Montserrat Torrejón

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.

Anti-inflammatory effects of high-dose inhaled fluticasone versus oral prednisone in asthma exacerbations.

The objective of the present study was to investigate the kinetics of high doses of inhaled steroid fluticasone in comparison with oral steroid prednisone on plasma protein leakage and bronchial eosinophilia in adults with moderate asthma exacerbations. The study design was a randomised, double-blind, placebo-controlled prospective trial. In total, 45 patients treated at the emergency department for moderate asthma exacerbations were recruited and 39 were assigned to receive fluticasone and placebo of prednisone (19 patients), or prednisone and placebo of fluticasone (20 patients). Medication was administered to all patients via a metered-dose inhaler and spacer (16 puffs; 4,000 μg·day−1 or placebo) plus one pill (prednisone 30 mg·day−1 or placebo). Spirometry and induced sputum for differential cell counts, albumin and α2-macroglobulin levels and blood eosinophils, interleukin-5 and granulocyte-macrophage colony-stimulating factor levels were obtained before treatment and at 2, 6 and 24 h after treatment. Symptoms clearly improved after 24 h in both groups. No differences were seen between groups in peak expiratory flow or forced expiratory flow in one second, which improved progressively but then decayed slightly after 24 h. Eosinophil counts in sputum also improved over time in both groups. The effect was faster with fluticasone than with prednisone, but was partially lost at 24 h. However, plasma proteins in sputum and eosinophil count in blood both decreased until 24 h, with no significant differences between groups. There was no correlation between eosinophil counts and plasmatic protein levels. In conclusion, both treatments improved symptoms, airway obstruction and inflammation, and plasma protein leakage at 24 h. Prednisone reduced blood eosinophil counts, while fluticasone reduced airway eosinophil counts, suggesting that the anti-inflammatory performance of fluticasone is exerted locally.

A repeated short educational intervention improves asthma control and quality of life.

We assessed the effectiveness of an asthma educational programme based on a repeated short intervention (AEP-RSI) to improve asthma control (symptom control and future risk) and quality of life. A total of 230 adults with mild-to-moderate persistent uncontrolled asthma participated in a 1-year cluster randomised controlled multicentre study. The AEP-RSI was given in four face-to-face sessions at 3-month intervals, and included administration of a written personalised action plan and training on inhaler technique. Centres were randomised to the AEP-RSI (intervention) group or usual clinical practice group. Specialised centres using a standard educational programme were the gold standard group. A significant improvement in the Asthma Control Test score was observed in all three groups (p<0.001), but improvements were higher in the intervention and gold standard groups than in the usual clinical practice group (p=0.042), which also showed fewer exacerbations (mean±sd; 1.20±2.02 and 0.56±1.5 versus 2.04±2.72, respectively) and greater increases in the Mini Asthma Quality of Life Questionnaire scores (0.95±1.04 and 0.89±0.84 versus 0.52±0.97, respectively). The AEP-RSI was effective in improving asthma symptom control, future risk and quality of life. An educational programme based on a repeated short intervention for asthma is effective and easily to use in practice http://ow.ly/QUEx7

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.

Respuesta inflamatoria de la exacerbación asmática de instauración rápida

UNLABELLED The association between onset of asthma exacerbation and the inflammatory response has not been sufficiently studied. OBJECTIVE To determine the differential mechanisms of the rapid onset (RO) asthma exacerbation. METHODS We designed a prospective, multicentre study that included 34 patients who suffered from asthma exacerbation. They were distributed into three groups of asthmatics, depending of the time of onset: from 0 to 24h, from 25 to 144h and more than 145h. We collected clinical data, sputum, blood and urine samples when first seen at the clinic and the next 24h later, and differential cell counts and biomarkers were determined RESULTS The asthmatics who suffered a RO exacerbation showed a higher elastase concentration, (1.028±1.140; 310±364; 401±390ng/ml) (P<0.05) and albumin (46.2±4.3; 42±3.4; 39.9±4.8g/l) (P<0.05) in the blood sample. Neutrophils, eosinophils (blood or sputum), eosinophil cationic protein (ECP) (blood), interleukin 8 (IL(8)) (blood) and leukotriene E4 (LTE(4)) (urine) were high in the three groups (P>0.05). We demonstrated an association between the onset of exacerbation and the severity of obstruction (FEV(1)) (r=-0.360; P=0.037), eosinophils in sputum (r=-0.399; P=0.029), albumin (r=-0.442; P=0.013), and IL(8) in sputum (r=0.357; P=0.038). CONCLUSIONS The results suggest a rapid inflammatory response, both neutrophilic and eosinophilic, in the asthmatic exacerbation. However, the swelling in the bronchi may play an important role in the initial inflammatory response in the exacerbations depending of time of onset.

Inflammatory Response of Rapid Onset Asthma Exacerbation

Abstract The association between onset of asthma exacerbations and inflammatory response has not been sufficiently studied. Objective To determine the inflammatory mechanisms of rapid onset (RO) asthma exacerbations. Method We designed a prospective, multicentre study that included 34 patients from accident and emergency departments who suffered from asthma exacerbations. They were distributed into three groups, depending on the asthma onset speed: fast ( 145 h). Clinical data was collected from sputum, blood and urine samples when first treated and after 24h, so as to determine the inflammatory cell counts and soluble markers. Results The asthmatics who suffered a RO exacerbation showed higher elastase [1.028 (1.140); 310 (364); 401 (390) ng/ml] (P .05). An association was shown between the onset of exacerbation and the severity of obstruction (FEV1) (r=−0.360; P=.037), eosinophils in sputum (r=−0.399; P=.029), albumin (r=−0.442; P=.013), and IL8 in sputum (r=0.357; P=.038). Conclusions The results suggest early activation of neutrophilic and eosinophilic responses in asthma exacerbations. However, bronchial swelling may play an important role in the initial inflammatory response in the exacerbations depending on the speed of the onset.

