Quality indicators of asthma care derived from the Spanish Guidelines for Asthma Management (GEMA 4.0): a multidisciplinary team report

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Dissociation of lung function, dyspnea ratings and pulmonary extension in bronchiectasis.

UNLABELLED: Bronchiectasis is a heterogeneous disease in terms of its clinical and functional presentation. Some isolated parameters have been used to assess the severity of bronchiectasis or its response to treatment. A study was undertaken to evaluate whether lung function, dyspnea and extension of the disease are separate entities in the impact of bronchiectasis upon patients using factor analysis. Patients with bronchiectasis diagnosed by high-resolution computed tomography (HRCT) and airflow obstruction defined by FEV1/FVC<70% were included. Data were collected relating to clinical history, three different clinical ratings of dyspnea (Medical Research Council (MRC), Borg scale and Basal Dyspnea Index), the extent of bronchiectasis and functional variables. A total of 81 patients (mean age (SD): 69.5 (8.7)) years were included. The degree of dyspnea (MRC) was 1.9 (0.8). Mean FEV1 was 1301 ml (56.9% pred.). Four factors were found that accounted for 84.1% of the total data variance. Factor 1 (45.6% of the data variance) included the three measurements of dyspnea. Factor 2 (16% variance) comprised airflow obstruction parameters (FEV1, FEV1/FVC and PEF). Factor 3 (13.8% variance) included RV/TLC and RV (lung hyperinflation). Factor 4 (8.6% variance) included bronchiectasis extent. Dyspnea was more closely correlated with lung hyperinflation (r:0.33-0.54) than with airflow obstruction parameters (r:0.17-0.26). CONCLUSIONS: Airflow obstruction, dyspnea, lung hyperinflation and the lung extent of the bronchiectasis are four independent entities in the impact of bronchiectasis upon patients.

[Can home prophylaxis for venous thromboembolism reduce mortality rates in patients with chronic obstructive pulmonary disease?]. / Puede reducir la mortalidad de los pacientes con EPOC la profilaxis domiciliaria de la enfermedad tromboembólica venosa?

OBJECTIVE: The incidence of venous thromboembolism (VTE) in patients with chronic obstructive pulmonary disease (COPD) ranges from 20% to 60% in different studies and the mortality rates are higher for patients with both conditions. Heparin prophylaxis is therefore usually prescribed for COPD patients who are hospitalized for exacerbation. Once their situation becomes stable, however, they are discharged to home without prophylaxis even though the low level of physical activity their disease allows continues to put them at risk for VTE. The aim of this study was to test the efficacy of home heparin prophylaxis on reducing the incidence of VTE and on the overall mortality rate in patients with severe COPD. PATIENTS AND METHODS: We conducted a prospective, randomized controlled trial of 87 patients with severe COPD who required home oxygen therapy (> or =18 h/d) and whose physical activity was highly restricted. A total of 44 patients received low molecular weight heparin (3500 IU/d of bemiparin) subcutaneously for 6 months. The outcome measures were incidence of VTE and mortality at 3 and 6 months. RESULTS: Four patients (9.1%) died in the heparin group and 9 (20.4%) died in the control group; the difference was not statistically significant (P=.23). VTE without pulmonary embolism developed in 1 patient (2%) in each group. Slight bleeding complications appeared in 9 patients (20.4%) in the heparin group and 1 patient (2.3%) in the control group, a difference that was statistically significant (P=.015). CONCLUSIONS: Home prophylaxis with heparin does not reduce the incidence of VTE or overall mortality in patients with severe COPD.

¿Puede reducir la mortalidad de los pacientes con EPOC la profilaxis domiciliaria de la enfermedad tromboembólica venosa? / Can home prophylaxis for venous thromboembolism reduce mortality rates in patients with Chronic Obstructive Pulmonary disease?

