Patrick A Flume, James D Chalmers, Kenneth N Olivier
Lancet 2018; 392: 880–90
Bronchiectasis is characterised by pathological dilation of the airways. More specifically, the radiographic demonstration of airway enlargement is the common feature of a heterogeneous set of conditions and clinical presentations. No approved therapies exist for the condition other than for bronchiectasis caused by cystic fibrosis. The heterogeneity of bronchiectasis is a major challenge in clinical practice and the main reason for difficulty in achieving endpoints in clinical trials. Recent observations of the past 2 years have improved the understanding of physicians regarding bronchiectasis, and have indicated that it might be more effective to classify patients in a different way. Patients could be categorised according to a heterogeneous group of endotypes (defined by a distinct functional or pathobiological mechanism) or by clinical phenotypes (defined by relevant and common features of the disease). In doing so, more specific therapies needed to effectively treat patients might finally be developed. Here, we describe some of the recent advances in endotyping, genetics, and disease heterogeneity of bronchiectasis including observations related to the microbiome.
Walter Vincken, Mark L. Levy, Jane Scullion, Omar S. Usmani,
P.N. Richard Dekhuijzen and Chris J. Corrigan on behalf of the ADMIT group
We present an extensive review of the literature to date pertaining to the rationale for using a spacer/valved holding chamber (VHC) to deliver inhaled therapy from a pressurised, metered-dose inhaler, a discussion of how the properties of individual devices may vary according to their physical characteristics and materials of manufacture, the potential risks and benefits of ancillaries such as valves, and the evidence that they contribute tangibly to the delivery of therapy.
We also reiterate practical recommendations for the correct usage and maintenance of spacers/VHCs, which we trust offer practical help and advice to patients and healthcare professionals alike.
Sushmita Pamidi, R. John Kimoff
Emerging literature suggests that sleep-disordered breathing (SDB) worsens over the course of pregnancy and is associated with adverse maternal and fetal outcomes. Earlier studies, using mainly snoring as a surrogate marker for SDB, have shown an increase in the prevalence of SDB during pregnancy compared with that in the pregravid state. More recently, prospective observational studies in which the investigators ascertained SDB by using complete poly- somnography have shown a prevalence ranging from approximately 17% to 45% in the third trimester. Pregnancy itself can be associated with daytime hypersomnolence, so complaints of increasing fatigue and sleepiness during pregnancy are not specific for SDB. Moreover, snoring in isolation also has relatively poor sensitivity and specificity as a screening tool for diagnosing maternal SDB. The indications for screening for SDB during routine obstetric prenatal visits are still unclear, but observational studies indicate that maternal SDB is linked with the develop- ment of adverse pregnancy outcomes, such as gestational hypertension and gestational diabetes mellitus. Some studies also have identified a relationship between maternal SDB and the delivery of infants who are small for gestational age. Aside from a few small interventional studies of CPAP in pregnant patients with gestational hypertension, little currently is known about whether treatment of SDB during pregnancy improves clinical outcomes for the mother and/or baby. Additional current knowledge gaps include elucidating underlying mechanisms of maternal SDB, determining optimal treatment strategies, and understanding the trajectory of SDB after delivery.
Fernández Fabrellas E (coord), Chiner E, Gimeno E, Giner J, Hernández C, Peiró M, Valeiro B, Vilaró J
Aumentar y mejorar el conocimiento de la EPOC es uno de los principales objetivos que la Sociedad Española de Neumología y Cirugía Torácica (SEPAR) pretende alcan- zar con el desarrollo del Año SEPAR 2015-2016 de la EPOC y el Tabaco. Son muchas las herramientas que se están empleando para llevarlo a cabo, pero sin duda, una de las más directas e importantes es este libro, que nace con la idea de aportar respuestas prácticas y concretas a aquellos interrogantes que un enfermo de EPOC y sus cuida- dores puedan tener.
El libro CONVIVIR CON LA EPOC surge de la necesidad de disponer de una guía sen- cilla, práctica y actualizada que, a través de un lenguaje fácil de comprender para el lector, se convierta en un libro de cabecera que aporte seguridad y con anza a todos aquellos que quieran conocer algo más sobre una importante enfermedad respiratoria causada principalmente por el consumo de tabaco, la EPOC.
