Noninvasive ventilation for severely acidotic patients in respiratory intermediate care units : Precision medicine in intermediate care units.

BACKGROUND: Severe acidosis can cause noninvasive ventilation (NIV) failure in chronic obstructive pulmonary disease (COPD) patients with acute hypercapnic respiratory failure (AHRF). NIV is therefore contraindicated outside of intensive care units (ICUs) in these patients. Less is known about NIV failure in patients with acute cardiogenic pulmonary edema (ACPE) and obesity hypoventilation syndrome (OHS). Therefore, the objective of the present study was to compare NIV failure rates between patients with severe and non-severe acidosis admitted to a respiratory intermediate care unit (RICU) with AHRF resulting from ACPE, COPD or OHS. METHODS: We prospectively included acidotic patients admitted to seven RICUs, where they were provided NIV as an initial ventilatory support measure. The clinical characteristics, pH evolutions, hospitalization or RICU stay durations and NIV failure rates were compared between patients with a pH ≥ 7.25 and a pH < 7.25. Logistic regression analysis was performed to determine the independent risk factors contributing to NIV failure. RESULTS: We included 969 patients (240 with ACPE, 540 with COPD and 189 with OHS). The baseline rates of severe acidosis were similar among the groups (45 % in the ACPE group, 41 % in the COPD group, and 38 % in the OHS group). Most of the patients with severe acidosis had increased disease severity compared with those with non-severe acidosis: the APACHE II scores were 21 ± 7.2 and 19 ± 5.8 for the ACPE patients (p < 0.05), 20 ± 5.7 and 19 ± 5.1 for the COPD patients (p < 0.01) and 18 ± 5.9 and 17 ± 4.7 for the OHS patients, respectively (NS). The patients with severe acidosis also exhibited worse arterial blood gas parameters: the PaCO2 levels were 87 ± 22 and 70 ± 15 in the ACPE patients (p < 0.001), 87 ± 21 and 76 ± 14 in the COPD patients, and 83 ± 17 and 74 ± 14 in the OHS patients (NS)., respectively Further, the patients with severe acidosis required a longer duration to achieve pH normalization than those with non-severe acidosis (patients with a normalized pH after the first hour: ACPE, 8 % vs. 43 %, p < 0.001; COPD, 11 % vs. 43 %, p < 0.001; and OHS, 13 % vs. 51 %, p < 0.001), and they had longer RICU stays, particularly those in the COPD group (ACPE, 4 ± 3.1 vs. 3.6 ± 2.5, NS; COPD, 5.1 ± 3 vs. 3.6 ± 2.1, p < 0.001; and OHS, 4.3 ± 2.6 vs. 3.7 ± 3.2, NS). The NIV failure rates were similar between the patients with severe and non-severe acidosis in the three disease groups (ACPE, 16 % vs. 12 %; COPD, 7 % vs. 7 %; and OHS, 11 % vs. 4 %). No common predictive factor for NIV failure was identified among the groups. CONCLUSIONS: ACPE, COPD and OHS patients with AHRF and severe acidosis (pH ≤ 7.25) who are admitted to an RICU can be successfully treated with NIV in these units. These results may be used to determine precise RICU admission criteria.

[EFFECTS OF WEIGHT LOSS AFTER BARIATRIC SURGERY ON PULMONARY FUNCTION TESTS AND OBSTRUCTIVE SLEEP APNEA IN MORBIDLY OBESE WOMEN]. / EFECTO DE LA PÉRDIDA DE PESO TRAS LA CIRUGÍA BARIÁTRICA SOBRE LA FUNCIÓN RESPIRATORIA Y EL SÍNDROME DE APNEAS-HIPOPNEAS DEL SUEÑO EN MUJERES CON OBESIDAD MÓRBIDA.

