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Trotz der jüngsten bedeutenden Innovationen in der Behandlung der chronisch-obstruktiven Lungenerkrankung (chronic obstructive pulmonary disease, COPD) wurden in der patientenzentrierten Medizin keine wesentlichen Fortschritte erzielt. Die Empfehlungen der aktuellen Leitlinien basieren auf den Durchschnittsergebnissen klinischer Studien, was zur Folge hat, dass die medizinische Praxis als «mittelwertbasiert» bezeichnet werden kann. Auf der Patienten­ebene ist das therapeutische Ansprechen jedoch variabel. Zudem führt die Variabilität des klinischen Bildes im Wechselspiel mit den Komorbiditäten dazu, dass ein komplexes klinisches Szenario entsteht, mit dem die Ärzte umgehen müssen. Aus diesem Grund gibt es bislang keinen Konsens über einen praktischen Ansatz bei der Kombination von Komorbiditäten und Markern des klinischen Bildes im Therapie-Algorithmus. Diesbezüglich steht der Arzt ab dem ersten Patientenbesuch vor vier wichtigen Dilemmata: 1. Stellung der korrekten Diagnose «COPD» in Abgrenzung zu anderen Atemwegserkrankungen wie etwa Bronchialasthma; 2. Festlegung des initialen Therapieansatzes auf Grundlage der klinischen Merkmale des jeweiligen Falles; 3. Festlegung der diagnostischen Strategie für Patienten, die nicht auf die Therapie ansprechen; 4. Festlegung einer Strategie für die Verlaufskontrolle mit zwei genau definierten Zeiträumen, je nachdem, ob eine engmaschige oder eine langfristige Verlaufskontrolle erforderlich ist. Die vorliegende Arbeit geht auf die Hauptdilemmata bei der Suche nach einem patientenzentrierten Ansatz für das COPD-Management ein und liefert Vorschläge, wie diese alle in einer einzigen, einfach anwendbaren Strategie kombiniert werden können.

Background: The study of hematic concentrations of alpha1 antitrypsin (AAT) is currently one step in the diagnosis of AAT deficiency. To try to clarify the relevance of the laboratory techniques, we carried out a systematic review of the literature. Methods: Studies evaluating the quantification of AAT in peripheral blood were searched in PubMed in July 2021. The selection criteria included (1) any type of study design that included a quantification of AAT in peripheral blood; (2) studies written in English or Spanish; (3) studies evaluating human beings; and (4) studies involving adults. Results: Out of 207 studies, the most frequently used techniques were nephelometry (43.9%), followed by ELISA (19.8%) and turbidimetry (13.5%). Altogether, 182 (87.9%) cases expressed their results in units of gram, while 16 (7.7%) articles expressed them in units of mole. Only 2.9% articles referred to the standard used, 43.5% articles indicated the commercial kit used, and 36.2% indicated the analyzer used. Conclusions: The technical aspects of these determinations are not always reported in the literature. Journals should be attentive to these technical requirements and ensure that they are included in the works in which AAT is determined in order to ensure a correct interpretation of the study findings.

Grants for projects of the Association of Pulmonologists of the South. Neumosur. Project: Expression of transcription factors sensitive to hypoxia, inflammatory response and oxidative stress at the systemic and muscular level in three clinical models of hypoxemia. Research grants 2012 SEPAR. Code: 051|2012. Expression of transcription factors sensitive to hypoxia, the inflammatory response, oxidative stress and peripheral muscle involvement in three clinical models of hypoxemia.