Objetivo: La incidencia de enfermedad tromboembólica venosa (ETV) en pacientes con enfermedad pulmonar obstructiva crónica (EPOC) oscila entre el 20 y el 60% según las series, y la mortalidad por ETV es superior en estos enfermos. Por ello suele prescribirse profilaxis con heparina a los pacientes con EPOC hospitalizados por una agudización. Sin embargo, una vez que se estabiliza su situación, se les remite a su domicilio sin dicha profilaxis, a pesar de que la escasa actividad física que les permite su enfermedad sigue constituyendo un factor de riesgo para la aparición de ETV. El objetivo de este estudio ha sido analizar si la profilaxis domiciliaria con heparina reduce la aparición de ETV y la mortalidad global en los enfermos con EPOC evolucionada. Pacientes y métodos: Se ha realizado un ensayo clínico prospectivo aleatorizado con 87 pacientes afectados de EPOC grave que precisaban oxigenoterapia domiciliaria (18 h o más al día), con una alta limitación de la actividad física. Un total de 44 sujetos recibió heparina de bajo peso molecular (HBPM; 3.500 U/día de bemiparina) por vía subcutánea durante 6 meses. Las variables estudiadas fueron la incidencia de ETV y la mortalidad a los 3 y 6 meses. Resultados: Durante el estudio fallecieron 4 pacientes del grupo que recibió HBPM (9,1%) y 9 del grupo control (20,4%); las diferencias entre ambos grupos no fueron estadísticamente significativas (p = 0,23). Presentó trombosis venosa profunda sin embolia pulmonar un paciente de cada grupo (2%). Aparecieron complicaciones hemorrágicas leves en 9 pacientes del grupo con HBPM (20,4%), frente a una en el grupo control (2,3%), diferencia que fue estadísticamente significativa (p = 0,015). Conclusiones: La profilaxis domiciliaria con heparina no reduce la aparición de ETV ni la mortalidad global en los pacientes con EPOC avanzada

Objective: The incidence of venous thromboembolism (VTE) in patients with chronic obstructive pulmonary disease (COPD) ranges from 20% to 60% in different studies and the mortality rates are higher for patients with both conditions. Heparin prophylaxis is therefore usually prescribed for COPD patients who are hospitalized for exacerbation. Once their situation becomes stable, however, they are discharged to home without prophylaxis even though the low level of physical activity their disease allows continues to put them at risk for VTE. The aim of this study was to test the efficacy of home heparin prophylaxis on reducing the incidence of VTE and on the overall mortality rate in patients with severe COPD. Patients and methods: We conducted a prospective, randomized controlled trial of 87 patients with severe COPD who required home oxygen therapy (>=18 h/d) and whose physical activity was highly restricted. A total of 44 patients received low molecular weight heparin (3500 IU/d of bemiparin) subcutaneously for 6 months. The outcome measures were incidence of VTE and mortality at 3 and 6 months. Results: Four patients (9.1%) died in the heparin group and 9 (20.4%) died in the control group; the difference was not statistically significant (P=.23). VTE without pulmonary embolism developed in 1 patient (2%) in each group. Slight bleeding complications appeared in 9 patients (20.4%) in the heparin group and 1 patient (2.3%) in the control group, a difference that was statistically significant (P=.015). Conclusions: Home prophylaxis with heparin does not reduce the incidence of VTE or overall mortality in patients with severe COPD

[Changes in spirometric parameters and arterial oxygen saturation during a mountain ascent to over 3000 meters]. / Cambios espirométricos y en la saturación arterial de oxígeno durante la ascensión a una montaña de más de 3.000 metros.

OBJECTIVE: To ascertain whether climbing a mountain over 3000 meters high produces any alterations in ventilation, whether such alterations are modified by acclimatization, and whether they correlate with changes in arterial oxygen saturation (SaO2) or the development of acute mountain sickness (AMS). SUBJECTS AND METHODS: The following parameters were measured in 8 unacclimatized mountaineers who climbed Aneto (3404 m) and spent 3 days at the summit: forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), airway response to inhaled terbutaline, SaO2, and the symptoms of AMS. RESULTS: At the summit, mean (SD) FEV1 declined by 12.3% (5.7%) and mean FVC by 7.6% (6.7%) while the ratio of FEV1 to FVC remained normal. The means for both parameters were higher on the following day. No airway response to bronchodilator treatment was observed. The restriction disappeared entirely on descent. At the peak, SaO2 increased progressively as the climbers became acclimatized. During the ascent, FEV1 correlated with SaO2 (r=0.79). One participant who suffered from AMS had a ratio of FEV1 to FVC less than 70% and the worst SaO2 during the 3 days on the summit. Obstruction preceded the AMS symptoms, did not respond to bronchodilator treatment, and disappeared when the climber descended. CONCLUSIONS: The mountaineers who climbed over 3000 meters presented restriction that correlated with hypoxemia. This restriction did not respond to bronchodilator treatment, improved with acclimatization, and disappeared on descent. One person with AMS presented obstruction that did not respond to terbutaline and disappeared on descent.

