Cristina Martínez González

Normativa para el diagnóstico y seguimiento de la silicosis

Silicosis is one of the occupational respiratory diseases most commonly encountered in our setting. It is caused by inhalation of crystalline silica that triggers a fibrotic response in the lung parenchyma. It presents as diffuse interstitial disease and clinical expression ranges from asymptomatic forms to chronic respiratory failure. Diagnosis is based on clinical history and radiological findings. There is no effective treatment, and once diagnosed, the patient must avoid all sources of occupational exposure. In these guidelines, the clinical, radiological and functional aspects of silicosis are reviewed, and strategies for diagnosis, monitoring and classification of patients are proposed, along with recommendations regarding the occupational implications of this disease.

Participación del neumólogo en la evaluación de la capacidad laboral de personas con enfermedades respiratorias

Una gran proporcion de los individuos que acuden a las consultas de neumologia son adultos en situacion laboral activa, y con frecuencia refieren disnea de esfuerzo que les dificulta el desempeno de su trabajo. En otras ocasiones los pacientes son remitidos por las unidades de valoracion de incapacidades para solicitar un informe acerca de su enfermedad. Si a esto anadimos que el diagnostico de una enfermedad respiratoria debe acompanarse de unas prescripciones terapeuticas que, ademas de farmacos, incluyan recomendaciones sobre los habitos de vida, nutricion, ejercicio fisico y actividad laboral, hay sobradas razones para que el neumologo se implique en la evaluacion de la capacidad laboral de los pacientes con enfermedades respiratorias. El objetivo de esta revision es ofrecer al neumologo una vision amplia de los procedimientos medico-legales que permiten evaluar el menoscabo funcional provocado por la enfermedad respiratoria, asi como recomendar al paciente unas condiciones laborales adecuadas para la prevencion y el tratamiento de su enfermedad.

Niveles elevados de carboxihemoglobina: fuentes de exposición a monóxido de carbono

INTRODUCTION Inhalation of carbon monoxide (CO) can result in poisoning, with symptoms ranging from mild and nonspecific to severe, or even death. CO poisoning is often underdiagnosed because exposure to low concentrations goes unnoticed, and threshold values for normal carboxyhemoglobin vary according to different authors. The aim of our study was to analyze carboxyhemoglobin (COHb) levels in an unselected population and detect sources of CO exposure METHODS In a cross-sectional descriptive study, we analyzed consecutive arterial blood gas levels processed in our laboratory. We selected those with COHb≥2.5% in nonsmokers and ≥5% in smokers. In these cases a structured telephone interview was conducted. RESULTS Elevated levels of COHb were found in 64 (20%) of 306 initial determinations. Of these, data from 51 subjects aged 65±12 years, 31 (60%) of which were men, were obtained. Mean COHb was 4.0%. Forty patients (78%) were non-smokers with mean COHb of 3.2%, and 11 were smokers with COHb of 6.7%. In 45 patients (88.2%) we detected exposure to at least one source of ambient CO other than cigarette smoke. CONCLUSIONS A significant proportion of individuals from an unselected sample had elevated levels of COHb. The main sources of CO exposure were probably the home, so this possibility should be explored. The population should be warned about the risks and encouraged to take preventive measures.

The Role of the Pulmonologist in the Assessment of Disability in Patients With Respiratory Disease

A high percentage of the individuals who consult respiratory medicine specialists are working adults, and these patients often complain that dyspnea on exertion hinders their ability to do their job. In other cases, patients are referred for assessment by those responsible for evaluating disability. Furthermore, diagnosis of a respiratory disease should be accompanied by a therapeutic regimen which, in addition to pharmacotherapy, should include advice on lifestyle, nutrition, and physical exercise and recommendations on the kind of work the patient can undertake. Pulmonologists are therefore heavily involved in the assessment of disability in patients with respiratory diseases. The aim of this review is to offer respiratory specialists a broad view of the medical and legal procedures used to evaluate functional impairment caused by respiratory disease, and suggest how they can make recommendations to these patients concerning the appropriate working conditions for the prevention and treatment of their disease.

Recomendaciones sobre el diagnóstico y manejo de la enfermedad pleural y pulmonar por asbesto

Asbestos is the term used for a set of mineral silicates that tend to break up into fibers. Its use has been associated with numerous diseases affecting the lung and pleura in particular, all of which are characterized by their long period of latency. Asbestos, moreover, has been recognized by the WHO as a Group IA carcinogen since 1987 and its use was banned in Spain in 2002. The publication in 2013 of the 3rd edition of the specific asbestos health monitoring protocol, together with the development of new diagnostic techniques, prompted the SEPAR EROM group to sponsor publication of guidelines, which review the clinical, radiological and functional aspects of the different asbestos-related diseases. Recommendations have also been made for the diagnosis and follow-up of exposed patients. These recommendations were drawn up in accordance with the GRADE classification system.

