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Bronchiectasis is a complex and heterogeneous disease. Its pathophysiology is poorly understood, but chronic bronchial infection plays an important role in its natural history, and is associated with poor quality of life, more exacerbations and increased mortality. Pseudomonas aeruginosa, Haemophilus influenzae and Staphylococcus aureus are the most common bacteria related to chronic bronchial infection. Non-tuberculous mycobacteria, fungi and respiratory viruses are also present during clinical stability, and may increase the risk of acute exacerbation. Chronic inflammation is present in bronchiectasis, especially neutrophilic inflammation. However, macrophages and eosinophils also play a key role in the disease. Finally, airway epithelium has innate mechanisms such as mucociliary clearance and antibacterial molecules like mucins and antimicrobial peptides that protect the airways from pathogens. This review addresses how the persistence of microorganisms in the airways and the imbalance of the immune system contribute to the development of chronic bronchial infection in bronchiectasis.

Esta investigación busca identificar los posibles efectos del incremento en la inversión en energía geotérmica para su uso en los hogares mexicanos y su beneficio económico en las tarifas domésticas que han registrado un alza del 35% durante los últimos 10 años. Mediante el modelo econométrico panel de efectos fijos se identificaron resultados donde muestra que para el tipo de tarifa más común en la zona central, el aumento de la inversión en centrales geotérmicas está en función de la demanda cuando hay aumento de ventas internas y reducción en costos de producción. Lo anterior incentivaría a detonar el sector geotérmico para empresas del estado y privadas con beneficios monetarios y ambientales. Debido a la escasez de información en tal sector, se utilizaron únicamente los datos públicos disponibles de la Secretaría de Energía. La originalidad de la investigación permite identificar el efecto económico y la apertura de la geotermia en el mercado energético en beneficio de los mexicanos. Se concluye que con un factor de planta elevado en centrales geotérmicas, estimularía la inversión con la consiguiente reducción en las tarifas.

PurposeThis work analyzes the economic impact of an economic crisis on consumption in Spanish households, detecting inequalities in household consumption according to the age of the main breadwinner and changes in consumption patterns. In particular, the effects of the financial crisis of 2008 on household consumption are studied and divided according to the main breadwinner's age group to obtain the economic impact of the fall in consumption in young households.Design/methodology/approachThe input–output tables of the Spanish economy during the years 2005 and 2015 and data on household consumption based on age group have been used. Economic impact is estimated through multisector modeling, specifically a demand model expressed in monetary terms. This model allows us to obtain the direct impact on the sectors offering the demanded services and the indirect impact due to increase in intermediate demand from these sectors on the rest of them.FindingsThe results obtained show the changes in household consumption and its effects on different productive sectors, highlighting the following sectors: real estate activities, electricity, gas, steam and air conditioning supply, accommodation and food service activities and manufacturing.Originality/valueThis study measures the impact of an economic crisis on the consumption of young households, analyzing all groups of households according to the main breadwinner's age, with the added value of studying the impact of this variation on household consumption and quantifying the positive and negative impact on the different sectors of activity of the Spanish economy.

Bronchiectasis refers to both a clinical disease and a radiological appearance that has multiple causes and can be associated with a range of conditions. Disease heterogeneity and the absence of standardised definitions have hampered clinical trials of treatments for bronchiectasis and are important challenges in clinical practice. In view of the need for new therapies for non-cystic fibrosis bronchiectasis to reduce the disease burden, we established an international taskforce of experts to develop recommendations and definitions for clinically significant bronchiectasis in adults to facilitate the standardisation of terminology for clinical trials. Systematic reviews were used to inform discussions, and Delphi processes were used to achieve expert consensus. We prioritised criteria for the radiological diagnosis of bronchiectasis and suggest recommendations on the use and central reading of chest CT scans to confirm the presence of bronchiectasis for clinical trials. Furthermore, we developed a set of consensus statements concerning the definitions of clinical bronchiectasis and its specific signs and symptoms, as well as definitions for chronic bacterial infection and sustained culture conversion. The diagnosis of clinically significant bronchiectasis requires both clinical and radiological criteria, and these expert recommendations and proposals should help to optimise patient recruitment into clinical trials and allow reliable comparisons of treatment effects among different interventions for bronchiectasis. Our consensus proposals should also provide a framework for future research to further refine definitions and establish definitive guidance on the diagnosis of bronchiectasis.

