Artificial Intelligence Applied to Forced Spirometry in Primary Care.

Introduction: This study aims to create an artificial intelligence (AI) based machine learning (ML) model capable of predicting a spirometric obstructive pattern using variables with the highest predictive power derived from an active case-finding program for COPD in primary care. Material and methods: A total of 1190 smokers, aged 30-80 years old with no prior history of respiratory disease, underwent spirometry with bronchodilation. The sample was analyzed using AI tools. Based on an exploratory data analysis (EDA), independent variables (according to mutual information analysis) were trained using a gradient boosting algorithm (GBT) and validated through cross-validation. Results: With an area under the curve close to unity, the model predicted a spirometric obstructive pattern using variables with the highest predictive power: FEV1_theoretical_pre values. Sensitivity: 93%. Positive predictive value: 94%. Specificity: 97%. Negative predictive value: 96%. Accuracy: 95%. Precision: 94%. Conclusion: An ML model can predict the presence of an obstructive pattern in spirometry in a primary care smoking population with no prior diagnosis of respiratory disease using the FEV1_theoretical_pre values with an accuracy and precision exceeding 90%. Further studies including clinical data and strategies for integrating AI into clinical workflow are needed.

Introducción: Este estudio tiene como objetivo crear un modelo de aprendizaje automático (ML) basado en inteligencia artificial (IA) capaz de predecir un patrón obstructivo espirométrico utilizando variables con el mayor poder predictivo derivado de un programa activo de búsqueda de casos de enfermedad pulmonar obstructiva crónica (EPOC) en Atención Primaria. Materiales y métodos: Un total de 1.190 fumadores, de entre 30 y 80 años, sin antecedentes de enfermedad respiratoria, fueron sometidos a espirometría con IA artificial. Sobre la base de un análisis de datos exploratorio (EDA), las variables independientes (según el análisis de información mutua) se entrenaron utilizando un algoritmo de gradiente de aumento (GBT) y se validaron mediante validación cruzada. Resultados: Con un área bajo la curva cercana a la unidad, el modelo predijo un patrón obstructivo espirométrico utilizando los valores del FEV1 prebroncodilatador. Sensibilidad: 93%. Valor predictivo positivo: 94%. Especificidad: 97%. Valor predictivo negativo: 96%. Precisión: 95%. Precisión: 94%. Conclusión: Un modelo ML puede predecir la presencia de un patrón obstructivo en la espirometría en una población fumadora de atención primaria sin diagnóstico previo de enfermedad respiratoria utilizando los valores FEV1 prebroncodilatadores con una exactitud y precisión superiores al 90%. Se necesitan más estudios que incluyan datos clínicos y estrategias para integrar la IA en el flujo de trabajo clínico.

Obstructive sleep apnea and cardiovascular events in elderly patients.

INTRODUCTION: In recent decades, life expectancy has increased considerably. The cardiovascular effects of Obstructive Sleep Apnea (OSA) in the elderly lead to patient disability and high resource consumption. Intermittent nocturnal hypoxia leads to hemodynamic stress and adrenergic activation, which promotes cardiovascular disease. However, chronic intermittent hypoxia may protect elderly patients from cardiovascular events (CVE) due to biological adaptation. AREAS COVERED: OSA patients are at increased risk of cardiovascular events. The severity of OSA increases cardiovascular risk, and this association also exists in the elderly. This article reviews the association between OSA, CPAP treatment, and CVE, particularly stroke and coronary heart disease (CHD), in the elderly. MEDLINE and the Cochrane Collaboration databases were searched from inception to July 2021. EXPERT COMMENTARY: Although a positive association between OSA and the incidence of cardiovascular disease in the elderly has been established, the role of sleep apnea in certain cardiovascular events remains controversial. Most authors agree that untreated OSA is a risk factor for stroke or worse stroke prognosis. However, the association between OSA and CHD is usually less pronounced than between OSA and stroke, especially in the elderly.

Combined intermittent and sustained hypoxia is a novel and deleterious cardio-metabolic phenotype.

