Ángel Gayete

Identification and prospective validation of clinically relevant chronic obstructive pulmonary disease (COPD) subtypes

Background Chronic obstructive pulmonary disease (COPD) is increasingly considered a heterogeneous condition. It was hypothesised that COPD, as currently defined, includes different clinically relevant subtypes. Methods To identify and validate COPD subtypes, 342 subjects hospitalised for the first time because of a COPD exacerbation were recruited. Three months after discharge, when clinically stable, symptoms and quality of life, lung function, exercise capacity, nutritional status, biomarkers of systemic and bronchial inflammation, sputum microbiology, CT of the thorax and echocardiography were assessed. COPD groups were identified by partitioning cluster analysis and validated prospectively against cause-specific hospitalisations and all-cause mortality during a 4 year follow-up. Results Three COPD groups were identified: group 1 (n=126, 67 years) was characterised by severe airflow limitation (postbronchodilator forced expiratory volume in 1 s (FEV1) 38% predicted) and worse performance in most of the respiratory domains of the disease; group 2 (n=125, 69 years) showed milder airflow limitation (FEV1 63% predicted); and group 3 (n=91, 67 years) combined a similarly milder airflow limitation (FEV1 58% predicted) with a high proportion of obesity, cardiovascular disorders, diabetes and systemic inflammation. During follow-up, group 1 had more frequent hospitalisations due to COPD (HR 3.28, p<0.001) and higher all-cause mortality (HR 2.36, p=0.018) than the other two groups, whereas group 3 had more admissions due to cardiovascular disease (HR 2.87, p=0.014). Conclusions In patients with COPD recruited at their first hospitalisation, three different COPD subtypes were identified and prospectively validated: ‘severe respiratory COPD’, ‘moderate respiratory COPD’, and ‘systemic COPD’.

Utilidad de la punción aspirativa transbronquial guiada con ultrasonografía endobronquial (USEB) radial para el diagnóstico de adenopatías mediastínicas

INTRODUCTION Transbronchial needle aspiration (TBNA) is a bronchoscopic technique that has been shown to be useful for sampling enlarged mediastinal lymph nodes. The yield of this technique can be increased by using endobronchial ultrasound (EBUS) to guide needle placement. The aim of the present study was to compare the yield of radial EBUS-guided TBNA to that of conventional TBNA in the analysis of mediastinal lymph nodes. PATIENTS AND METHODS All patients undergoing either EBUS-guided or conventional TBNA for the diagnosis of mediastinal lymph nodes between January 2006 and May 2007 were studied consecutively. Histology results were used as a reference standard in the patients treated surgically. In cases in which surgery was not indicated, the results of cytology or of clinical follow-up of at least 6 months duration were used. RESULTS TBNA was performed in 117 patients, and a total of 143 lymph nodes were punctured (mean shortest [SD] diameter, 17.9 [8]mm). The samples obtained were diagnostic in 58 patients (49.6%) and in 70 lymph nodes (49.0%). For paratracheal and hilar stations, the yield of radial EBUS-guided TBNA was superior to that of conventional TBNA (59.2% compared to 34.1%, P=.02). CONCLUSIONS Radial EBUS guidance increases the diagnostic yield of TBNA in paratracheal and hilar lymph node stations.

Mass of intercostal muscles associates with risk of multiple exacerbations in COPD.

BACKGROUND The potential role of decreased respiratory muscle mass, if any, in mediating the susceptibility to exacerbation in COPD patients has not been determined. We hypothesized that a decrease in respiratory muscle mass is associated with increased risk of multiple hospital admissions due to acute exacerbations of the disease. METHODS Eligible cases and controls (n=20) were identified from records of our departments pulmonary clinic. Ten subjects diagnosed with COPD (males, 66+/-7yr, Body Mass Index (BMI)=26+/-4kg/m(2)) were identified as fragile patients. Fragility was defined as four or more admissions in the previous year due to severe exacerbations of the disease. Fragile patients were matched with 10 non-fragile controls, defined as COPD patients who had required only one admission due to exacerbation of the disease. Criteria for 1:1 matching included ethnicity, gender, age, BMI, degree of airflow obstruction (i.e., FEV(1)), comorbidity and chronic treatment. Multiple computed tomography (CT) scan slices were obtained to assess area and attenuation coefficients of multiple upper limb, thorax, abdomen and lower limb muscles. RESULTS CSA of intercostal and abdominal muscles was significantly decreased in fragile COPD patients (right side intercostals, mean relative difference (MRD)=-14%, p=0.010; OR (95% CI)=2.2 (1.1-4.8), p=0.021; left side, MRD=-13%, p=0.007; OR=2.2 (1.1-4.5), p=0.027). CSA and attenuation coefficients of all other muscle compartments showed no statistical differences between the two study groups but showed the same trend. Strength of the inspiratory and expiratory muscles did not differ between the two study groups. CONCLUSIONS This study shows that the risk for multiple admissions due to a COPD exacerbation associates with a marked decrease in the CSA of the intercostal muscle compartment.