Background We aimed to describe the effectiveness and safety of inhaled antibiotics in chronic obstructive pulmonary disease (COPD) patients, as well as the patient profile in which they are usually prescribed and the patient groups that can most benefit from this treatment. Methods Multicentre retrospective observational cohort study in COPD patients who had received ≥1 dose of inhaled antibiotics in the last 5 years. Clinical data from the two years prior to and subsequent to the start of the treatment were compared. Primary outcome: COPD exacerbations. Secondary outcomes: side effects, symptomatology (sputum purulence, dyspnoea), microbiological profile and pathogen eradication. Results Of 693 COPD patients analyzed (aged 74.1; 86.3% men; mean FEV1 = 43.7%), 71.7% had bronchiectasis and 46.6% presented chronic bronchial infection (CBI) by Pseudomonas aeruginosa (PA). After 1 year of treatment with inhaled antibiotics, there was a significant decrease in the number of exacerbations (−33.3%; P Conclusions In COPD patients with multiple exacerbations and/or CBI by any PPM (especially PA), inhaled antibiotics appear to be an effective and safe treatment, regardless of the presence of bronchiectasis.

Study objective: There is very limited information about the effect of continuous positive airway pressure (CPAP) in the very elderly. Here we aimed to analysed the effect of CPAP on a clinical cohort of patients with obstructive sleep apnea (OSA) >= 80 years old. Methods: Post-hoc pooled analysis of two open-label, multicenter clinical trials aimed to determine the effect of CPAP in a consecutive clinical cohort of elderly (>= 70 years old) with moderate-to-severe OSA (apnea-hipopnea index >= 15 events/hour) randomized to receive CPAP or no CPAP for three months. Those consecutive patients >= 80 years old were included in the study. The primary endpoint was the change in Epworth Sleepiness scale (ESS). Secondary outcomes included sleep-related symptoms, quality of life, neurocognitive and mood status as well as office blood pressure measurements. Results: From the initial 369 randomized individuals with >= 70 years, 97 (26.3%) with >= 80 years old were included (47 in the CPAP group and 50 in the no-CPAP group). The mean (SD) age was 81.5 (2.4) years. Average use of CPAP was 4.3 (2.6) hours/night (53% with good adherence) Patients in the CPAP group significantly improved snoring and witnessed apneas as well as AHI (from 41.9 to 4.9 events/hour). However no clinical improvements were seen in ESS (>= 1.2 points, 95%CI, 0.2 to >= 2.6), any domain of QSQ, any neurocognitive test, OSA-related symptoms, depression/anxiety or blood pressure levels. Conclusions: The present study does not support the use of CPAP in very elderly patients with moderateto-severe OSA. (C) 2021 Elsevier B.V. All rights reserved.

Recientemente dos eventos exógenos han provocado desequilibrios económicos y sociales en la mayoría de los países: la crisis sanitaria del COVID-19 en 2020 y el conflicto bélico entre Rusia y Ucrania en 2022. La principal manifestación de estos eventos ha ocurrido a través de la inflación. En México, el crecimiento constante en los precios no se observaba desde la década de los noventa. Sin duda, esta situación provocará un endurecimiento de la política monetaria, lo que impactará negativamente en el crecimiento económico. Sin embargo, no basta solamente con alcanzar altas tasas de crecimiento económico; adicionalmente, es necesario fortalecer el sistema educativo y de salud, así como distribuir de manera equitativa la riqueza generada, sin omitir el fomento a la inversión pública y privada, permitiendo así el aumento en los niveles de empleo. Todo ello está encaminado a disminuir la desigualdad social e impulsar el desarrollo económico. Bajo este contexto, la presente obra contiene un enfoque multifactorial, expone un trabajo con una visión plural, con el fin de enriquecer las aportaciones hacia un mismo objetivo: presentar los factores que han impulsado o inhibido el desarrollo económico en México. La obra se divide en diez capítulos, los cuales han sido agrupados en cinco secciones, en función de la similitud de factores. De esta manera se tienen factores de crecimiento, entorno macroeconómico, mercado laboral, normatividad y COVID-19.