INTRODUCTION: obesity impacts on respiratory function and also it acts as a risk factor for obstructive sleep apnea (OSA). AIMS: to study the effects of bariatric surgery on pulmonary function tests and on OSA in morbidly obese women over 4 years. METHODS: fifteen morbidly obese women (mean body mass index [BMI] 50.52 ± 12.71 kg.m-2, mean age 40.13 ± 10.06 years) underwent pulmonary function tests (PFT) in two opportunities (before and after weight loss surgery). PFT included spirometry, body plethysmography and measure of maximal inspiratory mouth pressure (PImax) and of tension-time index for inspiratory muscles. Also, in both opportunities, resting arterial blood gas tensions were evaluated and a full night sleep register was performed. RESULTS: BMI significantly decreased after bariatric surgery (-44.07 kg.m-2 [CI 95% -38.32 - -49.81]). Also, there was a significantly increase in forced expiratory volume in 1 second (FEV1) (p < 0.01), forced vital capacity (FVC) (p < 0.01), expiratory reserve volume (ERV) (p = 0.040), functional residual capacity (FRC) (p = 0.009) and a decline in airways resistance (Raw) (p = 0.018). Concerning sleep registers, apnea hypopnea index (p = 0.001) and desaturation index (p = 0.001) were also reduced after weight loss. Improve in ERV had a significant correlation with weight loss (r = 0.774, p = 0.024). Conclussions: pulmonary function tests and apnea hypopnea index improve after bariatric surgery in mor bidly obese women. Improvement of ERV is well correlated with weight loss.

Introducción: la obesidad afecta a la función respiratoria e incrementa el riesgo de síndrome de apneas-hipopneas del sueño (SAHS). Objetivo: evaluar el efecto de la cirugía bariátrica, en mujeres con obesidad mórbida, sobre la función respiratoria y sobre el índice de apneas-hipopneas (IAH) tras dos años de seguimiento. Métodos: se incluyeron 15 mujeres (índice de masa corporal [IMC] medio 50,52 ± 12,71 kg.m-2, edad media 40,13 ± 10,06 años). Los enfermos fueron analizados en dos fases: previo a la cirugía bariátrica y tras dos años de la misma. En cada visita se valoraron las medidas antropométricas y se realizaron pruebas de función respiratoria consistentes en espirometría, pletismografía, medida de la presión inspiratoria máxima y del índice de tensión-tiempo de los músculos inspiratorios, así como análisis de gases arteriales. Por último, también se efectuó una poligrafía cardiorrespiratoria durante el sueño. Resultados: tras la cirugía bariátrica el IMC disminuyó en 44,07 kg.m-2 (IC 95% 38,32 ­ 49,81). De igual forma, se observaron incrementos significativos en el volumen espiratorio forzado al primer segundo (FEV1) (p < 0,01), la capacidad vital forzada (FVC) (p < 0,01), el volumen de reserva espiratorio (ERV) (p = 0,040), la capacidad funcional residual (FRC) (p = 0,009) y la resistencia de las vías aéreas (Raw) (p = 0,018). Por otra parte, el IAH (p = 0,001) y el índice de desaturación de oxígeno (p = 0,001) disminuyeron tras la cirugía. Se observó una correlación significativa entre el grado de pérdida de peso y el incremento del ERV (0,774, p = 0,024). Conclusiones: tras dos años desde la cirugía bariátrica se siguen observando mejorías significativas en la función respiratoria y en la gravedad del SAHS. La mejoría del ERV estaría en relación directa con los niveles de peso perdido.

Evolución de pacientes con esclerosis lateral amiotrófica atendidos en una unidad multidisciplinar / Outcome of patients with amyotrophic lateral sclerosis attending in a multidisciplinary care unit

Introducción: La esclerosis lateral amiotrófica (ELA) es una enfermedad con muy mal pronóstico, con una mortalidad del 50% a los 18 meses tras el diagnóstico. Las unidades multidisciplinares pretenden mejorar la calidad de vida y la supervivencia de los enfermos de ELA. El objetivo de nuestro estudio es evaluar cada 3 meses la evolución de pacientes atendidos en la unidad de ELA desde el momento del diagnóstico y durante 24 meses. Material y métodos: Se realizó un estudio observacional prospectivo de pacientes atendidos en la unidad de ELA siguiendo una vía clínica desde el momento del diagnóstico y con revisiones trimestrales desde 2006 a 2010. La edad de inicio, el deterioro de la situación funcional (escala ALSFRS-r), el deterioro de la función respiratoria y la aparición de disfagia y de signos de depresión y/o de deterioro cognitivo fueron evaluados en relación con la localización inicial de los síntomas (bulbar [B], miembros superiores [MMSS], miembros inferiores [MMII]). Resultados: 42 pacientes (30V y 12M) fueron evaluados (edad media de inicio±desviación estándar de 57,97±14,56 años). Se encontró una distribución igual por localización de inicio de los síntomas (B 14 pacientes, MMSS 14, MMII 14). El deterioro funcional (B –26,89 pts.; MMSS –22,48 pts.; MMII –22,66 pts.), la necesidad de uso de BIPAP (B 64,28%; MMSS 35,71%, MMII 50%), la presencia de disfagia (B 85,71; MMSS 42.85; MMII 71.42%), de signos de depresión (B 78,57%, MMSS 35,71%; MMII 64,28%) y de deterioro cognitivo (B 42,85%; MMSS 21,42; MMII 35,71%) fue mayor a los 24 meses de evolución en los pacientes de inicio bulbar. No hubo diferencias en los datos de mortalidad (global 23,80%). Conclusiones: El tratamiento en unidades multidisciplinares no varía la evolución neurológica de la enfermedad pero favorece la aplicación de cuidados multidisciplinares e incrementa la supervivencia de los enfermos de ELA independientemente de su forma de inicio (AU)

