Factores asociados al inicio de la lactancia materna y razones de la madre para la toma de su decisión / Predictors of breastfeeding initiation and maternal reasons for this decision

Introducción: Los beneficios de la lactancia materna (LM) son bien conocidos. En estudios previos se constata que aproximadamente un 20% de las madres deciden no iniciarla. Existe un escaso conocimiento de los factores que predicen tal decisión y los motivos maternos para ello. En este estudio analizamos la prevalencia de inicio de la LM, los factores asociados y las razones maternas al respecto. Método: Estudio de prevalencia de inicio de la LM de gestaciones ≥ 36 semanas. Recogida de variables mediante encuestas presenciales en las primeras 24 horas posparto. Estudio multivariante de los factores asociados al inicio de la LM. Resultados: Se estudió un total de 452 pares, madre-recién nacido. El 81% inició la LM. Los factores favorecedores fueron la opinión favorable de la pareja (odds ratio [OR]= 28,49; intervalo de confianza [IC] del 95%: 5,34-151,95), la opinión neutral de la abuela materna (OR= 4,79; IC del 95%: 0,99-23,76), haber dado LM al hijo previo (OR= 22,63; IC del 95%: 5,68-90,07) y residir en la misma provincia donde está ubicado el hospital (OR= 47,34; IC del 95%: 16,09-139,31). Los factores desfavorecedores fueron: el hábito tabáquico de la madre (OR= 0,37; IC del 95%: 0,15-0,92), haber tenido abortos previos (OR= 0,35; IC del 95%: 0,20-0,60) y precisar tratamiento farmacológico al iniciar la lactancia (OR= 0,25; IC del 95%: 0,08-0,74). Conclusiones: Aportamos ciertos factores conocidos y otros novedosos asociados al inicio de la LM y los motivos de la madre para la toma de su decisión. Los tratamientos farmacológicos maternos son un factor asociado para no iniciar la LM, corregible con un asesoramiento adecuado. Urge adoptar medidas correctoras para conseguir tasas de inicio de la LM cercanas al 100%. Es necesaria la unificación de criterios respecto a lo que se considera «inicio de la LM» para comparar resultados de futuras investigaciones (AU)

Introduction: Breastfeeding benefits have been clearly demonstrated, but nearly 20% of mothers don’t start breastfeeding. Related factors to this decision and maternal reasons have been poorly investigated. We asses initiation breastfeeding rate, maternal reasons and the factors linked to their decision. Method: This is a prevalence study of initiation breastfeeding rate in a sample of mothers who delivered after 36 weeks of gestation. Six trained investigators collected variables by structured questionnaires, asking the mothers in the hospital within the first 24 hours after delivery. Bivariate and multivariate analysis of the data were performed. Results: Eighty one percent of the mothers started breastfeeding. Positive associated factors were: a good opinion of mother’s partner about breastfeeding (OR= 28.49; CI 95%: 5.34-151.95), neutral opinion of grandmother about breastfeeding (OR= 4.79; CI 95%: 0.99-23.76), positive breastfeeding experience with previous sibling (OR= 22.63; CI 95%: 5.68-90.07) and coming from the same province where the hospital is located (OR= 47.34; CI 95%: 16.09- 139.31). Negative related factors were: maternal smoking habit (OR= 0.37; CI 95%: 0.15-0.92), previous abortions (OR= 0.35; CI 95%: 0.20-0.60) and maternal pharmacological treatment at the beginning of breastfeeding (OR= 0.25; CI 95%: 0.08-0.74). Conclusions: We have described not only known but other new factors associated with the breastfeeding initiation, and maternal reasons for making their decisions. Pharmacological treatment is one of the factors clearly implicated in the beginning of formula-feeding, and this decision is avoidable with a correct counselling. Increasing breastfeeding initiation rates is strongly recommended with new public health interventions. Common criteria of what consider as a “breastfeeding initiation” are required for future research (AU)

Factores asociados al abandono precoz de la lactancia materna en una región del este de España / Factors associated with early weaning in a Spanish region