Introduction The coexistence of COPD and bronchiectasis seems to be common and associated with a worse prognosis than for either disease individually. However, no definition of this association exists to guide researchers and clinicians. Methods We conducted a Delphi survey involving expert pulmonologists and radiologists from Europe, Turkey and Israel in order to define the “COPD– [bronchiectasis] BE association”. A panel of 16 experts from EMBARC selected 35 statements for the survey after reviewing scientific literature. Invited participants, selected on the basis of expertise, geographical and sex distribution, were asked to express agreement on the statements. Consensus was defined as a score of ≥6 points (scale 0 to 9) in ≥70% of answers across two scoring rounds. Results 102 (72.3%) out of 141 invited experts participated in the first round. Their response rate in the second round was 81%. The final consensus definition of “COPD–BE association” was: “The coexistence of (1) specific radiological findings (abnormal bronchial dilatation, airways visible within 1 cm of pleura and/or lack of tapering sign in ≥1 pulmonary segment and in >1 lobe) with (2) an obstructive pattern on spirometry ([forced expiratory volume in 1 s] FEV1/[forced vital capacity] FVC, A group of experts from EMBARC has generated a consensus definition of COPD and bronchiectasis association based on the coexistence of radiological findings, bronchial obstruction, compatible symptoms and exposure to smoke or toxic agents (ROSE criteria) https://bit.ly/3g3cdld

Obstructive sleep apnea (OSA) is associated with increased incidence of both cerebrovascular and coronary events and of overall cardiovascular risk. However, it seems that these relationships are less clear in the elderly population. On the other hand, continuous positive airway pressure (CPAP), the treatment of choice for severe and symptomatic OSA patients, seems to be more effective in preventing cerebrovascular than coronary events, also in the elderly. This review describes the existing literature in the field and exposes the different hypotheses that try to explain these phenomena. There is a growing body of evidence showing that low-grade intermittent hypoxia (a feature that characterized OSA) is associated with increased levels of hypoxia-inducible factor 1 (HIF-1) and vascular endothelial growth factor (VEGF) which in turn lead to neovascularization in the coronary tree (preconditioning hypoxia hypothesis). However, little is known about the effect of intermittent hypoxia in the formation of new vessels in the cerebral vasculature. Moreover, the effect of intermittent hypoxia in both coronary and cerebral vessels could change with age. On the other hand, recent randomized clinical trials have shown that CPAP may not be effective in preventing cardiovascular events in the context of secondary prevention. However, a more detailed analysis of the results and subsequent meta-analyses show that this treatment exerts a protective effect in cerebrovascular disease but not in cardiovascular diseases, especially in elderly patients. Although OSA is clearly related to an increased cardiovascular risk, this seems less obvious in the elderly and in the coronary vessels. As a consequence, the effect of CPAP in the elderly with coronary disease remains controversial.

The isolation of Pseudomonas aeruginosa (PA) in patients with chronic obstructive pulmonary disease (COPD) is associated with increased mortality. Yet, factors associated with first PA sputum isolation, and PA persistence have not been investigated before. The objective of the present study was to investigate risk factors for new acquisition and persistence of PA infection and their relationship with all-cause mortality in patients with COPD. Post-hoc analysis of prospectively collected cohort of 170 COPD patients (GOLD II-IV) who were free of previous PA isolation and followed up every 3-6 months for 85 [50.25-110.25] months. PA was isolated for the first time in 41 patients (24.1%) after 36 [12-60] months of follow-up. Risk factor for first PA isolation were high cumulative smoking exposure, severe airflow limitation, previous severe exacerbations, high fibrinogen levels and previous isolation of Haemophilus Influenzae. PA was isolated again one or more times during follow-up in 58.5% of these patients. This was significantly associated with the presence of CT bronchiectasis and persistence of severe exacerbations, whereas the use of inhaled antibiotic treatment after the first PA isolation (at the discretion of the attending physician) reduced PA persistence. During follow-up, 79 patients (46.4%) died. A single PA isolation did not increase mortality, but PA persistence did (HR 3.06 [1.8-5.2], p = 0.001). We conclude that PA occurs frequently in clinically stable COPD patients, risk factors for a first PA isolation and PA persistence are different, and the latter (but not the former) is associated with increased all-cause mortality.

