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.

Estudios de prevalencia del síndrome de apneas obstructivas del sueño en la población adulta / Studies of prevalence of obstructive sleep apnea syndrome in adult population

El síndrome de apnea-hipopnea obstructiva del sueño (SAHOS) es un trastorno respiratorio común asociado con múltiples consecuencias adversas para la salud y su prevalencia ha aumentado en paralelo con el aumento de la obesidad en la población. MÉTODOS: revisión sistemática que examina los estudios de prevalencia de SAHOS en la población general. Se incluyeron los estudios transversales y los componentes transversales de los estudios longitudinales que midieron objetivamente la prevalencia de SAHOS en adultos empleando instrumentos de laboratorio. Se evaluaron cuarenta estudios poblacionales de las 8.876 publicaciones encontradas en la búsqueda sistemática realizada en PubMed y otras bases de datos. RESULTADOS: Se ha observado importantes diferencias metodológicas en los estudios poblacionales, lo cual ha determinado una amplia variación en la prevalencia de SAHOS reportada, con un valor promedio de 36,9% (IC95% 28,3-45,4%) en hombres y 24,0% (IC 95% 16,3-31,6%) en mujeres. Se ha reportado un aumento en la prevalencia de SAHOS en el curso del tiempo desde 1987 hasta el 2020. Esta condición es más prevalente en varones, aumenta progresivamente con la edad y se asocia a la obesidad. La somnolencia diurna excesiva se ha asociado al diagnóstico de SAHOS, pero sólo una fracción de los sujetos con índice de apnea-hipopnea ≥ 5 eventos/hora presentan somnolencia diurna. CONCLUSIÓN: La prevalencia de SAHOS ha aumentado en los estudios poblacionales realizados en el curso del tiempo. La variabilidad reportada en la prevalencia de SAHOS probablemente esté relacionada con los diferentes equipos y definiciones operacionales empleados en el proceso diagnóstico, y las características de los sujetos examinados, incluyendo el importante aumento de la obesidad en la población.

Obstructive sleep apnea syndrome (OSAS) is a common disorder associated with multiple adverse health consequences and its prevalence is increasing in parallel with global rising in obesity. METHODS: We have developed a systematic review to examine obstructive sleep apnea syndrome prevalence studies in adults in the general population. We included the cross-sectional studies and the cross-sectional components of longitudinal studies that objectively measured OSAS in adults using laboratory instruments. Forty studies out of 8,876 articles found by systematically searching in PubMed and other databases were included in this review. RESULTS: Substantial methodological heterogeneity in population prevalence studies has been observed, determining a wide variation in OSAS prevalence defined at an apnea-hypopnea index (AHI) ≥ 5 events/hour, the average OSAS prevalence was 36.9% (CI95% 28.3-45.4%) in men and 24.0% (CI95% 16.3-31.6%) in women. The OSAS prevalence has increased over the time. OSAS is more prevalent in men than in women and increases with age and obesity. Excessive daytime sleepiness has been suggested as the most important symptom associated to OSAS, but only a fraction of subjects with AHI ≥ 5 events/hour report daytime sleepiness. CONCLUSION: The prevalence of OSAS has increased in epidemiological studies over time. The differences in reported prevalence of obstructive sleep apnea are probably due to different diagnostic equipment, operational definitions, study design and characteristics of included subjects, including effects of the obesity epidemic.

Manejo preoperatorio de pacientes con enfermedades respiratorias crónicas / Preoperative care of patients with chronic respiratory disorders

Chronic respiratory disease is the 3rd leading cause of death in Chile and its prevalence is increasing significantly in the world, so it is very common that we find patients with these pathologies undergoing elective surgical procedures. Perioperative complications are more frequent in these patients than in the general population, so it is essential adequate preoperative evaluation and management in them. Chronic obstructive pulmonary disease (COPD) is a major predictor of postoperative complications; therefore preoperative bronchodilators and inhaled corticosteroids are indicated in patients with this disease who will undergo elective surgery, particularly related to lung cancer. Likewise, COPD patients who will undergo coronary artery bypass graft surgery (CABG) should receive oral or intramuscular corticosteroids preoperatively. Smoking is an independent risk factor for developing postoperative respiratory complications in thoracic surgery, so patients should stop this habit at least 4 weeks before elective surgery in order to significantly reduce such complications. A poorly controlled asthma is a specific risk factor for developing postoperative pulmonary complications, therefore these patients should be treated preoperatively with inhaled bronchodilators exclusive if they have mild asthma, bronchodilators associated with inhaled corticosteroids in the case of a moderate asthma, and inhaled bronchodilators associated to inhaled and oral corticosteroids, if they have severe asthma.

