Varón con enfermedad cavitaria pulmonar

Granulomatosis with polyangiitis (Wegener) (GPA) was diagnosed in a 44 year-old-man who had a relapse 6 years after diagnosis with the “air crescent” sign on chest CT. Seven years after his diagnosis the patient presented a new relapse with cavitary lung disease, and high levels of anti-proteinase 3 antibodies, suggesting disease activity; however, a transbronchial biopsy showed histological findings of tuberculosis (TB). The association between TB and GPA is rarely informed; moreover TB and GPA have similar findings including both clinical and anti-proteinase 3 antibodies.     

Resultados funcionales del trasplante pulmonar en la enfermedad pulmonar obstructiva crónica

IntroductionLung transplantation (LT) is a therapeutic option with controversial results in chronic obstructive pulmonary disease (COPD). We aimed to analyze the outcomes of transplantation in terms of lung function and to identify prognostic factors.MethodA retrospective analysis of 107 patients with COPD receiving lung transplants in the La Fe Hospital between 1991 and 2008 was performed. Preoperative variables, pulmonary function tests before and after LT, surgical procedure variables and long-term monitoring, expressed as mean or percentage, as applicable, were analyzed. Spirometric results before and after LT were analyzed. Linear or logistic regression were used for multivariate analysis depending on the variable.ResultsNinety-four men (87.9%) and 13 women (12.1%) were transplanted, with a mean age ± standard deviation of 52.58 ± 8.05 years; 71% of LTs were double-lung transplantations. Spirometric values improved after LT: FVC: +1.22 L (+34.9%), FEV₁: +1.66 L (+56.7%) and FEF_25-75: +1.85 L (+50.8%); P = .001. This functional improvement was maintained after 5 years only in the group with BODE score > 7 (P = .001). Recipient height, type of LT, use of extracorporeal circulation during the surgical procedure, presence of bronchiolitis obliterans syndrome and the age and cause of death of the donor significantly influenced lung function over time.ConclusionsLT improves lung function in COPD patients. This improvement was maintained at 5 years only in patients with BODE > 7. Double lung transplantation provides better functional results than single-lung transplantation.     

Enfermedad pulmonar obstructiva crónica y osteoporosis

Osteoporosis is one of the systemic effects associated with chronic obstructive pulmonary disease (COPD). Risk factors for bone loss include smoking, skeletal muscle weakness, low bone mass index (BMI), vitamin D deficiency, glucocorticoid use, hypogonadism and systemic inflammation. The most important clinical feature is vertebral fracture, due to its significant morbidity and mortality. The treatment of osteoporosis includes calcium and vitamin D, bisphosphonates, anabolic agents and pulmonary rehabilitation. Prospective studies are required to determine the prevalence of osteoporosis in COPD and to identify which patients are at high risk for osteoporotic fracture. The development of new drugs to control systemic inflammation may contribute to specific treatments for osteoporosis in COPD.     

Patrones radiológicos en la enfermedad pulmonar intersticial

Interstitial lung disease (ILD), or diffuse infiltrative lung disease, includes a heterogeneous group of processes characterized by the appearance of an inflammatory reaction in the alveolar wall, triggered by different antigens.This group represents a spectrum of diseases with distinct causes; furthermore, there is confusing variation in the use of nomenclature.The imaging method of choice in the evaluation and diagnosis of ILD is high-resolution computed tomography (HRCT), as it confirms the presence of lung disease and establishes the correct diagnosis of associated complications. However, the definitive diagnosis of these diseases requires consistency between the clinical and pathological findings. The radiologic images obtained by HRCT in this group of diseases are highly useful, especially to avoid unnecessary biopsies. For these reasons, clinicians should be familiar with the basic radiologic patterns associated with this special group of lung diseases: septal, reticular, nodular, ‘ground glass’, cystic, and condensation. This article describes the characteristics and presentation of these patterns and reviews some of the most frequent ILD, with special emphasis on their main radiological patterns.     