Cambios espirométricos y en la saturación arterial de oxígeno durante la ascensión a una montaña de más de 3.000 metros / Changes in spirometric parameters and arterial oxygen saturation during a mountain ascent to over 3000 meters

Objetivo: Averiguar si en la ascensión a una montaña de más de 3.000 m se produce alguna alteración ventilatoria, si ésta se modifica por la aclimatación y si se relaciona con los cambios en la saturación arterial de oxígeno (SaO2) o con la aparición de síntomas de mal de montaña agudo (MAM). Sujetos y métodos: En 8 montañeros no aclimatados que ascendieron a la cumbre del Aneto (3.404 m) y permanecieron 3 días en ella medimos: la capacidad vital forzada (FVC), el volumen espiratorio forzado en el primer segundo (FEV1), la respuesta a la inhalación de terbutalina, la SaO2 y los síntomas de MAM. Resultados: Al llegar a la cumbre disminuyeron el FEV1 (12,3 ± 5,7%) y la FVC (7,6 ± 6,7%) con la relación FEV1/FVC% normal. Al día siguiente aumentaron ambos parámetros. No hubo respuesta al tratamiento broncodilatador. La restricción se corrigió totalmente al descender. La SaO2 en la cumbre aumentó progresivamente con la aclimatación. Durante la ascensión el FEV1 se correlacionó con la SaO2 (r = 0,79). Un participante con MAM presentó FEV1/FVC menor del 70% y la peor SaO2 durante la estancia en la cima. Esta obstrucción precedió a los síntomas, no cedió con tratamiento broncodilatador y se corrigió con el descenso. Conclusiones: Los montañeros que ascienden a montañas de más de 3.000 m presentan una restricción que se correlaciona con la hipoxemia, no mejora con el tratamiento broncodilatador, se alivia con la aclimatación y desaparece con el descenso. Un sujeto con MAM sufrió una obstrucción que no respondió a la terbutalina y desapareció con el descenso

Objective: To ascertain whether climbing a mountain over 3000 meters high produces any alterations in ventilation, whether such alterations are modified by acclimatization, and whether they correlate with changes in arterial oxygen saturation (SaO2) or the development of acute mountain sickness (AMS). Subjects and methods: The following parameters were measured in 8 unacclimatized mountaineers who climbed Aneto (3404 m) and spent 3 days at the summit: forced vital capacity (FVC), forced expiratory volume in 1 second (FEV1), airway response to inhaled terbutaline, SaO2, and the symptoms of AMS. Results: At the summit, mean (SD) FEV1 declined by 12.3% (5.7%) and mean FVC by 7.6% (6.7%) while the ratio of FEV1 to FVC remained normal. The means for both parameters were higher on the following day. No airway response to bronchodilator treatment was observed. The restriction disappeared entirely on descent. At the peak, SaO2 increased progressively as the climbers became acclimatized. During the ascent, FEV1 correlated with SaO2 (r=0.79). One participant who suffered from AMS had a ratio of FEV1 to FVC less than 70% and the worst SaO2 during the 3 days on the summit. Obstruction preceded the AMS symptoms, did not respond to bronchodilator treatment, and disappeared when the climber descended. Conclusions: The mountaineers who climbed over 3000 meters presented restriction that correlated with hypoxemia. This restriction did not respond to bronchodilator treatment, improved with acclimatization, and disappeared on descent. One person with AMS presented obstruction that did not respond to terbutaline and disappeared on descent

Repercusión de la EPOC sobre el estado de salud / No disponible

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¿Agonistas adrenérgicos beta2 de acción prolongada como primera elección? / No disponible

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[Internal consistency and validity of the Spanish version of the St. George's respiratory questionnaire for use in patients with clinically stable bronchiectasis]. / Consistencia interna y validez de la versión española del St. George's Respiratory Questionnaire para su uso en pacientes afectados de bronquiectasias clínicamente estables.