Recomendaciones para la evaluación médica de la capacidad laboral en el enfermo respiratorio crónico

Chronic respiratory diseases often cause impairment in the functions and/or structure of the respiratory system, and impose limitations on different activities in the lives of persons who suffer them. In younger patients with an active working life, these limitations can cause problems in carrying out their normal work. Article 41 of the Spanish Constitution states that «the public authorities shall maintain a public Social Security system for all citizens guaranteeing adequate social assistance and benefits in situations of hardship». Within this framework is the assessment of fitness for work, as a dual-nature process (medico-legal) that aims to determine whether it is appropriate or not to recognise a persons right to receive benefits which replace the income that they no longer receive as they cannot carry out their work, due to loss of health. The role of the pulmonologist is essential in evaluating the diagnosis, treatment, prognosis and functional capacity of respiratory patients. These recommendations seek to bring the complex setting of fitness for work evaluation to pulmonologists and thoracic surgeons, providing action guidelines that allow them to advise their own patients about their incorporation into working life.

El aire es nuestro: la importancia de mantener su calidad

Resumen La preocupacion y el interes por conocer los efectos perjudiciales a largo plazo de la contaminacion atmosferica en la salud respiratoria han impulsado la realizacion de diferentes estudios, algunos de cuyos resultados se han publicado a lo largo del ano. Con motivo del ano SEPAR medioambiente, desde el area de enfermedades respiratorias de origen ocupacional y medioambiental (EROM) revisaremos los avances en los efectos de la contaminacion atmosferica en la salud respiratoria y las acciones emprendidas por SEPAR. El objetivo principal del ano medioambiente SEPAR es informar al ciudadano en general y al enfermo respiratorio, en particular, de los beneficios de respirar un aire limpio. La educacion es el primer paso para conseguir nuestros objetivos. Se trata de educar a los mas jovenes para introducir unos habitos de conducta duraderos que promuevan una actitud respetuosa con el medio ambiente, inculcar la necesidad de un desarrollo sostenible a traves de un consumo energetico responsable y una reduccion en la emision de contaminantes. El ciudadano informado reclamara a los gobernantes politicas de salud publica dirigidas a mantener la calidad del aire que respiramos. La web www.elaireesnuestro.com ofrece contenidos didacticos e informativos.

Valoración de la discapacidad en los enfermos respiratorios

The evaluation of the disabilities of patients with respiratory disease is regulated by the Spanish Ministry of Labor and Social Security, as are disabilities of any other type. We believe, however, that in respiratory pathologies this evaluation is especially complicated because, as they are chronic processes, they inter-relate with other systems. Furthermore, they tend to have occasional exacerbations; therefore, normal periods may alternate with other periods of important functional limitations. The present document arises from the desire of SEPAR to update this topic and to respond to the requests of respiratory disease patient associations who have asked us to do so. In this paper, we analyze the current situation of work disability legislation as well as the determination of degrees and percentages, including the current criteria for assigning disabilities due to respiratory tract deficiencies. Lastly, we propose work guidelines that would improve the existing scenario and outline this evaluation for specific pathologies.

Actualización en enfermedad respiratoria y exposición ambiental: una relación invisible

