Short-term Airway Clearance Management in people with stable Bronchiectasis

Introducción La expectoración crónica es uno de los síntomas respiratorios más prevalentes en personas con bronquiectasias y se asocia con un peor estado clínico y un fuerte impacto en la vida social. A pesar de que el uso de técnicas de drenaje de secreciones (DS) y agentes hiperosmolares es recomendado para facilitar el manejo diario de la tos productiva en pacientes con bronquiectasias, la calidad de su evidencia es todavía bajamoderada y su grado de recomendación varía de débil a fuerte. Por este motivo, se requiere evaluar en profundidad nuevos enfoques terapéuticos a corto plazo que faciliten el DS y que no hayan sido investigados hasta la fecha, para poder diseñar futuros ensayos clínicos a largo plazo con mayor nivel de garantía. Por consiguiente, el objetivo de esta tesis fue investigar que enfoque terapéutico a corto plazo facilita en mayor medida el DS en personas adultas diagnosticadas de bronquiectasias en periodo de estabilidad clínica, al igual que averiguar cómo interpretar correctamente los beneficios clínicos de estas intervenciones.Métodos Dos ensayos clínicos aleatorizados y cruzados se llevaron a cabo para comparar la efectividad a corto plazo de tres técnicas espiratorias lentas de DS (drenaje autógeno, espiración lenta con glotis abierta en decúbito infralateral [ETLGOL] y presión espiratoria positiva temporal [TPEP]) y tres soluciones salinas para inhalar (suero hipertónico [SH], suero hipertónico con ácido hialurónico [SH+AH] y suero isotónico [SI]) en personas con bronquiectasias. El objetivo primario en ambos ensayos clínicos fue el peso húmedo de la cantidad de esputo expectorada durante las sesiones. Además, se realizó un análisis ad‐hoc utilizando las muestras de esputo de ambos ensayos clínicos para examinar la fiabilidad de la cantidad de esputo durante 24 horas, así como la diferencia importante mínima (DIM) después de una sesión de DS en bronquiectasias. Finalmente, se examinó mediante un estudio de viabilidad/factibilidad el potencial uso de los ruidos respiratorios adventicios analizados de forma computacional como herramienta de evaluación de los efectos a corto plazo del DS en pacientes con bronquiectasias.Resultados (1) Las técnicas de drenaje autógeno y ELTGOL favorecieron en mayor grado la expectoración durante las sesiones que la técnica TPEP en personas con bronquiectasias en estabilidad clínica; siendo el drenaje autógeno la técnica preferida por los participantes; (2) la solución SH+AH fue tan efectiva como la solución de SH y mejor que la solución de SI facilitandola expectoración; sin embargo presentó un mejor perfil de seguridad que el SH en personas conbronquiectasias en periodo de estabilidad clínica y por esto fue la técnica de elección por los participantes; (3) el peso húmedo de la cantidad de esputo expectorada durante 24 horas presentó una fiabilidad aceptable; sin embargo su nivel de concordancia fue ligeramente amplio, especialmente para niveles de expectoración elevados. Además, se estimó que una reducción de al menos 6,4 g. en la cantidad de esputo expectorada durante las 24 horas posteriores a una intervención de DS, o un cambio relativo de alrededor del ‐17% con respecto al nivel basal, es la DIM; (4) el uso de los ruidos respiratorios adventicios analizados de forma computacional fue una herramienta viable/factible y parece ser que el número de crujidos espiratorios graves es la mejor variable para utilizar en futuros estudios.Conclusión Los hallazgos de esta tesis resaltan cuáles son los enfoques terapéuticos de DS a corto plazo más efectivos en personas con bronquiectasias en periodo de estabilidad clínica. Por lo tanto, el próximo paso es diseñar y realizar ensayos clínicos a largo plazo que analicen los efectos de estos enfoques terapéuticos en personas con bronquiectasias.Background Daily sputum expectoration is one of the most common respiratory symptoms in people with bronchiectasis. It is associated with poor health outcomes and negative impacts on social life. Although the use of airway clearance techniques (ACTs) and hyperosmolar agents is recommended to more easily manage chronic productive cough, the quality of evidence is still low-moderate and the level of recommendation ranges from weak to strong in bronchiectasis. However, there is a need to evaluate in-depth the short-term effects of airway clearance therapeutic approaches that are so far under-investigated in bronchiectasis in order to design optimal long-term future trials in this field. Therefore, the aims of this thesis were to investigate what is the short-term effectiveness of airway clearance therapeutic approaches in adults with clinically stable bronchiectasis and how to correctly interpret the clinical benefits observed after these interventions. Methods Two randomised, three-way crossover trials were conducted to compare the short-term effectiveness of three slow-expiratory ACTs (autogenic drainage, slow-expiration with glottis opened in lateral posture [ELTGOL] and temporary positive expiratory pressure [TPEP]) and three inhaled saline solutions (hypertonic saline [HS], hyaluronic acid + HS [HA + HS] and isotonic saline [IS]) in people with bronchiectasis. Wet sputum weight during sessions was selected as the primary outcome in both trials. Moreover, an ad hoc analysis was performed using the sputum samples of both studies to evaluate the reliability of 24-hour sputum weight and the minimal important difference (MID) after short-term airway clearance sessions in bronchiectasis. Finally, a feasibility study was conducted to examine the potential use of computerised adventitious respiratory sounds (ARS) as an outcome measure to assess the short-term effects of airway clearance sessions in bronchiectasis. <br /