Usefulness of the Exhaled Breath Temperature Plateau in Asthma Patients

Background: Exhaled breath temperature (EBT) has recently been proposed as a noninvasive marker of bronchial inflammation in patients with asthma. However, the usefulness of EBT in everyday clinical practice is not well established. Results to date are contradictory and are mainly derived from small, pediatric populations. A comparison of results is further complicated by the use of different equipment and measurements. Objective: We performed a comprehensive study to determine whether EBT is related to asthma control, disease severity, bronchial obstruction, or bronchial inflammation. Methods: Sixty-nine patients on maintenance treatment for asthma were included in a cross-sectional study. At the same visit, we measured the EBT plateau (EBTp) using an X-halo Breath Thermometer (Delmedica, Singapore), the fraction of exhaled nitric oxide (FeNO), spirometry, and inflammatory cell count in induced sputum, and we administered the Asthma Control Test questionnaire. Results: No significant differences were found between EBTp measurements and the level of asthma control, disease severity, bronchial obstruction, FeNO levels, or inflammatory asthma phenotypes. We found a significant difference between EBTp and gender. The EBTp was 34.07°C (SD 0.74) in women and 34.38°C (0.46) in men (p = 0.038). We also found a significant correlation between EBTp measurements and the induced sputum eosinophil count (R = -0.348, p = 0.003). Conclusions: The results of this study do not support the usefulness of the EBTp in asthma management in routine clinical practice. Further research using standardized methods is needed to determine the potential use of the EBTp measurement in asthma management.

Variabilidad del fenotipo inflamatorio del asma en el esputo inducido. Frecuencia y causas

INTRODUCTION Recent studies have found variability in asthma inflammatory phenotypes determined by the inflammatory cells in induced sputum (IS). The aim of this study was to determine the frequency and factors affecting inflammatory phenotype variability in IS. METHODS Retrospective observational study that included 61 asthmatic patients who underwent at least two IS tests over a period of 5 years. They were classified according to their baseline inflammatory phenotype and subsequently grouped according to phenotype variability (persistent eosinophilic, persistent non-eosinophilic and intermittent eosinophilic). Demographic, clinical and functional data and factors potentially influencing IS variability were collected in all cases. RESULTS Of the 61 patients, 31 (50.8%) had a change with respect to baseline inflammatory phenotype. Of these, 16 (51.6%) were eosinophilic, 5 (16.1%) neutrophilic, 1 (3.2%) mixed and 9 (29.1%) paucigranulocytic. According to phenotype variability, 18 patients (29.5%) were classified as persistent eosinophilic, 17 (27.9%) non-persistent eosinophilic, and 26 (42.6%) intermittent eosinophilic. Smoking and recent asthma exacerbation were significantly associated with increased risk of variability of the IS inflammatory phenotype (OR=6.44; p=.013; 95% CI=1.49-27.80 and OR=5.84; p=.022; 95% CI=1.29-26.37, respectively). CONCLUSION Half of asthma patients, predominantly those with eosinophilic phenotype, present a change in IS inflammatory phenotype. This variability is associated with smoking and recent asthma exacerbation. Data suggest these factors can modify the classification of IS inflammatory phenotype in clinical practice.

Bronchial Exudate of Serum Proteins During Asthma Attack

OBJECTIVE Although altered vascular permeability and edema of the bronchial mucosa are associated with asthma attack, their influence on its severity remains unknown. We address this issue by comparing relative indices for the concentration of albumin (RIAlb) and alpha2-macroglobulin (RIalpha2M) in induced sputum and peripheral blood from patients with exacerbated asthma, patients with stable asthma, and control subjects. PATIENTS AND METHODS Forty-six volunteers participated in the study: 14 with exacerbated asthma (forced expiratory volume in the first second [FEV1] 74.3% [SD, 20.8%] of reference), 23 with stable asthma (FEV1 93.6% [7.5%]), and 9 controls (FEV1 101.1% [9.9%]). The concentrations of albumin and alpha2-macroglobulin were quantified by immunoturbidimetry and immunonephelometry, respectively. The relative index was then calculated by dividing the concentration in sputum supernatant by the concentration in peripheral blood. RESULTS The mean RIAlb was 1.2 (1.1) in the control group, 2.9 (3.1) in the stable asthma group, and 6.0 (6.7) in the exacerbated asthma group. The RIalpha2M values were 11.7 (10.9), 11.9 (14.7), and 3.2 (3.8) for the control group and stable and exacerbated asthma groups, respectively. The increases in the RIAlb values between all groups, and the decrease in the RIalpha2M value between the exacerbated asthma and control groups were statistically significant (P<.05). The percentage of neutrophils, but not of eosinophils, in sputum was correlated with the RIAlb (r=0.39; P=.008) but not the RIalpha2M (r=-0.035; P=.82). FEV1 displayed an inverse relationship with the RIAlb (r=-0.43; P=.009) but not with the RIalpha2M (r=-0.206; P=.24). No correlation was found between oxyhemoglobin saturation and either the RIAlb (r=-0.33; P=.19) or the RIalpha2M (r=-0.12; P=.84). CONCLUSIONS Vascular permeability is altered during asthma exacerbations and appears to be correlated with the presence of neutrophils and the degree of bronchial obstruction.