INTRODUCCIÓN: La lactancia materna (LM) tiene indudables beneficios para el recién nacido. En estudios previos se constata un abandono precoz de la misma, existiendo escasa evidencia sobre los factores asociados. Nuestro objetivo ha sido conocer la prevalencia de LM durante los primeros 12 meses posparto y analizar los factores asociados a su abandono. MATERIAL Y MÉTODOS: Estudio prospectivo, con inclusión consecutiva de pares (madre y recién nacido) hasta muestra requerida. Recogida de variables mediante encuestas maternas según el programa de seguimiento. Análisis estadístico bivariado y multivariado. RESULTADOS: Se seleccionaron 452 pares en los que se constató el inicio de la LM en el 81% de los casos, persistiendo a los 3 y 6 meses el 39 y 21% total, respectivamente. Los factores asociados al abandono precoz fueron: gestación tras técnicas de reproducción asistida (OR = 5,58; IC 95%: 2,62-11,91), hábito tabáquico materno (OR = 1,56; IC 95%: 1,10-2,22), expectativas pobres sobre la duración de la lactancia (OR = 2,19; IC 95%: 1,49-3,23), utilización de pezoneras (OR = 2,57; IC 95%: 1,69-3,90), uso rutinario del chupete durante el primer mes posparto (OR = 1,39; IC 95%: 1,02-1,91), madre con estudios universitarios (OR = 0,59; IC 95%: 0,40-0,88), asistencia a clases prenatales (OR = 0,68; IC 95%: 0,49-0,94), y sensación materna de leche suficiente al alta (OR = 0,66; IC 95%: 0,47-0,92). CONCLUSIONES: Las tasas de abandono de la LM en nuestro medio son elevadas, sin alcanzarse los objetivos de las recomendaciones internacionales al respecto. Se describen factores implicados ya conocidos y otros novedosos. Se recomiendan estrategias de intervención encaminadas a prolongar la LM

INTRODUCTION: Breastfeeding has undoubtedly great benefits. Previous studies have found anearly dropout. Only a few studies have investigated related factors. Our aim was to find outon-going breastfeeding rates along the first 12 months after birth and analyse factors associated with early weaning. MATERIAL AND METHODS: This is a prospective study including consecutive pairs (mother and newborn) till completion of the required sample. Variables were collected performing a structured program of surveys to the mothers. Bivariate and multivariate analysis of the data was performed. RESULTS: A total of 452 pairs were recruited. It was found that 81% of them started breastfeeding, with a prevalence of breastfeeding of 39% and 21% at 3 and 6 months after birth, respectively. Factors associated with early discontinuation of breastfeeding were: pregnancy induced by assisted reproduction methods (OR = 5.58; 95% CI: 2.62-11.91), maternal smoking(OR = 1.56; 95% CI: 1.10-2.22), poor maternal expectations about the duration of breastfeeding(OR = 2.19; 95% CI: 1.49-3.23), use of nipple shields for breastfeeding (OR = 2.57; 95% CI:1.69-3.90), pacifier use on a regular basis during the first month after delivery (OR = 1.39; 95%CI: 1.02-1.91), maternal university educational level (OR = 0,59; 95% CI: 0,40-0,88), attending birth preparation programs during pregnancy (OR = 0,68; 95% CI: 0,49-0,94), and believing having enough milk output at the time of discharge (OR = 0,66; 95% CI: 0,47-0,92). CONCLUSIONS: International recommendations about duration of breastfeeding are not achieved in our country because of high rates of early weaning. We describe the known factors involved and other novel factors. The implementation of interventions to increase breastfeeding rates and to prevent early weaning are strongly recommended

[Factors associated with early weaning in a Spanish region]. / Factores asociados al abandono precoz de la lactancia materna en una región del este de España.

INTRODUCTION: Breastfeeding has undoubtedly great benefits. Previous studies have foundan early dropout. Only a few studies have investigated related factors. Our aim was to find out on-going breastfeeding rates along the first 12 months after birth and analyse factors associated with early weaning. MATERIAL AND METHODS: This is a prospective study including consecutive pairs (mother and newborn) till completion of the required sample. Variables were collected performing a structured program of surveys to the mothers. Bivariate and multivariate analysis of the data was performed. RESULTS: A total of 452 pairs were recruited. It was found that 81% of them started breastfeeding, with a prevalence of breastfeeding of 39% and 21% at 3 and 6 months after birth, respectively. Factors associated with early discontinuation of breastfeeding were: pregnancy induced by assisted reproduction methods (OR=5.58; 95% CI: 2.62-11.91), maternal smoking (OR=1.56; 95% CI: 1.10-2.22), poor maternal expectations about the duration of breastfeeding (OR=2.19; 95% CI: 1.49-3.23), use of nipple shields for breastfeeding (OR=2.57; 95% CI: 1.69-3.90), pacifier use on a regular basis during the first month after delivery (OR=1.39; 95% CI: 1.02-1.91), maternal university educational level (OR=0,59; 95% CI: 0,40-0,88), attending birth preparation programs during pregnancy (OR=0,68; 95% CI: 0,49-0,94), and believing having enough milk output at the time of discharge (OR=0,66; 95% CI: 0,47-0,92). CONCLUSIONS: International recommendations about duration of breastfeeding are not achieved in our country because of high rates of early weaning. We describe the known factors involved and other novel factors. The implementation of interventions to increase breastfeeding rates and to prevent early weaning are strongly recommended.