Introduction: Amyotrophic lateral sclerosis (ALS) is a disease with very poor prognosis, and a mortality of 50% at 18 months after diagnosis. Multidisciplinary units attempt to improve the quality of life and survival of patients with ALS. The aim of this study is to evaluate every 3 months, over a 24-month period, the outcome of patients treated at the ALS unit since the time of diagnosis. Material and methods: We performed a prospective observational study of patients treated in the ALS unit following a clinical pathway since the time of diagnosis with quarterly reviews from 2006 to 2010. The age of onset, functional impairment (ALSFRS-r), impairment of respiratory function, dysphagia and signs of depression and/or cognitive impairment were evaluated in relation to the initial location symptoms (bulbar [B], upper limbs [UL], lower limbs [LL]). Results: A total of 42 patients (30 males and 12 females) were evaluated (mean age at onset of 57.97years old, SD 14.56). There was an even distribution by location of onset of symptoms (B 14 patients, UL 14, LL 14.) Functional impairment (B –26,89 points, UL –22,48 points, LL –22,66 points), the need for use of BIPAP (B 64.28%; UL 35.71%; LL 50%), the presence of dysphagia (B 85.71; UL 42.85; LL 71.42%), signs of depression (B 78.57%; UL 35.71%; LL 64.28%) and cognitive impairment (B 42.85%; UL 21.42; LL 35.71%) was higher at 24 months of progression in patients with bulbar onset. There was no difference in mortality data (23.80% overall). Conclusions: The treatment in multidisciplinary units does not change the neurological progression of the disease, but increases the survival of ALS patients regardless of their initial onset, emphasising the use of multidisciplinary care (AU)

Outcome of patients with amyotrophic lateral sclerosis attending in a multidisciplinary care unit.

INTRODUCTION: Amyotrophic lateral sclerosis (ALS) is a disease with very poor prognosis, and a mortality of 50% at 18 months after diagnosis. Multidisciplinary units attempt to improve the quality of life and survival of patients with ALS. The aim of this study is to evaluate every 3 months, over a 24-month period, the outcome of patients treated at the ALS unit since the time of diagnosis. MATERIAL AND METHODS: We performed a prospective observational study of patients treated in the ALS unit following a clinical pathway since the time of diagnosis with quarterly reviews from 2006 to 2010. The age of onset, functional impairment (ALSFRS-r), impairment of respiratory function, dysphagia and signs of depression and/or cognitive impairment were evaluated in relation to the initial location symptoms (bulbar [B], upper limbs [UL], lower limbs [LL]). RESULTS: A total of 42 patients (30 males and 12 females) were evaluated (mean age at onset of 57.97 years old, SD 14.56). There was an even distribution by location of onset of symptoms (B 14 patients, UL 14, LL 14.) Functional impairment (B -26,89 points, UL -22,48 points, LL -22,66 points), the need for use of BIPAP (B 64.28%; UL 35.71%; LL 50%), the presence of dysphagia (B 85.71; UL 42.85; LL 71.42%), signs of depression (B 78.57%; UL 35.71%; LL 64.28%) and cognitive impairment (B 42.85%; UL 21.42; LL 35.71%) was higher at 24 months of progression in patients with bulbar onset. There was no difference in mortality data (23.80% overall). CONCLUSIONS: The treatment in multidisciplinary units does not change the neurological progression of the disease, but increases the survival of ALS patients regardless of their initial onset, emphasising the use of multidisciplinary care.