Chronic obstructive pulmonary disease (COPD) is the leading cause of hospitalization for chronic respiratory illness in Spain. In recent years hospital admissions due to bronchiectasis have been increasing, although it is not known whether this is in proportion to COPD hospitalizations. Our main objective was to analyze the temporal evolution of discharges due to COPD, bronchiectasis, and their combination, and secondly, to assess their impact on in-hospital mortality and healthcare costs. We performed a retrospective study, based on the analysis of the Minimum Basic Data Set (MBDS) of hospital discharges using data from Spanish Ministry of Health with diagnostic codes of COPD or bronchiectasis between 2004 and 2015. We found 3 356 186 discharges with a diagnosis of COPD or bronchiectasis. After exclusions, 1 386 430 episodes were analyzed: 85.2% with COPD, 8.4% bronchiectasis, and 6.4% with both pathologies. Mean age of patients was 74.8 (10.9) years and with a male predominance of 80.1%. The increase in the annual number of discharges was greater in the two groups with bronchiectasis: 48.8% in the bronchiectasis group and 55.4% in the mixed group, compared to 6.6% in the COPD group. The mean length of stay was greater in both groups with bronchiectasis (

Introduction: Interest in bronchiectasis is increasing due to its rising prevalence, associated with aging populations and the extended use of high-resolution chest tomography (HRCT), and the resul...

The use of inhaled antibiotics was initially almost exclusively confined to patients with cystic fibrosis (CF). However, it has been extended in recent decades to patients with non-CF bronchiectasis or chronic obstructive pulmonary disease who present with chronic bronchial infection by potentially pathogenic microorganisms. Inhaled antibiotics reach high concentrations in the area of infection, which enhances their effect and enables their long-term administration to defeat the most resistant infections, while minimizing possible adverse effects. New formulations of inhaled dry powder antibiotics have been developed, providing, among other advantages, faster preparation and administration of the drug, as well as avoiding the requirement to clean nebulization equipment. In this review, we analyze the advantages and disadvantages of the different types of devices that allow the inhalation of antibiotics, especially dry powder inhalers. We describe their general characteristics, the different inhalers on the market and the proper way to use them. We analyze the factors that influence the way in which the dry powder drug reaches the lower airways, as well as aspects of microbiological effectiveness and risks of resistance development. We review the scientific evidence on the use of colistin and tobramycin with this type of device, both in patients with CF and with non-CF bronchiectasis. Finally, we discuss the literature on the development of new dry powder antibiotics.

Resumen Introduccion El Registro Espanol de Bronquiectasias de la SEPAR (RIBRON) comenzo como una plataforma longitudinal de recogida de datos de pacientes con esta enfermedad. El objetivo del presente estudio es describir tanto su funcionamiento, como analizar las caracteristicas de los pacientes con bronquiectasias segun el sexo. Metodos Entre febrero de 2015 y 2019, fueron incluidos 1.912 pacientes adultos diagnosticados de bronquiectasias procedentes de 43 centros. Todos los pacientes presentaron al menos datos completos de 79 variables basicas necesarias y controladas mediante una auditoria externa. Resultados Edad media fue de 67,6 anos (15,2), el 63,9% mujeres. El sintoma mas comun fue la tos productiva en el 78,3%, que fue mucopurulenta-purulenta en el 45,9%. La etiologia mas frecuente fue la postinfecciosa en el 40,4%, siendo idiopaticas en el 18,5%. Pseudomonas aeruginosa fue el microorganismo mas frecuentemente aislado con el 40,4%, el 25,6% en forma de infeccion cronica. El numero anual de agudizaciones leve-moderadas/graves fue de 1,62 (1,9)/0,59 (1,3). El 50% de los pacientes presentaron obstruccion al flujo aereo (el 17% grave). La localizacion mas frecuente fueron los lobulos inferiores. El valor medio del FACED /E-FACED/BSI fue de 2,06 (1,7)/2,67 (2,2)/7,8 (4,5), respectivamente. El 66,7% de los pacientes tomaban corticoides inhalados, el 19,2% macrolidos y el 19,5% antibioticos inhalados. Las mujeres presentaron un perfil de menor gravedad que los varones en terminos clinico-funcionales y etiologicos, pero semejante perfil infeccioso, radiologico y terapeutico. Conclusiones RIBRON representa un excelente mapa de las caracteristicas de las bronquiectasias en nuestro pais. Dos tercios de los pacientes son mujeres que presentaron unas caracteristicas propias, de menor gravedad de la enfermedad.