OBJECTIVE: To analyze the reliability and validity of the St. George's Respiratory Questionnaire (SGRQ) for use in patients with clinically stable bronchiectasis. MATERIAL AND METHODS: The SGRQ (50 items on 3 scales--symptoms, activity, and impact) was administered to 102 patients (mean [SD] age, 69.5 [8.7] years; 63% men) with clinically stable bronchiectasis. Disease severity was classified according parameters such as airflow obstruction (forced expiratory volume in 1 second), colonization by Pseudomonas aeruginosa, extent of bronchiectasis, symptoms, daily quantity of sputum, and number of exacerbations. Internal consistency (Cronbach's alpha and correlation between items and between item and scale), concurrent validity (correlation between items and clinical variables), predictive validity (correlation between items and severity), and construct validity (factorial analysis of main components) were assessed. RESULTS: The internal consistency of the SGRQ was excellent (Cronbach's alpha between 0.81 and 0.87 for the different scales, and 0.90 for the overall score). Concurrent validity was high, as correlations between items and clinical variables were significant and followed the expected distribution. The SGRQ differentiated between degrees of disease severity, regardless of the clinical variable used. The factorial analysis showed a construct of 4 factors that were only moderately similar to the original structure of the questionnaire, due mainly to inclusion of a small number of questions with conditioned response and others with low discriminatory capacity. CONCLUSIONS: The SGRQ shows excellent concurrent and predictive internal consistency and validity, though restructuring of the original construct would be advisable before use in patients with stable bronchiectasis.

Consistencia interna y validez de la versión española del St. George’s Respiratory Questionnaire para su uso en pacientes afectados de bronquiectasias clínicamente estables / Internal consistency and validity of the spanish version of the St. George´s Respiratory Questionnaire for use in patients with clinically stable bronchiectasis

OBJETIVO: Analizar la fiabilidad y validez del St. George’s Respiratory Questionnaire (SGRQ) para su uso en pacientes afectados de bronquiectasias estables. MATERIAL Y MÉTODOS: El SGRQ (50 ítems en 3 escalas: síntomas, actividad e impacto) se administró a 102 pacientes (edad media ± desviación estándar de 69,5 ± 8,7 años; 63% varones) con bronquiectasias clínicamente estables. Se clasificó la gravedad según diferentes parámetros: obstrucción al flujo respiratorio (volumen espiratorio forzado en el primer segundo), colonización por Pseudomonas aeruginosa, extensión de las bronquiectasias, síntomas, cantidad de esputo diario y número de agudizaciones. Se calcularon la consistencia interna (alfa de Cronbach y correlación ítem-ítem e ítems-escala), la validez concurrente (correlación ítems-variables medidas), la validez predictiva (correlación ítems-parámetros de gravedad) y la validez de constructo (análisis factorial de componentes principales). RESULTADOS: La consistencia interna del SGRQ fue excelente (alfa de Cronbach entre 0,81 y 0,87 para las distintas escalas, y 0,90 para la puntuación total). La validez concurrente fue elevada, ya que las correlaciones ítems-variables medidas fueron significativas y se distribuyeron de la forma prevista. El SGRQ permitió diferenciar adecuadamente los distintos grados de gravedad de la enfermedad independientemente de los parámetros utilizados. El análisis factorial mostró un constructo de 4 factores que se asemejaba tan solo de forma moderada a la estructura original del cuestionario, sobre todo por la inclusión de preguntas con bajo porcentaje de respuestas obligadas y otras con bajo poder discriminatorio. CONCLUSIONES: El SGRQ presenta una excelente consistencia interna y validez tanto concurrente como predictiva, si bien sería recomendable una reestructuración previa del constructo original para su uso en pacientes con bronquiectasias estables