Feasibility of computerized adventitious respiratory sounds to assess the effects of airway clearance techniques in patients with bronchiectasis

Objective: To examine the feasibility of adventitious respiratory sound (ARS) as an outcome measure to assess the effects of airway clearance techniques (ACTs) in outpatients with bronchiectasis. Methods: ARS were registered pre/post four ACTs sessions. Clinical outcomes included: number of crackles (coarse and fine), number of wheezes (monophonic and polyphonic), wheezes occupation rate (%) and sputum quantity. Feasibility outcomes of ARS included: reasons for exclusion, suitability, safety, equipment and time required, magnitude of change after intervention and sample size estimation. Results: Seven patients (49.7 ± 20.5 years; FEV1 69.3 ± 15.8% predicted) were included. Recordings from four patients were excluded due to excessive environment noise. All ARS measurements were completed without any adverse events. An electronic stethoscope was acquired and the time spent to complete each assessment was 6 ± 3.5 min. The largest changes were observed for number of expiratory coarse crackles [effect size (95%CI) ES = 0.40 (0.01–0.79)], which correlated moderately with sputum quantity (r = 0.56), and inspiratory monophonic wheezes [ES = 0.61 (0.22–1.00)]. The estimated sample size for a full crossover trial was 46. Conclusions: ARS is feasible to assess the effects of ACTs in patients with bronchiectasis. Expiratory coarse crackles seem to be the most appropriate ARS parameter, but this finding needs to be confirmed in an adequately powered trial.publishe

Impact of Hypertonic Saline Solutions on Sputum Expectoration and Their Safety Profile in Patients with Bronchiectasis: A Randomized Crossover Trial

Background: The role of hyaluronic acid plus hypertonic saline (HA+HS) as a mucoactive treatment in patients with bronchiectasis is still unknown. This study evaluated whether HA+HS solution enhances similar sputum quantity with better safety profile than HS alone in patients with bronchiectasis. Methods: In this double-blind randomized crossover trial, three solutions (7% HS; 0.1% HA +7%HS; and 0.9% isotonic saline, IS) were compared in outpatients with bronchiectasis and chronic sputum expectoration. Participants inhaled each solution across four consecutive sessions. All sessions, except on session 3, also included 30 minutes of airway clearance technique. A 7-day washout period was applied. Sputum weight was collected during the sessions (primary outcome) as well as during a 24-hour follow-up. The Leicester Cough Questionnaire (LCQ) and lung function were measured before/after each treatment arm. Safety was assessed by the monitoring of adverse events (AEs). Results: Twenty-eight patients with bronchiectasis (mean age of 64.0 (17.9) and FEV1% 60.9 (24.6) of predicted) were recruited. HS and HA+HS promoted similar expectoration during sessions, both being greater than IS [median difference HS vs. IS 3.7 g (95% CI 0.5-6.9); HA+HS vs. IS 3.2 g (95%CI 0.5-5.9)]. Sputum expectorated exclusively during the ACT period was similar across all treatment arms [HS vs. IS −0.3 g (95% CI −1.7 to 0.9); HA+HS vs. IS 0.0 g (95% CI −1.3 to 1.4); HS vs. HA+HS 0.0 g (95% CI −1.2 to 0.4)]. Sputum collected over the 24-hour follow-up tended to be lower for HS and HA+HS compared with IS [HS vs. IS −1.7 g (95% CI −4.2 to 0.0); HA+HS vs. IS −1.1 g (95%CI −3.6 to 0.7)]. No differences in LCQ or lung function were observed. Most severe AEs were reported using HS. Conclusion: HS and HA+HS were more effective on sputum expectoration than IS in patients with bronchiectasis, reporting HA+HS better safety profile than HS

ERS International Congress, Madrid, 2019: highlights from the Allied Respiratory Professionals' Assembly.