STUDY OBJECTIVES: Chronic obstructive pulmonary disease and obstructive sleep apnea overlap syndrome is associated with excess mortality, and outcomes are related to the degree of hypoxemia. People at high altitudes are susceptible to periodic breathing, and hypoxia at altitude is associated with cardio-metabolic dysfunction. Hypoxemia in these scenarios may be described as superimposed sustained hypoxia (SH) plus intermittent hypoxia (IH), or overlap hypoxia (OH), the effects of which have not been investigated. We aimed to characterize the cardio-metabolic consequences of OH in mice. METHODS: C57BL/6J mice were subjected to either SH (FiO2 = 0.10), IH (FiO2 = 0.21 for 12 h, and FiO2 oscillating between 0.21 and 0.06, 60 times/hour, for 12 h), OH (FiO2 = 0.13 for 12 h, and FiO2 oscillating between 0.13 and 0.06, 60 times/hour, for 12 h), or room air (RA), n = 8/group. Blood pressure and intraperitoneal glucose tolerance test were measured serially, and right ventricular systolic pressure (RVSP) was assessed. RESULTS: Systolic blood pressure transiently increased in IH and OH relative to SH and RA. RVSP did not increase in IH, but increased in SH and OH by 52% (p < .001) and 20% (p = .001). Glucose disposal worsened in IH and improved in SH, with no change in OH. Serum low- and very-low-density lipoproteins increased in OH and SH, but not in IH. Hepatic oxidative stress increased in all hypoxic groups, with the highest increase in OH. CONCLUSIONS: OH may represent a unique and deleterious cardio-metabolic stimulus, causing systemic and pulmonary hypertension, and without protective metabolic effects characteristic of SH.

Bronchial Infection and Temporal Evolution of Bronchiectasis in Patients With Chronic Obstructive Pulmonary Disease.

BACKGROUND: Bronchiectasis (BE) impact the clinical course and prognosis of patients with chronic obstructive pulmonary disease (COPD). Yet, the temporal evolution of BE in these patients is unknown. This study seeks to assess the temporal evolution of BE in persons with COPD. METHODS: 201 moderate-to-severe patients were recruited between 2004 and 2007 and followed up at least every 6 monts (median of 102 months). To investigate the temporal evolution of BE, in 2015 a second high-resolution computed tomography scan (HRCT) was obtained in survivors and compared with the one obtained at recruitment. RESULTS: 99 (49.3%) died during follow-up. The second HRCT could be obtained in 77 patients and showed that (1) in 27.3% of patients BE never developed, in 36.4% they remained stable, in 16.9% they increased in size and/or extension, and in 19.5% new BE emerged; and that (2) the presence of chronic purulent sputum (hazard ratio [HR], 2.8 [95% confidence interval {CI}, 1.3-5.8]), number of hospitalizations due to exacerbatons (HR, 1.2 [95% CI, 1.1-1.5]), and number of pathogenic microorganism (PPM) isolations (HR, 1.1 [95% CI, 1.02-1.3]) were independent risk factors for the progression or development of BE. CONCLUSIONS: The presence of chronic purulent sputum production, number of PPMs isolated in sputum, and number of hospitalizations due to exacerbations of COPD are independent risk factors of BE progression in patients with COPD.

Increased Incidence of Stroke, but Not Coronary Heart Disease, in Elderly Patients With Sleep Apnea.

Background and Purpose- The influence of age on the relationship between obstructive sleep apnea (OSA) and the incidence of hard cardiovascular events remains controversial. We sought to analyze the relationship between OSA and the incidence of stroke and coronary heart disease in a large cohort of elderly patients, as well as to investigate the role of continuous positive airway pressure (CPAP) treatment in these associations. Methods- Post hoc analysis of a prospective observational study of consecutive patients ≥65 years studied for OSA suspicion at 2 Spanish University Hospitals. Patients with an apnea-hypopnea index (AHI) <15 were the reference group. OSA was defined by an AHI ≥15 and classified as untreated (CPAP not prescribed or compliance <4 hours/day), mild-moderate (AHI 15-29), untreated severe (AHI ≥30), and CPAP-treated (AHI ≥15 and CPAP compliance ≥4 hours/day). Results- 859 and 794 elderly patients were included in the stroke and coronary heart disease analyses, respectively. The median (interquartile range) follow-up was 72 (50-88.5) and 71 (51.5-89) months, respectively. Compared with the reference group, the fully adjusted hazard ratios for the incidence of stroke were 3.42 (95% CI, 1.37-8.52), 1.02 (95% CI, 0.41-2.56), and 1.76 (95% CI, 0.62-4.97) for the untreated severe OSA group, CPAP-treated group, and untreated mild-moderate OSA group, respectively. No associations were shown between any of the different OSA groups and coronary heart disease incidence. Conclusions- The incidence of stroke, but not coronary heart disease, is increased in elderly patients with untreated severe OSA. Adequate CPAP treatment may reduce this risk.

