Jordi Giner

Normativa sobre la utilización de fármacos inhalados

Estas recomendaciones, realizadas en el seno del Área de Enfermería de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR), pretenden completar en su vertiente más práctica las pautas de tratamiento establecidas en las normativas sobre el manejo del asma y la EPOC en nuestro medio. No existe ninguna duda de que la vía inhalatoria es la preferible y la más utilizada para la administración de fármacos en neumología, especialmente en el área de los broncodilatadores y de los antiinflamatorios, y en el ámbito de las dos entidades citadas anteriormente. Sin embargo, la información disponible a partir de diversas encuestas llama la atención sobre los defectos existentes en su correcta utilización. Buena parte de estas incorrecciones son atribuibles al desconocimiento existente sobre la adecuada utilización de inhaladores. Por este motivo y, a petición del Comité Científico de la Sociedad, llegan hasta ustedes estas recomendaciones, con el bien entendido de que tienen como objetivo principal hacer más fácil y comprensible el manejo de todos los utensilios que nos proporcionan medicación por vía inhalatoria. El texto contempla aquellos aparatos actualmente en uso pero, al tratarse de un área en gran movilidad, es de suponer que en los próximos años va a mejorar ostensiblemente esta forma de administración de fármacos. Deberemos, pues, estar alerta ante las innovaciones que sin duda van a ir apareciendo.

A controlled trial of noninvasive ventilation for chronic obstructive pulmonary disease exacerbations

PURPOSE This prospective, multicenter, double-blind, placebo-controlled study tested the hypothesis that noninvasive positive pressure ventilation reduces the need for endotracheal intubation in patients hospitalized in a pulmonary ward because of acute exacerbation of chronic obstructive pulmonary disease. MATERIALS AND METHODS Seventy-five consecutive patients with exacerbation (pH, 7.31 +/- 0.02; Pao(2), 45 +/- 9 mm Hg; Paco(2), 69 +/- 13 mm Hg) were randomly assigned to receive noninvasive ventilation or sham noninvasive ventilation during the first 3 days of hospitalization on top of standard medical treatment. RESULTS The need for intubation (according to predefined criteria) was lower in the noninvasive ventilation group (13.5% vs 34%, P < .01); in 31 patients with pH not exceeding 7.30, these percentages were 22% and 77%, respectively (P < .001). Arterial pH and Paco(2) improved in both groups, but changes were enhanced by noninvasive ventilation. Length of stay was lower in the noninvasive ventilation group (10 +/- 5 vs 12 +/- 6 days, P = .06). In-hospital mortality was similar in both groups. CONCLUSIONS These results demonstrate that noninvasive positive pressure ventilation, in a pulmonary ward, reduces the need for endotracheal intubation, particularly in the more severe patients, and leads to a faster recovery in patients with acute exacerbation of chronic obstructive pulmonary disease.

Airway inflammation in the elite athlete and type of sport

Background: The prevalence of asthma and bronchial hyper-responsiveness is greater in elite athletes than in the general population, and its association with mild airway inflammation has recently been reported. Objective: To study the relationship between the type of sport practised at the highest levels of competition (on land or in water) and sputum induction cell counts in a group of healthy people and people with asthma. Material and methods: In total, 50 athletes were enrolled. Medical history, results of methacholine challenge tests and sputum induced by hypertonic saline were analysed Results: Full results were available for 43 athletes, who were classified by asthma diagnosis and type of sport (land or water sports). Nineteen were healthy (10 land and 9 water athletes) and 24 had asthma (13 land and 11 water athletes). Although the eosinophil counts of healthy people and people with asthma were significantly different (mean difference 3.1%, 95% CI 0.4 to 6.2, p = 0.008), analysis of variance showed no effect on eosinophil count for either diagnosis of asthma or type of sport. However, an effect was found for neutrophil counts (analysis of variance: F = 2.87, p = 0.04). There was also a significant correlation between neutrophil counts and both duration of training and bronchial hyper-responsiveness among athletes exposed to water (Spearman’s rank correlations, 0.36 and 0.47, p = 0.04 and 0.04, respectively). Conclusions: Elite athletes who practice water sports have mild neutrophilic inflammation, whether or not asthma is present, related to the degree of bronchial hyper-reactivity and the duration of training in pool water.