The objective of the study was to analyze the factors associated with chronic bronchial infection (CBI) due to methicillin-susceptibleA prospective, longitudinal, multicenter study was conducted with patients included in the RIBRON registry between January 2015 and October 2020. The inclusion criteria were an age of 18 years or older and an initial diagnosis of bronchiectasis. Patients recorded in the registry had a situation of clinical stability in the absence of an exacerbation in the four weeks before their inclusion. All patients were encouraged to provide a sputum sample at each visit for microbiological culture. Annual pulmonary function tests were performed according to the national spirometry guidelines.A total of 426 patients were ultimately included in the study: 77 patients (18%) with CBI due to SA and 349 (82%) who did not present any isolation of PPMs in sputum. The mean age was 66.9 years (16.2), and patients 297 (69.7%) were female, with an average BMI of 25.1 (4.7) kg/mPatients with non-CF bronchiectasis with CBI due to SA were younger, with lower FEV1% values, more significant extension of bronchiectasis, and a higher number of exacerbations of mild to moderate symptoms than those with no PPM isolation in respiratory secretions. The reduction in FEV1% was -1.19% (95% CI: -2.09, -0.69) (

Resumen A pesar de que es conocido que la presencia cronica de microorganismos en las vias aereas de pacientes con enfermedad pulmonar obstructiva cronica (EPOC) en fase de estabilidad conlleva una evolucion desfavorable, ninguna guia de manejo de la enfermedad establece pautas sobre como diagnosticar y tratar este tipo de casos. Con la intencion de orientar a los profesionales, desde la Sociedad Espanola de Neumologia y Cirugia Toracica (SEPAR) se ha elaborado un documento que pretende aportar respuestas clinicas sobre el manejo de pacientes con EPOC en los que se aislan microorganismos de forma puntual o persistente. Dado que la heterogeneidad de las evidencias cientificas disponibles no permite crear una Guia de Practica Clinica, se ha elaborado un documento basado en la literatura cientifica existente y/o en la propia experiencia clinica que aborda tanto la definicion de las diferentes situaciones clinicas como su diagnostico y manejo. El texto ha sido consensuado entre un amplio numero de neumologos con gran experiencia clinica y cientifica en este ambito. Este documento cuenta con el aval del Comite Cientifico de SEPAR.

Although the chronic presence of microorganisms in the airways of patients with stable chronic obstructive pulmonary disease (COPD) confers a poor outcome, no recommendations have been established in disease management guidelines on how to diagnose and treat these cases. In order to guide professionals, the Spanish Society of Pulmonology and Thoracic Surgery (SEPAR) has prepared a document which aims to answer questions on the clinical management of COPD patients in whom microorganisms are occasionally or habitually isolated. Since the available scientific evidence is too heterogeneous to use in the creation of a clinical practice guideline, we have drawn up a document based on existing scientific literature and clinical experience, addressing the definition of different clinical situations and their diagnosis and management. The text was drawn up by consensus and approved by a large group of respiratory medicine experts with extensive clinical and scientific experience in the field, and has been endorsed by the SEPAR Scientific Committee.

