Relación entre la presión inspiratoria pico y la activación mecánica de los músculos inspiratorios durante respiración tranquila en pacientes con EPOC

En la enfermedad pulmonar obstructiva crónica (EPOC) la fuerza muscular inspiratoria (FMI) y la eficiencia mecánica de los músculos inspiratorios (EMMI) podrían verse reducidas como consecuencia de la hiperinsuflación. En este trabajo se registraron la presión inspiratoria en boca (PIpico) y la activación mecánica de los músculos inspiratorios en 10 pacientes EPOC severos y muy severos, durante respiración tranquila. Para determinar la activación mecánica de los músculos inspiratorios se empleó la señal mecanomiográfica diafragmática: MMGdi. La amplitud de la señal MMGdi fue estimada a través de índices lineales (ARV: valor rectificado medio) y no lineales (MLZ: Lempel-Ziv multiestado, y fSampEn: entropía muestral con valores de tolerancia fijos). Nuestra hipótesis es que el ratio entre PIpico, que refleja la FMI, y la amplitud de la señal MMGdi constituye una expresión de la EMMI. Los resultados obtenidos muestran ligeras diferencias entre la PIpico registrada en EPOC severos y muy severos, así como una correlación débil a moderada con los parámetros de función pulmonar y los índices estudiados. Sin embargo, mientras mayor es el grado de severidad (que supone un mayor grado de hiperinsuflación) mayor es el nivel de activación mecánica de los músculos inspiratorios. La activación mecánica de los músculos inspiratorios y la EMMI estimadas mediante MLZ estuvieron mejor correlacionadas con la función pulmonar que ARV y fSampEn. Por consiguiente, la estimación de la actividad mecánica del diafragma mediante el MLZ de la señal MMGdi podría mejorar la estimación no invasiva de la FMI y la EMMI, incluso para niveles muy bajos de esfuerzo inspiratorio.Peer ReviewedPostprint (author’s final draft

Differences in acoustic features of cough by pneumonia severity in patients with COVID-19: a cross-sectional study

BackgroundAcute respiratory syndrome due to coronavirus 2 (SARS-CoV-2) is characterised by heterogeneous levels of disease severity. It is not necessarily apparent whether a patient will develop a severe disease or not. This cross-sectional study explores whether acoustic properties of the cough sound of patients with coronavirus disease (COVID-19), the illness caused by SARS-CoV-2, correlate with their disease and pneumonia severity, with the aim of identifying patients with a severe disease.MethodsVoluntary cough sounds were recorded using a smartphone in 70 COVID-19 patients within the first 24 h of their hospital arrival, between April 2020 and May 2021. Based on gas exchange abnormalities, patients were classified as mild, moderate, or severe. Time- and frequency-based variables were obtained from each cough effort and analysed using a linear mixed-effects modelling approach.ResultsRecords from 62 patients (37% female) were eligible for inclusion in the analysis, with mild, moderate, and severe groups consisting of 31, 14 and 17 patients respectively. 5 of the parameters examined were found to be significantly different in the cough of patients at different disease levels of severity, with a further 2 parameters found to be affected differently by the disease severity in men and women.ConclusionsWe suggest that all these differences reflect the progressive pathophysiological alterations occurring in the respiratory system of COVID-19 patients, and potentially would provide an easy and cost-effective way to initially stratify patients, identifying those with more severe disease, and thereby most effectively allocate healthcare resources

Early diagnosis of acute myocardial infarction in the elderly using more sensitive cardiac troponin assays

Aims To examine the diagnostic accuracy of sensitive cardiac troponin (cTn) assays in elderly patients, since elevated levels with sensitive cTn assays were reported in 20% of elderly patients without acute myocardial infarction (AMI). Methods and results In this multi-centre study, we included 1098 consecutive patients presenting with symptoms suggestive of AMI, 406 (37%) were >70 years old. Measurement of three investigational sensitive cTn assays [Roche high-sensitive cTnT (hs-cTnT), Siemens cTnI-Ultra, and Abbott-Architect cTnI) and the standard assay (Roche cTnT) was performed in a blinded fashion. The final diagnosis was adjudicated by two independent cardiologists. Acute myocardial infarction was the adjudicated final diagnosis in 24% of elderly patients. Among elderly patients without AMI, baseline cTn levels were elevated above the 99th percentile in 51% with Roche hs-cTnT, in 17% with Siemens TnI-Ultra, and 13% with Abbott-Architect cTnI. The diagnostic accuracy as quantified by the area under the receiver operating characteristic (ROC) curve (AUC) was significantly greater for the sensitive cTn assays compared with the standard assay (AUC for Roche hs-cTnT, 0.94; Siemens cTnI-Ultra, 0.95; and Abbott-Architect cTnI, 0.95 vs. AUC for the standard assay, 0.90; P < 0.05 for comparisons). The best cut-offs for the sensitive cTn-assays determined by the ROC-curve in elderly patients differed clearly from those in younger patients. Furthermore, the prognostic value regarding 90-day mortality varied among the sensitive cTn assays. Conclusion Sensitive cTn assays have high diagnostic accuracy also in the elderly. Mild elevations are common in elderly non-AMI patients, therefore the optimal cut-off levels are substantially higher in elderly as compared with younger patients. Furthermore, sensitive cTn assays yielded different prognostic value (ClinicalTrials.gov number, NCT00470587

