Role of asthma as a risk factor in severity and mortality in COVID-19 varies in literature. In 2020, 4CMortality score was published, which through 8 parameters in the initial evaluation (age, sex, comorbidity index Charlson, respiratory rate, peripheral oxygen saturation, renal function, Glasgow scale and C-reactive protein) stratified risk of in-hospital mortality from COVID-19 into low(0-3 points), intermediate(4-8), high(9-14) and very high(from 15). Our objective is to assess usefulness of 4CMortality in asthmatic patients admitted for COVID-19 and to verify the degree of correlation between the score and the mortality data and hospital stay. Observational retrospective study of asthmatic patients admitted for COVID-19 between March 2020 and March 2021. Statistical analysis is performed using Fisher9s exact test(risk scale-death), ANOVA(risk scale-days hospitalization), and Kaplan Meier curve, considering statistically significant those results with a p<0.05. Sample of 99 patients, 18 in low risk group, 35 intermediate risk, 44 high risk and 2 very high risk. In terms of mortality, 7 deaths(high risk, 15.9%) and 2(very high risk, 100%), statistically significant (Fisher 17.07, p<0.0001). In terms of hospitalization days, median 7 days(low risk), 10(intermediate risk), 17 (high risk) and 5 (very high risk); statistically significant(F 6.37, p 0.001). In the survival analysis, median survival of 7 days(low-risk), 10(intermediate risk) and 19(high risk)(Log Rank 32.887, p<0.0001)(Fig 1). In conclusion, 4CMortality score is a good tool to establish the probability of poor evolution in asthmatic patients admitted for COVID-19 due to increased mortality and hospital stay.

Introduction: Asthma is an inflammatory disease with several inflammation mediators involved in its pathogenesis which are target of biological drugs used as new treatments for patients with poorly controlled asthma (PCA), such as Reslizumab, which acts in the interleukin-5 (IL-5) pathway. We conducted this study to analyze the clinical, spirometric response and safety of treatment with Reslizumab in patients with eosinophilic PCA. Materials and methods: Observational study with a cohort of 24 patients who started treatment with Reslizumab between February 2018 and December 2021 in a tertiary care hospital with prospective follow-up at 4 months, one year and 2 years. Results: Among the 24 patients included, 21 were women (87.5%), the mean age was 51 years, 12 patients have already completed one year of follow-up and 5 patients two years. The mean number of exacerbations in the previous year was 3(±1.8), at one year of follow-up 0.29 (±0.5) and the 5 patients who have been on treatment for 2 years have not had any in this period. Regarding the forced expiratory volume in the first minute (FEV1), the previous mean was 2032ml (75%) ; it increased to 2477ml (90%) at 4 months and remained the same at one year and at two years increased to 2664 ml (94%). The previous asthma control test(ACT) mean was 14(±4), at 4 months 22(±1.6), at year 23 (±1.3)and at two years 24(± 0.5)). We found no adverse events other than those described in the pivotal studies. Conclusions: In our population of patients with PCA, reslizumab achieves good control with a significant reduction in exacerbations, a significant increase in pulmonary function tests from 4 months after its administration

Our aim is to evaluate the safety and efficacy of one-session bilateral whole lung lavage (BWLL) assisted by ECMO as a treatment for pulmonary alveolar proteinosis (PAP). Observational retrospective study of PAP cases treated in our center by BWLL in one-session with ECMO assistance from August 2020-November 2021. BWLL was performed in an operating room under general anesthesia, with double-lumen orotracheal intubation and assisted by ECMO, lasting 4-5 hours. During the technique, aliquots of around 1L of saline (heated at 37 C) are instilled into the lung. Subsequently, they are extracted passively by gravity until a clear alveolar fluid is obtained. In total, a total of approximately 10 L are instilled into each lung(Fig. 1). A few hours after the procedure, ECMO is only maintained by recirculating and is removed after 24 hours if there are no incidents. During study time 5 BWLL were performed in 3 patients, women, middle-aged, without comorbidity. In the first case, the first WLL was unilateral, without ECMO assistance, producing cardiorespiratory arrest, recovered in the operating room. In a second time an BWLL was performed in one-session assisted by ECMO, without complications. BWLL was performed without complications in cases 2 and 3. In case 3, the procedure was repeated due to persistence of gas exchange alteration. Finally, in all cases there was a correction of gas exchange alteration as well as clinical and radiological improvement (Fig 2). In conclusion: -BWLL in one-session assisted by ECMO is an effective and safe treatment for PAP. -ECMO use could be useful in other high-risk airway treatments.

