ABSTRACT The tobacco epidemic has been one of the biggest public health threats, and smoking is one of the world's largest preventable causes of premature death. An estimated 15.4% of all deaths in the world are attributable to tobacco smoking. The present review aims to describe addiction to tobacco smoking and vaping. Tobacco and vaping devices contain nicotine, a highly addictive drug, which explains why smoking is so prevalent and persistent. Electronic cigarettes are a group of novel nicotine or tobacco products that have rapidly gained popularity in recent years. Electronic cigarette devices allow for the use of other drugs, including THC, while the lax regulation may allow for the introduction of toxic compounds that can lead to acute or subacute toxicity, such as the e-cigarette- or vaping-associated lung injury that has been linked to vitamin E acetate. In addition, regular vapers and heated tobacco devices emit toxins, although at lower concentrations than burned tobacco. However, more and more side effects have been identified. No new effective treatment for nicotine addiction has been developed recently, despite its huge adverse impact on overall health and other outcomes. As for the primary line of medications, the last one started in 2006, the varenicline, demonstrating a low interest in developing new medications against smoking, an unacceptable state of affairs, given the huge impact of smoking on morbidity and mortality.

ABSTRACT Background The values of arterial blood gases (ABG) change with altitude above sea level; empirical verification is essential because ventilatory acclimatization varies with ethnicity and a population's adaptation. Objective The aim of the study was to describe ABG in a healthy population residing at 2,240 meters above sea level, to identify the mean level of alveolar ventilation (PaCO2), and to know whether a progressive increase in PaCO2 occurs with age and the impact of increasing body mass index (BMI). Methods We conducted a cross-sectional study in a referral center for respiratory diseases in Mexico City. Associations among variables with correlation coefficient and regression models of PaO2, SaO2, and P(A-a)O2 as dependent variables as a function of age, BMI, minute ventilation, or breathing frequency were explored. Results Two hundred and seventeen healthy subjects were evaluated with a mean age of 40 ± 15 years, mean of the PaO2 was 71 ± 6 mmHg, SaO2 94% ± 1.6%, PaCO2 30.2 ± 3.4 mmHg, HCO3 20 ± 2 mmol/L, BE-2.9 ± 1.9 mmol/L, and the value of pH was 7.43 ± 0.02. In a linear regression, the main results were PaO2 = 77.5-0.16*age (p < 0.0001) and with aging P(A-a)O2 tended to increase 0.12 mmHg/year. PaCO2 in women increased with age by 0.075 mmHg/year (p = 0.0012, PaCO2 =26.3 + 0.075*age). SaO2 and PaO2 decreased significantly in women with higher BMI 0.14% and 0.52 mmHg per kg/m2, (p = 0.004 and 0.002 respectively). Conclusion Mean PaCO2 was 30.7 mmHg, implying a mean alveolar ventilation of around 30% above that at sea level.

ABSTRACT A large world population resides at moderate altitudes. In the Valley of Mexico (2240 m above sea level) and for patients with respiratory diseases implies more hypoxemia and clinical deterioration, unless supplementary oxygen is prescribed or patients move to sea level. A group of individuals residing at 2500 or more meters above sea level may develop acute or chronic mountain disease but those conditions may develop at moderate altitudes although less frequently and in predisposed individuals. In the valley of México, at 2200 m above sea level, re-entry pulmonary edema has been reported. The frequency of other altitude-related diseases at moderate altitude, described in skiing resorts, remains to be known in visitors to Mexico City and other cities at similar or higher altitudes. Residents of moderate altitudes inhale deeply the city's air with all pollutants and require more often supplementary oxygen.

Abstract: Chronic obstructive pulmonary disease (COPD) is the third leading cause of global death, and the disease burden is further increased by multiple comorbidities, including some psychological disorders, like anxiety and depression, among others. This interplay between mental health and COPD has become a subject of intense study in recent years. Our objective was to describe the psychological factors associated with COPD, the interplay of factors leading to psychological impacts, and to analyze the effective treatment and intervention alternatives available. A narrative literature search was performed in PubMed and Cochrane Library, by using a snow-ball search technique to identify papers published on the subject. A search was conducted for relevant original articles with emphasis on years 2015-2021. Relevant was the emphasis of a multidisciplinary team to support patients with COPD, experts on psychological factors associated with the disease, especially on anxiety and depression. Treatments available, including psychological interventions demonstrated an improvement in quality of life, adherence to treatments, reduced hospitalizations, symptomatology and exacerbations.