Lifetime occupational exposure to dusts, gases and fumes is associated with bronchitis symptoms and higher diffusion capacity in COPD patients.

Background Occupational exposure to dusts, gases and fumes has been associated with reduced FEV1 and sputum production in COPD patients. The effect of occupational exposure on other characteristics of COPD, especially those reflecting emphysema, has not been studied in these patients. Methods We studied 338 patients hospitalized for a first exacerbation of COPD in 9 Spanish hospitals, obtaining full occupational history in a face-to-face interview; job codes were linked to a job exposure matrix for semi-quantitative estimation of exposure to mineral/biological dust, and gases/fumes for each job held. Patients underwent spirometry, diffusing capacity testing and analysis of gases in stable conditions. Quality of life, dyspnea and chronic bronchitis symptoms were determined with a questionnaire interview. A high- resolution CT scan was available in 133 patients. Results 94% of the patients included were men, with a mean age of 68(8.5) years and a mean FEV1% predicted 52 (16). High exposure to gases or fumes was associated with chronic bronchitis, and exposure to mineral dust and gases/fumes was associated with higher scores for symptom perception in the St. George’s questionnaire. No occupational agent was associated with a lower FEV1. High exposure to all occupational agents was associated with better lung diffusion capacity, in long-term quitters. In the subgroup with CT data, patients with emphysema had 18% lower DLCO compared to those without emphysema. Conclusions In our cohort of COPD patients, high exposure to gases or fumes was associated with chronic bronchitis, and high exposure to all occupational agents was consistently associated with better diffusion capacity in long-term quitters.

Toxicidad pleuropulmonar precoz asociada al tratamiento con cabergolina, un fármaco antiparkinsoniano

Describimos un caso de derrame pleural, engrosamiento pericardico y afectacion pulmonar en un paciente con sintomas de tos seca, disnea, edemas y afectacion cutanea de extremidades inferiores. Cuatro meses antes habia iniciado tratamiento con cabergolina (Sogilen ® ). Se demostro la existencia de derrame pleural, engrosamiento pericardico y alteracion de las pruebas funcionales respiratorias (obstruccion del flujo aereo, incremento de la resistencia de las vias aereas y disminucion de la capacidad de transferencia de monoxido de carbono). La escala de Naranjo imputo una relacion “probable” entre el farmaco y los efectos adversos detectados. Incluimos la evaluacion evolutiva tras 2 meses de seguimiento, durante el cual se documento una mejoria lenta e incompleta de las alteraciones funcionales respiratorias. En el ambito de nuestra practica neumologica, este caso constituye la primera descripcion clinica de toxicidad pleuropulmonar precoz asociada al tratamiento con cabergolina.

Left Ventricular Noncompaction: Imaging Findings and Diagnostic Criteria

OBJECTIVE The objectives of this article are to review the imaging findings of left ventricular noncompaction (LVNC) at echocardiography, cardiac MRI, and MDCT; to discuss diagnostic criteria for and the advantages and limitations of these imaging techniques; and to describe pitfalls that can lead to misinterpretation of findings of LVNC. CONCLUSION LVNC is a cardiac disease of emerging importance, and imaging has a key role in its diagnosis. Accordingly, radiologists should be familiar with LVNC imaging findings to realize an accurate diagnosis.

Non-invasive Functional Evaluation of the Reserve in Fatigue and the Diaphragm Structure using Transthoracic Echography in B and M Modes

a b s t r a c t The diaphragm is the principal respiratory muscle. Its special characteristics have made it difficult to design instruments capable of performing a non-invasive evaluation of its structure and function in humans. The present study was designed to evaluate the potential use of ultrasound as a non-invasive method to fulfil these objectives. Methods: The study consisted of three phases: (1) ultrasound study in autopsy samples (n=10) of a segment of the thoracic-abdominal wall, from the bottom to the parietal peritoneum (i.e., thoracic wall, diaphragm, pleura and peritoneum structures), (2) static ultrasound study of the previous structures and the diaphragm in healthy subjects (n=10) to standardised lung volumes; and (3) dynamic ultrasound study of the contraction-relaxation of the diaphragm in the same subjects, calculating its maximum velocity of relaxation (MVrdi, mm/sec) during a specific inspiratory resistance test. Results: The ultrasound enabled the pleural and peritoneal limits of the diaphragm to be identified, and quantify its thickness (Tdi), both ex-vivo and in-vivo, in all cases. The dynamic study of the Tdi showed a linear increase directly associated with the lung volume measurement, as well as a cyclical increase during inspiratory movements at rest. In the resistance test, the MVrdi was maximal with low loads and gradually decreased until reaching a minimum nadir (∆≈ -70% of the initial value) in claudication (fatigue). The MVrdi has a high precision in diagnosing claudication. Conclusions: Transthoracic ultrasound of the diaphragm is a non-invasive method that gives promising results in the structural and functional evaluation (i.e. fatigue risk) of that muscle. These findings are of pathophysiological interest and could be of use in the clinical care context.