Rationale and aim. Sleep studies should be performed under stable condition to achieve correct obstructive sleep apnoea (OSA) diagnosis. However, real-life conditions sometimes lead to perform sleep studies after an acute respiratory hypercapnic failure (ARHF) treated with non-invasive mechanical ventilation (NIMV). The aim of the study was to evaluate the usefulness of sleep studies during an acute scenario in terms of long-term CPAP prescription and its effect on subsequent AHRF episodes. Methods: Observational study of a historic cohort of patients admitted for ARHF in need of NIMV during 2017-2019. Once the AHRF was resolved, a sleep study was performed to rule out OSA during admission, and continuous positive airway pressure (CPAP) was prescribed if an apnoea-hypopnea index > 30 was documented. Two groups were designed: CPAP adherent (>4 hours/night) and No CPAP group. Main outcome was AHRF readmission. Statistical analysis included multivariate logistic regression analysis. Results: A total of 147 patients were admitted for AHRF and 41 patients were diagnosed of severe OSA during admission (27.9%). Mean BMI was 38 ± 7.8 kg/m2. Main AHRF aetiology was a combination of COPD and obesity (43.9%). During follow-up 27 patients showed long-term CPAP adherence (65.9%), and 9 presented incident AHRF (22%), 6 in the No CPAP group (42.8%) and 3 in the adherent group (11.1%). CPAP use associated with less incident AHRF (Table 1). Conclusions: Two out of three patients diagnosed of severe OSA during an AHRF admission in need of NIMV showed long-term CPAP adherence. Incident AHRF episodes were reduced by CPAP use.

Introduction: Carbon monoxide (CO) competes with oxygen (O2) for the same hemoglobin binding points. This substance has 210 times greater affinity than that of O2. CO poisoning is a frequent cause of death in many cases of individuals with intoxication. Chronic inhalation even at low concentrations can cause health issues as cardiological and neurological problems. Carboxyhemoglobin (COHb) levels in the blood should be less than 2.5%, but in smokers it can increase to 10%. In addition to tobacco, CO inhalation in the home or other environments can be a reason for its elevation. Our objective is to evaluate the relationship between COHb levels and tobacco consumption. Material and methods A cross-sectional, descriptive study, evaluating arterial blood gases (ABG) results performed during june and july 2021 in a lung function lab of a tertiary university hospital. Patients with respiratory failure (pO2 < 60mmHg) and using home oxygen therapy were excluded. Results: Total sample size was 86 patients, mean age of 71.7 years (+/−14) and 59.3% male. Based on tobacco history 41.9% were non-smokers, 10.5% were active smokers, and 47.7% were ex-smokers. COHb levels between these groups was analyzed, establishing 2.5% COHb in arterial blood as the cut-off point, based on previous studies. Thus, it was possible to objectify how blood COHb levels are higher among smokers (89%) than among non-smokers (13,9%), being this difference statistically significant (p<0.01). Conclusions: COHb levels were higher among subjects with a smoking habit. This results can alter interpretation of the lung diffusion measurement among smokers, so measuring these levels can help improve the interpretation of this test.

Introduction: Cardiopulmonary exercise test (CPET) evaluates physiological adaptation to exercise by progressive increase of external load. It´s indicated for patients with unexplained dyspnea despite apropriate diagnostic workup. This study aim is to estimate functional aerobic capacity and establish whether respiratory, muscular or cardiovascular manifestations appear in response to the muscular stress and at what level is revealed, as well as trying to estimate an etiology. Material and methods: Descriptive study of adults who attended the lung function tests lab to perform CPET for unexplained dyspnea. Results: 49 patients were included, with a mean age of 58 years (SD 12), 69.4% (34) were women. Regarding comorbidities, 45% (22) had a Charlson index less than 1 and 40% (20) were obese. Complete lung function tests were previously performed, being almost all of them within reference range. Results include mean maximum power reached was 114 watts (SD 35), mean maximal oxygen consumption(VO2 max) per kilogram of weight was 17.5 (SD 4.3), the 75% of patients reached the lactate threshold (>40% of VOmax), 94% of the patients had an increase in lactate with exertion while 88% of the patients had a CO2 equivalent at the lactate threshold less than 35. 23 (46.9%) patients finished the test due to leg fatigue and 19 (38.8%) to dyspnea and 2 had cardiovascular manifestations that forced the examiner to stop the test. 21 patients (47.7%) suggested acardiovascular cause, 3 (6.8%) pulmonary vascular pathology, 4 lack of training (9.1%), 6 (13.6%) was multifactorial and 7 (15.9%) had adequate cardiovascular, muscular and respiratory response. Conclusions: CPET suggested etiology of unexplained dyspnea in most patients with complete diagnostic workup