Jose Luis López-Campos,1,2 Laura Carrasco Hernández,1,2 Borja Ruiz-Duque,1 Rocio Reinoso-Arija,1 Candelaria Caballero-Eraso1,2 1Unidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío/Universidad de Sevilla, Seville, Spain; 2Centro de Investigación Biomédica en Red de Enfermedades Respiratorias (CIBERES), Instituto de Salud Carlos III, Madrid, SpainCorrespondence: Jose Luis López-CamposUnidad Médico-Quirúrgica de Enfermedades Respiratorias, Instituto de Biomedicina de Sevilla (IBiS), Hospital Universitario Virgen del Rocío, Avda. Manuel Siurot, s/n, Seville, 41013, SpainTel +34 955013166Email lopezcampos@separ.esAbstract: Recent advances in inhaled drugs and a clearer definition of the disease have made the task of managing COPD more complex. Different proposals have been put forward which combine all the available treatments and the different clinical presentations in an effort to select the best therapeutic options for each clinical context. As COPD is a chronic progressive disease, the escalation of therapy has traditionally been considered the most natural way to tackle it. However, the notion of COPD as a constantly progressing disease has recently been challenged and, in specific areas, this points to the possibility of a de-escalation in treatment. In this context, the clinician requires simple, specific recommendations to guide these changes in treatment in their daily clinical practice. To accomplish this, the first step must be a correct evaluation and an accurate initial preliminary diagnosis of the patient’s condition. Thereafter, the first escalation in therapy must be introduced with caution as the disease progresses, since clinical trials are not designed with clinical decision-making in mind. During this escalation, three possibilities are open to change the current treatment for a different one within the same family, to increase non-pharmacological interventions or to increase the pharmacological therapies. Beyond that point, a patient with persistent symptoms represents a complex clinical scenario which requires a specialized approach, including the evaluation of different respiratory and non-respiratory comorbidities. Unfortunately, there are few de-escalation studies available, and these are mainly observational in nature. The debate on de-escalation in pharmacological treatment, therefore, involves two main discussion points: the withdrawal of bronchodilators and the withdrawal of inhaled steroids. Altogether, the scheme for modifying treatment must be more personalized than just adding molecules, and the therapeutic response and its conditioning factors should be evaluated at each step before proceeding further.Keywords: COPD, escalation of treatment, pharmacological therapies, precision medicine

Over recent decades, a number of studies have revealed the possible role of different types of diets, as well as the nutritional elements they are made up of, in the pathogenesis of chronic obstructive pulmonary disease (COPD). To date, dietary factors have been identified to play a role in the prevention of COPD, with evidence from antioxidant nutrients, vitamins, and fiber intake. Additionally, certain dietary patterns such as the Mediterranean diet, together with other Western diets, provide evidence of the influence on COPD development, promoting lung health through nutritional approaches, and giving us an opportunity for intervention. The effect of diet on COPD is conveyed by 3 mechanisms: regulation of inflammation, oxidative stress, and carbon dioxide produced/oxygen intake. Current advances have begun to highlight the possible role of diet in modifying gene expression in certain individuals that predisposes them to COPD through epigenetic modifications. The relation between dietary intake and epigenetic factors has therefore outlined nutriepigenomics as a possible missing link in the relation between environmental exposure to smoke and the appearance of a subsequent chronic bronchial obstruction. This review summarizes the evidence regarding the influence of dietary patterns and nutrients and epigenetic regulatory mechanisms on COPD development and prevention with the aim of encouraging clinical research on the impact of dietary modifications on COPD-related clinical outcomes. This review highlights the importance of proposing and carrying out future studies focused on the modulating effects of certain nutrients on epigenetic changes in patients with specific COPD phenotypes (bronchiectasis, emphysema, asthma/COPD, chronic bronchitis), and their individual responses to cigarette smoking, environmental pollution, or other noxious particles. The objectives of these future studies must be directed to the development of novel therapeutic approaches and personalized management of COPD.