Desde aquí deseo expresar mi más sincero agradecimiento y mi felicitación a los pro- fesionales SEPAR (enfermería, sioterapia y neumología) que con gran ilusión han par- ticipado en la coordinación y redacción de los diferentes temas tratados.
Rochwerg B, Brochard L, Elliott MW, Hess D, Hill NS, Nava S, Navalesi P (members of the steering committee); Antonelli M, Brozek J, Conti G, Ferrer M, Guntupalli K, Jaber S, Keenan S, Mancebo J, Mehta S, Raoof S(members of the task force)
Noninvasive mechanical ventilation (NIV) is widely used in the acute care setting for acute respiratory failure (ARF) across a variety of aetiologies. This document provides European Respiratory Society/American Thoracic Society recommendations for the clinical application of NIV based on the most current literature.
The guideline committee was composed of clinicians, methodologists and experts in the field of NIV. The committee developed recommendations based on the GRADE (Grading, Recommendation, Assessment, Development and Evaluation) methodology for each actionable question. The GRADE Evidence to Decision framework in the guideline development tool was used to generate recommendations. A number of topics were addressed using technical summaries without recommendations and these are discussed in the supplementary material.
This guideline committee developed recommendations for 11 actionable questions in a PICO (population– intervention–comparison–outcome) format, all addressing the use of NIV for various aetiologies of ARF. The specific conditions where recommendations were made include exacerbation of chronic obstructive pulmonary disease, cardiogenic pulmonary oedema, de novo hypoxaemic respiratory failure, immunocompromised patients, chest trauma, palliation, post-operative care, weaning and post-extubation.
This document summarises the current state of knowledge regarding the role of NIV in ARF. Evidence- based recommendations provide guidance to relevant stakeholders.
Mandal S, Suh ES, Harding R, Vaughan-France A, Ramsay M, Connolly B, Bear DE, MacLaughlin H, Greenwood SA, Polkey MI, Elliott M, Chen T, Douiri A, Moxham J, Murphy PB, Hart N
Respiratory management of obesity hypoventilation syndrome (OHS) focusses on the control of sleep-disordered breathing rather than the treatment of obesity. Currently, there are no data from randomised trials of weight loss targeted rehabilitation programmes for patients with OHS.
A 3-month multimodal hybrid inpatient-outpatient motivation, exercise and nutrition rehabilitation programme, in addition to non invasive ventilation (NIV), would result in greater per cent weight loss compared with standard care.
A single-centre pilot randomised controlled trial allocated patients to either standard care or standard care plus rehabilitation. Primary outcome was per cent weight loss at 12 months with secondary exploratory outcomes of weight loss, exercise capacity and health-related quality of life (HRQOL) at the end of the rehabilitation programme to assess the intervention effect.
Thirty-seven patients (11 male, 59.8±12.7 years) with a body mass index of 51.1±7.7 kg/m2 were randomised. At 12 months, there was no between-group difference in per cent weight loss (mean difference -5.9% (95% CI -14.4% to 2.7%; p=0.17)). At 3 months, there was a greater per cent weight loss (mean difference -5% (95% CI -8.3% to -1.4%; p=0.007)), increased exercise capacity (6 min walk test 60 m (95% CI 29.5 to 214.5) vs 20 m (95% CI 11.5 to 81.3); p=0.036) and HRQL (mean difference SF-36 general health score (10 (95% CI 5 to 21.3) vs 0 (95% CI -5 to 10); p=0.02)) in the rehabilitation group.
In patients with OHS, a 3-month comprehensive rehabilitation programme, in addition to NIV, resulted in improved weight loss, exercise capacity and QOL at the end of the rehabilitation period, but these effects were not demonstrated at 12 months, in part, due to the limited retention of patients at 12 months.
Horton EJ, Mitchell KE, Johnson-Warrington V, Apps LD, Sewell L, Morgan M, Taylor RS, Singh SJ
Standardised home-based pulmonary rehabilitation (PR) programmes offer an alternative model to centre-based supervised PR for which uptake is currently poor. We determined if a structured home-based unsupervised PR programme was non-inferior to supervised centre-based PR for participants with COPD.