Opinión, conocimientos y grado de seguimiento referidos por los profesionales sanitarios españoles de la Guía Española para el Manejo del Asma (GEMA). Proyecto GEMA-TEST

Objetivo Se sospecha que el seguimiento de las recomendaciones terapeuticas del asma entre los profesionales sanitarios es bajo. El presente estudio se ha realizado con el objeto de determinar la opinion, el conocimiento y cumplimiento de las recomendaciones de la Guia Espanola para el Manejo del Asma (GEMA) entre los profesionales sanitarios espanoles. Material y metodos Se elaboro un cuestionario de 15 preguntas de respuesta multiple que recogian la opinion y conocimiento general sobre las guias de asma, el grado de seguimiento de estas y, especificamente, de las recomendaciones diagnosticas y terapeuticas de la GEMA. El cuestionario se cumplimento de forma voluntaria, individual y anonima. Resultados Rellenaron el cuestionario 1.066 profesionales: 241 (22,6%) neumologos y 244 (22,9%) profesionales de enfermeria de la Sociedad Espanola de Neumologia y Cirugia Toracica (SEPAR); 221 (20,7%) pediatras-neumologos de la Sociedad Espanola de Neumologia Pediatrica (SENP); 220 (20,6%) medicos de atencion primaria de la Sociedad Espanola de Medicina de Familia y Comunitaria (semFYC); 181 (17%) medicos de atencion primaria de la Sociedad Espanola de Medicina Rural y Generalista (SEMERGEN), y 38 (3,6%) de otras sociedades. De ellos, 805 (76%) opinaron que las guias para el manejo del asma eran utiles o muy utiles y 771 (72%) conocian la GEMA, pero 388 (36%) reconocian que seguian poco o nunca sus recomendaciones. Entre los medicos participantes, 243 (30,3%) fueron clasificados como malos cumplidores de la GEMA. El analisis multivariante revelo que los profesionales provenientes de las areas centro y sur espanolas, los de atencion primaria, los poco convencidos de la utilidad de las guias o los que no las conocen, y los que no empleaban la espirometria se asociaron con un menor cumplimiento de la guia. Conclusiones Si bien la mayoria de los profesionales sanitarios espanoles encuestados conoce y estima positiva la GEMA, el grado de cumplimiento de esta es bajo. Los futuros programas docentes encaminados a difundir las guias de asma deberian considerar el perfil del medico no cumplidor de la GEMA e incorporar estrategias educativas dirigidas especificamente a dichos profesionales.

Identification of airway bacterial colonization by an electronic nose in Chronic Obstructive Pulmonary Disease

BACKGROUND Airway bacterial colonization by potentially pathogenic microorganisms occurs in a proportion of patients with Chronic Obstructive Pulmonary Disease (COPD). It increases airway inflammation and influences outcomes negatively. Yet, its diagnosis in clinical practice is not straightforward. The electronic nose is a new non-invasive technology capable of distinguishing volatile organic compound (VOC) breath-prints in exhaled breath. We aim to explore if an electronic nose can reliably discriminate COPD patients with and without airway bacterial colonization. METHODS We studied 37 clinically stable COPD patients (67.8 ± 5.2 yrs, FEV1 41 ± 10% ref.) and 13 healthy controls (62.8 ± 5.2 yrs, FEV1 99 ± 10% ref.). The presence of potentially pathogenic microorganisms in the airways of COPD patients (n = 10, 27%) was determined using quantitative bacterial cultures of protected specimen brush. VOCs breath-prints were analyzed by discriminant analysis on principal component reduction, resulting in cross-validated accuracy values. Area Under Receiver Operating Characteristics (AUROC) was calculated using multiple logistic regression. RESULTS Demographic, functional and clinical characteristics were similar in colonized and non-colonized COPD patients but their VOC breath-prints were different (accuracy 89%, AUROC 0.92, p > 0.0001). Likewise, VOCs breath-prints from colonized (accuracy 88%, AUROC 0.98, p < 0.0001) and non-colonized COPD patients (accuracy 83%, AUROC 0.93, p < 0.0001) were also different from controls. CONCLUSIONS An electronic nose can identify the presence of airway bacterial colonization in clinically stable patients with COPD.