Síndrome de Swyer-James-McLeod; descripción de un caso y breve revisión de la literatura / Swyer-James-McLeod Syndrome: a case report and brief review of the literature

Resumen. El síndrome de Swyer-James-McLeod se caracteriza por ser una patología adquirida, generalmente de causa infecciosa, en las primeras etapas de la vida. Ello provoca una hipoplasia del pulmón afectado, con características anatomopatológicas que se describen como una bronquiolitis obliterante adquirida. La clínica que presentan los pacientes es muy variada, desde formas paucisintomáticas hasta cuadros graves con infecciones respiratorias severas de repetición (AU)

Abstract. The Swyer-James-McLeod syndrome is characterized by being an acquired condition, generally due to an infectious cause, in the early stages of life. It causes hypoplasia of the affected lung, with anatomic-pathological characteristics that are described as acquired bronchiolitis obliterans. The symptoms presented by the patients vary greatly, going from paucisymptomatic forms to severe pictures with recurrent severe respiratory infections (AU)

[Effective long-term noninvasive ventilation of a woman with kyphoscoliosis and sinus venosus atrial septal defect]. / Eficacia de la ventilación no invasiva a largo plazo en una paciente con cifoscoliosis asociada a comunicación interauricular tipo seno venoso.

Atrial septal defects comprise one of the most common congenital cardiac malformations in adults and adolescents. However, such septal defects are rarely associated with chest wall diseases. When they are, respiratory failure soon develops and is severe. Cases in which the long-term course of disease is favorable with noninvasive ventilation have not been reported in the literature. We present the case of a 71-year-old woman with kyphoscoliosis, sinus venosus atrial septal defect, severe pulmonary hypertension, respiratory failure, and heart failure. We describe her response to treatment with noninvasive mechanical ventilation.

[Evaluation of a home hospitalization program in patients with exacerbations of chronic obstructive pulmonary disease]. / Evaluación de un programa de hospitalización domiciliaria en pacientes con EPOC agudizada.

OBJECTIVE: We carried out a randomized controlled trial to evaluate the efficacy of a home hospitalization (HH) program for patients hospitalized for exacerbation of chronic obstructive pulmonary disease (COPD). PATIENTS AND METHODS: Patients who were clinically stable and had stable arterial blood gases were randomized to the conventional hospitalization group or the HH group. RESULTS: Of the 88 patients evaluated, 40 (20 in each group) were enrolled. No differences were observed in baseline characteristics, in clinical recovery, or arterial blood gases between the 2 groups at discharge. At 1-month follow up there were no differences in mortality or in the number of readmissions. The mean length of hospitalization in patients with HH was 9.2 days (4 days in hospital and 5 days at home), compared to 12.2 days in patients with conventional hospitalization. CONCLUSIONS: Our results show that a hospital-supervised HH program including the participation of pneumologists and nursing staff allows for the recovery of patients hospitalized for exacerbation of COPD who have stable symptoms and arterial blood gases with no increase in the rate of readmission, relapse, or therapeutic failure.

[Aberrant left subclavian artery associated with Kommerell's diverticulum: chance finding in a 75-year-old patient]. / Arteria subclavia izquierda aberrante asociada a divertículo de Kommerell. Hallazgo casual en un paciente de 75 años.

The most common anomaly of the aortic arch is the occurrence of a left aortic arch with an aberrant right subclavian artery. Other, less common anomalies have also been described. These include the occurrence of a right aortic arch with an aberrant left subclavian artery that, in addition, has a diverticulum at its site of origin known as Kommerell's diverticulum. All cases described in the literature have occurred in individuals younger than 35 years of age, generally with symptoms related to tracheal or esophageal compression. We present the case of a patient diagnosed by chance with this rare anomaly at 75 years of age.

Arteria subclavia izquierda aberrante asociada a divertículo de Kommerell. Hallazgo casual en un paciente de 75 años / Aberrant left subclavian artery associated with Kommerell's diverticulum: chance finding in a 75-year-old patient

La anomalía del arco aórtico más frecuente es la existencia de un arco aórtico izquierdo acompañado de una arteria subclavia derecha aberrante. Se han descrito otras anomalías más raras, entre las que se encuentra la existencia de un arco aórtico derecho asociado a una arteria subclavia izquierda aberrante que, además, tiene en su origen un divertículo, denominado divertículo de Kommerell. Todos los casos descritos en la bibliografía se han producido en sujetos menores de 35 años, generalmente con síntomas relacionados con compresión traqueal o esofágica. Presentamos el caso de un paciente diagnosticado de esta rara anomalía de forma casual a la edad de 75 años