Relación entre la transfusión de concentrado de hematíes y la gravedad de la enterocolitis necrotizante en prematuros / Relation between packed red blood cell transfusion and severity of necrotizing enterocolitis in premature infants

Objetivo. Se ha propuesto que las transfusiones de concentrado de hematíes (TCH) determinan formas de enterocolitis necrotizante (ECN)más severas. Se pretende investigar si las ECN con antecedente de TCH alcanzan una mayor gravedad. Material y métodos. En un estudio retrospectivo de prematuros con ECN se consideraron dos grupos: con antecedente de TCH (grupoTR) y sin antecedente de TCH (grupo No-TR). Se consideraron como resultados principales la gravedad de la ECN, determinada según el estadio de Bell (EB) mayor durante el transcurso de la enfermedad, si fue necesario realizar tratamiento quirúrgico y la mortalidad. Posteriormente se analizaron por separado aquellos pacientes que habían recibido la TCH en las 48 h previas al inicio de los síntomas. Al comparar los grupos se utilizó la prueba exacta de Fisher o la de Chi cuadrado para elEB, el tratamiento quirúrgico, la mortalidad y las variables cualitativas (..) (AU)

Objective. It has been proposed recently that red blood cell transfusions(RBCT) might increase severity in infants with necrotizing enterocolitis (NEC). We intend to study if patients who have received red blood transfusions before the onset of NEC develop more severe forms of this entity. Methods. A retrospective study was carried out including prematures with NEC. Two groups were considered: with previous RBCT(TR) and without previous RBCT (No-TR). The main outcomes of the study were severity of NEC, according to the Bell stage (BS), surgical treatment and mortality. Patients who were treated with RBCT 48hours prior to the onset of NEC symptoms were analysed separately afterwards. Comparison of groups was made with the Fisher test or the Chi square test for the BS, surgery, mortality and nominal variables; the U Mann-Whitney test was used for numeric variables. Results. Forty-six patients were included for the investigation (28 in TR and 18 in No-TR). In the TR Group 20/28 neonates reached a BS II;8/28 BS III; 10 were operated on and there were 7 deaths. In the No-TR group 14/18 patients were classified as EB II; 4/18 as BS III, 3 patients (AU)

[Relation between packed red blood cell transfusion and severity of necrotizing enterocolitis in premature infants]. / Relación entre la transfusión de concentrado de hematíes y la gravedad de la enterocolitis necrotizante en prematuros.

OBJECTIVE: It has been proposed recently that red blood cell transfusions (RBCT) might increase severity in infants with necrotizing enterocolitis (NEC). We intend to study if patients who have received red blood transfusions before the onset of NEC develop more severe forms of this entity. METHODS: A retrospective study was carried out including prematures with NEC. Two groups were considered: with previous RBCT (TR) and without previous RBCT (No-TR). The main outcomes of the study were severity of NEC, according to the Bell stage (BS), surgical treatment and mortality. Patients who were treated with RBCT 48 hours prior to the onset of NEC symptoms were analysed separately afterwards. Comparison of groups was made with the Fisher test or the Chi square test for the BS, surgery, mortality and nominal variables; the U Mann-Whitney test was used for numeric variables. RESULTS: Forty-six patients were included for the investigation (28 in TR and 18 in No-TR). In the TR Group 20/28 neonates reached a BS II; 8/28 BS III; 10 were operated on and there were 7 deaths. In the No-TR group 14/18 patients were classified as EB II; 4/18 as BS III, 3 patients needed surgery and Idied. No relation was found between RBCT and BS (p = 0.39), RBCT and surgery (RR = 2.7; CI 95%: 0.64-11.97; p = 0.19), or RBCT and mortality (RR = 4.5; CI 95%: 0.6-36.6; p = 0.09). In those patients who received a RBCT 48 hours before the initial symptoms there were 3 EB II and 3 EB III; 4 infants required surgical treatment and there were 2 exitus. Comparing this subgroup and the rest of the sample there were only significant differences in the need of surgical treatment: patients who received a RBCT 48 hours before the onset of NEC were at an increased risk for surgery of 2.6 (CI 95%: 1.2-5.1; p = 0.045) but there were not different when surgical treatment and mortality were considered. CONCLUSIONS: These results do not support clearly the hypothesis that there is a relation between previous treatment with RBCT and the severity of NEC.

Varicella-zoster virus pneumonia in an adult population: has mortality decreased?