Introduction: Chronic respiratory diseases and neuromuscular disorders are associated with respiratory muscle weakness, one of the main causes of development of respiratory failure. In patients with suspected respiratory muscle weakness, maximal inspiratory pressure (PImax), maximal expiratory pressure (PEmax), sniff nasal inspiratory pressure (SNIP) or forced vital capacity (FVC) measurement in seated and supine position are diagnostic methods of such pathology. This study’s aim is to determine diagnostic accuracy for respiratory muscle weakness when PImax and SNIP separately and in combination. Material and methods Descriptive cross-sectional study, in which the value of the PImax, PEmax and SNIP have been collected, alongside seated and supine position FVC spirometry testing between January and June 2021 in a tertiary university hospital. Results: Sample size was 100 patients. Mean age was 56.8 years (+/− 17.6) and 53% were male. Pathological threshold of PImax were one-third of reference values based on sex and age. SNIP value less than 35% of normal value according to the sex and age of the patients was considered pathological. Patients that were referred to a specialized laboratory for assessment of possible respiratory muscle weakness showed diagnosis in 18% by PImax, 57% by SNIP and 16% by PImax plus SNIP. Conclusions: Individualized assessment of the PImax and SNIP tends to overdiagnose respiratory muscle weakness, hence that both tests should be regarded not as interchangeable but as complementary for diagnosis.

Objective: We aim to assess trends in the influenza vaccination rate among COPD patients, identify which groups have higher rates, and analyze differences by sex. Methods: Cross-sectional study based on data from the European Health Survey for Spain carried out in the years 2020 and 2014 and from the Spanish National Health Interview Survey for the years 2017 and 2012. The study population comprised all persons aged ≥40 years. Results: 65,447 participants interviewed in the four surveys analyzed. COPD prevalence 5.9% (n=3855). IV uptake among COPD patients was 57.8% versus 28.6% for those without COPD (p <0.001). Men with COPD reported higher uptake in all the surveys studied. The uptake did not show a significant variation overtime for neither man nor woman with COPD. By age groups, among COPD subjects, uptake reached the highest value in 2020 (70.9%) for those aged ≥65 years, with a slight, but not significant, improvement from year 2012 (67.1%). However, among those aged 40 to 64 years the uptake was 33.3% in 2020 with a significant reduction from 2012 (39.4%; p=0.039). Multivariable logistic showed no significant changed in uptake overtime among participants with COPD. Men were vaccinated more frequently than women (OR 1.28; 95%, CI 1.12-1.47) and the probability of receiving the vaccine rose with age. Conclusions: In COPD patients, influenza vaccination uptake is below desirable levels and has not improved from 2012 to 2020. Current result suggests a worsening of uptake among younger COPD individuals. Sex differences are found, with consistent and constant lower uptake among women with COPD.

Spirometry is the main pulmonary function test and is essential for the evaluation and monitoring of respiratory diseases. Its utility transcends the field of Respiratory Medicine, is becoming increasingly important in primary care and applications have even been described outside the field of respiratory diseases. This document is therefore intended to serve as support for all health professionals who use spirometry, providing recommendations based on the best scientific evidence available. An update of the indications and contraindications of the test is proposed. The document sets out recommendations on the requirements necessary for conventional spirometers and portable office equipment, as well as on spirometer hygiene and quality control measures. Spirometric parameters that must be considered, performance of manoeuvres, criteria for acceptability and repeatability of measurements and their quality control are defined. A proposal is also established for presentation of the results and an evaluation and interpretation is proposed according to information generated in recent years. Finally, lines of adaptation and integration of spirometry in the field of new technologies are considered. © 2013 SEPAR. Published by Elsevier España, S.L. All rights reserved.

