Iñigo Ojanguren

Do Low Molecular Weight Agents Cause More Severe Asthma than High Molecular Weight Agents

Introduction The aim of this study was to analyse whether patients with occupational asthma (OA) caused by low molecular weight (LMW) agents differed from patients with OA caused by high molecular weight (HMW) with regard to risk factors, asthma presentation and severity, and response to various diagnostic tests. Methods Seventy-eight patients with OA diagnosed by positive specific inhalation challenge (SIC) were included. Anthropometric characteristics, atopic status, occupation, latency periods, asthma severity according to the Global Initiative for Asthma (GINA) control classification, lung function tests and SIC results were analysed. Results OA was induced by an HMW agent in 23 patients (29%) and by an LMW agent in 55 (71%). A logistic regression analysis confirmed that patients with OA caused by LMW agents had a significantly higher risk of severity according to the GINA classification after adjusting for potential confounders (OR = 3.579, 95% CI 1.136–11.280; p = 0.029). During the SIC, most patients with OA caused by HMW agents presented an early reaction (82%), while in patients with OA caused by LMW agents the response was mainly late (73%) (p = 0.0001). Similarly, patients with OA caused by LMW agents experienced a greater degree of bronchial hyperresponsiveness, measured as the difference in the methacholine dose-response ratio (DRR) before and after SIC (1.77, range 0–16), compared with patients with OA caused by HMW agents (0.87, range 0–72), (p = 0.024). Conclusions OA caused by LMW agents may be more severe than that caused by HMW agents. The severity of the condition may be determined by the different mechanisms of action of these agents.

Two short interventions to reduce health care requirements in asthma patients. A multicentre controlled study (ASTHMACAP II)

BACKGROUND AND OBJECTIVE Asthma control is suboptimal. The objective of this study was to reduce health care requirements and work absenteeism. MATERIAL AND METHODS Multicenter randomized controlled study investigating asthma control, educational parameters, health service use, and absenteeism. After adjusting treatment according to GINA recommendations, control group patients (CG) followed their physicians recommendations, while intervention group (IG) patients additionally underwent a 5-minute educational intervention. This protocol was repeated at 3 months, and a final assessment was carried out at 6 months. RESULTS 479 patients (mean age 40 (SD 17) years) were recruited from primary care, and 334 completed the study. Comparatively, IG patients showed an improvement at the 3- and 6-month evaluations in the six educational parameters (P<0.001) and required fewer urgent visits to the GP for exacerbations [RR=0.49 (95% CI 0.26-0.90); P<0.04], and before the third evaluation, also in urgent GP visits [RR=0.25 (95% CI 0.12-0.52); P<0.001]. Before this third evaluation, IG had fewer scheduled visits to the GP [RR=0.48 (95% CI 0.28-0.82); P<0.003], and fewer visits to the primary care [RR=0.40 (95% CI 0.18-0.87); P<0.05], and to hospital emergency rooms [RR=0.13 (95% CI 0.04-0.42); P<0.001]. In addition, before the third evaluation, IG patients were less often absent from work [RR=0.22 (95% CI 0.05-0.98); P<0.03] or unable to work at home [RR=0.31 (95% CI 0.12-0.82); P<0.02]. CONCLUSIONS Two short educational interventions improved asthma education and decreased the use of health resources and work absenteeism.

Specific inhalation challenge: the relationship between response, clinical variables and lung function