Varicella-zoster virus (VZV) pneumonia is one of the most serious complications of this infection in adults. The objective of this study was to analyze the epidemiological and clinical characteristics in a large sample of patients with VZV pneumonia. This was a 10-y retrospective, descriptive, observational study. We studied 46 patients with VZV pneumonia, 21 men and 25 women, with a mean age 36 +/-11 y. A contact with an index case was observed in 57%, 76 were active smokers, 6.5% consumed drugs and 2 women were pregnant. The symptoms were: fever (83%), cough (83%), dyspnoea (63%), pleuritic pain (70%), and haemoptysis (6%) and started 3-5 days after the onset of blisters, except in 11% in whom respiratory symptoms appeared first. Arterial blood gases showed a mean PO(2)/FiO(2) of 308 +/-101 and 30 patients had a PO(2) of <55 mmHg--11 of these (4%) were admitted to the ICU, 8 required mechanical ventilation. Comparison of patients in the ICU with those on the general ward showed differences in the duration of fever (6.1 +/- 4.2 vs 3.2 +/- 1.1 days, p <0.001), mean stay (16.8+/-9.3 vs 7.2+/-2.4 days, p <0.001) and complications such as acute renal failure (p = 0.01) and acute respiratory failure (p < 0.001). Despite the severity of disease, no patient died. Once diagnosed, 98% were treated with acyclovir, combined with steroids in 6 and with antibiotics in 3 complicated with bacterial pneumonia. The prevalence for the period was 0.33 cases/100,000 inhabitants/y. In conclusion, VZV pneumonia has a severe course and accounts for a high percentage of admissions to the intensive care unit. The absence of mortality may be related to early treatment with acyclovir. Smoking was a risk factor for VZV pneumonia.

[Recent advances in research on neonatal resuscitation: an update]. / Investigación en reanimación neonatal: últimos avances.

Coinciding with the Annual Meeting of the Pediatric Academic Societies (PAS) last May 2008 in Honolulu (Hawaii, USA), Professor Colin Morley and his colleagues (University of Melbourne, Australia) held a Workshop on Research in Neonatal Resuscitation. Experts in the field presented their results and future projects over 2 days. The subjects presented during the workshop were: oxygen, air and oximetry; when and where to apply surfactant; neonatal resuscitation research techniques; teaching neonatal resuscitation; cellular physiology and biology; CPAP/PEEP/prolonged inspiration; video recording during resuscitation. Sessions were characterized by an interactive discussion. Our intention is to tell about some of the most innovative aspects that might interest our neonatal colleagues who did not have the opportunity to attend the meeting. As much of the information contained in this article is on experiments based, we recommend the reader not to consider it for immediate application in clinical practice until it has been validated by sufficient proof.

Investigación en reanimación neonatal: últimos avances / Recent advances in research on neonatal resuscitation: an update

En mayo de 2008 y en coincidencia con la reunión anual de las Pediatric Academic Societies, se realizó en Honolulu (Hawaii, EE. UU.) un simposio sobre Investigación en reanimación neonatal, organizado por el profesor Colin Morley (Universidad de Melbourne, Australia). Durante 2 días, expertos en el área de la investigación en reanimación neonatal presentaron sus resultados y proyectos. Las áreas estudiadas fueron oxígeno, aire y oximetría; cuándo y dónde aplicar el agente tensioactivo; técnicas de investigación en reanimación neonatal; enseñanza de reanimación neonatal; fisiología y biología celulares; presión positiva continua en la vía respiratoria, presión positiva final espiratoria e inspiración prolongada, y grabación mediante vídeo de la reanimación. El simposio se caracterizó por una discusión activa. En este artículo se relatan aquellos aspectos más novedosos que pueden ser de interés para los neonatólogos que no tuvieron la oportunidad de asistir. Ya que mucha de la información que se presenta en este artículo procede del campo experimental, es recomendable que el lector no la traslade directamente a la práctica clínica hasta que haya sido avalada por pruebas suficientes (AU)

Coinciding with the Annual Meeting of the Pediatric Academic Societies (PAS) last May 2008 in Honolulu (Hawaii, USA), Professor Colin Morley and his colleagues (University of Melbourne, Australia) held a Workshop on Research in Neonatal Resuscitation. Experts in the field presented their results and future projects over 2 days. The subjects presented during the workshop were: oxygen, air and oximetry; when and where to apply surfactant; neonatal resuscitation research techniques; teaching neonatal resuscitation; cellular physiology and biology; CPAP/PEEP/prolonged inspiration; video recording during resuscitation. Sessions were characterized by an interactive discussion. Our intention is to tell about some of the most innovative aspects that might interest our neonatal colleagues who did not have the opportunity to attend the meeting. As much of the information contained in this article is on experiments based, we recommend the reader not to consider it for immediate application in clinical practice until it has been validated by sufficient proof (AU)

Neumonía en la población mayor de 70 años y con estado funcional limitado: estudio caso-control de pacientes institucionalizados / Pneumonia in the elderly population over 70 year with limited functional condition: case-control study of institutionalized patients

