Ramón Fernández

Nasal Versus Oronasal Mask in Home Mechanical Ventilation: The Preference of Patients as a Strategy for Choosing the Interface

INTRODUCTION: In home mechanical ventilation (HMV), the mask is a key factor for patient comfort and therapeutic adherence. There is no evidence on the best strategy for choosing the mask in HMV. OBJECTIVE: To explore patient preference when prescribing the mask for HMV treatment and assess its relationship with effectiveness. METHODS: A prospective study with repeated measures in stable patients receiving home nocturnal ventilation. Alternating oronasal mask (ONM) and nasal mask (NM) were tested in day and overnight sessions, with arterial blood gas measured and SpO2 monitored. At the end of each evening session, patients rated interface comfort using a visual analog scale. At 3 months we evaluated adherence and effectiveness of the treatment. RESULTS: Twenty-nine subjects (mean ± SD age 65 ± 13 y, 44% male) completed the study. Initial functional values were PCO2 57.4 ± 5.2 mm Hg and time with SpO2 < 90% (T90) 81.5 ± 9.5%. Both ONM and NM significantly decreased PCO2 and T90. Over a third (38%) of our subjects preferred ONM, while NM was deemed more comfortable in general. At 3 months, effectiveness and adherence showed no differences between those treated with NM or ONM. CONCLUSIONS: Patient choice is an effective criterion for selecting the interface in HMV treatment.

Nocturnal home pulse oximetry: variability and clinical implications in home mechanical ventilation.

Background: Nocturnal home pulse oximetry (NHPO) provides information by measuring a series of variables: time spent with SaO2 <90% expressed as percentage (T90) or in minutes (Tm90), mean SaO2 (MnS), and lowest SaO2 (LwS.) The presence of significant nocturnal desaturation has been proposed as a parameter in decision making with regard to initiating home mechanical ventilation (HMV) or monitoring HMV effectiveness. However, there is limited information on the possible variability of the test, and this could influence the interpretation of results. Objectives: To explore the variability between 2 consecutive measurements of NHPO and to determine clinical applications in HMV. Methods: The patients presented diseases susceptible to HMV treatment and were enrolled in stable condition without respiratory failure. NHPO was conducted on 2 consecutive nights. The variables analyzed were: T90, Tm90, Mns, and LwS. The coefficient of variation (CV), a concordance coefficient (CC), and the Bland-Altman method were used in order to explore the variability. Results: We studied 40 cases. Two were excluded, and the remaining 38 were aged 58 ± 16 years (19 males). Eighteen were receiving HMV. CV values exceeded 100% for T90 and Tm90 and were below 5% for MnS and LwS. The CC for T90, Tm90, and LwS showed confidence intervals with lower limits below 0.5, while for MnS the value was 0.88 (0.79–0.93). Conclusions: There is a wide variability in NHPO recordings for T90, Tm90, and LwS, so a single determination to detect nocturnal desaturation may not be valid for decision making; the parameter with the least interindividual variability and intraindividual variability was MnS.

Community-Acquired Pneumonia and Empyema Caused by Citrobacter koseri in an Immunocompetent Patient

Citrobacter species, belonging to the family Enterobacteriaceae, are environmental organisms commonly found in soil, water, and the intestinal tracts of animals and humans. Citrobacter koseri is known to be an uncommon but serious cause of both sporadic and epidemic septicemia and meningitis in neonates and young infants. Most cases reported have occurred in immunocompromised hosts. The infections caused by Citrobacter are difficult to treat with usual broad spectrum antibiotics owing to rapid generation of mutants and have been associated with high death rates in the past. We believe this is the first case described in the literature of a community-acquired pneumonia and empyema caused by Citrobacter koseri in an immunocompetent adult patient.

Seguir las recomendaciones, un desafío en el asma ocupacional

In a great many jobs, workers inhale aerosol substances that can cause asthma, aggravate pre-existing asthma, or cause symptoms that mimic asthma. Both occupational asthma and work-aggravated asthma are common entities. Ten percent of adult asthma cases are thought to be job-related, and more than 25% of asthma patients of working age can suffer exacerbations related to their working conditions.1 In occupational asthma, the best therapy is to avoid the causal agent2; this involves leaving the job and obtaining a certificate of incapacity due to an occupational disease, which would entitle the patient to receive disability benefit. Being classed as “unfit for work” is not always advantageous, and depending on the age, profession and social and economic circumstances of the worker it can even be detrimental to a greater or lesser extent. However, in the case of work-aggravated asthma due to non-specific stimuli, controlling factors such as cold, irritants, exercise, stress and treatment non-compliance, and facilitating adherence and optimizing therapy can often suffice to allow a return to work. Other processes that mimic asthma, such as reactive airway dysfunction syndrome, irritable larynx syndrome and COPD, however, must be ruled out. Therefore, when a worker reports asthma symptoms linked to occupational exposure, it is essential, from a therapeutic, occupational and economic perspective, to determine which process is involved.3 Occupational asthma must be diagnosed as soon as possible on the basis of objective tests that can ensure the highest degree of certainty; this, however, is far from simple. Scientific societies and groups of experts have devised algorithms that can be used with available tools to facilitate what is essentially a complex diagnosis.4,5 Today’s recommendations are reliable and can help clinicians take the right decisions.6 According to the widely accepted definition, occupational asthma is “a disease characterized by variable airflow limitation and/or airway hyperresponsiveness due to causes and conditions attributable to a particular occupational environment and not to stimuli encountered outside the workplace”,7 and the first step is to confirm the presence of the disease. Diagnostic criteria for