This article provides an overview of outstanding sessions that were (co)organised by the Allied Respiratory Professionals' Assembly during the European Respiratory Society International Congress 2019 in Madrid, Spain. Session content was mainly targeted at allied respiratory professionals such as respiratory physiologists, respiratory physiotherapists and respiratory nurses, and is summarised in this document. Short take-home messages related to pulmonary function testing highlight the importance of quality control. Furthermore, novel findings regarding the assessment of functional status call attention to bodily factors that can affect functional status. Regarding pulmonary rehabilitation, data were presented about the use of equipment and type of exercise training in COPD and lung cancer. Recent developments in physical activity-related research give insight in enablers of physical activity after hospital admission. The importance of integrated respiratory care was also highlighted, with the occupational therapist, nurse, and nutritional and psychological counsellor playing a pivotal role, which relates directly to research in the field of respiratory nursing that formulates the need for more nursing led-interventions in the future. To conclude, this review provides readers with valuable insight into some of the emerging and future areas affecting clinical practice of allied healthcare professionals

Assessment of humoral immune response to two mRNA SARS-CoV-2 vaccines (Moderna and Pfizer) in healthcare workers fully vaccinated with and without a history of previous infection

Aims: Presence of anti-S1 region of SARS-CoV-2 spike protein was analysed, at two and eight months, in 477 immunocompetent healthcare workers in Zaragoza, Spain, vaccinated with mRNA-1273 (Moderna) or BNT162b2 (Pfizer). Methods and results: Antibody analysis was performed with Alinity i System (Abbott). At 2 months, 100% of vaccinated had anti-S1 IgG (mean = 13, 285 AU ml-1). This value was significantly higher with Moderna (18, 192 AU ml-1) than with Pfizer (10, 441 AU ml-1). The mean value of anti-S1 IgG after vaccination was significantly higher in patients with than without previous infection (18, 539 vs. 7919 AU ml-1); in both groups was significantly higher with Moderna than with Pfizer (21, 881 vs. 15, 733 AU ml-1 and 11, 949 vs. 6387 AU ml-1), respectively. At 8 months, 100% of patients were IgG positive, with higher levels with Moderna than with Pfizer. Nevertheless, in ensemble of cases, a mean decrease of antibody levels of 11, 025 AU ml-1 was observed. Conclusion: At 2 and 8 months after vaccination, IgG response persists with both vaccines but with important decrease which suggests the need for revaccination. Significance and impact of study: The study contributes to know the immune status after vaccination with two of more used anti-SARS-CoV-2 vaccines. This knowledge is important for establishing the best vaccination strategy. © 2022 The Authors. Journal of Applied Microbiology published by John Wiley & Sons Ltd on behalf of Society for Applied Microbiology

Persistence of Anti-S1 IgG against SARS-CoV-2 eight months after the Booster dose of Vaccine in naive and previously infected healthcare workers

Our aim was to evaluate the immune response of healthcare workers included in the RIPOVAC study, after receiving a booster dose (third dose), in terms of intensity and persistence of induced antibodies. In the second phase of the RIPOVAC study, between December 2021 and January 2022, eight months after the second dose, 389 voluntary, immunocompetent, non-pregnant healthcare workers received a booster dose of SARS-CoV-2 vaccine, and a serum sample was obtained. Two groups of patients were established: with and without previous SARS-CoV-2 infection. In order to quantify anti-S1 IgG (AU/mL) we used CMIA (Abbott). All of the health workers were anti-S IgG positive 8 months after receiving the booster dose of the vaccine, with a mean of 17,040 AU/mL. In 53 patients without previous infection, antibody levels increased by a mean of 10,762 AU/mL. This figure is seven times higher than the one produced after the second dose (1506 AU/mL). The booster dose produces a robust elevation of the antibody level, which persists at 8 months, with levels significantly higher than those reached after the second dose, which allow one to predict a persistence of more than one year. The study demonstrates the efficacy of the booster dose of anti-SARS-CoV-2 vaccines

Respiratory Physiotherapy in Post-COVID-19: A Decision-Making Algorithm for Clinical Practice