Objetivo. La neumonía adquirida en la comunidad (NAC) de los ancianos supone un problema sanitario de importancia creciente por su prevalencia y mortalidad. Entre los factores que habitualmente se relacionan con una mala evolución destacan la edad avanzada, el mal estado funcional y la procedencia de una institución sociosanitaria como las residencias de ancianos. En este estudio hemos seleccionado una población mayor de 70 años con una capacidad funcional limitada (índice de Barthel < 50) con el objetivo de conocer si el proceder de una residencia de ancianos es un factor aislado que se asocia a un peor pronóstico de la NAC. Pacientes y método. Seleccionamos 87 pacientes mayores de 70 años de un estudio longitudinal prospectivo y multicéntrico de las NAC hospitalizadas durante un año. Analizamos la evolución y el curso de la NAC en función de su lugar de procedencia y realizamos después un estudio caso-control de los ancianos mayores de 70 años con índice de Barthel inferior a 50, incluyendo 21 ancianos procedentes de residencia y 21 procedentes de su domicilio particular. Resultados. En la NAC de los pacientes mayores de 70 años, los que proceden de residencia presentan con más frecuencia cuadro confusional y llegan a Urgencias con menores cifras de presión arterial sistólica y diastólica, menor saturación arterial de oxígeno, mayor afectación radiológica y peor índice de Fine, a lo que se suma que fallecen con más frecuencia. Cuando limitamos la población a mayores de 70 años con índice de Barthel menor de 50, no encontramos diferencias en los pacientes institucionalizados frente al resto. Conclusión. En los ancianos mayores de 70 años con NAC, aquéllos que proceden de residencias asistidas tienen mayor mortalidad, sin embargo cuando la capacidad funcional es mala (Barthel < 50) el lugar de procedencia (comunidad o residencia de ancianos) pierde importancia y se convierte en una variable que no influye más que otras en la evolución y el curso clínico de la NAC (AU)

Objective. Community acquired pneumonia (CAP) of the elderly is an increasingly important growing health problem due to its prevalence and mortality. Among the factors that are usually related with poor evolution are advanced age, poor functional status and coming from a socio-health care institution such as residential homes for the elderly. In this study, we have chosen a population over 70 years of age with limited functional capacity (Barthel Index < 50) in order to know if coming from a residential home for the elderly is an isolated factor that is associated to worse prognosis of CAP. Patients and methods. We selected 87 patients over 70 years from a prospective and multicenter study of the hospitalized CAPs during one year. We analyzed the evolution and course of the CAP based on place or origin and then conducted a case-control study of the elderly over 70 years with the Barthel under 50, including 21 elderly from residences and 21 from the own home. Results. In elderly patients over 70 years with CAP, those coming from the residence have a confusional picture more often and come to emergency with lower values of systolic and diastolic blood pressure, lower arterial oxygen saturation, greater involvement on the x-ray, Fine Index is worse and die more often. When we limit the population to those over 70 years with Barthel under 50, we do not find differences in institutionalized patients versus the others. Conclusion. In the elderly over 70 years with CAP, patients from assisted living residences have greater mortality. However, when functional capacity is bad (Barthel < 50), place or origin (community or elderly residence) loses importance and becomes a variable that has no more influence than others in the clinical evolution and course of the CAP (AU)

[Pneumonia in the elderly population over 70 years with limited functional condition: case-control study of institutionalized patients]. / Neumonía en la población mayor de 70 años y con estado funcional limitado: estudio caso-control de pacientes institucionalizados.

OBJECTIVE: Community acquired pneumonia (CAP) of the elderly is an increasingly important growing health problem due to its prevalence and mortality. Among the factors that are usually related with poor evolution are advanced age, poor functional status and coming from a socio-health care institution such as residential homes for the elderly. In this study, we have chosen a population over 70 years of age with limited functional capacity (Barthel Index < 50) in order to know if coming from a residential home for the elderly is an isolated factor that is associated to worse prognosis of CAP. PATIENTS AND METHODS: We selected 87 patients over 70 years from a prospective and multicenter study of the hospitalized CAPs during one year. We analyzed the evolution and course of the CAP based on place or origin and then conducted a case-control study of the elderly over 70 years with the Barthel under 50, including 21 elderly from residences and 21 from the own home. RESULTS: In elderly patients over 70 years with CAP, those coming from the residence have a confusional picture more often and come to emergency with lower values of systolic and diastolic blood pressure, lower arterial oxygen saturation, greater involvement on the x-ray, Fine Index is worse and die more often. When we limit the population to those over 70 years with Barthel under 50, we do not find differences in institutionalized patients versus the others. CONCLUSION: In the elderly over 70 years with CAP, patients from assisted living residences have greater mortality. However, when functional capacity is bad (Barthel < 50), place or origin (community or elderly residence) loses importance and becomes a variable that has no more influence than others in the clinical evolution and course of the CAP.

[Neurofibromatosis in children. Our experience]. / Neurofibromatosis en niños. Nuestra experiencia.

