Ramón Fernández Álvarez

Age, comorbidity, treatment decision and prognosis in lung cancer

Fluid (ml) ‘Usual’ thickener 785 202 (701–903) 0.47 Pre-thickened 795 346 (745–1091) Protein (g) ‘Usual’ thickener 7 3 (4–7) 0.001 Pre-thickened 15 7 (10–17) Energy (kCal) ‘Usual’ thickener 267 50 (254–304) 0.0001 Pre-thickened 583 241 (543–784) Calcium (mg) ‘Usual’ thickener 25 8 (22–30) 0.0001 Pre-thickened 544 156 (467–623) Vitamin C (mg) ‘Usual’ thickener 35 48 (13–61) 0.001 Pre-thickened 170 134 (128–262) Vitamin D (μg) ‘Usual’ thickener 0 0 0.00001 Pre-thickened 5 2 (4–6)

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.

Contaminación del aire interior y su impacto en la patología respiratoria

Humans spend a considerable amount of their time breathing air inside enclosed spaces in which, due to various sources, there may be contaminants that deteriorate the air quality. This is an important risk factor for the health of the general population. This review evaluates the contaminants that are present in the air of indoor air spaces, describing the sources that generate them as well as the physiopathological mechanisms and the diseases that they may cause in the respiratory system.

Neumonía adquirida en la comunidad por gérmenes atípicos: tratamiento y evolución

Objetivo Estudiar la evolucion de un grupo de neumonias extrahospitalarias causadas por germenes atipicos ( Mycoplasma pneumoniae, Legionella spp., Coxiella burnetii y Chlamydophila pneumoniae ) en funcion del tratamiento empirico recibido. Pacientes y metodos Entre enero de 1996 y febrero de 2001 ingresaron en nuestra unidad 390 casos de neumonia, de los que 89 estaban causados por germenes atipicos. Los pacientes se dividieron retrospectivamente en 2 grupos segun el tratamiento empirico pautado: grupo A, al que se habia proporcionado cobertura frente a germenes atipicos (quinolonas o macrolidos), y grupo B, al que no se habia proporcionado dicha cobertura. Se estudio la evolucion segun las diferencias entre ambos grupos en la estancia hospitalaria, la resolucion radiologica, el reingreso en el primer mes tras el alta y la mortalidad. Resultados El grupo de estudio lo constituyeron 89 pacientes con neumonia causada por germenes atipicos (39 en el grupo A y 50 en el B). Las variables estudiadas no mostraron diferencias significativas entre ambos grupos. Conclusiones En nuestra serie de neumonias extrahospitalarias la cobertura antibiotica frente a germenes atipicos no mejoro la evolucion clinica y radiologica de los pacientes.

Home Mechanical Ventilation through Mask: Monitoring Leakage and Nocturnal Oxygenation at Home

Background: Leakage is common in patients receiving home mechanical ventilation (HMV) via a face mask. Although pressure ventilators have partial compensatory capacity, excessive leakage can compromise the effectiveness of treatment. Home ventilators are equipped with built-in software which provides information on leakage. However, the values of leakage and their effects in routine clinical practice are currently little known. Objective: To measure leakage in stable patients on nocturnal HMV and its impact on treatment effectiveness. Methods: Consecutive outpatients on HMV were recruited. Nocturnal pulse oximetry was performed at home and leakage was measured using the ventilator’s built-in software. We measured: mean SpO2, percentage of time with SpO2 <90% (T90), mean leakage (meanL), maximum leakage (maxL), and minimum leakage (minL) during the ventilation session. We estimated ventilator capacity to compensate for leakage according to inspiratory positive airway pressure and divided the patients into two groups: those with leak compensation and those without. Results: The study included 41 patients [mean age, 64 years (SD 11.9); 23 (56%) women]. Nocturnal pulse oximetry showed an SpO2 of 94% (±2.9) and a T90 of 10% (±21.7). Leakage (in l/min) was: meanL, 32.2 (±15.3); maxL, 64.8 (±28.5), and minL, 18.8 (±10.6). Seven cases (17%) had leakage greater than the ventilator compensatory capacity, but no significant difference in SpO2 or T90 was observed between patients with or without leak compensation. Conclusions: A wide variation between maxL and minL was observed in our series; 17% of cases had higher leakage values than the compensatory capacity of the ventilator, but this did not affect nocturnal oxygenation.Background: Leakage is common in patients receiving home mechanical ventilation (HMV) via a face mask. Although pressure ventilators have partial compensatory capacity, excessive leakage can compromise the effectiveness of treatment. Home ventilators are equipped with built-in software which provides information on leakage. However, the values of leakage and their effects in routine clinical practice are currently little known. Objective: To measure leakage in stable patients on nocturnal HMV and its impact on treatment effectiveness. Methods: Consecutive outpatients on HMV were recruited. Nocturnal pulse oximetry was performed at home and leakage was measured using the ventilator’s built-in software. We measured: mean Sp O 2 , percentage of time with Sp O 2 ! 90% (T90), mean leakage (meanL), maximum leakage (maxL), and minimum leakage (minL) during the ventilation session. We estimated ventilator capacity to compensate for leakage according to inspiratory positive airway pressure and divided the patients into

