Bronchial Infection and Temporal Evolution of Bronchiectasis in Patients With Chronic Obstructive Pulmonary Disease

[Background]: Bronchiectasis (BE) impact the clinical course and prognosis of patients with chronic obstructive pulmonary disease (COPD). Yet, the temporal evolution of BE in these patients is unknown. This study seeks to assess the temporal evolution of BE in persons with COPD.[Methods]: 201 moderate-to-severe patients were recruited between 2004 and 2007 and followed up at least every 6 monts (median of 102 months). To investigate the temporal evolution of BE, in 2015 a second high-resolution computed tomography scan (HRCT) was obtained in survivors and compared with the one obtained at recruitment.[Results]: 99 (49.3%) died during follow-up. The second HRCT could be obtained in 77 patients and showed that (1) in 27.3% of patients BE never developed, in 36.4% they remained stable, in 16.9% they increased in size and/or extension, and in 19.5% new BE emerged; and that (2) the presence of chronic purulent sputum (hazard ratio [HR], 2.8 [95% confidence interval {CI}, 1.3–5.8]), number of hospitalizations due to exacerbatons (HR, 1.2 [95% CI, 1.1–1.5]), and number of pathogenic microorganism (PPM) isolations (HR, 1.1 [95% CI, 1.02–1.3]) were independent risk factors for the progression or development of BE.[Conclusions]: The presence of chronic purulent sputum production, number of PPMs isolated in sputum, and number of hospitalizations due to exacerbations of COPD are independent risk factors of BE progression in patients with COPD

The evolution of the ventilatory ratio is a prognostic factor in mechanically ventilated COVID-19 ARDS patients

Background: Mortality due to COVID-19 is high, especially in patients requiring mechanical ventilation. The purpose of the study is to investigate associations between mortality and variables measured during the first three days of mechanical ventilation in patients with COVID-19 intubated at ICU admission. Methods: Multicenter, observational, cohort study includes consecutive patients with COVID-19 admitted to 44 Spanish ICUs between February 25 and July 31, 2020, who required intubation at ICU admission and mechanical ventilation for more than three days. We collected demographic and clinical data prior to admission; information about clinical evolution at days 1 and 3 of mechanical ventilation; and outcomes. Results: Of the 2,095 patients with COVID-19 admitted to the ICU, 1,118 (53.3%) were intubated at day 1 and remained under mechanical ventilation at day three. From days 1 to 3, PaO2/FiO2 increased from 115.6 [80.0-171.2] to 180.0 [135.4-227.9] mmHg and the ventilatory ratio from 1.73 [1.33-2.25] to 1.96 [1.61-2.40]. In-hospital mortality was 38.7%. A higher increase between ICU admission and day 3 in the ventilatory ratio (OR 1.04 [CI 1.01-1.07], p = 0.030) and creatinine levels (OR 1.05 [CI 1.01-1.09], p = 0.005) and a lower increase in platelet counts (OR 0.96 [CI 0.93-1.00], p = 0.037) were independently associated with a higher risk of death. No association between mortality and the PaO2/FiO2 variation was observed (OR 0.99 [CI 0.95 to 1.02], p = 0.47). Conclusions: Higher ventilatory ratio and its increase at day 3 is associated with mortality in patients with COVID-19 receiving mechanical ventilation at ICU admission. No association was found in the PaO2/FiO2 variation

Clustering COVID-19 ARDS patients through the first days of ICU admission. An analysis of the CIBERESUCICOVID Cohort

Background Acute respiratory distress syndrome (ARDS) can be classified into sub-phenotypes according to different inflammatory/clinical status. Prognostic enrichment was achieved by grouping patients into hypoinflammatory or hyperinflammatory sub-phenotypes, even though the time of analysis may change the classification according to treatment response or disease evolution. We aimed to evaluate when patients can be clustered in more than 1 group, and how they may change the clustering of patients using data of baseline or day 3, and the prognosis of patients according to their evolution by changing or not the cluster.Methods Multicenter, observational prospective, and retrospective study of patients admitted due to ARDS related to COVID-19 infection in Spain. Patients were grouped according to a clustering mixed-type data algorithm (k-prototypes) using continuous and categorical readily available variables at baseline and day 3.Results Of 6205 patients, 3743 (60%) were included in the study. According to silhouette analysis, patients were grouped in two clusters. At baseline, 1402 (37%) patients were included in cluster 1 and 2341(63%) in cluster 2. On day 3, 1557(42%) patients were included in cluster 1 and 2086 (57%) in cluster 2. The patients included in cluster 2 were older and more frequently hypertensive and had a higher prevalence of shock, organ dysfunction, inflammatory biomarkers, and worst respiratory indexes at both time points. The 90-day mortality was higher in cluster 2 at both clustering processes (43.8% [n = 1025] versus 27.3% [n = 383] at baseline, and 49% [n = 1023] versus 20.6% [n = 321] on day 3). Four hundred and fifty-eight (33%) patients clustered in the first group were clustered in the second group on day 3. In contrast, 638 (27%) patients clustered in the second group were clustered in the first group on day 3.Conclusions During the first days, patients can be clustered into two groups and the process of clustering patients may change as they continue to evolve. This means that despite a vast majority of patients remaining in the same cluster, a minority reaching 33% of patients analyzed may be re-categorized into different clusters based on their progress. Such changes can significantly impact their prognosis