The most common anomaly of the aortic arch is the occurrence of a left aortic arch with an aberrant right subclavian artery. Other, less common anomalies have also been described. These include the occurrence of a right aortic arch with an aberrant left subclavian artery that, in addition, has a diverticulum at its site of origin known as Kommerell’s diverticulum. All cases described in the literature have occurred in individuals younger than 35 years of age, generally with symptoms related to tracheal or esophageal compression. We present the case of a patient diagnosed by chance with this rare anomaly at 75 years of age

[Aerophagia due to noninvasive mechanical ventilation: a first manifestation of silent gastric carcinoma]. / Aerophagia due to noninvasive mechanical ventilation: a first manifestation of silent gastric carcinoma.

Noninvasive mechanical ventilation (NIV) techniques have proven useful in treating patients with respiratory insufficiency of various etiologies. The problems most frequently associated with this ventilatory technique are the appearance of nasal and oropharyngeal dryness, pressure sores where the nasal mask touches the skin, ocular irritation due to air leakage and epistaxis. Aerophagia appears in up to half the patients with NIV and may lead to discontinuing treatment. Drugs that accelerate gastrointestinal transit, changes in the respirator settings or changing the ventilatory modality may help to ameliorate the problem. When the symptoms arising from abdominal distension due to NIV are intense and persistent, the coexistence of an underlying abdominal pathology must be ruled out. We report the cases of two patients with these characteristics in whom gastroscopy revealed gastric carcinoma. We think that patients with persistent symptoms of aerophagia that cannot be controlled by the usual measures should undergo endoscopic exploration to rule out silent gastric disease.

Evolución de la esclerosis lateralamiotrófica a través de la funciónpulmonar / The progression of amyotrophic lateral sclerosis: respiratory function

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Aerofagia por ventilación mecánica no invasiva:primera manifestación de un carcinoma gástrico silente / Aerophagia due to noninvasive mechanical ventilation: a first manifestation of silent gastric carcinoma

Las técnicas de ventilación mecánica no invasiva (VNI) han demostrado su utilidad en el tratamiento de pacientes con insuficiencia respiratoria de diverso origen. Los problemas más frecuentemente relacionados con esta modalidad ventilatoria son la aparición de sequedad nasal y orofaríngea, lesiones cutáneas en los puntos de apoyo de la mascarilla nasal, irritación ocular por fuga aérea y epistaxis. La aerofagia aparece hasta en la mitad de los pacientes con VNI y puede ser motivo de abandono del tratamiento. Fármacos que aceleran el tránsito gastrointestinal, modificaciones en la regulación del respirador y cambios de la modalidad ventilatoria pueden ayudar a mejorar este problema. Cuando los síntomas derivados de la distensión abdominal por VNI son intensos y persistentes, se debe excluir la coexistencia de patología abdominal subyacente. Presentamos el caso de dos pacientes con estas características a quienes se les realizó una gastroscopia que objetivó la existencia de un carcinoma gástrico. Pensamos que en los pacientes con síntomas persistentes por aerofagia, que no se controlan con las medidas habituales, es preciso realizar una endoscopia digestiva con objeto de descartar la existencia de patología gástrica silente (AU)

[Analysis of logistical and organizational aspects of a cruise for patients with chronic respiratory insufficiency. The RESpIRA Expedition and the COPD Cruise]. / Análisis de los aspectos logísticos y organizativos de un crucero para pacientes con insuficiencia respiratoria crónica. La Expedición RESpIRA y el Crucero de la EPOC.

Patients with chronic respiratory insufficiency who are receiving domiciliary oxygen therapy and mechanical ventilation report great difficulty in taking complex trips involving several destinations and prolonged stays away from home. Such patients share a common need for home equipment whose technology is relatively sophisticated, a condition that limits their freedom of movement. We are referring to systems for delivering oxygen therapy and mechanical respirators. Given that such patients have problems traveling by air, we hypothesized that a cruise would be an ideal alternative, given that travel would take place in the hotel itself. A cruise would facilitate the logistics of the journey, given that the equipment would have to be set up at only one setting. Working with these assumptions, we have thus far organized two cruises for chronic respiratory insufficiency patients: the "RESpIRA Expedition" and the "COPD Cruise". Our experience shows that the organizational problems to be coped with are patient recruitment, financing and choice of itinerary. With those aspects clear, organizers must then obtain the authorization of the cruise operator, including the approval of the medical and safety personnel on board. After obtaining permission for the cruise and as soon as the organizers know how many patients will travel, a list of oxygen therapy equipment (respirators and disposable supplies) must be compiled. Finally, equipment suppliers must be found. Afterwards, all that remains is to enjoy the trip. The participation of physicians responsible for domiciliary oxygen therapy and mechanical ventilation programs is essential for making patients feel safe and for assuring solutions for technical and medical problems that might arise.