Role of sleep apnea and continuous positive airway pressure therapy in the incidence of stroke or coronary heart disease in women.

RATIONALE: It is unknown whether obstructive sleep apnea (OSA) may be a risk factor for incident cardiovascular events in women. OBJECTIVES: We sought to investigate whether OSA increases the incidence of a composite of stroke or coronary heart disease (CHD) in women, and the role of continuous positive airway pressure (CPAP) treatment on this association. METHODS: This was a prospective, observational study conducted in two Spanish teaching hospitals between 1998 and 2007. Consecutive women referred for suspected OSA and free of previous stroke and CHD were analyzed. Women with an apnea-hypopnea index (AHI) less than 10 comprised the control group, and those with an AHI greater than or equal to 10 were diagnosed with OSA and classified as CPAP-treated (adherence ≥ 4 h/d) or untreated (adherence < 4 h/d or not prescribed). The follow-up ended in December 2010. MEASUREMENTS AND MAIN RESULTS: A total of 967 women were studied (median follow-up, 6.8 yr; interquartile range, 5.2-8.2). The untreated OSA group showed a greater incidence rate of the composite outcome than the control group (2.19 vs. 0.54 per 100 person-years; P < 0.0005). Compared with the control group, the fully adjusted hazard ratios for the composite outcome incidence were 2.76 (95% confidence interval [CI], 1.35-5.62) for the untreated OSA group, and 0.91 (95% CI, 0.43-1.95) for the CPAP-treated group. When the type of cardiovascular event was separately assessed, untreated OSA showed a stronger association with incident stroke (adjusted hazard ratio, 6.44; 95% CI, 1.46-28.3) than with CHD (adjusted hazard ratio, 1.77; 95% CI, 0.76-4.09). CONCLUSIONS: In women, untreated OSA is associated with increased incidence of serious cardiovascular outcomes, particularly incident stroke. Adequate CPAP treatment seems to reduce this risk.

Impacto del síndrome de apneas-hipopneas durante el sueño en el anciano / Sleep apnea-hypopnea syndrome impact in the elderly. Towards a specific diagnosis and therapeutic approach

La prevalencia y la gravedad del Síndrome de Apneas-Hipopneas durante el sueño (SAHS) aumentan con la edad. A pesar de ello se trata de una enfermedad infradiagnosticada y actualmente no existe un consenso claro sobre cual debe ser el enfoque diagnóstico y terapéutico de los pacientes de edad avanzada. El número de ancianos está aumentando en nuestro país de manera significativa en los últimos años, así como el número de pacientes de edad avanzada remitidos a las Unidades de Sueño para estudio de un posible SAHS, probablemente como consecuencia de una mayor concienciación de las consecuencias negativas sobre la salud de esta enfermedad. Se estima que una cuarta parte de los estudios de sueño se realiza en pacientes mayores de 65 años y de estos a más de la mitad se les prescribe tratamiento con presión positiva continua en la vía aérea (CPAP) sin una evidencia científica clara que lo justifique. A falta de nuevas recomendaciones específicas, las guías vigentes sostienen que la edad no debe ser un factor limitante a la hora de decidir el tratamiento de los pacientes de edad avanzada. Dado el incremento en la longevidad observado en las últimas décadas en nuestro país, el elevado gasto que supone esta patología y las consecuencias sobre la salud en los individuos que la padecen, descubrir cuál es el diagnóstico y tratamiento más apropiado en los pacientes de edad avanzada con SAHS debe ser un objetivo prioritario en la investigación clínica (AU)