[Resumen] La pandemia causada por la enfermedad de la COVID-19 ha supuesto un gran reto para los profesionales del sistema sociosanitario, intensificándose con el manejo y atención de las manifestaciones clínicas que potencialmente pueden presentarse de manera persistente en las personas que han superado la enfermedad. Para ello, la fisioterapia respiratoria se presenta como piedra angular dentro del modelo de abordaje interdisciplinar que requiere esta población. Dado que la implementación de esta opción terapéutica continúa siendo limitada en España, es imprescindible realizar una evaluación integral y exhaustiva de la persona que nos permita establecer criterios de selección a fin de optimizar el uso de los recursos humanos y materiales existentes. Para ello, se propone un algoritmo de decisión terapéutica basado en pruebas de evaluación validadas y objetivas de las posibles manifestaciones clínicas del paciente. La aplicación de este algoritmo, en cualquier nivel asistencial (atención especializada y atención primaria/comunitaria) junto con la atención centrada en la persona, el impulso del uso de los espacios comunitarios verdes y azules de las ciudades y un adecuado uso de las tecnologías de la comunicación y la información, nos permitirá optimizar el modelo de atención de fisioterapia respiratoria en el contexto actual, marcado por la COVID-19.[Abstract] The outbreak of COVID-19 has posed a great challenge for the healthcare system which has been later aggravated by the need of managing clinical manifestations and potential sequelae in COVID-19 survivors. In this context, respiratory Physiotherapy emerges as a cornerstone in the interdisciplinary management warranted in this population. Given that the implementation and resources available for the interdisciplinary therapeutic interventions in Spain is scarce, it is essential to perform a comprehensive, exhaustive and personalised assessment. This will allow us to establish more accurate selection criteria in order to optimise the use of existing human and material resources. To this end, we propose here a decision-making algorithm for clinical practice to assess the clinical manifestations in people recovered from COVID-19 based on well-established, validated tests and assessment tools. This algorithm can be used at any clinical practice environment (primary care/community or hospital-based), combined with a patient-centered model and the use of community and e-Health resources and its application to improve the Physiotherapy care of these patients in the COVID-19 era

Maximal respiratory pressure reference equations in healthy adults and cut-off points for defining respiratory muscle weakness

[Abstract] Introduction: Maximal inspiratory and expiratory pressures (PImax/PEmax) reference equations obtained in healthy people are needed to correctly interpret respiratory muscle strength. Currently, no clear cut-off points defining respiratory muscle weakness are available. We aimed to establish sex-specific reference equations for PImax/PEmax in a large sample of healthy adults and to objectively determine cut-off points for respiratory muscle weakness. Methods: A multicentre cross-sectional study was conducted across 14 Spanish centres. Healthy non-smoking volunteers aged 18-80 years stratified by sex and age were recruited. PImax/PEmax were assessed using uniform methodology according to international standards. Multiple linear regressions were used to obtain reference equations. Cut-off points for respiratory muscle weakness were established by using T-scores. Results: The final sample consisted of 610 subjects (314 females; 48 [standard deviation, SD: 17] years). Reference equations for PImax/PEmax included body mass index and a squared term of the age as independent variables for both sexes (p<0.01). Cut-off points for respiratory muscle weakness based on T-scores ≥2.5 SD below the peak mean value achieved at a young age were: 62 and 83cmH2O for PImax and 81 and 109cmH2O for PEmax in females and males, respectively. Conclusion: These reference values, based on the largest dataset collected in a European population to date using uniform methodology, help identify cut-off points for respiratory muscle weakness in females and males. These data will help to better identify the presence of respiratory muscle weakness and to determine indications for interventions to improve respiratory muscle function

Famílies botàniques de plantes medicinals

Facultat de Farmàcia, Universitat de Barcelona. Ensenyament: Grau de Farmàcia, Assignatura: Botànica Farmacèutica, Curs: 2013-2014, Coordinadors: Joan Simon, Cèsar Blanché i Maria Bosch.Els materials que aquí es presenten són els recull de 175 treballs d’una família botànica d’interès medicinal realitzats de manera individual. Els treballs han estat realitzat per la totalitat dels estudiants dels grups M-2 i M-3 de l’assignatura Botànica Farmacèutica durant els mesos d’abril i maig del curs 2013-14. Tots els treballs s’han dut a terme a través de la plataforma de GoogleDocs i han estat tutoritzats pel professor de l’assignatura i revisats i finalment co-avaluats entre els propis estudiants. L’objectiu principal de l’activitat ha estat fomentar l’aprenentatge autònom i col·laboratiu en Botànica farmacèutica