Editorial

Obstruction in small airways—A challenge to medicine

Calcular la edad pulmonar espirométrica del fumador. Conocer las diferencias entre la edad cronológica y la edad pulmonar espirométrica antes y un año tras el abandono del tabaco. Averiguar si los datos de consumo de tabaco influyen en dichas diferencias. Analizar estos datos en el subgrupo de pacientes EPOC.

Pacientes que acuden a nuestra consulta de deshabituación tabáquica; se les realiza una espirometría antes y un año tras dejar de fumar. Cálculo de la edad pulmonar espirométrica basal y al año del abandono. Análisis estadístico con SPSS 11.0.

117 pacientes, 58,10% mujeres; edad media 47,10 años, edad inicio consumo 16,45 años, consumo medio diario 26,40 cigarrillos. Las cifras de consumo de tabaco no mostraban diferencias significativas entre ambos sexos. La edad media pulmonar del fumador era superior a la cronológica, tanto en varones como en mujeres (12,58 y 1,13 años, respectivamente). Tras un año de abstinencia, el pulmón de los varones tenía 10,97 años más que el propio paciente, mientras que en mujeres la edad pulmonar estaba por debajo de la edad cronológica en 3,67 años. Los datos de consumo de tabaco mostraban correlación con la edad pulmonar antes y después del abandono en ambos sexos. Los fumadores que tenían valores de función pulmonar de EPOC eran 18 (55,6% varones). Estos pacientes presentaban mayores diferencias entre las edades pulmonares final e inicial en ambos sexos frente a la serie global.

El pulmón del fumador está “envejecido”. Tras el abandono del tabaco se consigue un rejuvenecimiento del pulmón del fumador. Los pulmones femeninos se benefician más del abandono. La carga tabáquica tiene clara influencia sobre la edad pulmonar inicial y sobre el beneficio tras el abandono. Los pulmones de pacientes EPOC se benefician más del abandono del tabaco.

To calculate the spirometry lung age of the smoker. To know the differences between chronological age and spirometric lung age before and at one year of quitting smoking. To find out if the tobacco consumption data influence in these differences. To analyze these data in the COPD patient subgroup.

Patients who come to our smoking cessation clinic: a spirometry is performed before and one year after they quit smoking. The baseline spirometric lung age and age at one year of smoking cessation is calculated. Statistical analysis is performed with the SPSS 11.0.

117 patients, 58.10% women; mean age 47.10 years, age of onset consumption 16.45 years, mean daily consumption 26.40 cigarettes. There were no significant differences between both genders for tobacco consumption levels. Mean lung age of the smoker is greater than the chronological one, both in men and women (12.58 and 1.13 years, respectively). After one year of abstinence, the lung of the men had 10.97 years more than the real age of the patient, while the lung age in the woman was 3.67 years below the chronological age. The tobacco consumption data showed a correlation with the lung age before and after cessation in both genders. Eighteen (55.6% men) of the smokers had lung function levels of COPD. These patients showed greater differences between the final and initial lung ages in both genders compared to the global series.

The lung of the smoker is “aged.” After smoking cessation, the smoker's lung was rejuvenated. Female lungs benefit more from the cessation. The tobacco load has a clear influence on the initial lung age and on benefit after cessation. The lungs of COPD patients benefit more from smoking cessation.

Valorar los cambios en la función pulmonar tras un año de abstinencia de los fumadores que son seguidos en la consulta de deshabituación tabáquica. Conocer la influencia de las características del consumo en la pérdida y posterior variación en los parámetros funcionales respiratorios.

Estudio prospectivo longitudinal de fumadores que realizan un intento de deshabituación. Historia clínica general y de tabaquismo en la primera visita. Espirometría con test broncodilatador previo y al año tras la deshabituación.

Se han estudiado 68 pacientes (56,1% mujeres), con una edad media de 47,46 años. Fumaban 23,54 cigarrillos/ día desde los 17,02 años. Tras un año sin fumar existían diferencias significativas en todos los parámetros funcionales respiratorios estudiados (FEV1, FVC y FEV1/FVC). No existían diferencias tras un año según sexo, edad ni parámetros de consumo (edad inicio y cigarros/día). Aquellos que no tenían parámetros funcionales de EPOC obtenían una mayor diferencia anual. Las mujeres con EPOC que fumaban más de un paquete al día y que se iniciaron en el consumo antes de los 17 años se beneficiaban más del abandono.

Existe una ganancia en los parámetros funcionales respiratorios tras la cesación del consumo de tabaco. Esta ganancia se hace más evidente si se abandona el hábito antes de que se afecten los parámetros funcionales. Las mujeres EPOC con mayor carga acumulada de tabaco son las que más se benefician del abandono.

Evaluate the changes in pulmonary function after one year of abstinence of smokers who are followed-up in the smoking cessation consultation. Know the influence of the usage characteristics in the loss and subsequent variation in the respiratory functional parameters.

Prospective, longitudinal study of smokers who made an attempt to quick smoking. General clinical history and smoking history on the first visit. Spirometry with previous bronchodilator test and at one year after cessation.

A total of 68 patients (56,1% women) with a mean age of 47, 46 years were studied. They smoked 23,54 cigarettes/day since 17,02 years of age. After one year without smoking, there were significant differences in all the respiratory functional parameters studied (FEV1, FVC and FEV1/FVC). There were no differences after one year according to gender, age or consumption parameters (onset age and cigarettes/day). Those who had no functional parameters of COPD obtained a greater annual difference. COPD women who smoked more than one pack a day and who initiated smoking before 17 years of age benefited the most from quitting.