Introduction The specific inhalation challenge (SIC) is considered the gold standard for the diagnosis of occupational asthma (OA). However, its use is not standardised, and the intensity of exposure is regulated empirically. The aim of this study was to identify clinical variables and/or pulmonary function variables able to predict the scale of patients’ response to SIC. Material and methods All patients who underwent SIC at our centre between 2005 and 2013 were studied. Anthropometric characteristics, atopic status, type of causal agent, latency times, pulmonary function tests and SIC results were analysed. Results Two hundred and one patients (51% men) were assessed, of whom 86 (43%) had positive SIC. In the patients with positive results, 29 (34%) were exposed to high molecular weight (HMW) agents and 57 (64%) to low molecular weight (LMW) agents. Patients with a positive SIC exposed to HMW agents had a higher fall in FEV1 after SIC compared with those exposed to LMW agents (p=0.036). The type of asthmatic reaction after SIC also differed between the groups (p=0.020). The logistic regression analysis showed that patients with a higher PC20 before SIC were less likely to have severe decreases in FEV1 after SIC after adjusting for potential confounders (OR=0.771, 95% CI 0.618 to 0.961, p=0.021). Conclusions The scale of the response to SIC is influenced mainly by the degree of bronchial hyper-responsiveness, regardless of whether the causative agent is HMW or LMW, or whether the response is early or late.

La tomografía computarizada de alta resolución y la fibrobroncoscopia en el estudio del asma grave

We report the case of a 73-year-old woman who in 2012 developed a clinical picture of dyspnea on exertion, wheezing, and repeated episodes of acute bronchitis. Forced spirometry was performed, showing FVC: 1.58 l (62%), FEV1: 1.17 l (64%), FEV1/FVC: 0.73, with significant FVC changes on bronchodilator challenge. The chest X-ray showed no pathological findings. A diagnosis of asthma was given, and treatment with inhaled corticosteroids began with little clinical response. The patient was referred to a pulmonologist in 2016 with a probable diagnosis of severe asthma, and forced spirometry was repeated, showing FVC: 1.54 l (61%), FEV1: 1.04 l (57%), FEV1/FVC: 0.67. In view of these findings, high-resolution computed tomography (HRCT) of the chest was performed, revealing an image of calcium density in the bronchus of the right lower lobe with small distal atelectasis. Fiberoptic bronchoscopy confirmed the presence of a foreign body that could be extracted with forceps, despite significant inflammation of the adjacent bronchial mucosa. The patient was unable to remember any episode of aspiration that could be related. The pathology laboratory reported that the sample was consistent with a fragment of bony tissue (Fig. 1). After extraction, the patient’s previous clinical symptoms resolved.

Estudio de los mecanismos implicados en la génesis y evolución del asma (proyecto MEGA): creación y seguimiento a largo plazo de una cohorte de pacientes asmáticos

The general aim of this study is to create a cohort of asthma patients with varying grades of severity in order to gain greater insight into the mechanisms underlying the genesis and course of this disease. The specific objectives focus on various studies, including imaging, lung function, inflammation, and bronchial hyperresponsiveness, to determine the relevant events that characterize the asthma population, the long-term parameters that can determine changes in the severity of patients, and the treatments that influence disease progression. The study will also seek to identify the causes of exacerbations and how this affects the course of the disease. Patients will be contacted via the outpatient clinics of the 8 participating institutions under the auspices of the Spanish Respiratory Diseases Networking System (CIBER). In the inclusion visit, a standardized clinical history will be obtained, a clinical examination, including blood pressure, body mass index, complete respiratory function tests, and FENO will be performed, and the Asthma Control Test (ACT), Morisky-Green test, Asthma Quality of Life Questionnaire (Mini AQLQ), the Sino-Nasal Outcome Test 22 (SNOT-22), and the Hospital Anxiety and Depression scale (HADS) will be administered. A specific electronic database has been designed for data collection. Exhaled breath condensate, urine and blood samples will also be collected. Non-specific bronchial hyperresponsiveness testing with methacholine will be performed and an induced sputum sample will be collected at the beginning of the study and every 24 months. A skin prick test for airborne allergens and a chest CT will be performed at the beginning of the study and repeated every 5 years.