A total of 287 participants with COPD who were referred to PR (187 male, mean (SD) age 68 (8.86) years, FEV1% predicted 48.34 (17.92)) were recruited. They were randomised to either centre-based PR or a structured unsupervised home-based PR programme including a hospital visit with a healthcare professional trained in motivational interviewing, a self-management manual and two telephone calls. Fifty-eight (20%) withdrew from the centre-based group and 51 (18%) from the home group. The primary outcome was dyspnoea domain in the chronic respiratory disease questionnaire (Chronic Respiratory Questionnaire Self-Report; CRQ-SR) at 7 weeks. Measures were taken blinded. We undertook a modified intention-to-treat (mITT) complete case analysis, comparing groups according to original random allocation and with complete data at follow-up. The non-inferiority margin was 0.5 units.
There was evidence of significant gains in CRQ-dyspnoea at 7 weeks in both home and centre-based groups. There was inconclusive evidence that home-based PR was non-inferior to PR in dyspnoea (mean group difference, mITT: -0.24, 95% CI -0.61 to 0.12, p=0.18), favouring the centre group at 7 weeks.
The standardised home-based programme provides benefits in dyspnoea. Further evidence is needed to definitively determine if the health benefits of the standardised home-based programme are non-inferior or equivalent to supervised centre-based rehabilitation.
La Sociedad Española de Neumología y Cirugía Torácica (SEPAR) ha editado una guía con información para pacientes sobre enfermedades respiratorias.
Puedes consultar la guía y descargarla en este link.
Rodríguez-Fuster A, Belda-Sanchis J, Aguiló R, Embun R, Mojal S, Call S, Molins L, Rivas de Andrés JJ; on behalf of GECMP-CCR-SEPAR.
Eur J Cardiothorac Surg. 2013 Oct 3. [Epub ahead of print]
Little information is available on postoperative morbidity and mortality after pulmonary metastasectomy. We describe the postoperative morbidity and mortality in a large multicentre series of patients after a first surgical procedure for pulmonary metastases of colorectal carcinoma (CRC) and identify the pre- and intraoperative variables influencing the clinical outcome.
A prospective, observational and multicentre study was conducted. Data were collected from March 2008 to February 2010. Patients were grouped into Groups A and B according to the presence or absence of postoperative complications. Variables in both groups were compared by univariate and multivariate analyses. P-values of <0.05 were considered statistically significant.
A total of 532 patients (64.5% males) from 32 hospitals were included. The mean (SD) ages of both study groups were similar [68 (10) vs 67 (10) years, P = NS). A total of 1050 lung resections were performed (90% segmentectomies or wedge, n = 946 and 10% lobectomies or greater, n = 104). Group A included 83 (15.6%) patients who developed a total of 100 complications. These included persistent air leaks in 18, atelectasis in 13, pneumonia in 13, paralytic ileum in 12, arrhythmia in 9, acute respiratory distress syndrome in 4 and miscellanea in 31. Reoperation was performed in 5 (0.9%) patients due to persistent air leaks in 4 and lung ischaemia in 1. The mortality rate was 0.4% (n = 2). Causes of death were sepsis in 1 patient and ventricular fibrillation in 1. In the multivariate analysis, lobectomy or greater lung resection [odds ration (OR) 1.9, 95% confidence interval (95% CI) 1.04-3.3, P = 0.03], respiratory co-morbidity (OR 2.3, 95% CI 1.1-4.6, P = 0.01) and cardiovascular co-morbidity (OR 2, 95% CI 1-3.8, P = 0.02) were independent risk factors for postoperative morbidity. Video-assisted surgery vs thoracotomy showed a protective effect (OR 0.3, 95% CI 0.1-0.8, P = 0.01).
The first episode of lung surgery for pulmonary metastases of CRC was associated with very low mortality and reoperation rates (<1%). The postoperative morbidity rate was 16%. Independent risk factors of postoperative morbidity were major lung resection and respiratory and/or cardiovascular co-morbidity. Video-assisted surgery showed a protective effect.
R Embún, F Fiorentino, T Treasure, JJ Rivas, L Molins, On behalf of Grupo Español de Cirugía Metástasis Pulmonares de Carcinoma Colo-Rectal (GECMPCCR) de la Sociedad Española de Neumología y Cirugía Torácica (SEPAR).
To capture an accurate contemporary description of the practice of pulmonary metastasectomy for colorectal carcinoma in one national healthcare system.