Significant contributions have been made in the past year on different aspects of occupational/environmental respiratory disease. In the case of neoplastic diseases associated with asbestos inhalation, the areas of most interest have been in the search for tumour markers, the importance of the determination of asbestos fibre deposits in biological samples, and new therapeutic schemes in malignant pleural mesothelioma. A consensus article has been published on occupational asthma, in which some clinical evidenced-based recommendations are established, directed at the diagnosis and management of work-related asthma. As regards hypersensitivity-induced pneumonitis, the clinical and evolutionary aspects of this disease have been described in a large series of 86 patients with pigeon-fancier lung. There have also been interesting studies published this year that emphasise the need to take an occupational history in patients with respiratory symptoms in order to look for a causal or synergic relationship with smoking. Finally, the results of studies have been published which were directed at elucidating the role of urban contamination, mainly caused by road traffic, in the deterioration of lung function. A recent study showed that it would be possible to achieve a significant reduction in urban mortality attributed to urban contamination by reducing the levels of PM 2.5. They conclude that more restrictive standards need to be adopted in Europe to protect the health of the population, which coincides with the proposal by the World Health Organisation.Resumen En el ultimo ano, se han producido contribuciones relevantes en diferentes aspectos de la patologia laboral/ambiental respiratoria. En el caso de las enfermedades neoplasicas asociadas a la inhalacion de asbesto, las areas de interes mas recientes se situan en la busqueda de marcadores tumorales, la importancia de la determinacion del deposito de fibras de amianto en muestras biologicas y en los nuevos regimenes terapeuticos en el mesotelioma pleural maligno. En el asma relacionada con el trabajo, se ha publicado un articulo de consenso en el que se establecen unas recomendaciones basadas en evidencias clinicas, dirigidas al diagnostico y el manejo del asma relacionada con el trabajo. En referencia a las neumonitis por hipersensibilidad, en una amplia serie de 86 pacientes con pulmon del cuidador de aves se describen las caracteristicas clinicas y evolutivas de esta patologia. En este ano se han publicado ademas interesantes estudios que enfatizan la necesidad de realizar una historia laboral en los pacientes con sintomas respiratorios para sospechar una relacion causal o sinergica con el tabaco. Finalmente, se han publicado resultados de diferentes trabajos dirigidos a elucidar el papel de la contaminacion urbana, principalmente derivada del trafico rodado, en el deterioro de la funcion pulmonar. Un estudio reciente demuestra que seria posible obtener una significativa reduccion de la mortalidad atribuida a la contaminacion urbana, reduciendo los niveles de PM 2,5, y concluye que en Europa es necesario adoptar estandares mas restrictivos para proteger la salud de los ciudadanos, coincidiendo con la propuesta de la Organizacion Mundial de la Salud.: Significant contributions have been made in the past year on different aspects of occupational/environmental respiratory disease. In the case of neoplastic diseases associated with asbestos inhalation, the areas of most interest have been in the search for tumour markers, the importance of the determination of asbestos fibre deposits in biological samples, and new therapeutic schemes in malignant pleural mesothelioma. A consensus article has been published on occupational asthma, in which some clinical evidenced-based recommendations are established, directed at the diagnosis and management of work-related asthma. As regards hypersensitivity-induced pneumonitis, the clinical and evolutionary aspects of this disease have been described in a large series of 86 patients with pigeon-fancier lung. There have also been interesting studies published this year that emphasise the need to take an occupational history in patients with respiratory symptoms in order to look for a causal or synergic relationship with smoking. Finally, the results of studies have been published which were directed at elucidating the role of urban contamination, mainly caused by road traffic, in the deterioration of lung function. A recent study showed that it would be possible to achieve a significant reduction in urban mortality attributed to urban contamination by reducing the levels of PM 2.5. They conclude that more restrictive standards need to be adopted in Europe to protect the health of the population, which coincides with the proposal by the World Health Organisation.

Pruebas de función pulmonar en la fibrosis pulmonar idiopática: ¿más allá de la espirometría?

Since 1846, when John Hutchinson performed the first spirometry in London, the measurement of the air that can be mobilized during a maximum respiration has become the gold standard for the study of lung function.1 Dr. Hutchinson gave the name “vital capacity” to the volume of air that is mobilized in one deep expiration made after a maximum inspiration, and observed that individuals with lower values died prematurely. In 1947 Tiffeneau and Pinelli introduced the concept of velocity of the expired air,2 and since then both values, vital capacity (VC) and maximum expired volume in 1 s (MEVS or FEV1) have been integral parameters in the determination of respiratory function. Lung function tests in patients with a diagnosis of idiopathic pulmonary fibrosis (IPF) show the disease as a restrictive-type change impacting moderately on CO transfer (DLCO) with moderate hypoxemia and hypocapnia at rest, which, in the more advanced stages, develops into frank respiratory failure.3,4 International recommendations on the diagnosis and follow-up of IPF underline the importance of lung function testing in the control of this disease.5 The most recent clinical trials for the introduction of new drugs for treating this entity have adopted forced vital capacity (FVC) and DLCO as primary variables for confirming clinical efficacy.6,7 Nevertheless, the follow-up and control of IPF is an area where various authors are introducing new concepts and variables that better relate patient symptoms to prognosis, an essential step in a disease that carries such a heavy mortality burden. This has gradually led to the introduction of more complex determinations, including “total lung capacity”, “functional residual capacity”, “maximal exercise tolerance”, “pulmonary artery pressure”, etc., or the quantification of radiological images from new multidetector high-resolution computed tomography (HRCT) equipment. It is not surprising, then, that efforts are being made to introduce