OBJECTIVE: To analyze the reliability and validity of the St. George’s Respiratory Questionnaire (SGRQ) for use in patients with clinically stable bronchiectasis. MATERIAL AND METHODS: The SGRQ (50 items on 3 scales— symptoms, activity, and impact) was administered to 102 patients (mean [SD] age, 69.5 [8.7] years; 63% men) with clinically stable bronchiectasis. Disease severity was classified according parameters such as airflow obstruction (forced expiratory volume in 1 second), colonization by Pseudomonas aeruginosa, extent of bronchiectasis, symptoms, daily quantity of sputum, and number of exacerbations. Internal consistency (Cronbach’s alpha and correlation between items and between item and scale), concurrent validity (correlation between items and clinical variables), predictive validity (correlation between items and severity), and construct validity (factorial analysis of main components) were assessed. RESULTS: The internal consistency of the SGRQ was excellent (Cronbach’s alpha between 0.81 and 0.87 for the different scales, and 0.90 for the overall score). Concurrent validity was high, as correlations between items and clinical variables were significant and followed the expected distribution. The SGRQ differentiated between degrees of disease severity, regardless of the clinical variable used. The factorial analysis showed a construct of 4 factors that were only moderately similar to the original structure of the questionnaire, due mainly to inclusion of a small number of questions with conditioned response and others with low discriminatory capacity. CONCLUSIONS: The SGRQ shows excellent concurrent and predictive internal consistency and validity, though restructuring of the original construct would be advisable before use in patients with stable bronchiectasis

Hiperrespuesta bronquial en el asma. Patogenia y medición / No disponible

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[How can we assess the perception of induced dyspnea in chronic obstructive pulmonary disease?]. / Cómo valorar la percepción de la disnea inducida en la EPOC?

OBJECTIVE: To evaluate various methods for studying the perception of dyspnea in chronic obstructive pulmonary disease (COPD) using a new parameter, the change in Borg scale rating, and others already in use: the linear regression slope and the application of Stevens' law to the response perception curve--ie change in forced expiratory volume in 1 second (delta FEV1)--change in dyspnea (delta dyspnea). PATIENTS AND METHODS: A bronchial challenge test was performed on 70 patients with stable COPD and no contraindications for performing the test (European Respiratory Society criteria), during which dyspnea was measured (Borg scale) after each nebulization. Perception was analyzed using: a) the linear regression slope of delta FEV1 plotted against (delta dyspnea); b) the exponent n of Stevens' law (psi=k phi n, in which psi is delta dyspnea and phi is delta FEV1, with perception being poor when n<1 and good when n>1), and c) change in Borg: difference between dyspnea when FEV1 has fallen 20% and dyspnea after saline inhalation. Subjects were classified according to the slope and change in Borg as hypoperceivers, normal perceivers, or hyperperceivers. These 2 methods of classification were compared using the kappa statistic. RESULTS: According to the exponent n, all patients were hypoperceivers (n<1). According to the slope, there were 33 hypoperceivers, 28 normal perceivers, and 9 hyperperceivers. The change in Borg classified 37 subjects as hypoperceivers, 23 as normal perceivers, and 10 as hyperperceivers. All except 5 subjects were classified in the same way by the slope and the change in Borg (kappa=0.88). In most of the 5 cases of discrepancy, the slope classified subjects as better perceivers. CONCLUSIONS: The n exponent is not valid for evaluating the perception of dyspnea induced by a bronchial challenge test in COPD. Change in Borg is at least as useful as the slope for evaluating perception of dyspnea. The percentage of patients with this disease who are hyperperceivers is high.

Los broncodilatadores, esos fármacos maravillosos / No disponible

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Síndrome de hiperventilación y asma / No disponible

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Screening of malignant pleural effusion by discriminant analysis.

OBJECTIVE: To assess the value of discriminant analysis as a method of optimizing the discriminant power of routine parameters in differentiating between malignant and non-malignant pleural effusions. METHODS: Retrospective review of the medical records of 245 patients with exudative pleural effusion. RESULTS: The most powerful predictor of the malignant etiology of pleural effusion was a function that consisted of seven variables: age (years); effusion volume (coded as up to one third = 1, up to two thirds = 2, massive = 3); sedimentation rate (mm/h); monocyte count in the peripheral blood (cells/mm3); bloodstained exudate (coded as yes = 1, no = 2); and glucose (mg/dL) and iron (microg/dL) concentration in pleural fluid. This function showed a sensitivity of 77%, specificity of 85%, positive predictive value (PPV) of 76%, negative predictive value (NPV) of 86%, and was able to give an 82% rate of correct classification. In patients aged 50 years or younger, the NPV ranged between 91 and 98%, whereas in those older than 60 years, the PPV was 89%. CONCLUSION: The calculated discriminant function is a simple, rapid, and inexpensive method for screening patients with pleural effusion for malignant etiology.