INTRODUCTION: Neurofibromatosis type 1 (NF1) is an autosomal dominant disorder with a high index of spontaneous mutations and extremely varied and unpredictable clinical manifestations. It is diagnosed by the existence of certain clinical criteria which cannot appear until adulthood. PATIENTS AND METHODS: The clinical histories of the confirmed or possible cases of neurofibromatosis (NF) in the neuropaediatric databases at the Hospital Miguel Servet in Zaragoza and at the Hospital General in Guadalajara were analysed retrospectively. RESULTS: Cases were distributed in 46 NF1, six compatible with NF1, 11 with just marks, five with marks and a family history of marks, and two cases of segmentary NF. Among the confirmed cases of NF1, the following alterations were found: optic glioma (OG) in eight, and one of them developed a glioblastoma multiforme, multiple radicular neurofibromas in one, mental retardation in one and learning disorders in 13 of the 29 school aged children, afebrile seizures in three, precocious puberty in two and scoliosis in nine. Brain areas with hypersignals were found in 71% of the cases submitted to magnetic resonance imaging (MRI) (20 out of 28), including seven of the eight patients suffering from OG. DISCUSSION: Our case mix, like all the others, exemplifies the clinical heterogeneity and unpredictable progression of children with NF1 or who are suspected of suffering from it. We followed the most widely used method of clinical and ophthalmological control, and complementary examinations were performed according to the clinical features. If neuroimaging is used, it must be MRI.

¿Pubertad precoz mediada por betagonadotropina coriónica humana? / SS-hCG-induced precocious puberty?

No disponible

[The characteristics of the mechanical activity of the respiratory muscles during the diaphragmatic respiration technic]. / Características de la actividad mecánica de los músculos respiratorios durante la técnica de "respiración diafragmática".

UNLABELLED: Noteworthy among breathing training techniques is so-called diaphragmatic breathing. In spite of the technique's name, however, little is known of the functional characteristics of this ventilatory method. OBJECTIVE: To asses the mechanics of respiratory muscles, particularly diaphragm muscles, during diaphragmatic breathing in patients with severe chronic obstructive pulmonary disease (COPD). METHODS: Ventilatory pattern and respiratory pressures (abdominal [Pga], intrathoracic [Pes] and transdiaphragmatic [Pdi]) were studied in 10 patients with severe COPD in stable phase (age 69 +/- 6 years, FEV1 33 +/- 12% ref) at baseline and during deep breathing with spontaneous muscle recruitment (SMR) and during breathing training. Measurements were taken with the patient seated and in supine decubitus position. RESULTS: In seated position ventilatory pattern was similar with SMR and during breathing training. Mean Pdi during airflow, however, was greater during breathing training than with SMR (34.8 +/- 8.0 and 29.3 +/- 9.3 cmH2O, respectively, p < 0.05) for similar levels of Pes. Mechanical effectiveness of the diaphragm expressed as Vt/Pdi) was less during breathing training, however (36.1 +/- 10.4 and 49.5 +/- 15.8 cc/cmH2O, p < 0.05), with no changes in overall efficacy of respiratory muscles (Vt/Pes). In supine decubitus position, ventilatory patterns of SMR and breathing training were similar, although Vt and T1 were slightly higher in the latter (1,065 +/- 305 vs. 1,211 +/- 314 cc, p < 0.01; and 2.76 +/- 1.32 vs. 3.07 +/- 1.23 sec, p < 0.05). Pdi was also higher during breathing training (29.7 +/- 10.2 and 38.0 +/- 10.5 cmH2O, p < 0.05), although accompanied in this case by a higher Pes (21.2 +/- 7.5 to 26.4 +/- 8.4 cmH2O, p < 0.005). In supine decubitus position, the effectiveness of both diaphragm muscles and respiratory muscles overall was similar for both ventilatory modes. CONCLUSIONS: Breathing training truly involves greater use of the diaphragm, both in seated and supine decubitus positions. Breathing training does not provide greater ventilatory efficacy than SMR, however, in COPD patients.

Características de la actividad mecánica de los músculos respiratorios durante la técnica de "respiración diafragmática" / Respiratory muscle mechanics during diaphragmatic breathing