Exacerbations are crucial events during bronchiectasis progression.To explore the associations between bacterial, viral, and bacterial plus viral isolations and bronchiectasis exacerbations.In this prospective study, we enrolled 108 patients who were followed up every 3-6 months and at onset of exacerbations between March 2017 and November 2018. Spontaneous sputum was split for detection of bacteria (routine culture) and viruses (quantitative polymerase chain reaction). Symptoms and lung function were assessed during exacerbations.The median exacerbation rate was 2.0 (interquartile range: 1.0-2.5) per patient-year. At any visit, viral isolations (V+) occurred more frequently during onset of exacerbations [odds ratio (OR): 3.28, 95% confidence interval (95%CI): 1.76-6.12], as did isolation of new bacteria (NB+) (OR: 2.52, 95%CI: 1.35-4.71) and bacterial plus viral isolations (OR: 2.24, 95%CI: 1.11-4.55). Whilst coryza appeared more common in exacerbations with V+ than in exacerbations with no pathogen isolations and those with NB+, lower airway symptoms were more severe in exacerbations with NB+ (Viral isolations, isolation of new bacteria and bacterial plus viral isolation are associated with bronchiectasis exacerbations. Symptoms at exacerbations might inform clinicians the possible culprit pathogens.Las exacerbaciones son eventos cruciales durante la progresión de la bronquiectasia.Analizar las asociaciones entre el aislamiento de bacterias, virus y virus y bacterias juntas y las exacerbaciones de las bronquiectasias.En este estudio prospectivo se incluyó a 108 pacientes a los que se siguió cada 3-6 meses y al comienzo de las exacerbaciones entre marzo de 2017 y noviembre de 2018. La muestra de esputo espontáneo se dividió para la detección de bacterias (cultivo de rutina) y virus (reacción en cadena de la polimerasa cuantitativa). Se evaluaron los síntomas y la función pulmonar durante las exacerbaciones.La mediana de la tasa de exacerbación fue de 2,0 (rango intercuartil: 1,0-2,5) por paciente/año. En cualquier visita, los aislamientos de virus (V+) tuvieron lugar con mayor frecuencia durante el inicio de las exacerbaciones (Los aislamientos de virus, el aislamiento de nuevas bacterias y el aislamiento de bacterias y virus juntos están asociados a las exacerbaciones de las bronquiectasias. Los síntomas de las exacerbaciones pueden proporcionar información a los médicos sobre los posibles patógenos responsables.

Resumen: Las bronquiectasias (BQ) son una enfermedad tanto heterogénea en su presentación como compleja en su naturaleza. Una variable única no es capaz de captar el impacto total que las BQ producen sobre el individuo. Algunos autores han observado la presencia de algunos fenotipos clínicos más homogéneos en su clínica, pronóstico o respuesta al tratamiento, como el paciente con infección bronquial crónica por P. aeruginosa, el paciente «exacerbador» o el overlap (BQ + enfermedad pulmonar obstructiva crónica [EPOC]). Otros autores han desarrollado escalas multidimensionales que tratan de clasificar la gravedad o el pronóstico, teniendo en cuenta diferentes aspectos de la enfermedad como la clínica, la función pulmonar, la extensión radiológica o el perfil microbiológico entre otros. Finalmente, se están desarrollando herramientas clínicas que van un paso más allá y valoran las BQ como una enfermedad compleja, teniendo en cuenta no solo su gravedad, sino también su actividad biológica y la forma que el paciente tiene de vivir la enfermedad (impacto). Para ello, además de las puntuaciones multidimensionales de gravedad, se han venido desarrollando diferentes cuestionarios de calidad de vida específicos o se han validado para esta enfermedad aquellos que eran utilizados en otras patologías respiratorias, fundamentalmente EPOC. Por otro lado, se siguen investigando biomarcadores biológicos válidos que se relacionen con outcomes de importancia en BQ. Abstract: Bronchiectasis is a disease that is both heterogeneous in form and complex in nature. The overall impact of bronchiectasis on the individual cannot be captured by a single variable. Some authors have observed the presence of some more homogeneous clinical phenotypes in terms of symptoms, prognosis or response to treatment in, for example, patients with chronic P. aeruginosa bronchial infection, exacerbators or patients with bronchiectasis and COPD overlap. Other authors have developed multidimensional scales that attempt to classify severity or prognosis, taking into account different aspects of the disease, such as symptoms, lung function, radiological extension, and microbiological profile, among others. Finally, clinical tools are being developed that go a step further and consider bronchiectasis as a complex disease, taking into account not only its severity, but also its biological activity and impact on the patient's way of life. To this end, multidimensional severity scores and different specific quality of life questionnaires have been developed, and those used in other respiratory pathologies, mainly COPD, have been validated for this disease. On another front, the search continues for valid biological biomarkers associated with outcomes of importance in bronchiectasis.