Repeated thoracentesis: an important risk factor for eosinophilic pleural effusion?

BACKGROUND: Eosinophilic pleural effusion (EPE) is a relatively rare clinical condition. Repeated thoracenteses (RTs) are normally considered a frequent cause of EPE. Yet, to our knowledge, there is no firm evidence (apart from anecdotal case reports) supporting such a statement. OBJECTIVE: To investigate potential relationships between the number, type (with or without pleural biopsy) and time elapsed between RTs and the number of eosinophils present in pleural fluid samples. METHODS: We reviewed retrospectively 273 pleural fluid samples belonging to 120 patients (79 males, 41 females), attended in our institution from 1992 to 2000, whose clinical management had required RTs. Apart from the anthropometric and clinical data of each patient, we included the following variables in the analysis: number of thoracenteses performed in each individual, number of pleural biopsies carried out at each thoracentesis and time between consecutive thoracenteses. We also recorded the total (and differential) leukocyte count, red blood cell count, as well as the main biochemical, microbiological and histological data of both the pleural fluid and peripheral blood samples. RESULTS: We did not observe any significant change in the percentage of eosinophils in relation to the number of thoracenteses performed per patient. This lack of relationship was also observed in the subgroup of patients who required one (or more) pleural biopsies (n = 111) (regardless of the number of biopsies). Our results suggest that RTs are not an important risk factor for the development of EPE, regardless of the time elapsed between two thoracenteses. CONCLUSION: We believe, therefore, that multiple punctures should not longer be considered a prevalent cause of pleural eosinophilia.

Maximal static respiratory pressures in children and adolescents.

This study was designed to establish reference values of maximal static respiratory pressures in children and adolescents in our community, and compare them with previous studies. Participants were recruited from three schools (randomly chosen from those located in the metropolitan area of the city of Valencia) after appropriate consent. None of the participants had a previous history of pulmonary, cardiac, and/or skeletal abnormalities, and all of them had normal spirometry. Forced spirometry (Spirotrac III, Vitalograph) and maximal inspiratory (P(ImaxRV)) and expiratory (P(EmaxTLC)) pressure values (Sibelmed 163) were obtained by the same investigator, following national guidelines (SEPAR 1990).We studied 392 subjects (185 males, 207 females) whose ages ranged from 8-17 years. The reproducibility of measurements was investigated in a subgroup of 88 participants (randomly selected from the total sample, and stratified for age and gender) by means of the intraclass correlation coefficient (P(EmaxTLC), 0.98; P(ImaxRV), 0.95). P(EmaxTLC) and P(ImaxRV) values were significantly different between males and females (P < 0.0001) and were normally distributed. A stepwise, linear multiple regression model was built in each gender group (male/female) for the prediction of P(ImaxRV) and P(EmaxTLC) values. Independent variables (weight, height, and age) and their potential interactions were forced to enter the model in order to maximize the square of the multiple correlation coefficient of the resultant equation. This model turned out to be applicable (homoscedasticity, independence, and normality requirements) for P(ImaxRV) (in males and females) and for P(EmaxTLC) (in males but not in females). Variables included in the model were age and the product of weight and height. Their predictive power ranged between 0.21-0.51. In conclusion, P(ImaxRV) and P(EmaxTLC) values increase with age from 8 until 17 years. In all age groups, values were higher in males than in females. Weight, height, and age are included in the predictive equations for P(ImaxRV) (in males and females) and P(EmaxTLC) (in males). Their predictive value is similar to that reported by other authors and ranges between 0.21-0.51. This model is not suitable for the prediction of P(EmaxTLC) in females; the observed mean and range should be used instead.