There is an improvement gain in the respiratory functional parameters after smoking cessation. This improvement is clearer if the habit is discontinued before the functional parameters are affected. COPD women with greater accumulated burden of tobacco are those who benefit the most from quitting.

We used a tracking index to measure the reproducibility of single breath nitrogen test variables (CV/VC, CC/TLC, ...N₂/L) and spirometric variables (FEV₁ and FEV₁/FVC) and to compare the characteristics of individuals whose pulmonary function tracks well with those whose pulmonary function tracks poorly. Data were derived from two cohorts followed longitudinally over a 9-11 year period. All variables were adjusted for age, sex and height by expressing them as Z-scores. In all smoking groups and in both cohorts, the tracking index was highest for FEV₁, indicating that this variable was the most reproducible over the period of follow-up; ...N./L and FEV₁/FVC had very similar but slightly lower tracking indices; CV/VC consistently had the lowest tracking indices. Tracking indices were generally higher in smokers than in nonsmokers. The reproducibility of CC/TLC increased over the period of follow-up whereas the FEV₁ reproducibility remained constant. We found no significant difference between those with high tracking indices and those with low indices in terms of sex, smoking status, prevalence of respiratory symptoms, history of respiratory disease, and rate of decline of FEV₁. We conclude that FEV₁ is the most reproducible of the variables examined, both within and between individuals, and that poor tracking or reproducibility are not related to smoking or to the presence of respiratory symptoms or disease.

Chronic obstructive pulmonary disease (COPD) is equated with chronic bronchitis and emphysema as one disease entity. In COPD airflow lindtation is relatively persistent unlike asthma. Tests for “small-airways disease” form no part of routine practice, for their accuracy in detecting pathological change is debatable. The proteolytic theory of the pathogenesis of emphysema highlights the role of neutrophel elastase, antielastases, oxidants, antioxidants, and thus of potential new treatments. Clinical features of COPD include breathlessness, cough, and sputum, with airflow obstruction and lung hyperinflation. The differential diagnosis includes bronchiectasis, cystic fibrosis, and pulmonary hypertension, but pulmonary fibrosis, etc., is distinguished by radiological infiltrates. Plain chest radiography cannot reliably diagnose emphysema in life, but a new method measuring lung density from the computed tomographic (CT) scan allows ration, quant tation, and diagnosis of emphysema (defined by enlargement of distal air spaces) in humans in life. “Pink puffers” with breathlessness, hyperinflation, mild hypoxemia, and a low Pco₂ are contrasted with “blue bloaters” with hypoxenda, secondary polycythemia, CO₂ retention, and pulmonary hypertension and cor pulmonare. Antismoking measures are a major aim in management. A bronchodilator regimen combining a slow release oral theophylline with an inhaled β₂-agonist, ipratropium, and high-dose inhaled steroids is proposed because even modest improvement in obstruction can help these patients. in acute exacerbat ns with purulent sputum, antimicrobials against Streptococcus pneunundee and Hemophilus irfluenzae are used with controlled oxygen therapy aiming to keep the arterial Po₂ over 50 mm Hg without the pH falling below 7.25. Influenza prophylaxis is recommended, but pneumococcal vaccination remains debatable. Chronic undernutrition in “emphysema” implies controlled trials of feeding regimens-but these remain to be assessed. Long-term oxygen therapy is the only treatment known to prolong life in blue bloaters, and oxygen concentrators and transtracheal oxygen delivery are discussed. Pulmonary vasodilators (e.g., (3z agonists, hydralazine, nifedipine, angiotensin-converting enzyme [ACE) inhibitors, etc.) have not yet been proved to provide long-term reduction in pulmonary arterial pressure. Blue bloaters have severe nocturnal hypoxemia in rapid eye movement (REM) sleep that is corrected by oxygen or the investigational drug almitrine. Combination of obstructive sleep apnea with COPD (the “overlap syndrome”) may require nasal continuous positive airway pressure (CPAP) as well as nocturnal oxygen. The value of inspiratory muscle training is not yet established by controlled trials, and the role of theophylline in improving diaphragmatic contractility remains controversial.

Peripheral airways of 2 mm or less in diameter were observed in 142 patients by means of an ultrathin bronchofiberscope measuring 1.8 mm in outside diameter. On the basis of the observed and photographed endoscopic findings, an endoscopic classification of peripheral airway lesions was proposed. The endoscopic findings showed changes in the bronchial wall consisting of reddening, pallor, absence of mucosal luster, edema, engorgement of blood vessels, irregular mucosal surface, and elevated mucosa. In the lumen, stenosis, obstruction, ectasis, and deformation due to pressure were recognized, in addition to excessive secretion and pigmentation as morphologic abnormalities or abnormal findings at bifurcation.

We evaluated the pulmonary status of 18 children 7 to 8 years after their hospitalization for chlamydial pneumonia of infancy. Pulmonary function tests (PFTs) and respiratory questionnaire results in this group were compared with those in a control group of 19 comparable children from the same community, and with values that other investigators have reported for normal children. Significant limitations of expiratory airflow were found (FEV₁, FEV₁/FVC, PEF, and FEF_25%–75%), as well as signs of abnormally elevated volumes of trapped air (FRC and RV/TLC ratios). These obstructive patterns were responsive to inhalation of isoproterenol. Moreover, a significantly greater number of patients had physician-diagnosed asthma than in the control group. The obstructive PFT abnormalities could not be accounted for by recognized risk factors, such as exposure to smoking at home or family history of atopy. Our results show that chlamydial pneumonia of infancy is associated with PFT abnormalities and respiratory symptoms 7 to 8 years after recovery from the acute illness.