Las enfermedades respiratorias crónicas son la tercera causa de muerte en Chile y su prevalencia está aumentando significativamente en el mundo, por lo cual es muy frecuente que nos encontremos con pacientes con estas patologías sometiéndose a procedimientos quirúrgicos electivos. En estos casos las complicaciones perioperatorias son más frecuentes que en la población general, por lo cual es indispensable una adecuada evaluación y manejo preoperatorio. La presencia de enfermedad pulmonar obstructiva crónica (EPOC) es un predictor mayor de complicaciones postoperatorias y deben indicarse broncodilatadores y corticoides inhalatorios preoperatorios en pacientes con esta patología que serán sometidos a cirugía electiva, especialmente en la relacionada a cáncer pulmonar. Así mismo, los pacientes con EPOC que se someterán a cirugía de revascularización miocárdica deben recibir además corticoides vía sistémica en el período preoperatorio. El tabaquismo es otro factor de riesgo independiente para desarrollar complicaciones respiratorias postoperatorias en cirugía torácica, por lo que los pacientes deberían suspender el consumo de tabaco por lo menos 4 semanas antes de la cirugía programada con el fin de disminuir significativamente dichas complicaciones. El asma bronquial mal controlada también es un factor de riesgo específico para desarrollar complicaciones pulmonares postoperatorias, por lo cual estos pacientes deben tratarse preoperatoriamente con broncodilatadores inhalatorios, asociados a corticoides inhalatorios u orales según la gravedad del asma.

Evaluación de un módulo de docencia ambulatoria de enfermedades respiratorias en el currículo de pregrado de Medicina / Evaluation of a teaching ambulatory module of respiratory diseases in the undergraduate medical curriculum

Background: As the focus of healthcare provision shifts towards ambulatory care, increasing attention must now be given to develop opportunities for clinical teaching in this setting. Aim: To assess teacher and students' views about the strengths and weaknesses of real and simulated patient interactions for teaching undergraduate students clinical skills in the ambulatory setting. Material and Methods: Fourth-year medical students were exposed in a systematic way, during two weeks, to real and simulated patients in an outpatient clinic, who presented common respiratory problems, such as asthma, chronic obstructive pulmonary disease, smoking and sleep apnea syndrome. After the clinical interview, students received feedback from the tutor and their peers. The module was assessed interviewing the teachers and evaluating the results qualitatively. Students evaluated the contents and quality of teaching at the end of the rotation. Results: Tutors identified the factors that facilitate ambulatory teaching. These depended on the module design, resources and patient care, of characteristics of students and their participation, leadership and interaction with professors. They also identified factors that hamper teaching activities such as availability of resources, student motivation and academic recognition. Most students evaluated favorably the interaction with real and simulated patients in the ambulatory setting. Conclusions: Teaching in the ambulatory setting was well evaluated by students and teachers. The use of qualitative methodology allowed contrasting the opinions of teachers and students.

Utilidad de la tomografía computada de tórax en la evaluación del paciente con hemoptisis no masiva / Usefulness of computed tomography of the thorax in the evaluation of patients with non massive hemoptysis

Ninety six patients, 60 male, aged 23 to 76 years old, who presented with hemoptysis to an University Hospital, were studied. All patients were studied with a chest radiographic, a fiberoptic bronchoscopy and a high resolution CT scan. The final causes of hemoptysis were bronchiectasis in 27 cases, broncogenic carcinoma in 24 cases and lung infections in nine. The source of bleeding was not identified in 18 patients (19 percent). CT scan clarified abnormalities seen in the chest radiograph in 30 patients (31 percent) and provided new diagnostic information in 13 (14 percent). CT scan correctly localized the source of bleeding found by fiberoptic bronchoscopy in 35 of 43 patients (81 percent), whereas chest radiograph did so in 27 (77 percent). All patients with bronchogenic carcinoma were identified by chest radiograph or bronchoscopy. Twenty of the 27 patients with bronchiectasis had radiological abnormalities in the chest radiograph. In only 2 patients, with lung metastasis and non conclusive chest radiograph and bronchoscopy, CT scan provided information that significantly modified clinical management. CT scan was useful to stage patients with bronchogenic carcinoma and to assess the extension of bronchiectasis, but its impact in the management and clinical evolution of patients was limited. Therefore we do not recommended the routine use of CT scan in the assessment of patients with hemoptysis