Factors affecting the relationship between psychological status and quality of life in COPD patients

<p>Abstract</p> <p>Background</p> <p>This study aims to (i) evaluate the association between anxiety and depressive symptoms and health-related quality of life (HRQoL); and (ii) identify the effect modifiers of this relationship in patients with chronic obstructive pulmonary disease (COPD).</p> <p>Methods</p> <p>A total of 337 clinically stable COPD patients answered the St. George's Respiratory Questionnaire (SGRQ) (assessing HRQoL) and the Hospital Anxiety and Depression Scale (HADS). Socio-demographic information, lung function, and other clinical data were collected.</p> <p>Results</p> <p>Most patients (93%) were male; they had a mean (SD) age of 68 (9) years and mild to very severe COPD (post-bronchodilator FEV₁52 (16)% predicted). Multivariate analyses showed that anxiety, depression, or both conditions were associated with poor HRQoL (for all SGRQ domains). The association between anxiety and total HRQoL score was 6.7 points higher (indicating a worse HRQoL) in current workers than in retired individuals. Estimates for patients with "both anxiety and depression" were 5.8 points lower in stage I-II than in stage III-IV COPD, and 10.2 points higher in patients with other comorbidities than in those with only COPD.</p> <p>Conclusions</p> <p>This study shows a significant association between anxiety, depression, or both conditions and impaired HRQoL. Clinically relevant factors affecting the magnitude of this association include work status, COPD severity, and the presence of comorbidities.</p

Impact of high-flow oxygen therapy during exercise in idiopathic pulmonary fibrosis: a pilot crossover clinical trial

[Background] Supplemental oxygen delivered with standard oxygen therapy (SOT) improves exercise capacity in patients with idiopathic pulmonary fibrosis (IPF). Although high-flow nasal cannula oxygen therapy (HFNC) improves oxygenation in other respiratory diseases, its impact on exercise performance has never been evaluated in IPF patients. We hypothesized that HFNC may improve exercise capacity in IPF subjects compared to SOT.[Methods] This was a prospective, crossover, pilot randomized trial that compared both oxygenation methods during a constant submaximal cardiopulmonary exercise test (CPET) in IPF patients with exertional oxygen saturation (SpO2) ≤ 85% in the 6-min walking test. The primary outcome was endurance time (Tlim). Secondary outcomes were muscle oxygen saturation (StO2) and respiratory and leg symptoms.[Results] Ten IPF patients [71.7 (6) years old, 90% males] were included. FVC and DLCO were 58 ± 11% and 31 ± 13% pred. respectively. Tlim during CPET was significantly greater using HFNC compared to SOT [494 ± 173 vs. 381 ± 137 s, p = 0.01]. HFNC also associated with a higher increase in inspiratory capacity (IC) [19.4 ± 14.2 vs. 7.1 ± 8.9%, respectively; p = 0.04], and a similar trend was observed in StO2 during exercise. No differences were found in respiratory or leg symptoms between the two oxygen devices.[Conclusions] This is the first study demonstrating that HFNC oxygen therapy improves exercise tolerance better than SOT in IPF patients with exertional desaturation. This might be explained by changes in ventilatory mechanics and muscle oxygenation. Further and larger studies are needed to confirm the benefits of HFNC in IPF patients and its potential usefulness in rehabilitation programs.This study has been funded by SEPAR 2017 (Fellowship) and Rio Hortega; ISCIII (Project and fellowship).Peer reviewe

Early diagnosis of acute myocardial infarction in patients with pre-existing coronary artery disease using more sensitive cardiac troponin assays

