Sagrario Mayoralas Alises

Perfiles de movilidad de los pacientes con oxigenoterapia crónica domiciliaria

Home oxygen therapy has been classically based on the use of compressed oxygen cylinders and portable oxygen (O(2)) concentrators. In the last few years, we have witnessed the advent of portable oxygen therapy equipment and liquid oxygen systems and even more recently portable O(2) concentrators. This equipment allows for greater patient mobility, which generates new issues that we must understand and approach adequately. One of these is selecting the best oxygen source for each patient. In doing so, it is necessary to compare the patient mobility profile with the mobility allowed by the O(2) sources in order to determine the degree of correlation between the two. Proper indication for home oxygen therapy, the selection of the right source and the titration of the oxygen flow are three components which we must face when deciding to prescribe home oxygen therapy. The patient must also cooperate with correct O(2) use.

Efficacy of High-Flow Oxygen by Nasal Cannula With Active Humidification in a Patient With Acute Respiratory Failure of Neuromuscular Origin

The treatment of choice for patients with respiratory failure of neuromuscular origin, especially in patients with hypercapnic respiratory acidosis, is noninvasive ventilation (NIV). Endotracheal intubation and invasive ventilation are indicated for patients with severe respiratory compromise or failure of NIV. In recent years, high-flow oxygen therapy and active humidification devices have been introduced, and emerging evidence suggests that high-flow oxygen may be effective in various clinical settings, such as acute respiratory failure, after cardiac surgery, during sedation and analgesia, in acute heart failure, in hypoxemic respiratory distress, in do-not-intubate patients, in patients with chronic cough and copious secretions, pulmonary fibrosis, or cancer, in critical areas and the emergency department. We report on a patient with amyotrophic lateral sclerosis who arrived at the emergency department with acute hypercapnic respiratory failure. She did not tolerate NIV and refused intubation, but was treated successfully with heated, humidified oxygen via high-flow nasal cannula. Arterial blood analysis after an hour on high-flow nasal cannula showed improved pH, PaCO2, and awareness. The respiratory acidosis was corrected, and she was discharged after 5 days of hospitalization. Her response to high-flow nasal cannula was similar to that expected with NIV. We discuss the mechanisms of action of heated, humidified high-flow oxygen therapy.

Portable Pulse-Dose Oxygen Concentrators Should Not Be Used With Noninvasive Ventilation

An increasing number of patients, mainly COPD and overlap-syndrome patients, simultaneously use home oxygen therapy and noninvasive ventilation (NIV) at night. Usually the oxygen source is a stationary concentrator. We report a patient who, without a medical recommendation, was using a portable oxygen concentrator during nocturnal NIV. In the laboratory, with the patient, we tested the portable oxygen concentrators triggering and oxygen delivery, with the supplemental oxygen connected at 3 different positions: near the ventilator, near the exhalation valve, and on the nasal mask port. We also tested the concentrators triggering capacity by placing the nasal prongs and the nasal mask independently. We tested ventilator inspiratory pressures of 10, 14, and 18 cm H2O, and expiratory pressures of 4 and 6 cm H2O. The portable oxygen concentrator did not detect the patients inspiratory effort or deliver the required oxygen flow at any of the tested settings. We recommended that the patient not use the portable oxygen concentrator during nocturnal NIV.

Ventilación mecánica no invasiva en la agudización de las enfermedades respiratorias

Noninvasive ventilation (NIV) utilization has experienced an exponential growth in the last 25 years immediately after the introduction of the positive pressure and the nasal mask. Patients with acute, chronic and acute on chronic respiratory failure are candidates to be treated by this therapeutic modality. Its utilization inside the hospital is very heterogeneous being indicated for diverse patients by different levels of complexity and severity levels. We have scientific evidence of the maximum level for certain problems such as COPD exacerbations with respiratory acidosis, acute pulmonary edema, or patients with solid and hematologic transplantation, although its utilization has been generalized to many other clinical scenes using minor levels of evidence. NIV is also used successfully in patients of advanced age, patients with do not intubate orders or even patients with severe comorbidities. Finally, NIV could be used as a palliative tool. The continuous technological evolution and the need of formation of the professionals demands organizational changes in the hospitals and the necessity to define specific areas for most severe patients, such as respiratory intermediate care units.