Supplemental Digital Content is available in the text BACKGROUND The effectiveness of prophylactic continuous positive pressure ventilation (CPAP) after thoracic surgery is not clearly established. OBJECTIVE The aim of this study was to assess the effectiveness of CPAP immediately after lung resection either by thoracotomy or thoracoscopy in preventing atelectasis and pneumonia. DESIGN A multicentre, randomised, controlled, open-label trial. SETTINGS Four large University hospitals at Madrid (Spain) from March 2014 to December 2016. PATIENTS Immunocompetent patients scheduled for lung resection, without previous diagnosis of sleep-apnoea syndrome or severe bullous emphysema. Four hundred and sixty-four patients were assessed, 426 were randomised and 422 were finally analysed. INTERVENTION Six hours of continuous CPAP through a Boussignac system versus standard care. MAIN OUTCOME MEASURES Primary outcome: incidence of the composite endpoint ‘atelectasis + pneumonia’. Secondary outcome: incidence of the composite endpoint ‘persistent air leak + pneumothorax’. RESULTS The primary outcome occurred in 35 patients (17%) of the CPAP group and in 58 (27%) of the control group [adjusted relative risk (ARR) 0.53, 95% CI 0.30 to 0.93]. The secondary outcome occurred in 33 patients (16%) of the CPAP group and in 29 (14%) of the control group [ARR 0.92, 95% CI 0.51 to 1.65]. CONCLUSION Prophylactic CPAP decreased the incidence of the composite endpoint ‘postoperative atelectasis + pneumonia’ without increasing the incidence of the endpoint ‘postoperative persistent air leaks + pneumothorax’.

Background: Bronchial thermoplasty (BT) is a minimally invasive procedure consisting of application of thermal energy into the airways to produce ablation of the hypertrophic smooth muscle. It was approved for use in moderate-severe asthma in Spain in 2010. Objectives: The aims of the present study are to analyze the effectiveness and the safety of BT in clinical practice in our center. Methods: Participants had a confirmed diagnosis of severe asthma and poor control without therapeutic alternative. Effectiveness was measured by comparing exacerbations, admissions rates, asthma control, and medication 1 year prior and 1 year after BT was completed. All complications appearing during the procedure and in the first year were recorded. Results: Patients had a mean age of 51 (SD 8) years and were predominantly female (17/23). The average number of activations per patient was 147 (16). The number of severe exacerbations was reduced by 75% (p < 0.001). A 38% reduction in admissions per year was also observed (p = 0.03). The Asthma Control Test improved by 7.1 (3.7) points (p = 0.018). Before BT, the dose of inhaled corticosteroids was 1,621 (1,015) µg of budesonide-equivalent and the dose of oral corticosteroids was 15 (13) mg of prednisone-equivalent. There was a reduction in 430 (731) µg of budesonide-equivalent (p = 0.02) and 4 (11) mg of prednisone (p = 0.094). No changes in lung function were observed. Complications were related mostly to exacerbation of asthma in the days following the procedure. Conclusions: BT is effective and safe for severe uncontrolled bronchial asthma in real clinical practice.

Acute heart failure (AHF) 913pid regurgitation, and less often required inotropic therapy.In comparison to HF-pEF, HFmrEF patients had lower BP on admission, with no differences in NYHA class, sodium and BNP concentrations, nor the frequency of mitral and tricuspid regurgitation.At hospital discharge, HFmrEF patients were less frequently prescribed diuretics, aldosterone antagonists, beta-blockers (BB), amiodarone and digoxin, but more frequently calcium channel blockers (CCB) than HFrEF patients.Compared to HFpEF patients, they were more frequently prescribed angiotensin converting enzyme inhibitors and BB, and less frequently -CCB.Patients with HFmrEF had higher BP and lower NYHA class on discharge compared to HFrEF patients, but similar to HFpEF.Length of hospital stay did not differ between all 3 groups (with a median of 7 days).In-hospital mortality in HFmrEF (1.7%) was more than twice lower than in HFrEF (3.8%), and almost twice as high as in HF-pEF (0.9%), but with no statistical difference between the groups, due to relatively low number of events.Conclusion: HFmrEF demonstrated an intermediate clinical profile between HF-pEF and HFrEF, but with more similarities to the HFpEF group.In terms of inhospital outcomes, there were no statistically significant differences between the groups with regard to length of hospital stay and in-hospital mortality.