Preditores de hipertensão pulmonar após tromboembolia pulmonar de risco intermédio a elevado

BackgroundPulmonary embolism (PE) is a common cardiovascular emergency that, when combined with chronic thromboembolic pulmonary hypertension (PH), is associated with high mortality and morbidity. We aimed to determine the incidence of and predisposing factors for the development of PH after a PE episode.MethodsA retrospective study was conducted in 213 patients admitted to an intensive care unit with intermediate-to-high risk PE between 2000 and 2010. Clinical data at admission were collected and the incidence of PH as assessed by echocardiography (estimated pulmonary systolic artery pressure over 40 mmHg) was determined. Multivariate analysis was used to determine predictors of development of PH.ResultsPH was detected in 12.4% of patients after a mean follow-up of three years. Only age (hazard ratio [HR] 1.09, 95% confidence interval [CI] 1.02-1.20 per year; p=0.012) and body mass index (HR 1.19, 95% CI 1.04-1.36) per kg/m2, p=0.013) emerged as independent predictors of the development of this complication during follow-up.ConclusionsPH after PE was a relatively common complication in our series. We identified advanced age and increased body mass index as predisposing factors.     

Circulación pulmonar: aportaciones del año 2009

A significant number of studies on pulmonary circulation diseases have been published in 2009 that are likely to have a notable clinical impact. Anticoagulant treatment is on the verge of a significant change with the arrival of new oral drugs that have an inhibitory effect over factor X (rivaroxaban, apixaban) or thrombin (dabigatran). New studies have shown an efficacy comparable to enoxaparin in the prevention of thromboembolic disease and in some cases a lower risk of haemorrhage. Also interesting is a study on the incidence of pulmonary thromboembolism in patients with chronic obstructive pulmonary disease, a little known aspect. A study that demonstrates some efficacy of rosuvastatin in the prevention of thromboembolic disease, something that could change our current practices.Pulmonary hypertension (PH) continues to produce numerous publications. One French study has shown a relatively low risk of developing PH in patients with systemic sclerosis over a period of 3 years. As regards treatment, ambrisentan seems to confirm it lower risk of hepatoxicity compared to other endothelin antagonists. A new phosphodiesterase-5 inhibitor, tadalafil, has made a strong impact on the PH scene during this year. Its results are similar to other oral drugs with a convenient posology. The surgical treatment of PH due to chronic thromboembolism in one of the hospitals of our country has been present with results that, particularly in the past few years, are perfectly comparable to other centres of excellence.To summarise, 2009 has continued to provide important news in the area of pulmonary circulation.     

Novedades diagnósticas y terapéuticas en fibrosis pulmonar progresiva

In addition to idiopathic pulmonary fibrosis (IPF), other diffuse interstitial lung diseases (ILD) are also associated with pulmonary fibrosis and occur in a variable proportion of patients, depending on the entity. The name given to this fibrotic component, that may progress despite treatment, is progressive pulmonary fibrosis (PPF). In this context, PPF is not an entity per se but a common clinical condition or behavior that may occur in association with different types of fibrosing diffuse ILDs, compromising patient prognosis. PPF is identified from worsening clinical, physiological, and/or radiological criteria during patient follow-up. Randomized clinical trials in patients with IPF or progressive non-IPF ILD have shown that treatment with antifibrotic drugs, either nintedanib or pirfenidone, slows progression. We are seeing the start of a new era in the clinical management of this subgroup of patients, offering the perfect opportunity for exploring still uncharted territories.     

Normativa SEPAR sobre disfunción muscular de los pacientes con enfermedad pulmonar obstructiva crónica

In patients with chronic obstructive pulmonary disease (COPD), skeletal muscle dysfunction is a major comorbidity that negatively impacts their exercise capacity and quality of life. In the current guidelines, the most recent literature on the various aspects of COPD muscle dysfunction has been included. The Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) scale has been used to make evidence-based recommendations on the different features. Compared to a control population, one third of COPD patients exhibited a 25% decline in quadriceps muscle strength, even at early stages of their disease. Although both respiratory and limb muscles are altered, the latter are usually more severely affected. Numerous factors and biological mechanisms are involved in the etiology of COPD muscle dysfunction. Several tests are proposed in order to diagnose and evaluate the degree of muscle dysfunction of both respiratory and limb muscles (peripheral), as well as to identify the patients’ exercise capacity (six-minute walking test and cycloergometry). Currently available therapeutic strategies including the different training modalities and pharmacological and nutritional support are also described.     