Red de redes en ventilación mecánica no invasiva

Sr. Director: Hemos leído con gran interés el artículo titulado “El futuro de la ventilación mecánica domiciliaria: redes o contenedores”, publicado recientemente en su prestigiosa Revista. Frente al modelo de centros de referencia para controlar los programas de ventilación mecánica domiciliaria (VMD), el autor se posiciona claramente a favor de la creación de redes no jerárquicas donde cada elemento asume diversos papeles en función de las necesidades del paciente. Según este modelo, el hospital más próximo al paciente llevaría el peso de la asistencia, pero ante casos especiales o complejos sería preferible buscar a profesionales con mayor experiencia en el tema. El equilibrio entre accesibilidad y pericia se mantendría sin predominio de una sobre otra. Estando completamente de acuerdo con el autor, nos gustaría, no obstante, realizar algunas consideraciones al respecto. En primer lugar, nos gustaría precisar la íntima relación existente entre la VMD y la ventilación mecánica no invasiva (VMNI). La mayor parte de los pacientes en programas de VMD realizan tratamiento con VMNI, mientras que los que reciben ventilación por traqueotomía son sólo una minoría. Hablar de VMD es hablar fundamentalmente de VMNI. El poder mantener a un paciente con insuficiencia ventilatoria en su domicilio realizando ventilación mecánica no es más que una parte del amplio espectro que implica la ventilación de pacientes con enfermedades agudas, subagudas y crónicas. Escarrabill habla de cada centro como si sólo un grupo reducido de personas trabajara en el campo de la VMNI. La historia de la VMNI ha ido ligada fundamentalmente al paciente con enfermedad crónica. Sin embargo, en los últimos años hemos asistido al desarrollo de la VMNI en el enfermo agudo, y son estos casos los que realmente pueden plantear problemas de complejidad que requieran la búsqueda de la pericia en contra de la accesibilidad. En el momento actual, el campo de acción de la VMNI dentro del hospital abarca muchas áreas hospitalarias y diversas especialidades. Urgencias, unidades de cuidados intensivos, reanimaciones quirúrgicas, unidades coronarias, planta de hospitalización de neumología y de medicina interna son zonas habituales de uso de la VMNI. Además de indicarse como alternativa ventilatoria, la VMNI se prodiga cada vez más como técnica de apoyo a maniobras invasivas (broncoscopia, endoscopia intervencionista) o a la propia cirugía tanto en el preoperatorio como durante la cirugía o en el postoperatorio inmediato. Pacientes con insuficiencia respiratoria crónica, pacientes con agudización de la enfermedad pulmonar obstructiva crónica (EPOC) o edema agudo de pulmón, pacientes inmunodeprimidos, postrasplantados de órganos sólidos o hematológicos con complicaciones respiratorias, así como el destete de pacientes con EPOC, son actualmente indicaciones de la VMNI con nivel de evidencia A. Son muchos los profesionales dentro de un hospital que pueden y deben conocer la VMNI. El debate de accesibilidad frente a pericia se plantea igualmente dentro del hospital. El neumólogo no puede asumir la VMNI intrahospitalaria en su totalidad. Es necesario crear una red interna de VMNI donde el neumólogo lidere el equipo de profesionales pertenecientes a diferentes unidades y servicios implicados en la VMNI. Esta red intrahospitalaria se conectará con las redes de otros hospitales, para configurar una red de redes de VMNI donde ésta debe ser accesible a todos, pero, por la pericia en algún tema concreto, será aconsejable el manejo de determinado tipo de problema en uno u otro centro. Habrá centros con más experiencia en destete con VMNI, frente a otros más familiarizados en pacientes con enfermedad neuromuscular; unos, expertos en pacientes críticos, frente a otros especializados en programas integrales de obesidad. La red de redes de VMNI se configura como un paso más avanzado de lo que simplemente supone una red en VMD.

Deberíamos reconsiderar los criterios de oxigenoterapia crónica domiciliaria en función de la altitud

FEV1 800 (32%) and FEV1/FVC 32. Chest radiography presented signs of chronic bronchopathy without any other findings of interest, and the stomach was visualized in its anatomically correct location. The patient reported continuous cough over the course of the last year, with little expectoration. The cough had increased, even interfering with sleep and making it impossible to speak normally. The existence of gastro-esophageal reflux had been ruled out by esophageal pH. The patient had come to the hospital’s Emergency Department reporting suffocating cough and dyspnea and was therefore hospitalized with the diagnosis of COPD exacerbation. Arterial gasometry showed: pH 7.40, PO2 64 mmHg with O2 at 2 l/min through nasal cannulae, PCO2 44 mmHg. The complementary studies done (chest radiograph, ECG, blood analysis) did not show relevant alterations or changes compared with previous studies. Given the intensity of the cough and its accentuation with oxygen therapy, we decided to administer O2 to the patient with AIRVO equipment (Fisher & Paykel, Auckland, New Zealand). The air flow from the device is regulated at 35 l/min and the O2 flow of the flow meter at 3 l/min, in order to achieve an estimated FiO2 of 28%. The clinical response was spectacular, with the complete disappearance of the cough 5 min after initiating the therapy. The patient continued with the treatment for one week and was later discharged with conventional HOT. One month afterwards, the patient was seen in the outpatient consultation. The cough had reappeared, but was much milder and tolerable.

