Estudi de la població bacteriana endobronquial en la Malaltia Pulmonar Obstructiva Crònica. Aplicació del raspall protegit

La caracterització de la població bacteriana de les vies respiratòries baixes dels pacients amb Malaltia Pulmonar Obstructiva Crònica (MPOC) a partir de l'esput, tant en fase estable com en fase d'agudització, ha d'interpretar-se amb cautela per la inherent contaminació orofaringea de la mostra. Per aquest motiu, s´han intentat buscar mètodes alternatius com l'aspirat transtraqueal o les tècniques fibrobroncoscòpies com el raspall protegit (RP), ambdues inicialment introduïdes pel diagnòstic de la pneumònia. Amb aquest última tècnica s´ha desenvolupat dos estudis que posteriorment foren publicats: #1. Monsó, Rosell, Bonet et al; Risk factors for lower bacterial colonization in chronic bronchitis, en J Eur Respir 1999; 13:338-92 i#2. Monsó, Ruiz, Rosell et al, Bacterial infection in chronic obstructive pulmonary disease. A study of stable and exacerbated outpatinets using the protected specimen brush, en Am J Resp Crit Care Med 1995; 152:1316-20) En el primer d'ells, es descriuen els factors de risc per a colonització bacteriana en 41 pacients amb bronquitis crònica i obstrucció lleu a moderada (FEV1 74%, DE 23%) detectant-se a partir d'un model de regressió logística que el tabaquisme actiu presenta una OR 9,8 (IC 95: 1,1 a 83,2); així mateix, en un subgrup de 18 pacients s'obtingué un segon RP, de la s'en deriva una concordança qualitativa del 72,2% i qualitativa del 47,4%. En el segon estudi, s'aplica la tècnica del RP en dos mostres de pacients amb MPOC, una en fase d'estabilitat i una altre en fase d'agudització, similars en quant a dades demogràfiques, història de tabaquisme i de funció respiratòria (FEV1 en pacients estables 51%, DE 23% i en pacients aguditzats 43%,DE 14). Els resultats microbiològics mostren cultius positius en estables del 25% i en els aguditzats del 51%, detectant-se com la càrrega bacteriana també s'incrementa: 5% dels pacients amb MPOC estable presenten concentracions bacterianes * 104 unitats formadores de colònies/ml mentre que en fase arriben al 24%. Els gèrmens que s'aïllen en fase estable corresponen a: Haemophilus influenzae 60%, Streptoccocus pneumoniae 30%, Moraxella catarrhalis 10%, Staphiloccocus aureus 10%, Pseudomonas aeruginosa 10% i Acinetobacter spp 10%; mentre que en fase d'agudització els percentatges no presentesn variacions significatives: Haemophilus influenzae 58%, Streptoccocus pneumoniae 17%, Moraxella catarrhalis 12%, Pseudomonas aeruginosa 12%. D'aquests dos estudis es pot concloure que el tabaquisme és un factor clarament afavoridor de la colonització bacteriana en la MPOC, que aquesta afecta un 25% del subjectes en fase estable i que quasi es duplica durant la fase d'agudització, a la vegada que la càrrega bacteriana també s'incrementa de forma significativa. El perfil bacterià no sembla que s'alteri de forma rellevant.Endobronchial bacteria obtained by sputum cultures in patients with chronic obstructive pulmonary disease (COPD) are often contaminated by oropharyngeal flora. Some alternatives techniques have been explored, like transtracheal aspiration or flexible bronchoscopic techniques like the protected specimen brush (PSB), though both were initially designed for the diagnosis of pneumonia. We have performed two studies based on the PSB that were published afterwards: #1. Monsó, Rosell, Bonet et al; Risk factors for lower bacterial colonization in chronic bronchitis, en J Eur Respir 1999; 13:338-92 and; #2. Monsó, Ruiz, Rosell et al, Bacterial infection in chronic obstructive pulmonary disease. A study of stable and exacerbated outpatients using the protected specimen brush, en Am J Resp Crit Care Med 1995; 152:1316-20.In the first study the risk factors for bacterial colonization were described in 41 stable patients with chronic bronchitis and mild to moderate COPD (FEV1 74%, DE 23%). Based on a logistic regression model, smoking was detected as the most important factor with an OD of 9,8 (IC 95: 1,1 a 83,2). In a subgroup of 18 patients, a second PSB was performed, showing a qualitative agreement of 72.2% and a quantitative agreement of 47.4%. In the second study, a PSB was performed in two similar groups of COPD patients, one in stable situation and the other in an acute exacerbation (FEV1 in stable patients 51%, DE 23% and in exacerbation : 43%,DE 14). The microbiological results show positive cultures in the 25% of stable patients and 51% in the exacerbated group; moreover, bacterial load is as well different: only 5% of stable patients have * 104 colony forming units/ml, while in the exacerbated situation there are 24%. Bacteria isolated in the stable situation were: Haemophilus influenzae 60%, Streptoccocus pneumoniae 30%, Moraxella catarrhalis 10%, Staphiloccocus aureus 10%, Pseudomonas aeruginosa 10% and Acinetobacter spp 10%; while in the exacerbated situation: Haemophilus influenzae 58%, Streptoccocus pneumoniae 17%, Moraxella catarrhalis 12%, Pseudomonas aeruginosa 12%, a globally similar profile.From both studies it can be concluded that smoking is a risk factor for bacterial colonization in COPD patients, that it affects the 25% of the studied group and that during the exacerbation situation, the percentage is nearly duplicated as well as a significant increment of the bacterial load is detected. The bacterial profile is nearly the same, which indicates a possible overgrowth of the preexisting bacterial population

Effectiveness of Intermediate Respiratory Care Units as an Alternative to Intensive Care Units during the COVID-19 Pandemic in Catalonia

Objectives: During the COVID-19 pandemic, the risk of collapse for the health system created great difficulties. We will demonstrate that intermediate respiratory care units (IRCU) provide adequate management of patients with non-invasive respiratory support, which is particularly important for patients with SARS-CoV-2 pneumonia. Methods: A prospective observational study of patients with COVID-19 admitted to the ICU of a tertiary hospital. Sociodemographic data, comorbidities, pharmacological, respiratory support, laboratory and blood gas variables were collected. The overall cost of the unit was subsequently analyzed. Results: 991 patients were admitted, 56 to the IRCU (from a of 81 admitted to the critical care unit). Mean age was 65 years (SD 12.8), Barthel index 75 (SD 8.3), Charlson comorbidity index 3.1 (SD 2.2), HTN 27%, COPD 89% and obesity 24%. A significant relationship (p < 0.05) with higher mortality was noted for the following parameters: fever greater than or equal to 39 degrees C [OR 5.6; 95% CI (1.2-2.7); p = 0.020], protocolized pharmacological treatment [OR 0.3; 95% CI (0.1-0.9); p = 0.023] and IOI [OR 3.7; 95% CI (1.1-12.3); p = 0.025]. NIMV had less of a negative impact [OR 1.8; 95% CI (0.4-8.4); p = 0.423] than IOI. The total cost of the IRCU amounted to euro66,233. The cost per day of stay in the IRCU was euro164 per patient. The total cost avoided was euro214,865. Conclusions: The pandemic has highlighted the importance of IRCUs in facilitating the management of a high patient volume. The treatment carried out in IRCUs is effective and efficient, reducing both admissions to and stays in the ICU