The prevalence and severity of sleep apnea-hypopnea syndrome (SAHS) increases with age. Nevertheless it is an underdiagnosed disease and there is currently no clear consensus on which should be the diagnostic and therapeutic approach in the elderly. In the last few years the elderly population is significantly increasing in our country, and the number of elderly patients referred to the Sleep Unit for suspected SAHS is also increasing, probably due to the increased awareness of the negative consequences of this disease on health. It is estimated that a quarter of the sleep studies are performed in patients older than 65 years and in more than a half of them the treatment with continuous positive airway pressure (CPAP) is prescribed with no clear scientific evidence to support it. In the absence of specific recommendations, current guidelines state that age should not be a limiting factor when deciding on the treatment of elderly patients. Considering the increased longevity observed in recent decades in our country, the high economic cost of this pathology and its consequences on health, it should be a priority in clinical research to find out what is the most appropriate diagnosis and treatment in this age froup (AU)

Long-term continuous positive airway pressure compliance in females with obstructive sleep apnoea.

Continuous positive airway pressure (CPAP) is the treatment of choice for obstructive sleep apnoea (OSA), but compliance and variables involved in long-term CPAP adherence in females with OSA are unknown. We performed an observational study including all consecutive females diagnosed with CPAP who started CPAP treatment in two Spanish teaching hospitals between 1999 and 2007 and were followed-up until December 2010. The Kaplan-Meier method was used to calculate the probability of continuing with CPAP treatment and a multivariate Cox regression analysis was used to identify baseline predictors of CPAP dropout. We analysed 708 females, median (interquartile range) age 60 (52-67) years and apnoea-hypopnoea index 43.0 (27.2-66.8). Females were followed for a median of 6.2 (4.2-7.7) years. The probability of still being on CPAP at 5 and 10 years was 82.8% and 79.9%, respectively. The median CPAP use was 6 (interquartile range 4-7) h · day(-1). In the multivariate analysis, independent baseline predictors of CPAP dropout were psychoactive medication (hazard ratio 1.47, 95% CI 1.03-2.08), age (hazard ratio 1.01, 95% CI 1.00-1.03) and CPAP pressure (hazard ratio 0.89, 95% CI 0.81-0.96). Long-term CPAP adherence in females with OSA is good. Psychoactive medication and increasing age were independent predictors of CPAP dropout, whereas higher CPAP was associated with continued treatment.

Cardiovascular mortality in obstructive sleep apnea in the elderly: role of long-term continuous positive airway pressure treatment: a prospective observational study.

RATIONALE: Obstructive sleep apnea (OSA) is a risk factor for cardiovascular death in middle-aged subjects, but it is not known whether it is also a risk factor in the elderly. OBJECTIVES: To investigate whether OSA is a risk factor for cardiovascular death and to assess whether continuous positive airway pressure (CPAP) treatment is associated with a change in risk in the elderly. METHODS: Prospective, observational study of a consecutive cohort of elderly patients (≥65 yr) studied for suspicion of OSA between 1998 and 2007. Patients with an apnea-hypopnea index (AHI) less than 15 were the control group. OSA was defined as mild to moderate (AHI, 15-29) or severe (AHI, ≥30). Patients with OSA were classified as CPAP-treated (adherence ≥ 4 h/d) or untreated (adherence < 4 h/d or not prescribed). Participants were monitored until December 2009. The end point was cardiovascular death. A multivariate Cox survival analysis was used to determine the independent impact of OSA and CPAP treatment on cardiovascular mortality. MEASUREMENTS AND MAIN RESULTS: A total of 939 elderly were studied (median follow-up, 69 mo). Compared with the control group, the fully adjusted hazard ratios for cardiovascular mortality were 2.25 (confidence interval [CI], 1.41 to 3.61) for the untreated severe OSA group, 0.93 (CI, 0.46 to 1.89) for the CPAP-treated group, and 1.38 (CI, 0.73 to 2.64) for the untreated mild to moderate OSA group. CONCLUSIONS: Severe OSA not treated with CPAP is associated with cardiovascular death in the elderly, and adequate CPAP treatment may reduce this risk.

Cardiovascular mortality in women with obstructive sleep apnea with or without continuous positive airway pressure treatment: a cohort study.