Fibrosis pulmonar mortal, con etanercept como posible desencadenante

La fibrosis pulmonar es una enfermedad que puede estar causada por agentes externos como determinados farmacos. Desde hace un tiempo se utilizan farmacos antagonistas del factor de necrosis tumoral (TNF) para ciertas enfermedades autoinmunitarias, siendo un ejemplo de estos farmacos el etanercept. Las fibrosis secundarias a medicamentos se caracterizan por la respuesta a la retirada del farmaco y a esteroides. En muy raras ocasiones se produce una fibrosis irreversible. Presentamos el caso de un paciente que desarrollo una fibrosis pulmonar tras iniciar tratamiento con etanercept y que tuvo un curso clinico nefasto a pesar de la retirada del anti-TNF y dosis altas de esteroides.

Factor de necrosis tumoral como marcador de inflamación precoz en fumadores sanos

BACKGROUND AND OBJECTIVES Smoking creates an inflammation that leads to lose of lung function. Tumor necrosis factor alpha (TNF-α) is a cytokine that plays an important role in the pathogenesis of chronic obstructive pulmonary disease. There is a need to develop methods for an early detection of an impaired lung function in smokers. We aimed to show that smokers have higher levels of TNF-α in serum and exhaled breath condensate (EBC). We also analysed the influence of sex, age and weight on TNF-α, and determined the association between smoking, pulmonary function and TNF-α. PATIENTS AND METHODS Prospective study of smokers and non-smokers without any known disease. Respiratory function tests, EBC and blood samples were performed before smoking cessation. STATISTICAL ANALYSIS SPSS 11.0. RESULTS Fifty-one patients (60.8% smokers), 56.9% females, mean age 39.88 years old. Smokers initiated at an age of 15.77 years; the mean of cigarettes/day was 21.68. Significant differences in TNF-α serum levels between smokers and non-smokers were observed (P<.043). Differences did not reach significance for EBC. For tobacco consumption data, only age at smoking initiation and serum TNF-α levels had a correlation. A significant relation between TNF-α serum levels and forced expiratory volume in one second and forced vital capacity was found. CONCLUSIONS Smokers show higher TNF-α levels in serum. Number of years of smoking has an influence on TNF-α levels. There is a modest correlation between pulmonary function and plasma TNF-α levels, but not for EBC.

Resolución de atelectasia obstructiva con ventilación mecánica no invasiva

Bronchoscopy is a commonly used technique in patients with atelectasis due to mucus plugs. We present here the case of an 82-year-old patient with a history of Meiges syndrome who developed acute respiratory failure due to atelectasis of the right upper lobe associated with hospital-acquired pneumonia. The patient had a severely reduced level of consciousness, significant work-of-breathing and severe hypercapnic acidosis, all of which contraindicated bronchoscopy. Bi-level noninvasive mechanical ventilation (NIMV) was initiated by way of a face mask. Progress was favourable, with clear clinical and gasometric improvement. The chest X-ray performed 12hours later showed complete resolution of the atelectasis. These data suggest that NIMV may be useful in the treatment of atelectasis is some critical patients.

Etanercept as a possible trigger of fatal pulmonary fibrosis

Pulmonary fibrosis can be caused by external agents, including certain drugs. For some time now, tumor necrosis factor antagonists such as etanercept have been used to treat certain autoimmune diseases. Fibrosis caused by medication responds to withdrawal of the drug and treatment with corticosteroids. Very rarely, fibrosis is irreversible. We present the case of a patient who developed pulmonary fibrosis after initiating treatment with etanercept. The clinical course was fulminant despite withdrawal of the drug and high doses of corticosteroids. La fibrosis pulmonar es una enfermedad que puede estar causada por agentes externos como determinados farmacos. Desde hace un tiempo se utilizan farmacos antagonistas del factor de necrosis tumoral (TNF) para ciertas enfermedades autoinmunitarias, siendo un ejemplo de estos farmacos el etanercept. Las fibrosis secundarias a medicamentos se caracterizan por la respuesta a la retirada del farmaco y a esteroides. En muy raras ocasiones se produce una fibrosis irreversible. Presentamos el caso de un paciente que desarrollo una fibrosis pulmonar tras iniciar tratamiento con etanercept y que tuvo un curso clinico nefasto a pesar de la retirada del anti-TNF y dosis altas de esteroides.