Rationale: Treatment of chronic obstructive pulmonary disease (COPD) with inhaled corticosteroids (ICS) is controversial, because it can reduce the risk of future exacerbations of the disease at the expense of increasing the risk of pneumonia.Objectives: To assess the relationship between the presence of chronic bronchial infection (CBI), reduced number of circulating eosinophils, ICS treatment, and the risk of pneumonia in patients with COPD.Methods: This was a post hoc long-term observational study of an historical cohort of 201 patients with COPD (Global Initiative for Chronic Obstructive Lung Disease II-IV) who were carefully characterized (including airway microbiology) and followed for a median of 84 months. Results were analyzed by multivariate Cox regression and network analysis.Measurements and Main Results: Mean age was 70.3 years, 90.5% of patients were male, mean FEV1 was 49%, 71.6% of patients were treated with ICS, 57.2% of them had bronchiectasis, and 20.9% had

Resumen: La aerosolterapia domiciliaria constituye el 10-14% de las terapias respiratorias domiciliarias. Permite administrar sustancias por vía inhalada mediante nebulizadores, alcanzando concentraciones superiores en el árbol bronquial, aunque con una gran variabilidad inter- e intraindividual, dependientes del tamaño de las partículas, la edad, el patrón respiratorio y las condiciones del paciente. En general, solo deberían emplearse combinaciones de sistemas de nebulización y fármacos que hayan demostrado eficacia y seguridad. Los ß2-agonistas de acción corta, con o sin anticolinérgicos, se emplean en la exacerbación de la enfermedad pulmonar obstructiva crónica y del asma en pacientes graves o frágiles que no pueden coordinar, cooperar o realizar las maniobras necesarias para usar otros dispositivos. Empleados en domicilio, los nebulizadores pueden disminuir el número de visitas a urgencias e ingresos hospitalarios, siempre combinados con planes de educación. Los antibióticos nebulizados de forma prolongada están indicados en la infección bronquial crónica por Pseudomonas aeruginosa en bronquiectasias asociadas o no a fibrosis quística, mediante nebulizadores específicos. La solución salina hipertónica, la desoxirribonucleasa y el ácido hialurónico nebulizado pueden reducir las agudizaciones en la fibrosis quística con afectación pulmonar leve o moderada.Con el fin de mejorar la eficiencia en el uso de la terapia nebulizada, se hacen recomendaciones para pacientes y prescriptores, insistiendo en que el control clínico y el seguimiento terapéutico de estos pacientes se debe llevar a cabo por los especialistas prescriptores. Se revisan las indicaciones, el uso correcto, los tipos y cuidados de los equipos y la suspensión de la terapia cuando ya no sea necesaria. Abstract: Home aerosol therapy accounts for 10%-14% of home respiratory therapies. It is used to administer inhaled substances through nebulizers, thus achieving higher concentrations in the airways, although inter and intra-individual variability may be significant, depending on the size of the particles, and the age, respiratory pattern and characteristics of the patient. In general, only combinations of nebulization systems and drugs that have demonstrated efficacy and safety should be used. Short-acting β2-agonists, with or without anticholinergics, are used in chronic obstructive pulmonary disease and asthma exacerbations, and in severe or frail patients who cannot coordinate, cooperate, or perform the necessary maneuvers required by other devices. Home use of nebulizers can reduce the number of emergency room visits and hospital admissions when combined with educational strategies. Long-term nebulized antibiotics administered by specific devices are indicated in chronic bronchial infection due to Pseudomonas aeruginosa, and in bronchiectasis associated or unassociated with cystic fibrosis. Nebulized hypertonic saline, deoxyribonuclease, and hyaluronic acid can reduce cystic fibrosis exacerbations with mild or moderate lung involvement.In order to improve the efficiency of nebulized therapy, we have developed recommendations for patients and prescribers, emphasizing that clinical monitoring and therapeutic follow-up of these patients should be carried out by prescribing specialists. Indications, correct use, types and care of the equipment, and discontinuation of treatment when it is no longer necessary, are reviewed.