BACKGROUND: Obstructive sleep apnea (OSA) is a risk factor for cardiovascular death in men, but whether it is also a risk factor in women is unknown. OBJECTIVE: To investigate whether OSA is a risk factor for cardiovascular death in women and assess whether continuous positive airway pressure (CPAP) treatment is associated with a change in risk. DESIGN: Prospective, observational cohort study. SETTING: 2 sleep clinics in Spain. PATIENTS: All women consecutively referred for suspected OSA between 1998 and 2007. INTERVENTION: Every woman had a diagnostic sleep study. Women with an apnea-hypopnea index (AHI) less than 10 were the control group. Obstructive sleep apnea was diagnosed when the AHI was 10 or higher (classified as mild to moderate [AHI of 10 to 29] or severe [AHI ≥30]). Patients with OSA were classified as CPAP-treated (adherence ≥4 hours per day) or untreated (adherence <4 hours per day or not prescribed). Participants were followed until December 2009. MEASUREMENTS: The end point was cardiovascular death. RESULTS: 1116 women were studied (median follow-up, 72 months [interquartile range, 52 to 88 months]). The control group had a lower cardiovascular mortality rate (0.28 per 100 person-years [95% CI, 0.10 to 0.91]) than the untreated groups with mild to moderate OSA (0.94 per 100 person-years [CI, 0.10 to 2.40]; P = 0.034) or severe OSA (3.71 per 100 person-years [CI, 0.09 to 7.50]; P < 0.001). Compared with the control group, the fully adjusted hazard ratios for cardiovascular mortality were 3.50 (CI, 1.23 to 9.98) for the untreated, severe OSA group; 0.55 (CI, 0.17 to 1.74) for the CPAP-treated, severe OSA group; 1.60 (CI, 0.52 to 4.90) for the untreated, mild to moderate OSA group; and 0.19 (CI, 0.02 to 1.67) for the CPAP-treated, mild to moderate OSA group. LIMITATION: The study was observational and not randomized, and OSA was diagnosed by 2 different methods. CONCLUSION: Severe OSA is associated with cardiovascular death in women, and adequate CPAP treatment may reduce this risk. PRIMARY FUNDING SOURCE: None.

Clinical efficacy and safety of budesonide-formoterol in non-cystic fibrosis bronchiectasis.

BACKGROUND: The aim of this study is to evaluate the efficacy and safety of medium-dose formoterol-budesonide combined inhaled treatment in a single inhaler compared with high-dose budesonide treatment in patients with non-cystic fibrosis (non-CF) bronchiectasis. METHODS: This is a 12-month randomized, double-blind, parallel-groups clinical trial, to run in 40 patients with non-CF bronchiectasis diagnosed by high-resolution CT scan of the chest, receiving formoterol-budesonide combined treatment (18/640 µg daily) or budesonide treatment (1,600 µg daily). Variables concerning clinical condition, health-related quality of life (HRQL), lung function, ß(2)-adrenergic agonist use, potentially pathogenic microorganism (PPM) isolates, and medication side effects were analyzed by intention-to-treat analysis. RESULTS: The study group receiving a formoterol-budesonide combined treatment showed a significant improvement, both clinically and statistically, of symptoms (dyspnea, number of coughs, and rescue ß(2)-adrenergic agonist-free days). Furthermore, we observed an HRQL improvement, with no changes in functional parameters or in PPM isolates, together with an important reduction in overall side effects, especially for those related to inhaled steroids, compared with the high-dose budesonide treatment group. CONCLUSIONS: Inhaled medium-dose formoterol-budesonide combined treatment in a single inhaler is more effective and safe compared with high-dose budesonide treatment in patients with non-CF bronchiectasis. TRIAL REGISTRY: ClinicalTrials.gov; No.: NCT00728715; URL: www.clinicaltrials.gov.

Tratamiento de las bronquiectasias no debidas a fibrosis quística / Treatment of Non-Cystic Fibrosis Bronchiectasis