Análisis de los aspectos logísticos y organizativosde un crucero para pacientes con insuficiencia respiratoriacrónica. La Expedición RESpIRA y el Crucero de la EPOC / Analysis of logistical and organizational aspects of a cruise for patients with chronic respiratory insufficiency. The RESpIRA Expedition and the COPD Cruise

Los pacientes con insuficiencia respiratoria crónica incluidos en programas de oxigenoterapia y ventilación mecánica domiciliaria refieren tener habitualmente grandes dificultades para realizar viajes complejos que impliquen diferentes destinos y permanencias prolongadas fuera de su domicilio habitual. Todos ellos tienen en común la necesidad de disponer de un equipamiento tecnológico más o menos sofisticado en casa que limita su libertad de movimientos. Hablamos de los sistemas de oxigenoterapia y respiradores mecánicos. Dadas las dificultades para viajar en avión que tienen este tipo de pacientes, nos planteamos que un crucero sería una alternativa ideal al ser el hotel el que se desplaza. Ello facilitaría la logística del viaje, pues sólo tendríamos que realizar la instalación de los equipos en un único emplazamiento. Con estas premisas hemos organizado hasta la fecha 2 cruceros para enfermos respiratorios crónicos, la Expedición RESpIRA y el Crucero de la EPOC. En nuestra experiencia, los problemas a los que debemos enfrentarnos a la hora de organizar un crucero para pacientes con insuficiencia respiratoria crónica se relacionan con el reclutamiento de pacientes, la financiación del viaje y la elección del itinerario que vamos a realizar. Una vez aclarados estos aspectos, hay que conseguir la autorización de la compañía naviera correspondiente, con el visto bueno de los servicios médicos y de seguridad de a bordo. Tras obtener el permiso para poder realizar el crucero y una vez que sepamos cuántos pacientes van a viajar, es necesario conocer qué material vamos a necesitar en términos de número de equipos de oxigenoterapia, respiradores y material fungible y, finalmente, dónde lo vamos a conseguir. Después sólo quedará disfrutar de la excursión. La participación de los médicos responsables de los programas de oxigenoterapia y ventilación mecánica domiciliaria es fundamental para transmitir seguridad a los pacientes y garantizar la solución de los problemas técnicos y médicos que pueden presentarse durante el viaje (AU)

Aplicaciones de la ventilación mecánica no invasiva en pacientes que reciben ventilación endotraqueal / Applications of non-invasive ventilation in patients with andotracheal ventilation

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[Evolution of Spanish scientific production in international respiratory system journals from 1987 to 1998]. / Evolución de la producción científica española en revistas internacionales de sistema respiratorio de 1987 a 1998.

BACKGROUND: A relevant increase in the clinical relevance of respiratory system area has occurred in the last few years. The aims of this study were: to analyze the evolution of production and impact of Spanish scientific activity in the respiratory system area between 1987 to 1998; and to assess the participation of the different Spanish autonomic communities in this activity. METHODS: Papers published in 38 international journals of respiratory system during this period of time were selected by the MedLine system, delimiting Spanish production. Geographical and institutional distribution of the production, specialist of authors, main publication journals and type of publication were recorded. Production and impact bibliometric indicators were estimated. RESULTS: The number of Spanish documents from 1987 to 1998 multiplied by eight, reaching the 1.49% of the total published documents in 1998. However, the growth model of scientific production during this period was lineal. The increase in the scientific production was associated with a increase over time in the expected impact factor. In 1998, expected impact factor was 2. 206. Forty-two percent of the papers were signed by pneumologists. The highest contributor were hospitals. The most productive autonomous communities were Catalonia, Cantabria and Madrid. The communities with the highest expected impact factor were Balears and Catalonia. CONCLUSIONS: A relevant increase has occurred in the scientific production and impact of Spanish biomedical activity in respiratory system area.