Aims We sought to examine the diagnostic and prognostic utility of sensitive cardiac troponin (cTn) assays in patients with pre-existing coronary artery disease (CAD). Methods and results We conducted a multicentre study to examine the diagnostic accuracy of one high-sensitive and two sensitive cTn assays in 1098 consecutive patients presenting with symptoms suggestive of acute myocardial infarction (AMI), of whom 401 (37%) had pre-existing CAD. Measurements of Roche high-sensitive cTnT (hs-cTnT), Siemens cTnI-Ultra, Abbott-Architect cTnI and the standard assay (Roche cTnT) were performed in a blinded fashion. The final diagnosis was adjudicated by two independent cardiologists. Acute myocardial infarction was the final diagnosis in 19% of CAD patients. Among patients with diagnoses other than AMI, baseline cTn levels were elevated above the 99th percentile with Roche hs-cTnT in 40%, with Siemens TnI-Ultra in 15%, and Abbott-Architect cTnI in 13% of them. In patients with pre-existing CAD, the diagnostic accuracy at presentation, quantified by the area under the receiver operator characteristic curve (AUC), was significantly greater for the sensitive cTn assays compared with the standard assay (AUC for Roche hs-cTnT, 0.92; Siemens cTnI-Ultra, 0.94; and Abbott-Architect cTnI, 0.93 vs. AUC for the standard assay, 0.87; P < 0.01 for all comparisons). Elevated levels of cTn measured with the sensitive assays predicted mortality irrespective of pre-existing CAD, age, sex, and cardiovascular risk factors. Conclusion Sensitive cTn assays have high-diagnostic accuracy also in CAD patients. Mild elevations are common in non-AMI patients and test-specific optimal cut-off levels tend to be higher in CAD patients than in patients without history of CAD. Sensitive cTn assays also retain prognostic value. (ClinicalTrials.gov number, NCT00470587

Ecuaciones de referencia de la capacidad aeróbica máxima ciclo-ergoespirometría para la población española adulta

[EN] Background: Frequently used reference values for clinical exercise testing have been derived from non-random samples and some with poorly defined maximal criteria. Our objective was to obtain population based reference values for peak oxygen uptake ( ̇VO2 ) and work rate (WR) for cardiopulmonary exercise testing in a representative sample of Caucasian Spanish men and women. Methods: 182 men and women, 20–85 years old, were included and exercised on cycle-ergometer to exhaustion. ( ̇VO2 ) and WR were measured. The equations obtained from this sample were validated in an independent cohort of 69 individuals, randomly sampled form the same population. Then a final equation merging the two cohorts (=251) was produced. Results: Height, sex and age resulted predictive of both ̇VO2 peak and WR. Weight and physical activity added very little to the accuracy to the equations. The formulas ̇VO2 peak = 0.017 · height (cm) − 0.023 · age (years) + 0.864 · sex (female = 0/male = 1) ± 179 l min−1 , and peak WR = 1.345 · height (cm) − 2.074 · age (years) + 76.54 · sex (female = 0/male = 1) ± 21.2 W were the best compromise between accuracy and parsimony. Conclusions: This study provides new and accurate ̇VO2 peak and WR rate reference values for individuals of European Spanish descent[ES] Antecedentes: Los valores de referencia utilizados con frecuencia para las pruebas de esfuerzo clínicas derivan de muestras no aleatorias y los criterios máximos para algunos de ellos están mal definidos. Nuestro objetivo fue obtener valores de referencia basados en la población general para el consumo máximo de oxígeno (VO 2 ) y la carga de trabajo (CT) para las pruebas de ejercicio cardiopulmonar a partir de una muestra representativa de varones y mujeres caucásicos españoles. Métodos: Se incluyeron 182 varones y mujeres, de entre 20 y 85 a ̃nos, que realizaron ejercicio en el cicloergómetro hasta el agotamiento. Se midieron el VO 2 y la CT. Las ecuaciones obtenidas de esta muestra se validaron en una cohorte independiente de 69 individuos, seleccionados aleatoriamente de la misma población. A continuación, se creó una ecuación final que fusionó las dos cohortes (n = 251). Resultados: La altura, el sexo y la edad resultaron predictivos tanto del ̇VO2 máximo como de la CT. El peso y la actividad física contribuyeron muy poco a la precisión de las ecuaciones. Las fórmulas ̇VO2 máximo = 0,017 × altura (cm) − 0,023 × edad (a ̃nos) + 0,864 × sexo (mujer = 0/varón = 1) ± 179 L × min−1 ; y CT máxima = 1,345 × altura (cm) − 2,074 × edad (a ̃nos) + 76,54 × sexo (mujer = 0/varón = 1) ± 21,2 W fueron el mejor equilibrio entre precisión y parsimonia. Conclusiones: Este estudio proporciona valores de referencia del ̇VO 2 máximo y la CT nuevos y precisos para personas de ascendencia espa ̃nola europea.This study was supported by a SEPAR (Sociedad Española de Neumología y Cirugía Torácica/Spanish society of Pulmonology and Thoracic Surgery) grant and NEUMOMADRD (Sociedad Madrileña de Neumología y Cirugía Torácica/Madrilenian Society of Pulmonology and Thoracic Surgery) research award