Estudio multicéntrico y prospectivo de “educación y enseñanza” del procedimiento de inhalación en pacientes respiratorios (estudio Eden)

Objetivo El gran inconveniente de utilizar farmacos por via inhalatoria es la deficiente tecnica utilizada. Los objetivos del estudio fueron evaluar los conocimientos que sobre los dispositivos de inhalacion tienen los pacientes que los utilizan y valorar el efecto sobre estos conocimientos de una sesion de instruccion en el uso de estos dispositivos de inhalacion Material y metodo Estudio multicentrico, prospectivo y descriptivo, pre y postintervencion, sobre la eficacia de una sesion de instruccion en la tecnica de utilizacion de los dispositivos de inhalacion: cartucho presurizado (MDI), camara de inhalacion (IC), dispositivo de autodisparo Autohaler ® (AMDI) y dispositivos de polvo Turbuhaler ® (PST) y Accuhaler ® (PSA). Se estudiaron un total de 349 pacientes que utilizaban habitualmente dispositivos de inhalacion para el tratamiento de su enfermedad respiratoria. Tras la evaluacion de los conocimientos teoricos sobre la via inhalatoria (comunes) y el dispositivo que utilizaban, asi como de la tecnica de inhalacion con el dispositivo estudio, se instruyo al paciente en la tecnica correcta y se evaluaron ambos conocimientos a los 2 y 8 meses de la intervencion Resultados Los conocimientos teoricos comunes fueron de 3,2 (1) sobre 6 puntos y los del dispositivo de 2,7 (1) sobre 4 puntos y los practicos de 77 (21) sobre 100 puntos. Tras la intervencion todos los conocimientos teoricos y practicos au-mentaron de forma estadisticamente significativa. Los co-munes fueron de 5,1 (1) a los 2 meses y de 5,2 (1) a los ocho; los del dispositivo, de 3,5 (0,6) y 3,6 (0,7), respectivamente, y los practicos, de 95 (11) y 96 (11) a los 2 y 8 meses, respecti-vamente Conclusiones El estudio EDEN pone de manifiesto que los conocimientos sobre dispositivos de inhalacion de los enfermos respiratorios, de una amplia muestra de la poblacion de Espana, aunque son aceptables, pueden mejorar con un programa adecuado de ensenanza. Mediante un esquemaconsensuado de aprendizaje se consigue, ademas, una muy correcta utilizacion practica de todos los dispositivos analizados. Creemos que de esta forma se consigue mejorar nota-blemente los sintomas y la calidad de vida de los enfermos respiratorios

Inflamación bronquial, clínica respiratoria y función pulmonar en el síndrome de Sjögren primario

INTRODUCTION There is no information available regarding the relationship between the respiratory symptoms or lung function and bronchial inflammation, measured by induced sputum. OBJECTIVES Description of the clinical characteristics, radiographic images and lung function of patients suffering from Primary Sjögren Syndrome (PSS), and to assess the relationship with the inflammatory airway profile. METHODS We analysed clinical, radiology, lung function tests, bronchial hyperresponsiveness and inflammatory data in the induced sputum from 36 consecutive patients with PSS. RESULTS A total of 58% of patients had hoarseness and 42% had cough and dispnea. No lung dysfunction was observed, although 46% (n=16) had a positive bronchial response. Lymphocytosis >2.6% in induced sputum was observed in 69% of all sputa. There was chronic cough in 29% of patients with lymphocytosis (n=24), whereas 73% were normal (n=11) (P=.02). The duration time of cough was less for the former (P=.02). On the contrary a positive bronchial response was associated with lymphocytosis >2.6% (P=.02). Lipophages were present in 55% of pathological sputa (n=22) (index >15) versus 18% of the non-pathological ones (n=11) (P=.05). CONCLUSION Hoarseness, cough and dyspnea are frequent respiratory symptoms in PSS, although there is a wide variation in the relationship with bronchial responsiveness and airway inflammation. Lymphocytosis in the airways is another site of the infiltrative process in PSS, and the induced sputum is a complementary tool in the identification of active inflammatory process.

Conocimientos y destreza en el manejo del inhalador Turbuhaler ® por parte del personal sanitario

