition, an attempt to classify the various manifestations of this type of asthma, a proposal for a stepwise diagnostic procedure, and phenotype-targeted treatment. A specific section has also been included on DCA in childhood, aimed at assisting healthcare professionals to improve the care of these patients.

Home mechanical ventilation for restrictive thoracic diseases: effects on patient quality-of-life and hospitalizations.

Forty-five patients with restrictive respiratory diseases, including thoracic wall diseases (TWD, n = 27) and neuromuscular diseases (NMD, n = 18), underwent 18 months of home mechanical ventilation (HMV) treatment. Treatment consisted of a two-level pressure system for 7h at night, with oxygen available if needed. Questionnaire-based assessments of health-related quality-of-life (HRQL) were evaluated before treatment and at 3, 6, 9, 12 and 18 months of follow-up. Hospitalization rates pre- and post-treatment were recorded, and the numbers need to treat (NNT) to avoid hospitalization and absolute risk reduction (ARR) rates were calculated. Several categories of HRQL, including physical function and vitality, improved significantly with treatment in both groups of patients; these improvements persisted over the entire 18 months. In contrast, other categories such as social function and mental health improved initially and declined subsequently. Hospitalizations decreased significantly with treatment. NNT calculations indicated that treatment would be needed for two TWD patients (ARR 63%) and one NMD patient (ARR 78%) to prevent one hospitalization per year per disease group. We conclude that improved quality-of-life and decreased hospitalizations make home non-invasive mechanical ventilation an useful treatment for patients with restrictive respiratory disorders.

[Respiratory changes during ascension to 8,000 meters mountain]. / Cambios respiratorios durante la ascensión a una montaña de más de 8.000 metros.

BACKGROUND: Our goal was to determine whether spirometric alterations occur during expeditions to 8,000-metre peaks, and whether these are modified by acclimatization or are related to acute mountain sickness, to arterial oxygen saturation (SaO2) or to muscular deterioration due to chronic hypoxic exposure. SUBJECTS AND METHOD: Forced vital capacity (FVC), forced expiratory volume in the first second (FEV1), inspiratory (MIP) and expiratory (MEP) maximal static pressures, grip strength in both hands, and SaO2 at rest and exercise were measured in eight subjects during an expedition to Gasherbrum II (8,035 m). RESULTS: Upon arrival at the base camp (5,200 m), both FVC and FEV1 decreased, with no changes in the FEV1/FVC ratio. FVC did not improve after a brief pressurisation in a portable hyperbaric chamber. A month later, FVC in the base camp returned to normal values. FVC fall correlated with both the severity of acute mountain sickness and weight loss. Resting SaO2 improved with acclimatisation and correlated with the previous hypoxic ventilatory response, both before and after acclimatisation. Acclimatisation led to a decrease in the exercise-induced SaO2 fall. Stay at a high altitude lowered body weight and grip strength, although MIP and MEP remained unchanged. CONCLUSIONS: We observed a restrictive alteration was corrected by with acclimatisation. This phenomenon seems to be related to a subclinical high-altitude pulmonary oedema rather than to an increase in the pulmonary vascular volume. Despite the high-altitude muscular deterioration, respiratory muscle weakness was not

Factors associated with bronchiectasis in patients with COPD.

BACKGROUND: Previous studies have shown a high prevalence of bronchiectasis in patients with moderate to severe COPD. However, the factors associated with bronchiectasis remain unknown in these patients. The objective of this study is to identify the factors associated with bronchiectasis in patients with moderate to severe COPD. METHODS: Consecutive patients with moderate (50% < FEV(1) ≤ 70%) or severe (FEV(1) ≤ 50%) COPD were included prospectively. All subjects filled out a clinical questionnaire, including information about exacerbations. Peripheral blood samples were obtained, and lung function tests were performed in all patients. Sputum samples were provided for monthly microbiologic analysis for 6 months. All the tests were performed in a stable phase for at least 6 weeks. High-resolution CT scans of the chest were used to diagnose bronchiectasis. RESULTS: Ninety-two patients, 51 with severe COPD, were included. Bronchiectasis was present in 53 patients (57.6%). The variables independently associated with the presence of bronchiectasis were severe airflow obstruction (OR, 3.87; 95% CI, 1.38-10.5; P = .001), isolation of a potentially pathogenic microorganism (PPM) (OR, 3.59; 95% CI, 1.3-9.9; P = .014), and at least one hospital admission due to COPD exacerbations in the previous year (OR, 3.07; 95% CI, 1.07-8.77; P = .037). CONCLUSION: We found an elevated prevalence of bronchiectasis in patients with moderate to severe COPD, and this was associated with severe airflow obstruction, isolation of a PPM from sputum, and at least one hospital admission for exacerbations in the previous year.

[Why do we look at asthma through the keyhole?]. / Por qué miramos el asma a través del ojo de la cerradura?

As happens with the rest of pathology, the study of asthma has been traditionally conducted from postulates set by reductionist science. That model still provides answers to theoretical and practical questions that establish diseases, but does not offer us a complete view of their complexity and multidimensionality. To overcome this limitation has emerged medicine directed towards systems based on the application of biological systems concepts and tools. Biological systems is a cross-disciplinary strategy which, from the data generated by the "-omic" sciences, helps to relate the elements of an organism or biological system, to understand the properties arising from the same and to generate mathematical models capable of predicting their dynamic behaviour. The application of biological systems to asthma starts is starting to make ground. The main challenge today is to understand the need to change focus. The starting point is to abandon the idea that asthma is exclusively an airways disease and considering that the whole lung is involved and, even more, the possibility that it is, at least in part, a systemic process. In view of our current limitations, to understand asthma and design personalised treatment strategies for each patient, requires thinking of systems medicine.