Validity of prognostic models of critical COVID-19 is variable. A systematic review with external validation

Objectives: To identify prognostic models which estimate the risk of critical COVID-19 in hospitalized patients and to assess their validation properties. Study design and setting: We conducted a systematic review in Medline (up to January 2021) of studies developing or updating a model that estimated the risk of critical COVID-19, defined as death, admission to intensive care unit, and/or use of mechanical ventilation during admission. Models were validated in two datasets with different backgrounds (HM [private Spanish hospital network], n = 1,753, and ICS [public Catalan health system], n = 1,104), by assessing discrimination (area under the curve [AUC]) and calibration (plots). Results: We validated 18 prognostic models. Discrimination was good in nine of them (AUCs ≥ 80%) and higher in those predicting mortality (AUCs 65%-87%) than those predicting intensive care unit admission or a composite outcome (AUCs 53%-78%). Calibration was poor in all models providing outcome's probabilities and good in four models providing a point-based score. These four models used mortality as outcome and included age, oxygen saturation, and C-reactive protein among their predictors. Conclusion: The validity of models predicting critical COVID-19 by using only routinely collected predictors is variable. Four models showed good discrimination and calibration when externally validated and are recommended for their use

Validity of prognostic models of critical COVID-19 is variable. A systematic review with external validation

To identify prognostic models that estimate the risk of critical COVID-19 in hospitalised patients and to assess their validation properties. We conducted a systematic review in Medline (up to January 2021) of studies developing or updating a model that estimated the risk of critical COVID-19, defined as death, admission to intensive care unit (ICU), and/or use of mechanical ventilation during admission. Models were validated in two datasets with different backgrounds (HM [private Spanish hospital network], n=1,753, and ICS [public Catalan health system], n=1,104); by assessing discrimination (area under the curve [AUC]) and calibration (plots). We validated 18 prognostic models. Discrimination was good in 9 of them (AUCs≥80%) and higher in those predicting mortality (AUCs 65-87%) than those predicting ICU admission or a composite outcome (AUCs 53-78%). Calibration was poor in all models providing outcome's probabilities and good in 4 models providing a point-based score. These four models used mortality as outcome, and included age, oxygen saturation, and C-reactive protein among their predictors. The validity of models predicting critical COVID-19 by using only routinely collected predictors is variable. Four models showed good discrimination and calibration when externally validated and are recommended for their use

Predictors and changes of physical activity in idiopathic pulmonary fibrosis

Background Different clinical predictors of physical activity (PA) have been described in idiopathic pulmonary fibrosis (IPF), but studies are lacking evaluating the potential role of muscle strength and anxiety and depression symptoms in PA limitation. Moreover, little is known about the impact of changes in PA in the course of the disease. The aim of the present study was to investigate the relationship between baseline PA and a wide range of variables in IPF, to assess its longitudinal changes at 12 months and its impact on progression free-survival. Methods PA was assessed by accelerometer and physiological, clinical, psychological factors and health-related quality of life were evaluated in subjects with IPF at baseline and at 12 month follow-up. Predictors of PA were determined at baseline, evolution of PA parameters was described and the prognostic role of PA evolution was also established. Results Forty participants with IPF were included and 22 completed the follow-up. At baseline, subjects performed 5765 (3442) daily steps and spent 64 (44) minutes/day in moderate to vigorous PA. Multivariate regression models showed that at baseline, a lower six-minute walked distance, lower quadriceps strength (QMVC), and a higher depression score in the Hospital Anxiety and Depression scale were associated to lower daily step number. In addition, being in (Gender-Age-Physiology) GAP III stage, having a BMI >= 25 kg/m(2) and lower QMVC or maximum inspiratory pressure were factors associated with sedentary behaviour. Adjusted for age, gender and forced vital capacity (FVC) (%pred.) a lower progression-free survival was evidenced in those subjects that decreased PA compared to those that maintained, or even increased it, at 12 months [HR 12.1 (95% CI, 1.9-78.8); p = 0.009]. Conclusion Among a wide range of variables, muscle strength and depression symptoms have a predominant role in PA in IPF patients. Daily PA behaviour and its evolution should be considered in IPF clinical assessment and as a potential complementary indicator of disease prognosis