Key Factors Associated With Pulmonary Sequelae in the Follow-Up of Critically Ill COVID-19 Patients

Introduction: Critical COVID-19 survivors have a high risk of respiratory sequelae. Therefore, we aimed to identify key factors associated with altered lung function and CT scan abnormalities at a follow-up visit in a cohort of critical COVID-19 survivors. Methods: Multicenter ambispective observational study in 52 Spanish intensive care units. Up to 1327 PCR-confirmed critical COVID-19 patients had sociodemographic, anthropometric, comorbidity and lifestyle characteristics collected at hospital admission; clinical and biological parameters throughout hospital stay; and, lung function and CT scan at a follow-up visit. Results: The median [p25–p75] time from discharge to follow-up was 3.57 [2.77–4.92] months. Median age was 60 [53–67] years, 27.8% women. The mean (SD) percentage of predicted diffusing lung capacity for carbon monoxide (DLCO) at follow-up was 72.02 (18.33)% predicted, with 66% of patients having DLCO < 80% and 24% having DLCO < 60%. CT scan showed persistent pulmonary infiltrates, fibrotic lesions, and emphysema in 33%, 25% and 6% of patients, respectively. Key variables associated with DLCO < 60% were chronic lung disease (CLD) (OR: 1.86 (1.18–2.92)), duration of invasive mechanical ventilation (IMV) (OR: 1.56 (1.37–1.77)), age (OR [per-1-SD] (95%CI): 1.39 (1.18–1.63)), urea (OR: 1.16 (0.97–1.39)) and estimated glomerular filtration rate at ICU admission (OR: 0.88 (0.73–1.06)). Bacterial pneumonia (1.62 (1.11–2.35)) and duration of ventilation (NIMV (1.23 (1.06–1.42), IMV (1.21 (1.01–1.45)) and prone positioning (1.17 (0.98–1.39)) were associated with fibrotic lesions. Conclusion: Age and CLD, reflecting patients’ baseline vulnerability, and markers of COVID-19 severity, such as duration of IMV and renal failure, were key factors associated with impaired DLCO and CT abnormalities

Spread of a SARS-CoV-2 variant through Europe in the summer of 2020.

Following its emergence in late 2019, the spread of SARS-CoV-21,2 has been tracked by phylogenetic analysis of viral genome sequences in unprecedented detail3–5. Although the virus spread globally in early 2020 before borders closed, intercontinental travel has since been greatly reduced. However, travel within Europe resumed in the summer of 2020. Here we report on a SARS-CoV-2 variant, 20E (EU1), that was identified in Spain in early summer 2020 and subsequently spread across Europe. We find no evidence that this variant has increased transmissibility, but instead demonstrate how rising incidence in Spain, resumption of travel, and lack of effective screening and containment may explain the variant’s success. Despite travel restrictions, we estimate that 20E (EU1) was introduced hundreds of times to European countries by summertime travellers, which is likely to have undermined local efforts to minimize infection with SARS-CoV-2. Our results illustrate how a variant can rapidly become dominant even in the absence of a substantial transmission advantage in favourable epidemiological settings. Genomic surveillance is critical for understanding how travel can affect transmission of SARS-CoV-2, and thus for informing future containment strategies as travel resumes. © 2021, The Author(s), under exclusive licence to Springer Nature Limited

