Cristian de la Roza

Utilización de la espirometría en el diagnóstico y tratamiento de la EPOC en atención primaria

Objetivo El objetivo del estudio ha sido evaluar las deficiencies y necesidades para la correcta utilizacion de la espirometria en el diagnostico y seguimiento del paciente con enfermedad pulmonar obstructiva cronica (EPOC) en atencion primaria (AP) y conocer las pautas habituales de tratamiento de esta enfermedad. Metodos Participaron 839 medicos de AP y cada uno de ellos cumplimento 2 cuestionarios, uno sobre el tratamiento de la EPOC y otro de utilizacion de la espirometria en su diagnostico y seguimiento. Resultados Destaco el bajo indice tanto de respuestas a la pregunta sobre la clasificacion de los pacientes en funcion de la gravedad de la obstruccion (no respondio el 10,7%) como de respuestas correctas en las preguntas sobre el tratamiento broncodilatador en fase estable (respuestas correctas: 15,1%). Las mayores tasas de respuestas correctas se obtuvieron en las preguntas referentes a la indicacion de la espirometria, todas ellas con un indice de acierto superior al 60%. Solo un 59,2% de los centros de AP realizaban espirometrias, sobre todo debido a la falta de formacion. En mas de un 30% de los casos el personal de enfermeria no habia recibido formacion especifica, lo que se reflejaba en un escaso seguimiento de las normativas en cuanto a calibracion (un 10,9% de los centros la realizaba diariamente), limpieza de los aparatos (un 13,9% no la hacia nunca) y recomendaciones al paciente (un 30% no daba recomendaciones el dia antes). Conclusiones Los medicos de AP conocen la utilidad de la espirometria en el diagnostico y seguimiento de la EPOC. Identifican la presencia de una obstruccion al flujo aereo, pero no se clasifica correctamente a los pacientes en funcion de su gravedad. Se ha observado una escasa disponibilidad de la espirometria en los centros de AP, asi como una escasa formacion en su manejo, lo que se refleja en un escaso seguimiento de las normativas de realizacion de la prueba.

Colour of sputum is a marker for bacterial colonisation in chronic obstructive pulmonary disease

BackgroundBacterial colonisation in chronic obstructive pulmonary disease (COPD) contributes to airway inflammation and modulates exacerbations. We assessed risk factors for bacterial colonisation in COPD.MethodsPatients with stable COPD consecutively recruited over 1 year gave consent to provide a sputum sample for microbiologic analysis. Bronchial colonisation by potentially pathogenic microorganisms (PPMs) was defined as the isolation of PPMs at concentrations of ≥102 colony-forming units (CFU)/mL on quantitative bacterial culture. Colonised patients were divided into high (>105 CFU/mL) or low (<105 CFU/mL) bacterial load.ResultsA total of 119 patients (92.5% men, mean age 68 years, mean forced expiratory volume in one second [FEV1] [% predicted] 46.4%) were evaluated. Bacterial colonisation was demonstrated in 58 (48.7%) patients. Patients with and without bacterial colonisation showed significant differences in smoking history, cough, dyspnoea, COPD exacerbations and hospitalisations in the previous year, and sputum colour. Thirty-six patients (62% of those colonised) had a high bacterial load. More than 80% of the sputum samples with a dark yellow or greenish colour yielded PPMs in culture. In contrast, only 5.9% of white and 44.7% of light yellow sputum samples were positive (P < 0.001). Multivariate analysis showed an increased degree of dyspnoea (odds ratio [OR] = 2.63, 95% confidence interval [CI] 1.53-5.09, P = 0.004) and a darker sputum colour (OR = 4.11, 95% CI 2.30-7.29, P < 0.001) as factors associated with the presence of PPMs in sputum.ConclusionsAlmost half of our population of ambulatory moderate to very severe COPD patients were colonised with PPMs. Patients colonised present more severe dyspnoea, and a darker colour of sputum allows identification of individuals more likely to be colonised.

Use of Spirometry in the Diagnosis and Treatment of Chronic Obstructive Pulmonary Disease in Primary Care

OBJECTIVE The aim of this study was to assess the use of spirometry for the diagnosis and follow-up of patients with chronic obstructive pulmonary disease (COPD) in primary care in terms of deficiencies and the requirements for its correct use, and to identify the regimens most commonly used in patients with COPD. METHODS The study included 839 primary care physicians, each of whom completed 2 questionnaires, one on treatment of COPD and the other on the use of spirometry for diagnosis and follow-up of the disease. RESULTS Notable among the results was the high number of questionnaires in which no response was given to the question on classification of patients according to the severity of airway obstruction (10.7% of cases) and the low number of correct responses to questions on treatment with bronchodilators during the stable phase of COPD (15.1%). The highest rate of correct responses was for questions regarding the indication for spirometry, all of which were answered correctly in more than 60% of cases. Only 59.2% of primary health care centers performed spirometry, mainly due to a lack of training. In more than 30% of cases the nursing staff had not received specific training, a finding that was reflected in the poor compliance with guidelines for calibration (10.9% of health care centers performed daily calibrations), cleaning of the spirometer (in 13.9% of cases the equipment was never cleaned), and providing patients with pretest recommendations (30% did not provide recommendations the day before spirometry). CONCLUSIONS Primary care physicians are aware of the usefulness of spirometry for the diagnosis and follow-up of COPD. Although they are able to recognize airflow obstruction, they do not classify patients correctly in terms of severity. Very limited availability of spirometry was observed in primary health care centers and there was little training in the use of the technique, a finding reflected in the poor compliance with guidelines for its use.

Déficit de alfa-1-antitripsina. Situación en España y desarrollo de un programa de detección de casos

Estudios realizados en Espana senalan que un 9% de la poblacion general de entre 40 y 70 anos esta afectada de enfermedad pulmonar obstructiva cronica (EPOC). El humo del tabaco es el factor causal en mas del 90% de los casos; sin embargo, se ha estimado que solo un 10-20% de los fumadores desarrollan EPOC. La causa se puede encontrar en la existencia de factores geneticos o ambientales que modulan el efecto toxico del tabaco. El factor genetico mas conocido es el deficit de alfa-1-antitripsina, que comporta un riesgo aumentado de desarrollar enfisema pulmonar en fumadores. Tanto la Organizacion Mundial de la Salud como la American Thoracic Society/European Respiratory Society en sus recientes normativas recomiendan establecer programas de deteccion del deficit de alfa-1-antitripsina en pacientes con EPOC. Esta estrategia es crucial en Espana, donde la enfermedad esta infradiagnosticada, sobre todo debido a un bajo indice de sospecha entre los medicos.

α1-Antitrypsin Deficiency: Situation in Spain and Development of a Screening Program

Studies undertaken in Spain indicate that 9% of the general population aged between 40 and 70 years is affected by chronic obstructive pulmonary disease (COPD). Although tobacco smoke is the causative factor in more than 90% of cases, it is estimated that only 10% to 20% of smokers develop COPD. This may be explained by the existence of genetic or environmental factors that modulate the toxic effects of tobacco. The best known genetic factor is alpha1-antitrypsin deficiency, which is associated with an increased risk of developing pulmonary emphysema in smokers. The most recent guidelines from both the World Health Organization and the American Thoracic Society/European Respiratory Society recommend the establishment of screening programs for the detection of alpha1-antitrypsin deficiency in patients with COPD. This strategy is crucial in Spain, where the disease is under diagnosed, mainly due to a low index of suspicion among doctors.