Las bronquiectasias presentan actualmente una importancia creciente tanto por el incremento en el número de diagnósticos que se realizan como por el impacto negativo que su presencia supone sobre la enfermedad de base que las genera. Un aspecto fundamental en estos pacientes es la colonización e infección de la mucosa bronquial por microorganismos potencialmente patógenos (MPP), causante en la mayoría de los casos del inicio del proceso inflamatorio crónico que termina con la destrucción y la dilatación del árbol bronquial que caracteriza a estos pacientes. El tratamiento de la colonización y de la infección bronquial crónica en estos pacientes se debe basar en la terapia antibiótica prolongada en sus distintas presentaciones, de las cuales la forma inhalada está adquiriendo un especial protagonismo en los últimos tiempos por su elevada eficacia y su escasa producción de efectos adversos importantes. Sin embargo, no debe pasarse por alto que el manejo del paciente con bronquiectasias debe ser multidisciplinar y multidimensional, dado que además del tratamiento antibiótico es imprescindible el trabajo de diferentes especialidades médicas y quirúrgicas para el manejo de las agudizaciones, los aspectos nutricionales, la fisioterapia respiratoria, la rehabilitación muscular, las complicaciones, la inflamación e hiperreactividad bronquial y la hipersecreción que caracteriza a estos pacientes(AU)

Bronchiectasis is currently growing in importance due to both the increase in the number of diagnoses made as well as the negative impact that its presence has on the baseline disease that generates it. A fundamental aspect in these patients is the colonization and infection of the bronchial mucous by potentially pathogenic microorganisms (PPM), which are the cause in most cases of the start of the chronic inflammatory process that results in the destruction and dilatation of the bronchial tree that is characteristic in these patients. The treatment of the colonization and chronic bronchial infection in these patients should be based on prolonged antibiotic therapy in its different presentations. Lately, the inhaled form is becoming especially prominent due to its high efficacy and limited production of important adverse effects. However, one must not overlook the fact that the management of patients with bronchiectasis should be multidisciplinary and multidimensional. In addition to antibiotic treatment, the collaboration of different medical and surgical specialties is essential for the management of the exacerbations, nutritional aspects, respiratory physiotherapy, muscle rehabilitation, complications, inflammation and bronchial hyperreactivity and the hypersecretion that characterizes these patients(AU)

[Treatment of non-cystic fibrosis bronchiectasis]. / Tratamiento de las bronquiectasias no debidas a fibrosis quística.

Bronchiectasis is currently growing in importance due to both the increase in the number of diagnoses made as well as the negative impact that its presence has on the baseline disease that generates it. A fundamental aspect in these patients is the colonization and infection of the bronchial mucous by potentially pathogenic microorganisms (PPM), which are the cause in most cases of the start of the chronic inflammatory process that results in the destruction and dilatation of the bronchial tree that is characteristic in these patients. The treatment of the colonization and chronic bronchial infection in these patients should be based on prolonged antibiotic therapy in its different presentations. Lately, the inhaled form is becoming especially prominent due to its high efficacy and limited production of important adverse effects. However, one must not overlook the fact that the management of patients with bronchiectasis should be multidisciplinary and multidimensional. In addition to antibiotic treatment, the collaboration of different medical and surgical specialties is essential for the management of the exacerbations, nutritional aspects, respiratory physiotherapy, muscle rehabilitation, complications, inflammation and bronchial hyperreactivity and the hypersecretion that characterizes these patients.

Antibióticos inhalados en el tratamiento de las bronquiectasias no debidas a fibrosis quística / Inhaled antibiotics in the treatment of noncystic fibrosis bronchiectasis

La utilización de antibióticos por vía inhalada en pacientes con bronquiectasias (BQ) no debidas a fibrosisquística (FQ) es una práctica cada vez más habitual. Si bien todavía no hay una indicación formal para su usoen este tipo de pacientes (actualmente sólo existe indicación para pacientes con FQ, y por lo tanto su utilizaciónsigue siendo de uso compasivo en nuestro país para pacientes con BQ no debidas a FQ hasta la llegada deevidencias científicas desde los ensayos clínicos puestos en marcha), los estudios realizados hasta el momentohan demostrado diferentes efectos positivos sobre algunos parámetros clave como la reducción en el númerode colonias, la disminución de la cantidad y purulencia del esputo, la mejoría de la calidad de vida delpaciente y una reducción en el número de agudizaciones, si bien presentan un escaso impacto sobre la pérdidaacelerada de la función pulmonar y un porcentaje variable de erradicaciones con escasa inducción de resistencias.Probablemente la situación más clara para la utilización de antibióticos inhalados en pacientes conBQ no debidas a FQ sea la colonización y, sobre todo, la infección crónica por Pseudomonas aeruginosa. Lagravedad de los efectos adversos suele ser escasa y relacionada con efectos locales irritantes de la vía aérea, sibien su frecuencia es mayor que la observada en los pacientes con FQ. Actualmente se están llevando a cabodiferentes estudios cuyo objetivo será sentar definitivamente las bases de la indicación de la antibioterapiainhalada en estos pacientes. Debido a las especiales características de esta forma de tratamiento (altas concentracioneslocales del fármaco con escasos efectos adversos sistémicos), no cabe duda de que los antibióticosinhalados se presentan como una terapia con un excelente futuro para el manejo ya no sólo de las bronquiectasias,sino también de muchas de las enfermedades de la vía aérea(AU)