El objetivo de este estudio ha sido evaluar entre nuestros profesionales sanitarios los conocimientos teoricos y la destreza en el manejo del inhalador de polvo seco Turbuhaler ® . Para ello, se estudiaron 118 personas pertenecientes a tres grupos laborales: 50 miembros del personal de enfermeria, 34 medicos internos residentes (MIR) y 34 medicos de plantilla del hospital. Los conocimientos teoricos se evaluaron mediante un cuestionario especifico, disenado al efecto. La destreza en el manejo se analizo por la demostracion practica de la tecnica inhalatoria, generalmente recomendada, con un inhalador placebo. El 6% de los medicos de plantilla, el 3% de los MIR y el 2% del personal de enfermeria contestaron correctamente el cuestionario teorico. El 21% de los medicos de plantilla, el 15% de los MIR y el 6% del personal de enfermeria efectuaron correctamente las maniobras de inhalacion. Sin embargo, cuando la destreza en el manejo del inhalador se evaluo de acuerdo con las maniobras que recomienda el fabricante del dispositivo (que eximen de la realizacion de la espiracion previa a la inhalacion y de la apnea posterior), se observo una mejora importante: el 41% de los medicos de plantilla, el 23% de los MIR y el 20% del personal de enfermeria efectuaron correctamente la inhalacion. Podemos concluir afirmando que: a) el conocimiento general del manejo del dispositivo Turbuhaler ® entre nuestros profesionales sanitarios es deficiente, b) el porcentaje de maniobras de inhalacion correctas observadas se duplica cuando estas se evaluan segun la tecnica de inhalacion recomendada por el fabricante y c) el personal sanitario deberia recibir una educacion especifica en las tecnicas de inhalacion requeridas para los diferentes dispositivos que habitualmente se emplean.

Control of Ventilation, Breathlessness Perception and Alexithymia in Near-Fatal Asthma

Several studies have demonstrated impaired control of ventilation in some patients with near-fatal asthma (NFA). The objective of our study was to determine a possible relationship between alexithymia (a cognitive processing disorder), control of ventilation, and breathlessness perception in patients who had an NFA attack. We analyzed data from 100 subjects: 50 with NFA, 25 asthmatics without NFA, and 25 non-asthmatic controls. Ventilatory responses to hypoxia and hypercapnia were measured by the rebreathing technique in terms of slope of ventilation and mouth occlusion pressure (P0.1). Breathlessness perception was assessed with the Borg scale and alexithymia with the Toronto Alexithymia Scale (TAS). No statistical differences were observed between groups in breathlessness perception and ventilatory responses. The mean (SD) TAS score of 63.6 (14.9) in the NFA group was significantly higher than the score of 56.4 (12.1) in the non-asthmatic group (p = 0.007). More subjects with alexithymia were identified in the NFA group (24%) than in the non-NFA group (12%) or the non-asthmatic control group (12%). Although the presence of alexithymia did not correlate with poor ventilatory responses or breathlessness perception, it was associated with a larger number of previous hospitalisations: 6.2 (8.1) in the NFA group and 2.8 (4.8) in the non-NFA group (p = 0.036). In conclusion, the prevalence of alexithymia is higher among NFA patients than among asthmatics who have not experienced NFA attacks. Neither altered breathlessness perception nor ventilatory response to hypoxia seems to play a role in NFA, although alexithymia may favor poor clinical control.

Spirometric Standards and Patient Characteristics: An Exploratory Study of Factors Affecting Fulfillment in Routine Clinical Practice

BACKGROUND: Spirometry is an apparently simple test, yet the recommended criteria for acceptability and reproducibility can be difficult to fulfill. This study aimed (1) to prospectively assess the number of tests that meet the American Thoracic Society/European Respiratory Society (ATS/ERS) 2005 acceptability and repeatability criteria in the routine practice of an experienced technician at a referral hospitals lung function laboratory, (2) to identify the most common errors, and (3) to explore patient characteristics possibly associated with failure to meet standards. METHODS: We prospectively evaluated 257 consecutive spirometries supervised by the same technician, who gave priority to achieving a minimum of 3 correct maneuvers within a maximum of 8 attempts. We recorded FVC, FEV1, expiratory time (TE), back-extrapolated volume (VE), end-of-test volume (VEOT), number of maneuvers with and without errors, and errors (VE > 0.15 L or 5% of FVC, TE < 6 s, and VEOT ≥ 0.025 L for ≥ 1 s). RESULTS: Two-hundred and fifteen spirometries (83.7%, 95% CI 78.6–87.7%) met the ATS/ERS 2005 criteria. Acceptability criteria were met in 73.9% (95% CI 71.2–76.3%) of the maneuvers and repeatability criteria in 90.7% (95% CI 86.5–93.6%). A mean ± SD of 3.3 ± 1.4 per subject was acceptable, and a mean ± SD of 4.5 ± 1.9 was obtained. TE and VEOT errors were the most common. CONCLUSIONS: Nearly 15% of the subjects failed to fulfill all the ATS/ERS 2005 criteria for spirometry performed even though they were coached by a qualified and regularly trained technician in a hospital lung function laboratory. The fact that the ATS/ERS 2005 criteria cannot be met by all patients in optimal technical conditions should be further considered and explored.