"Artículo escrito por un elevado número de autores, solo se referencian el que aparece en primer lugar, el nombre del grupo de colaboración, si le hubiere, y los autores pertenecientes a la UAM", El objetivo principal de este documento internacional de consenso sobre apnea obstructiva del sue˜no esproporcionar unas directrices que permitan a los profesionales sanitarios tomar las mejores decisionesen la asistencia de los pacientes adultos con esta enfermedad según un resumen crítico de la literaturamás actualizada. El grupo de trabajo de expertos se ha constituido principalmente por 17 sociedadescientíficas y 56 especialistas con amplia representación geográfica (con la participación de 4 sociedadesinternacionales), además de un metodólogo experto y un documentalista del Centro Cochrane Iberoame-ricano. El documento consta de un manuscrito principal, con las novedades más relevantes, y una seriede manuscritos online que recogen las búsquedas bibliográficas sistemáticas de cada uno de los aparta-dos del documento internacional de consenso. Este documento no cubre la edad pediátrica ni el manejodel paciente en ventilación mecánica crónica no invasiva (que se publicarán en sendos documentos deconsenso aparte)., The main aim of this international consensus document on obstructive sleep apnea is to provide guidelines based on a critical analysis of the latest literature to help health professionals make the best decisions in the care of adult patients with this disease. The expert working group was formed primarily of 17 scientific societies and 56 specialists from a wide geographical area (including the participation of 4 international societies), an expert in methodology, and a documentalist from the Iberoamerican Cochrane Center. The document consists of a main section containing the most significant innovations and a series of online manuscripts that report the systematic literature searches performed for each section of the international consensus document. This document does not discuss pediatric patients or the management of patients receiving chronic non-invasive mechanical ventilation (these topics will be addressed in separate consensus documents).

This article belongs to the Special Issue Current Perspectives in Management of Chronic Obstructive Pulmonary Disease., Despite recent notable innovations in the management of chronic obstructive pulmonary disease (COPD), no major advances in patient-centered medicine have been achieved. Current guidelines base their proposals on the average results from clinical trials, leading to what could be termed ‘means-based’ medical practice. However, the therapeutic response is variable at the patient level. Additionally, the variability of the clinical presentation interacts with comorbidities to form a complex clinical scenario for clinicians to deal with. Consequently, no consensus has been reached over a practical approach for combining comorbidities and disease presentation markers in the therapeutic algorithm. In this context, from the patients’ first visit, the clinician faces four major dilemmas: (1) establishing the correct diagnosis of COPD as opposed to other airway diseases, such as bronchial asthma; (2) deciding on the initial therapeutic approach based on the clinical characteristics of each case; (3) setting up a study strategy for non-responding patients; (4) pursuing a follow-up strategy with two well-defined periods according to whether close or long-term follow-up is required. Here, we will address these major dilemmas in the search for a patient-centered approach to COPD management and suggest how to combine them all in a single easy-to-use strategy., This manuscript has received a grant from Instituto de Salud Carlos III, FIS project PI18/00682 included in the Acción Estratégica en Salud, Plan Nacional de Investigación Científica, Desarrollo e Innovación Tecnológica 2013–2016, Instituto de Salud Carlos III, Fondos FEDER.

This article belongs to the Special Issue Rare Respiratory Diseases: A Personal and a Public Health Problem., Ever since the first studies, restoring proteinase imbalance in the lung has traditionally been considered as the main goal of alpha1 antitrypsin (AAT) replacement therapy. This strategy was therefore based on ensuring biochemical efficacy, identifying a protection threshold, and evaluating different dosage regimens. Subsequently, the publication of the results of the main clinical trials showing a decrease in the progression of pulmonary emphysema has led to a debate over a possible change in the main objective of treatment, from biochemical efficacy to clinical efficacy in terms of lung densitometry deterioration prevention. This new paradigm has produced a series controversies and unanswered questions which face clinicians managing AAT deficiency. In this review, the concepts that led to the approval of AAT replacement therapy are reviewed and discussed under a new prism of achieving clinical efficacy, with the reduction of lung deterioration as the main objective. Here, we propose the use of current knowledge and clinical experience to face existing challenges in different clinical scenarios, in order to help clinicians in decision-making, increase interest in the disease, and stimulate research in this field.

Amyotrophic lateral sclerosis (ALS) is a progressive neurodegenerative disorder that always affects the respiratory muscles. It is characterized by degeneration of motor neurons in the brain and spinal cord. Respiratory complications are the most common causes of death in ALS and typically occur within 3 to 5 years of diagnosis. Because ALS affects both upper and lower motor neurons, it causes hyperreflexia, spasticity, muscle fasciculations, muscle atrophy, and weakness. It ultimately progresses to functional quadriplegia. ALS most commonly begins in the limbs, but in about one-third of cases it begins in the bulbar muscles responsible for speech and swallowing.