Evaluación funcional no-invasiva de la reserva ante la fatiga y la estructura del diafragma mediante ecografía transtorácica en modos B y M

UNLABELLED The diaphragm is the principal respiratory muscle. Its special characteristics have made it difficult to design instruments capable of performing a non-invasive evaluation of its structure and function in humans. The present study was designed to evaluate the potential use of echography as a non-invasive method to fulfil these objectives. METHODS The study consisted of three phases: (1) echographic study in autopsy samples (n=10) of a segment of the thoracic-abdominal wall, from the bottom to the parietal peritoneum (i.e., thoracic wall, diaphragm, pleura and peritoneum structures), (2) static echographic study of the previous structures and the diaphragm in healthy subjects (n=10) to standardised lung volumes; and (3) dynamic echographic study of the contraction-relaxation of the diaphragm in the same subjects, calculating its maximum velocity of relaxation (MVrdi, mm/sec) during a specific inspiratory resistance test. RESULTS The echography enabled the pleural and peritoneal limits of the diaphragm to be identified, and quantitate its thickness (Tdi), both ex-vivo and in-vivo, in all cases. The dynamic study of the Tdi showed a linear increase directly associated with the lung volume measurement, as well as a cyclical increase during inspiratory movements at rest. In the resistance test, the MVrdi was maximal with low loads and gradually decrease until reaching a minimum nadir (Δ≈-70% of the initial value) in claudication (fatigue). The MVrdi has a high precision in diagnosing claudication. CONCLUSIONS Transthoracic echography of the diaphragm is a non-invasive method that gives promising results in the structural and functional evaluation (i.e. fatigue risk) of that muscle. These findings are of pathophysiological interest and could be of use in the clinical care context.

[Usefulness of radial endobronchial ultrasound-guided transbronchial needle aspiration for the diagnosis of mediastinal lymph nodes].

Abstract Introduction Transbronchial needle aspiration (TBNA) is a bronchoscopic technique that has been shown to be useful for sampling mediastinal lymph nodes. The yield of this technique can be increased by using endobronchial ultrasound (EBUS) to guide needle placement. The aim of the present study was to compare the yield of EBUS-guided TBNA to that of conventional TBNA in the analysis of mediastinal lymph nodes. Patients and Methods All patients undergoing either EBUS-guided or conventional TBNA for the diagnosis of mediastinal lymph nodes between January 2006 and May 2007 were studied consecutively. Histology results were used as a reference standard in patients treated surgically. In cases in which surgery was not indicated, the results of cytology or of clinical follow-up of at least 6 months duration were used. Results TBNA was performed in 117 patients and a total of 143 lymph nodes were punctured (mean shortest [SD] diameter, 17.9 [8] mm). The samples obtained were diagnostic in 58 patients (49.6%) and in 70 lymph nodes (49.0%). For paratracheal and hilar stations, the yield of EBUS-guided TBNA was superior to that of conventional TBNA (59.2% compared to 34.1%, P =.02). Conclusions Radial EBUS guidance increases the diagnostic yield of TBNA in paratracheal and hilar lymph node stations.

Early Pleuropulmonary Toxicity Associated With Cabergoline, an Antiparkinsonian Drug

We report a case of pleural effusion, pericardial thickening, and pulmonary involvement in a patient with dry cough, dyspnea, edema, and changes in the skin of the lower limbs. Treatment with cabergoline (Sogilen) had been started 4 months earlier. Pleural effusion, pericardial thickening, and impaired pulmonary function (airflow obstruction, increased airway resistance, and reduced carbon monoxide diffusing capacity) were observed. The Naranjo scale pointed to a probable relationship between cabergoline and these adverse effects. We report on outcome after 2 months of follow-up, during which time there was a slow and incomplete improvement in respiratory function. This is the first case in our practice setting of early pleuropulmonary toxicity associated with cabergoline.