Morbimortalidad de la resección pulmonar en pacientes octogenarios con cáncer de pulmón

ObjectiveEvaluate the restrictiveness of selection criteria for lung resection in lung cancer patients over 80 years of age compared to those applied in younger patients. Compare and analyze 30-day mortality and postoperative complications in both groups of patients.MethodsCase-controlled retrospective analysis. Study population: Consecutive patients undergoing elective anatomical lung resection. Population was divided into octogenarians (cases) and younger patients (controls). Variables determining surgical risk (BMI, FEV1%, postoperative FEV1%, FEV1/FVC, DLCO and pneumonectomy rate) were compared using either Wilcoxon or Chi-squared tests. Thirty-day mortality and morbidity odds ratio were calculated. A logistic regression model with bootstrap resampling was constructed, including postoperative complications as dependent variable and age and post-operative FEV1% as independent variables. Data were retrieved from a prospective database.ResultsNo statistically significant differences were found in BMI (P=.40), FEV1% (P=.41), postoperative FEV1% (P=.23), FEV1/FVC (P=.23), DLCO (P=.76) and pneumonectomy rate (P=.90). Case mortality was 1.85% and control mortality was 1.26% (OR: 1.48). Cardiorespiratory complications occurred in 12.80% of younger subjects and in 13.21% of patients aged 80 years or older. (OR: 1.03). In the logistic regression, only FEV1% was related to postoperative complications (P<.005).ConclusionSelection criteria for octogenarians are similar to those applied in the rest of the population. Advanced age is not a factor for increased 30-day mortality or postoperative morbidity.     

Factores clínicos asociados a enfermedad pulmonar por Aspergillus spp. en pacientes con enfermedad pulmonar obstructiva crónica

ObjectiveTo explore the clinical and epidemiological characteristics of chronic obstructive pulmonary disease (COPD) patients with Aspergillus spp. isolation from respiratory samples, and to identify which factors may help us to distinguish between colonisation and infection.MethodsA retrospective cohort study was performed. All patients with COPD and respiratory isolation of Aspergillus spp. over a 12-year period were included. Patients were assigned to 2 categories: colonisation and pulmonary aspergillosis (PA), which includes the different clinical forms of aspergillosis. A binary logistic regression model was performed to identify the predictive factors of PA.ResultsA total of 123 patients were included in the study: 48 (39.0%) with colonisation and 75 (61.0%) with PA: 68 with probable invasive pulmonary aspergillosis and 7 with chronic pulmonary aspergillosis. Spirometric stages of the GOLD classification were not correlated with a higher risk of PA. Four independent predictive factors of PA in COPD patients were identified: home oxygen therapy (OR: 4.39; 95% CI: 1.60-12.01; P = .004), bronchiectasis (OR: 3.61; 95% CI: 1.40-9.30; P = .008), hospital admission in the previous three months (OR: 3.12; 95% CI: 1.24-7.87; P = .016) and antifungal therapy against Candida spp. in the previous month (OR: 3.18; 95% CI: 1.16-8.73; P = .024).ConclusionsContinuous home oxygen therapy, bronchiectasis, hospital admission in the previous three months and administration of antifungal medication against Candida spp. in the previous month were associated with a higher risk of pulmonary aspergillosis in patients with COPD.     

Osteoartropatía hipertrófica con acro-osteolisis y neoformación ósea en un paciente con hipertensión pulmonar primaria

Hypertrophic osteoarthropathy is an entity characterized by a triad of periostitis of long bones, clubbing and arthritis. Radiologically there are two patterns, one characterized by new bone formation which predominates in patients with pulmonary disease, and another by acro-osteolysis that is most frequently associated with congenital heart disease. We report the case of a 30-year-old man diagnosed with primary pulmonary hypertension for two years, developing hypertrophic osteoarthropathy with a mixed radiological pattern.