A national registry set up in Spain by Grupo Español de Cirugía Metástasis Pulmonares de Carcinoma Colo-Rectal (GECMP-CCR).
32 Spanish thoracic units.
All patients with one or more histologically proven lung metastasis removed by surgery between March 2008 and February 2010. Interventions: Pulmonary metastasectomy for one or more pulmonary nodules proven to be metastatic colorectal carcinoma.
PRIMARY AND SECONDARY OUTCOME MEASURES:
The age and sex of the patients having this surgery were recorded with the number of metastases removed, the interval between the primary colorectal cancer operation and the pulmonary metastasectomy, and the carcinoembryonic antigen level. Also recorded were the practices with respect to mediastinal lymphadenopathy and coexisting liver metastases.
Data were available on 543 patients from 32 units (6–43/unit). They were aged 32–88 (mean 65) years, and 65% were men. In 55% of patients, there was a solitary metastasis. The median interval between the primary cancer resection and metastasectomy was 28 months and the serum carcinoembryonic antigen was low/normal in the majority. Liver metastatic disease was present in 29% of patients at some point prior to pulmonary metastasectomy. Mediastinal lymphadenectomy varied from 9% to 100% of patients.
The data represent a prospective comprehensive national data collection on pulmonary metastasectomy. The practice is more conservative than the impression gained when members of the European Society of Thoracic Surgeons were surveyed in 2006/ 2007 but is more inclusive than would be recommended on the basis of recent outcome analyses. Further analyses on the morbidity associated with this surgery and the correlation between imaging studies and pathological findings are being published separately by GECMP-CCR.
Siempre es una satisfacción comprobar que la consecución de una práctica consolida a un equipo. Éste es el caso de la cirugía videotoracoscópica y de la importancia que en los últimos años ha adquirido en el tratamiento del cáncer de pulmón.
Nuestros compañeros del Servicio de Cirugía Torácica de Aragón, se iniciaron en esta técnica en 2008 y el aprendizaje logrado desde entonces, les permite en la actualidad poder aplicar al 50 % de los pacientes candidatos a tratamiento quirúrgico este procedimiento, siendo el tercer grupo nacional con más experiencia en el mismo, información que queda reflejada en la nota de prensa que os adjunto.
Así mismo, los miembros cirujanos de nuestra Sociedad desean transmitir a través de esta secretaría, su agradecimiento a SADAR-PNEUMARAGÓN por la colaboración que mediante beca, sirvió de apoyo a la realización de estudios de validación de esta técnica.
Asma ocupacional es aquella entidad que se desarrolla por causas o condiciones derivadas de un determinado medio laboral y no por estímulos que se encuentran fuera del trabajo. El asma ocupacional constituye hoy en día la enfermedad respiratoria ocupacional más frecuente en la mayoría de los países industrializados y se calcula que la proporción de nuevos casos de asma atribuibles a la exposición laboral se sitúa en torno al 10-15%.
Puede desarrollarse tanto por un mecanismo inmunológico como no inmunológico. En su desarrolloinfluyen el tipo de agente al que se está expuesto, el nivel y modo de exposición y factores genéticos de susceptibilidad.
En el proceso diagnóstico concurre la confirmación de que el paciente tiene asma bronquial y la confirmación de que ésta se produce por causa laboral. Como demuestra la historia natural de la enfermedad, un diagnóstico precoz y las consiguientes acciones posteriores redundan en un mejor pronóstico de la misma.
Las bullas gigantes son espacios aéreos parenquimatosos, producidos por el atrapamiento de aire en su interior, que ocupan al menos un tercio del hemitórax y que provocan el colapso del parénquima pulmonar adyacente a ellas. Presentamos un fenómeno infrecuente denominado autobullectomía, que consiste en la regresión espontánea, total o parcial, de una bulla preexistente. Existen muy pocos casos descritos en la literatura y el nuestro es el primero que se manifi esta de forma bilateral y simultánea, asociado a una espectacular mejoría en las pruebas de función respiratoria.
CAA is a rare congenital anomaly in which the aortic arch is situated cranially in relation to its usual position, ascending into the neck above the clavicle.
A cervical arch is formed when atresia of the fourth primitive aortic arch occurs.
However, many patients with this anomaly are asymptomatic.