Spread of a SARS-CoV-2 variant through Europe in the summer of 2020

[EN] Following its emergence in late 2019, the spread of SARS-CoV-21,2 has been tracked by phylogenetic analysis of viral genome sequences in unprecedented detail3,4,5. Although the virus spread globally in early 2020 before borders closed, intercontinental travel has since been greatly reduced. However, travel within Europe resumed in the summer of 2020. Here we report on a SARS-CoV-2 variant, 20E (EU1), that was identified in Spain in early summer 2020 and subsequently spread across Europe. We find no evidence that this variant has increased transmissibility, but instead demonstrate how rising incidence in Spain, resumption of travel, and lack of effective screening and containment may explain the variant’s success. Despite travel restrictions, we estimate that 20E (EU1) was introduced hundreds of times to European countries by summertime travellers, which is likely to have undermined local efforts to minimize infection with SARS-CoV-2. Our results illustrate how a variant can rapidly become dominant even in the absence of a substantial transmission advantage in favourable epidemiological settings. Genomic surveillance is critical for understanding how travel can affect transmission of SARS-CoV-2, and thus for informing future containment strategies as travel resumes.S

Efecto del tratamiento a largo plazo con presión positiva contínua en la vía aérea (cpap), sobre la incidencia de eventos cardiovasculares no mortales (ecv) en ancianos con apnea del sueño

Objetivos: El Síndrome de Apneas-Hipopneas durante el Sueño (SAHS) se relaciona con un incremento de ECV en las edades medias de la vida, pero se desconoce si esta relación se mantiene en ancianos. El objetivo del presente estudio ha sido analizar el impacto del SAHS y del tratamiento con CPAP sobre los ECV incidentes en ancianos con sospecha clínica de SAHS. Metodología: Estudio observacional prospectivo de una cohorte consecutiva de 597 ancianos (≥ 65 años) estudiados por sospecha de SAHS entre 1999 y 2007. Se establecieron 4 grupos de estudio: 107 controles sin SAHS (IAH<15), 97 SAHS leve-moderada (IAH entre 15-29) sin CPAP, 58 SAHS grave (IAH≥30) sin CPAP y 335 SAHS con CPAP (al menos 3 horas/día). Se realizó un análisis de Cox para determinar el impacto independiente del SAHS y el tratamiento con CPAP sobre los ECV incidentes. Resultados: El seguimiento medio fue de 69 meses (rango intercuartil 49-87). Se produjeron 70 (11.7%) ECV incidentes. El SAHS grave no tratado con CPAP se asoció de forma independiente a una mayor aparición de ECV incidentes (HR 2.41, IC95% 1.08-5.38), mientras que en el grupo de SAHS tratado con CPAP (HR 1.08, IC95% 0.52-2.27) y SAHS leve-moderado sin CPAP (HR 1.87, IC95% 0.74-4.73) no se observó un aumento significativamente mayor de ECV comparado con el grupo control. Conclusiones: El SAHS grave no tratado con CPAP es un factor de riesgo independiente de ECV incidente en ancianos. El tratamiento con CPAP reduce este exceso de ECV a niveles semejantes a los del grupo control sin SAHS.Objectives: Obstructive sleep apnea (OSA) is a risk factor for nonfatal cardiovascular events (CVE) in middle-aged subjects, but it is not known whether it is also a risk factor in the elderly. The objectives of the study were to investigate the impact of OSA and continuous positive airway pressure (CPAP) treatment on the incidence of nonfatal CVE in the elderly. Methods: Prospective, observational study of a consecutive cohort of 597 elderly patients (≥65 yr) studied for suspicion of OSA between 1999 and 2007. Four groups were defined: 107 controls without OSA (AHI<15), 97 mild to moderate OSA (AHI, 15–29) without CPAP, 58 severe OSA (AHI ≥30) without CPAP and 335 CPAP-treated OSA (adherence ≥ 3 h/d). A multivariate Cox survival analysis was used to determine the independent impact of OSA and CPAP treatment on nonfatal CVE. Results: A total of 597 elderly were studied (median follow-up, 69 mo). Compared with the control group, the fully adjusted hazard ratios for nonfatal CVE were 2.41 (confidence interval [CI], 1.08 to 5.38) for the untreated severe OSA group, 1.08 (CI, 0.52 to 2.27) for the CPAP-treated group, and 1.87 (CI, 0.74 to 4.73) for the untreated mild to moderate OSA group. Conclusions: Severe OSA not treated with CPAP is associated with nonfatal CVE in the elderly, and adequate CPAP treatment reduces this risk to levels similar to those found in patients without OSA

Efecto del tratamiento a largo plazo con presión positiva contínua en la vía aérea (cpap) sobre la incidencia de eventos cardiovasculares no mortales en ancianos con apnea del sueño