En los últimos años se ha producido un aumento de la incidencia de las aspergilosis pulmonar invasiva (API), no sólo en pacientes inmunodeprimidos u oncohematológicos, sino también en aquellos con patología pulmonar crónica en tratamiento esteroideo. El objetivo de este estudio es analizar las características de los pacientes ingresados por API en un hospital terciario durante un periodo de 10 años y evaluar los factores asociados con su desarrollo. Se han revisado todos los pacientes diagnosticados de API ingresados en los servicios de Medicina Interna, Neumología y Cuidados Intensivos de nuestro hospital entre el 1 de enero de 1997 y el 31 de diciembre de 2006. La información se ha obtenido a través de la base de datos del servicio de archivo de nuestro hospital. Se han encontrado 39 pacientes, detectándose en dicho grupo una elevada incidencia de uso de ventilación mecánica invasiva previa a la aparición de la infección, así como de enfermedad pulmonar y de empleo de esteroides en su tratamiento previo. La mayoría de los pacientes han sido diagnosticados por cultivo, mientras que las técnicas antigénicas han mostrado un 17,9% de falsos negativos. El tratamiento antifúngico más ampliamente utilizado ha sido la anfotericina. Tanto la patología pulmonar como el tratamiento esteroideo asociado, así como el ingreso en una unidad de cuidados intensivos y la utilización de técnicas ventilatorias invasivas son factores que pueden predisponer a la aparición de una API. In recent years there has been an increase in the incidence of invasive pulmonary aspergillosis (IPA) not only in immunosuppressed or oncohematological patients but also in those suffering from chronic lung diseases treated with corticosteroids. This study has aimed to analyze the characteristics of patients admitted for IPA in a tertiary hospital over a 10-year period and to assess the associated factors with its development. We reviewed the cases of all IPA-diagnosed patients admitted to Internal Medicine, Pneumology and Intensive Care Unit of our hospital between January 1, 1997 and December 31, 2006, obtaining the information through the service's database file of our hospital. A total of 39 patients were found. A high incidence of use of invasive mechanical ventilation was observed before the onset of infection as well as lung disease and previous use of corticosteroids. Most of the patients had been diagnosed by culture, whereas antigenic techniques showed 17.9% false negatives. The most widely used antifungal treatment was amphotericin. Pulmonary disease associated with steroid treatment and admission to an intensive care unit and the use of noninvasive ventilatory techniques are factors that may predispose to the emergence of an IPA.

In this issue of the European Respiratory Journal , Troosters et al. 1 deliver another offspring to the numerous family 2–5 of analyses attempting to reinterpret the UPLIFT® study 5, a 4-yr trial specifically designed to test the reduction of decline in forced expiratory volume in 1 s (FEV1). While UPLIFT® was well powered, it turned out to be a negative study in its main outcome, with differences in the rate of FEV1 decline of 2 mL·yr−1 (p = 0.21) when measured post-bronchodilator (-40±1 (mean±sd) versus -42±1 mL·yr−1, respectively, for the treatment and control groups). Thus, the UPLIFT® conclusions were that “in patients with COPD [chronic obstructive pulmonary disease], therapy with tiotropium was associated with improvements in lung function, quality of life, and exacerbations during a 4-yr period but did not significantly reduce the rate of decline in FEV1” 5. It is possible that medications can only reduce the rate of decline to a certain “floor” value and therefore UPLIFT® was not able to detect differences because the comparison group was “too active”, since it included a large proportion of patients treated with long-acting β-agonists and/or inhaled corticosteroids. There is evidence to suggest that this might be the case, i.e. the two treatment arms of the TORCH (TOwards a Revolution in COPD Health) study 6 had rates of decline of -39±3 mL·yr−1 for the salmeterol/fluticasone combination, -42±3 mL·yr−1 for salmeterol or fluticasone alone and -55±3 mL·yr …

Respiratory physiology, the study of the function of the respiratory system in health and disease, was one of the core disciplines in respiratory medicine throughout the second half of the 20th Century. Moreover, clinical and basic physiologists were central to the creation of the European Respiratory Society (ERS) 20 yrs ago. Despite concerns that all the “interesting” questions in physiology had been answered, the last 20 yrs have shown that applying physiological principles to respiratory disease not only leads to new insights into how the lungs work when stressed, but has also identified new areas where the diagnosis and treatment of previously intractable or unrecognised physiological disorders has transformed the lives of large numbers of people. This editorial reflects this diversity of interest, but is only a snapshot of some of the exciting possibilities that a physiological approach to respiratory disease has made possible. By the late 1980s the key principles underpinning lung mechanics and gas exchange within the lung had been established and applied to most, but not all, problems. One orphan area was the understanding of the mechanisms controlling lung extravascular water volume. Although the lungs are functionally exposed to conditions causing an increase in microvascular filtration, such as capillary recruitment, increase in cardiac output and hypoxia, a common condition in cardiopulmonary disorders, the extracellular matrix normally limits extravascular water volume to <10% (interstitial oedema) 1. Matrix proteoglycans ensure low permeability of capillary endothelium and a fairly rigid interstitial matrix due to their assembly as link molecules within the matrix and among cells 1. However, a sustained condition of interstitial oedema, as well as lung overdistension, produces severe pulmonary complications, such as acute respiratory distress syndrome, which causes disruption of the extracellular matrix leading to an increase in microvascular permeability and unopposed fluid extravasation 1, 2. …