Entre las técnicas de fisioterapia respiratoria destaca la llamada "respiración diafragmática" (RD). Sin embargo, y a pesar de su nombre, apenas se conocen las características funcionales de esta modalidad ventilatoria. Objetivo: Evaluar la actividad mecánica de los músculos respiratorios, especialmente del diafragma, durante la RD en pacientes con EPOC grave. Métodos: En 10 enfermos de esas características en fase estable (69 ñ 6 años, FEV1 33 ñ 12 por ciento ref), se estudiaron el patrón ventilatorio y las presiones respiratorias (abdominal o Pga, intratorácica o Pes y transdiafragmática o Pdi), tanto en situación basal como durante la respiración profunda con reclutamiento muscular espontáneo (RME) y la RD. El estudio se realizó tanto en sedestación (SED) como en decúbito supino (DEC). Resultados: En SED, el patrón ventilatorio no presentó diferencias entre RME y RD. En cambio, la Pdi media a volumen corriente fue mayor durante la RD (respectivamente, 29,3 ñ 9,3 y 34,8 ñ 8,0 cmH2O; p < 0,05), para valores similares de Pes. Sin embargo, la efectividad mecánica del diafragma (expresada por el Vt/Pdi), era menor en RD (49,5 ñ15,8 y 36,1 ñ 10,4 cm3/cmH2O; p < 0,05), sin cambios en la efectividad global de los músculos respiratorios (Vt/Pes). En DEC, los resultados fueron similares respecto del patrón ventilatorio para RME y RD, aunque Vt y TI fueron algo superiores en la segunda (respectivamente, 1.065 ñ 305 y 1.211 ñ 314 cm3, p < 0,01; y 2,76 ñ 1,32 frente a 3,07 ñ 1,23 s, p < 0,05). La Pdi también presentó un valor más alto en RD (29,7 ñ 10,2 y 38,0 ñ 10,5 cmH2O; p < 0,05), acompañado en esta ocasión por una Pes también superior (21,2 ñ 7,5 a 26,4 ñ 8,4 cmH2O; p < 0,005).Siguiendo con el DEC, la efectividad tanto del diafragma como de la globalidad de los músculos respiratorios resultó simil r para ambas modalidades ventilatorias. Conclusiones: La RD realmente corresponde a un mayor uso del diafragma, tanto en SED como en DEC. Sin embargo, en pacientes con EPOC grave esto no se traduce en una mayor efectividad en términos ventilatorios, si se compara con la RME. (AU)

[Diaphragmatic function during exercise in patients with severe COPD]. / Función diafragmática durante el ejercicio en pacientes con EPOC severa.

UNLABELLED: Ventilatory requirements increase during exercise. The respiratory muscles of patients with chronic obstructive pulmonary disease (COPD) are at a particular disadvantage when dealing with such increased demand. The objective of this study was to evaluate the changes in respiratory muscles brought on by exercise in such patients. METHODS: Twelve patients with severe CFOPD (FEV1 < 50% ref., 63 +/- 7 years) were enrolled. Breathing patterns and esophageal (Pes and transdiaphragmatic (Pdi) pressures and SaO2 were measured during submaximal exercise/Ecsbmax, 60% of the maximum tolerated load). A sniff maneuver was performed with the patients breathing ambient air with added oxygen to achieve 99% SaO2. We also measured level of FRC by inductive plethysmograph in a subgroup of five patients. RESULTS: During EXsbmáx, SaO2 decreased (from 95.0 +/- 2.1 to 92.3 +/- 4.0%; p < 0.01); Vt increased (717 +/- 199 to 990 +/- 297 cc, p < 0.01), as did respiratory rate (RR, 17 +/- 6 a 28 +/- 9; p < 0.01). Pes and Pdi were greater at Vt, changing from -12.4 +/- 4.8 to -27.0 +/- 10.1 and 16.6 +/- 6.1 to 30.4 +/- 12.4 cmH2O, respectively (p < 0.01 in both cases), whereas no significant changes were observed for maximal effort (Pesmax, -61.4 +/- 16.5 cersus -65.9 +/- 15.2 cmH2O; Pdimac 89.7 +/- 26.1 versus 81.7 +/- 35.7 cmH2O). Used as a global measure, Pdi/Pdimáx worsened (0.21 +/- 0.12 a 0.42 +/- 0.20; p < 0.01), as dud the diaphragm tension-time (TTdi; 0.07 +/- 0.04 to 0.15 +/- 0.06, p < 0.01). Intrinsic positive end-expiratory pressure (PEEPi) increased an estimated 2.7 +/- 2.1 to 9.4 +/- 5.8 cmH2O (p < 0.001), while FRC (delta 357 +/- 274 ml). Durante el EXsbmáx with oxygen supplementation, SaO2 did not decrease. However supplementation, though Ti/TTOT and maximal pressures remained unchanged. CONCLUSIONS: Respiratory muscle function changes induced by Exsbmáx seem to relate mainly to a worsening of system mechanics.

[Capillary density and respiratory function in the external intercostal muscle]. / Densidad capilar y función respiratoria en el músculo intercostal externo.