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.

Monitoring Noninvasive Ventilation in Patients with Obesity Hypoventilation Syndrome: Comparison between Ventilator Built-in Software and Respiratory Polygraphy

Background: Polygraphy (PG) remains the standard method of assessing noninvasive ventilation (NIV) effectiveness. Built-in software (BIS) of recent NIV equipment provides estimates of some ventilator parameters, but their usefulness is unclear. Objectives: To assess the reliability of BIS compared with PG in a cohort of obesity hypoventilation syndrome (OHS) patients on NIV. Methods: Thirty stable OHS patients on NIV were evaluated in an outpatient setting with simultaneous PG and BIS recordings. The automated apnea-hypopnea event index (EIAUT) provided by Rescan and manual scoring based on available traces obtained from the software (EIBIS) were compared with manual PG scoring (EIPG). Each manual scoring was separately performed by 2 trained operators. Agreement between the 2 operators was assessed using the kappa coefficient. Pearson correlation and Bland-Altman plots were used to evaluate agreement between EIAUT, EIBIS, and EIPG. Results: Twenty-six cases were valid for analysis (age ±61 years, 17 men). All patients were ventilated in the spontaneous/timed mode (mean inspiratory positive airway pressure 17 ± 3 cm H2O, mean expiratory positive airway pressure 10 ± 3 cm H2O). Cohens kappa agreement between the operators was 0.7 for EIBIS and 0.84 for EIPG. EIBIS showed good correlation with EIPG (r2 = 0.79 p < 0.001), better than scoring provided by the automated analysis (r2 = 0.71, p < 0.006 for EIAUT vs. EIPG). Conclusions: In stable OHS patients on NIV, unattended home-based monitoring using Rescan is reproducible and reliable to assess quality of ventilation when compared with PG. In addition, manual scoring of events using data obtained with this device is more consistent than software-based automated analysis.

Neumonía adquirida en la comunidad: adenosindesaminasa plasmática como marcador etiolÓgico

Fundamento La adenosindesaminasa (ADA) es una enzima intracitoplasmatica cuya elevacionha sido demostrada tanto en procesos infecciosos que estimulan la inmunidad celular como enotro tipo de enfermedades (diabetes y hepatopatias, entre otras). El objetivo de este estudio esdeterminar la capacidad del ADA plasmatico (ADAp) para predecir el tipo de germen causanteen la neumonia adquirida en la comunidad (NAC) y poder guiar el tratamiento antibiotico empirico. Pacientes y metodo Estudio de cohortes (245 casos y 49 controles) para contrastar las diferenciasen el valor de ADAp estudiando tanto variables microbiologicas (tipo de germen) como factoresde comorbilidad y complicaciones. Se practico una regresion logistica. Resultados Las NAC causadas por germenes atipicos elevan significativamente el valor delADAp, que se normaliza en la convalecencia. Las variables con capacidad independiente paraelevar dicho valor fueron la presencia de germen «atipico» (odds ratio [OR] = 5,9), hepatopatia(OR = 5,8), diabetes (OR = 1,9) y toma previa de antibioticos (OR = 1,7). Conclusiones La ADAp puede ser utilizada como marcador etiologico para guiar el tratamientoantibiotico empirico en la NAC, en ausencia de diabetes, hepatopatia y toma de antibioticosprevia a la determinacion.

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.