En el artículo se analizan una serie de acontecimientos acaecidos en una comunidad pilagá de la provincia de Formosa, Argentina, que incluyó agresiones, dolencias psicofísicas, prácticas oníricas, desciframientos onirománticos, experiencias extáticas y procedimientos terapéuticos. Estos hechos tuvieron como protagonista principal a una mujer que transitó de un estado de insalubridad a otro de salud y, concomitantemente, adquirió una habilidad terapéutica considerada extraordinaria. El análisis de dichos acontecimientos y de los discursos pilagá que los interpretan, permite apreciar cómo se conjugan las creencias shamánica y evangélica, la manera en que el surgimiento de una enfermedad se articula con los conflictos intra-comunitarios y los deseos e identidades que los pilagá constituyen en diálogo con la sociedad envolvente.

Currently, there is much controversy surrounding the therapeutic approach to pulmonary function abnormalities in patients with bronchiectasis and, consequently, whether and when to use bronchodilators in these patients. National and international guidelines on the treatment of bronchiectasis in adults do not recommend the routine use of bronchodilators because there is no evidence that a significant response to a bronchodilator or the presence or hyperresponsiveness of the airway are good predictors of future effective clinical response. However, some guidelines recommend them in the presence of airway obstruction and/or special conditions, which vary according to the guideline in question, although there are no recommendations on optimal dosing and bronchodilator treatment combined with or without inhaled corticosteroids. Nonetheless, in contrast with guideline recommendations, bronchodilators are overused in real-world patients with bronchiectasis even in the absence of airway obstruction, as demonstrated by analysis of national and international registries. This overuse can be explained by the awareness of the existence of a solid pharmacological rationale that supports the use of bronchodilators in the presence of chronic airway obstruction independent of its aetiology. We performed a systematic review of the literature and were able to verify that there are no randomised controlled trials (apart from a small study with methodological limitations and a very recent trial involving a not-very-large number of patients), or any long-term observational studies on the short- or long-term effect of bronchodilators in patients with bronchiectasis. Therefore, we believe that it is essential and even urgent to evaluate the effects of bronchodilators in these patients with appropriately designed studies.

Due to their potent anti-inflammatory capacity (particularly in predominantly eosinophilic inflammation) and immunosuppressive properties, inhaled corticosteroids (ICSs) are widely used in asthmatic patients and also in individuals with chronic obstructive pulmonary disease (COPD) who suffer multiple exacerbations or have peripheral eosinophilia. However, there is little evidence for their use in non-cystic fibrosis bronchiectasis (hereafter, bronchiectasis). According to data extracted from large databases of bronchiectasis in adults, ICSs are used in more than 50% of patients without any scientific evidence to justify their efficacy and contrary to the recommendations of international guidelines on bronchiectasis that generally advise against their use. Indeed, bronchiectasis is a disease with predominantly neutrophilic inflammation and a high likelihood of chronic bacterial bronchial infection. Furthermore, it is known that due to their immunosuppressive properties, ICSs can induce an increase in bacterial infections. This manuscript aims to review the basic properties of ICSs, how they impact bronchiectasis in adults, the current position of international guidelines on this treatment, and the current indications and future challenges related to ICS use in bronchiectasis.

Sleepiness is one of the outcomes most used in randomized clinical trials (RCT) on the effect of treatments for obstructive sleep apnea (OSA). Furthermore, it is known that there is a placebo effect, especially in subjective measures. Therefore, given that sleepiness is a subjective measure, the objective of this systematic review with meta-analysis and three-level meta-regression was to assess the response to different placebos (pills and sham-CPAP) used in RCTs in OSA, both on subjective (Epworth Sleepiness Scale [ESS]) and objective (Multiple Sleep Latency Test [MSLT], Maintenance Wake Test [MWT], the Osler test and the Psychomotor Vigilance Task [PVT]). We observed a statistically significant placebo effect in both subjective and objective measures of hypersomnia, and in both sham-CPAP and pills. This placebo effect was greater, even clinically significant, in subjective measures (ESS: -2.84 points) and in those RCTs that used pills as a placebo. In the meta-regression, only a higher baseline value of the ESS and Osler test was related to the placebo effect.

International audience; No abstract available