Neumonitis por hipersensibilidad. Estudio diagnóstico menos invasivo

Ante un paciente afecto de una enfermedad pulmonar intersticial (EPI) el neumólogo sabe que en un cierto porcentaje se tratará de una neumonitis por hipersensibilidad (NH). Para llegar a su diagnóstico deberá recordar que, en este caso, suele tratarse de pacientes de menos de 60 años, no fumadores, casi siempre sin acropaquias y con una auscultación normal o en todo caso auscultándose crepitantes no velcro y, ocasionalmente, unos pocos sibilantes mesoinspiratorios, piantes, conocidos como chirping rales1,2. La tomografía computarizada de alta resolución (TCAR) mostrará en la forma aguda los característicos nodulillos centrolobulillares y zonas en vidrio deslustrado, sobre todo en los lóbulos superiores y en el lóbulo medio y la língula, o también un patrón en mosaico con zonas en vidrio deslustrado combinadas con otras áreas claras/hiperlucentes que traducen una insuflación por afectación inflamatoria bronquiolar centrolobulillar. En la forma crónica se visualizarán imágenes en mosaico y nodulillos centrolobulillares que traducen ya una cierta fibrosis y que, junto con zonas de panal, pueden visualizarse también en las bases. No descartaremos la NH si la TCAR muestra imágenes de neumonía intersticial usual, de neumonía intersticial no específica, o de neumonía organizada, e incluso si muestra una combinación de fibrosis y enfisema. Se realizará una meticulosa anamnesis buscando evidenciar un contacto previo con aves, plumas (edredones, etc.) u hongos (humedades, aerosoles con agua contaminada, spa, plancha a vapor, paredes enmohecidas, etc.). El resto de etiologías, como son los isocianatos, taladrinas, proteínas inhaladas, metales duros, etc., son causas menos frecuentes. Se realizará una determinación de inmunoglobulinas G especificas (IgGe) frente al suero (no deyecciones) de diferentes aves y frente a algunos hongos, lo que nos ayudará a saber si ha habido o no contacto con estos antígenos con respuesta inmunológica frente a ellos. Se practicará un lavado broncoalveolar (LBA) y también criobiopsias, ya que una cifra de linfocitos superior al 20% en el LBA y en la biopsia, una inflamación linfoplasmocitaria intersticial, junto

Inhalation challenge in the differential diagnosis of usual interstitial pneumonia.

Establishing when a patient with usual interstitial pneumonia (UIP) is truly idiopathic is fundamental. In this sense, the paper recently published by Wuyts et al. [1], is an excellent review of the various diseases that may present with a histopathology consistent with UIP. Specific inhalation challenge is useful for the differential diagnosis of usual interstitial pneumonia http://ow.ly/PX1q9

Radiologic pattern as a survival predictor in the rheumatoid artritis intersticial lung disease

Introduction: Rheumatoid Arthritis(RA) is a systemic autoimmune disease.Lung disease is the most common form of extra-articular involvement.The prevalence of interstitial lung disease associated with RA(RA-ILD) varies from 4 to 50% according to different series. Objective: To define the epidemiological characteristics of the AR-ILD and determine whether the radiological pattern can contribute the prognosis of these patients. Methods: Retrospective study of patients assessed at the ILD Program of our Center with a diagnosis of RA-ILD, between 2004-2013.Radiological pattern on CTscan was evaluated at diagnosis according to the presence of usual interstitial pneumonia (1) (RA-UIP or RA-NoUIP),and median survival of patients was also studied. Results :From the 653 patients included, 21 had RA-ILD diagnosis with an average age of 65 years(SD=+8,423), 71% were women.At diagnosis patients had mean FVC 64% and DLCO 45%.Of the 21 patients,42% had radiographic pattern of UIP,4% possible UIP,and 52% not UIP(1 bronchiolitis, 3 bronchiectasis,7 NSIP).There were no differences in prognostic factors studied between groups although the rheumatoid factor in RA-ILD was superior.Median survival was 89months;a stratified analysis showed a tendency for increased survival in RA-NoUIP group compared to RA-UIP(107vs.72 months;p= 0.1332).In the RA-UIP group, 4 out of 9 patients died(1 of which was transplanted) and in the RA-NoUIP group 1 of the 11 patients underwent transplantation and one died. Conclusion: The radiological pattern of interstitial lung disease in RA may be a prognostic factor in the evolution of these patients, although further studies are needed.(1).Am J Respir Crit Care Med.2011;183:788-824.