UNLABELLED: Changes in lung function have been related to adaptive structural modifications in respiratory muscles. OBJECTIVE: To evaluate the capillary density (Dcap) of the external intercostal muscle in patients with chronic obstructive pulmonary disease (COPD), and its possible relation to respiratory function. METHODS: Forty-two individuals (61 +/- 9 years old) underwent conventional lung function testing and evaluation of respiratory muscles (maximum pressures at rest and a tolerance test using Martyn's technique). The sample included 10 subjects with normal lung function and 32 COPD patients (FEV1 between 13 and 78% of reference), in stable phase and with no respiratory insufficiency (PaO2 > 60 mmHg). A local biopsy of the external intercostal muscle was taken from all subjects at the fifth intercostal space (anterior axillary [correction of axile]) on the non-dominant side. The sample was processed for morphometry and fiber typing with ATPase staining and for quantifying capillarity with Gomori's trichrome staining. RESULTS: The mean diameter was 61 +/- 10 micrograms, with type I fibers predominating (56 +/- 11%). Dcap was 2.8 +/- 0.6 capillaries/fiber (equivalent to 1.02 +/- 0.37 capillaries/mm2 of fibrillary surface). The number of capillaries/fiber was significantly higher in patients with severe COPD (FEV1 < 50% ref) than in controls (3.0 +/- 0.6 versus 2.3 +/- 0.5, p < 0.01) and was inversely related to FEV1 (r = -0.395, p < 0.01). Muscle capillarity was unrelated to other function variables, including markers of respiratory muscle function and gas exchange. CONCLUSION: The structural remodelling of external intercostal muscles in COPD patients also includes an increase in density of interfibrillary capillaries. This increase is proportional to the severity of obstruction and probably reflects an adaptive phenomenon.

Chronic obstructive pulmonary disease stage and health-related quality of life. The Quality of Life of Chronic Obstructive Pulmonary Disease Study Group.

BACKGROUND: The American Thoracic Society recently recommended that chronic obstructive pulmonary disease be staged on the basis of the percentage of predicted FEV1. OBJECTIVE: To examine 1) the relation between the american Thoracic Society system for staging chronic obstructive pulmonary disease and health-related quality of life and 2) the effect of self-reported comorbid conditions on health-related quality of life. DESIGN: Cross-sectional study. SETTING: Outpatient clinics of respiratory departments of four hospitals and one primary health care center in spain. PATIENTS: 321 consecutive male patients with chronic obstructive pulmonary disease. MEASUREMENTS: Functional respiratory impairment, FEV1, respiratory symptoms, and health-related quality of life. Respiratory symptoms and health-related quality of life were measured by using the Spanish version of the St. George's Respiratory Questionnaire and the Nottingham Health Profile. RESULTS: Patient scores on the St. George's Respiratory Questionnaire were moderately to strongly associated with disease staging (r = 0.27 to 0.51). Compared with reference values, values for health-related quality of life for patients with stage I disease were substantially higher on the St. George's Respiratory Questionnaire (6 and 34; p < 0.001) and values for impairment were significantly greater in stage 1 patients with comorbid conditions (19 and 36; P = 0.001). At least one concomitant chronic condition was found in 84% of study patients. Comorbid conditions only partly influenced the observed pattern of deterioration of health-related quality of life with worsening stages of disease. CONCLUSION: Staging criteria for chronic obstructive pulmonary disease based on percentage of predicted FEV1 separated groups of patients with varying degrees of impairment in health-related quality of life. Contrary to expectations, even patients with mild disease showed substantially compromised health-related quality of life. Comorbid conditions influenced the relation between chronic obstructive pulmonary disease and health-related quality of life.

Validity and reliability of the St George's Respiratory Questionnaire after adaptation to a different language and culture: the Spanish example.

We describe the adaptation into Spanish of the St George's Respiratory Questionnaire (SGRQ), a self-administered questionnaire developed by Jones et al. (1991) covering three domains of health in airways disease patients: symptoms, activity and impacts. For the adaptation, the forward and back-translation method by bilinguals was used, together with professional committee and lay panel. Once tested for feasibility and comprehension, 318 male chronic obstructive pulmonary disease (COPD) patients with a wide range of disease severity completed the Spanish version of the SGRQ. The clinical status of the patients was evaluated concurrently with the measurement of health status. Lung function was assessed in the 2 months before or after the questionnaire administration. The Spanish version of the SGRQ was acceptable and easy to understand. Cronbach's alpha reliability coefficient was 0.94 for the overall scale and 0.72 for "Symptoms", 0.89 for "Activity", and 0.89 for "Impacts" subscales. Correlation coefficients between the overall score and dyspnoea and % forced expiratory volume in one second (FEV1) were 0.59 and -0.45, respectively, and these correlations were higher than those observed between the clinical variables and the Nottingham Health Profile, a generic measure of health-related quality of life. Results of the study suggest that the Spanish version of the SGRQ is conceptually equivalent to the original, and similarly reliable and valid. Although further studies should complete the adaptation work, results suggest that the SGRQ may already be used in Spain and in international studies involving Spanish respiratory patients. According to the present approach, it appears to be feasible to adapt a specific questionnaire on health-related quality of life in respiratory disease to another language and culture.