Objetivos: El Síndrome de Apneas-Hipopneas durante el Sueño (SAHS) se relaciona con un incremento de ECV en las edades medias de la vida, pero se desconoce si esta relación se mantiene en ancianos. El objetivo del presente estudio ha sido analizar el impacto del SAHS y del tratamiento con CPAP sobre los ECV incidentes en ancianos con sospecha clínica de SAHS. Metodología: Estudio observacional prospectivo de una cohorte consecutiva de 597 ancianos (≥ 65 años) estudiados por sospecha de SAHS entre 1999 y 2007. Se establecieron 4 grupos de estudio: 107 controles sin SAHS (IAH<15), 97 SAHS leve-moderada (IAH entre 15-29) sin CPAP, 58 SAHS grave (IAH≥30) sin CPAP y 335 SAHS con CPAP (al menos 3 horas/día). Se realizó un análisis de Cox para determinar el impacto independiente del SAHS y el tratamiento con CPAP sobre los ECV incidentes. Resultados: El seguimiento medio fue de 69 meses (rango intercuartil 49-87). Se produjeron 70 (11.7%) ECV incidentes. El SAHS grave no tratado con CPAP se asoció de forma independiente a una mayor aparición de ECV incidentes (HR 2.41, IC95% 1.08-5.38), mientras que en el grupo de SAHS tratado con CPAP (HR 1.08, IC95% 0.52-2.27) y SAHS leve-moderado sin CPAP (HR 1.87, IC95% 0.74-4.73) no se observó un aumento significativamente mayor de ECV comparado con el grupo control. Conclusiones: El SAHS grave no tratado con CPAP es un factor de riesgo independiente de ECV incidente en ancianos. El tratamiento con CPAP reduce este exceso de ECV a niveles semejantes a los del grupo control sin SAHS.Objectives: Obstructive sleep apnea (OSA) is a risk factor for nonfatal cardiovascular events (CVE) in middle-aged subjects, but it is not known whether it is also a risk factor in the elderly. The objectives of the study were to investigate the impact of OSA and continuous positive airway pressure (CPAP) treatment on the incidence of nonfatal CVE in the elderly. Methods: Prospective, observational study of a consecutive cohort of 597 elderly patients (≥65 yr) studied for suspicion of OSA between 1999 and 2007. Four groups were defined: 107 controls without OSA (AHI<15), 97 mild to moderate OSA (AHI, 15-29) without CPAP, 58 severe OSA (AHI ≥30) without CPAP and 335 CPAP-treated OSA (adherence ≥ 3 h/d). A multivariate Cox survival analysis was used to determine the independent impact of OSA and CPAP treatment on nonfatal CVE. Results: A total of 597 elderly were studied (median follow-up, 69 mo). Compared with the control group, the fully adjusted hazard ratios for nonfatal CVE were 2.41 (confidence interval [CI], 1.08 to 5.38) for the untreated severe OSA group, 1.08 (CI, 0.52 to 2.27) for the CPAP-treated group, and 1.87 (CI, 0.74 to 4.73) for the untreated mild to moderate OSA group. Conclusions: Severe OSA not treated with CPAP is associated with nonfatal CVE in the elderly, and adequate CPAP treatment reduces this risk to levels similar to those found in patients without OSA

Increased Incidence of Stroke, but Not Coronary Heart Disease, in Elderly Patients With Sleep Apnea. Role of Continuous Positive Airway Pressure Treatment

[Background and Purpose] The influence of age on the relationship between obstructive sleep apnea (OSA) and the incidence of hard cardiovascular events remains controversial. We sought to analyze the relationship between OSA and the incidence of stroke and coronary heart disease in a large cohort of elderly patients, as well as to investigate the role of continuous positive airway pressure (CPAP) treatment in these associations.[Methods] Post hoc analysis of a prospective observational study of consecutive patients ≥65 years studied for OSA suspicion at 2 Spanish University Hospitals. Patients with an apnea-hypopnea index (AHI) <15 were the reference group. OSA was defined by an AHI ≥15 and classified as untreated (CPAP not prescribed or compliance <4 hours/day), mild-moderate (AHI 15–29), untreated severe (AHI ≥30), and CPAP-treated (AHI ≥15 and CPAP compliance ≥4 hours/day).[Results] 859 and 794 elderly patients were included in the stroke and coronary heart disease analyses, respectively. The median (interquartile range) follow-up was 72 (50–88.5) and 71 (51.5–89) months, respectively. Compared with the reference group, the fully adjusted hazard ratios for the incidence of stroke were 3.42 (95% CI, 1.37–8.52), 1.02 (95% CI, 0.41–2.56), and 1.76 (95% CI, 0.62–4.97) for the untreated severe OSA group, CPAP-treated group, and untreated mild-moderate OSA group, respectively. No associations were shown between any of the different OSA groups and coronary heart disease incidence.[Conclusions]The incidence of stroke, but not coronary heart disease, is increased in elderly patients with untreated severe OSA. Adequate CPAP treatment may reduce this risk