Inhaled antibiotics are increasingly used in patients with non-cystic fibrosis (CF) bronchiectasis. Currently,there is no formal indication for the use of this therapy in these patients as inhaled antibiotics are currentlyonly indicated in patients with CF. Therefore, prescription in patients with non-CF bronchiectasis will continueto be based on compassionate use until scientific evidence from ongoing clinical trials becomes available.However, the studies performed to date have shown several positive effects on some key parameters such asa reduction in the number of colonies and the quantity and purulence of sputum, improved quality of life andfewer exacerbations, although this therapy has little impact on accelerated loss of pulmonary function. Thepercentage of eradication varies, with a low rate of resistance. The clearest use of inhaled antibiotics inpatients with non-CF bronchiectasis is probably colonization, especially chronic infection with Pseudomonasaeruginosa. Adverse effects are usually mild and consist of local irritation of the airway, although theirfrequency is greater than that in patients with CF. Currently, various clinical trials are being carried out thataim to establish the indications for inhaled antibiotic therapy in these patients. Due to its special characteristics(high local concentrations of the drug with scarce systemic adverse effects), inhaled antibiotic therapy willundoubtedly be an excellent future option for the management of bronchiectasis, as well as of many otherdiseases of the airways(AU)

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.

Impacto multidimensional de las exacerbaciones de la EPOC / Multidimensional impact of COPD exacerbations

exacerbaciones. Estos episodios de descompensación clínica, que anteriormente se consideraban epifenómenosde la enfermedad, son juzgados hoy como elementos clave en el curso natural de la EPOC por cuanto generanuna gran carga asistencial y enormes costes, impactan de forma negativa sobre la calidad de vida de lospacientes, contribuyen de forma decidida a la progresión multidimensional de la enfermedad y, finalmente,condicionan su pronóstico. El artículo revisa la evidencia científica actual sobre el impacto multidimensionalque ejerce la exacerbación de la EPOC. Sin embargo, esta repercusión debe ser matizada. No todos los pacientessufren agudizaciones y no todas las exacerbaciones tienen las mismas consecuencias. La revisión pone elacento en la necesidad de estandarizar la propia definición de exacerbación y acotar conceptos como el defrecuencia, gravedad o duración del episodio. Estos aspectos condicionan finalmente las consecuencias de lapropia exacerbación e introducen variables que pueden tener incluso connotaciones terapéuticas. De hecho,cada día existe una mayor necesidad de identificar fenotipos clínicos específicos y personalizar el tratamiento.En este sentido, el fenotipo “exacerbador” se postula como una diana terapéutica de especial relevancia(AU)

One of the inherent characteristics of chronic obstructive pulmonary disease (COPD) is the occurrence ofexacerbations. These episodes of clinical decompensation, which used to be considered epiphenomena of thedisease, are now viewed as key elements in the natural history of COPD. Exacerbations generate huge clinicalworkload and enormous costs, impair patients’ quality of life, make a decisive contribution to themultidimensional progression of the disease and affect prognosis. The present article reviews the currentscientific evidence on the multifaceted impact of COPD exacerbations. However, the effects of exacerbationsare not homogeneous. Not all patients suffer exacerbations and not all exacerbations have the samerepercussions. This review highlights the need to standardize the definition of exacerbation, as well as that ofconcepts such as the frequency, severity, and duration of the episode. These factors influence the effect of theexacerbation itself and introduce variables that may affect treatment. Indeed, there is an increasing need toidentify specific clinical phenotypes and personalize treatment. Consequently, an “exacerbating” phenotypeis postulated as a therapeutic target of special importance(AU)