Resumen: La enfermedad pulmonar obstructiva crónica (EPOC) es la tercera causa principal de muerte a nivel mundial, y la carga de la enfermedad aumenta por múltiples comorbilidades, incluidos algunos trastornos psicológicos, como ansiedad y depresión, entre otros. Esta interacción entre la salud mental y la EPOC se ha convertido en un tema de intenso estudio en los últimos años. Nuestro objetivo fue describir los factores psicológicos asociados con la EPOC, la interacción de factores que conducen a un impacto en la enfermedad y analizar las alternativas de tratamiento e intervención efectivas disponibles. Se realizó una búsqueda de literatura narrativa en PubMed y Cochrane Library, utilizando una técnica de búsqueda de bola de nieve para identificar artículos publicados sobre el tema. Se realizó una búsqueda de artículos originales relevantes con énfasis en los años 2015-2021. Fue relevante el énfasis de un equipo multidisciplinario de apoyo a los pacientes con EPOC, resulta relevante la evaluación de factores psicológicos asociados a la enfermedad, especialmente ansiedad y depresión. Los tratamientos disponibles, incluidas las intervenciones psicológicas, demostraron una mejora en la calidad de vida, adherencia a los tratamientos, reducción de hospitalizaciones, sintomatología y exacerbaciones.

Abstract: Objective: To describe the possible risks associated to smoking in the spread and complications of Covid-19, emphasizing in the benefits of quitting smoking. Materials and methods: The narrative review methodology and the established process for Cochrane rapid reviews were used. Results: The scientific evidence related to smoking and Covid-19 remains limited. However, there is an already documented trend in cross-sectional, clinical studies and meta-analyses on the increased risk of adverse outcomes with Covid-19 associated with tobacco use. Conclusions: It is necessary to issue a warning that persons who smoke would have greater risks in the Covid-19 pandemic, which add to the many already known risks of tobacco use. Thus, quitting smoking becomes a relevant preventive measure to better confront SARS-CoV-2.

Resumen: Objetivo: Describir los posibles riesgos asociados de tabaquismo con contagio y complicaciones por Covid-19, haciendo hincapié en los beneficios de dejar de fumar. Material y métodos: Se utilizó la metodología de revisión narrativa y el proceso establecido para las revisiones rápidas Cochrane. Resultados: La evidencia científica relacionada con el tabaquismo y Covid-19 todavía es limitada. Existe una tendencia ya documentada en estudios clínicos transversales y metaanálisis del aumento del riesgo de resultados adversos para Covid-19 asociados con el consumo de tabaco. Conclusiones: Es necesario advertir que las personas que fuman tendrán mayores riesgos en la pandemia de Covid-19, los cuales se suman a los muchos ya conocidos del consumo de tabaco, de modo que dejar de fumar se convierte en una medida preventiva relevante para enfrentar mejor el SARS-CoV-2.

Abstract: Introduction: Forced spirometry is a diagnostic and prognostic tool in asthma and Chronic Obstructive Pulmonary Disease (COPD). The low use of the test is a problem that persists, particularly in the first level of care, generating underdiagnosis, and inadequate diagnosis of obstructive diseases. Learning the maneuver and interpretation of it is not a mandatory part of the academic program of medical students and residents routinely in many countries, including Mexico. Objective: To evaluate the possible reasons for the low use of spirometry in the first level of Care in Mexico and the impact of an educational program on the declarative an procedural learning of the test. Material and methods: Face-to-face training in spirometry, of 6 hours, was carried out to the staff of the primary care centers with the highest prevalence of acute respiratory infections in the Mexican Republic (phase I). Participants solved a survey about spirometry use before attending the course. Evaluation of 13 questions and a graphic interpretation exercise was applied before and after the session. They were instructed to deliver spirometry tests of biological controls to INER and receive feedback from pulmonologist. The staff that remained active was invited to become certified in spirometry based on NIOSH (phase II). The scores obtained pre and post-intervention during phase I were analyzed; as well as during phase II in the subgroup of participants who remained active. Results: 579 subjects attended the phase I training. 397 (68.6%) solved the pre-course survey. 83.9 and 78.9% reported attending more than one patient with the diagnosis of Asthma or COPD, respectively. 53.8% requested none spirometry in their monthly consultation. Among the causes, 39.7% consider it very important do not know how to perform it and not to have the equipment to do the test (30.5%). After the course, a significant improvement in declarative knowledge was observed compared to the diagnostic evaluation. 53.85 (RIC 38.46-69.23) versus 23.08 (RIC 7.69-30.77) respectively. After 10 months (7.17-14.5), only 77 participants went to phase II and took the spirometry certification course (18 hours) demonstrating stability in the theoretical score despite the elapsed time and good quality scores in the theoretical and practical evaluations after the 2nd intervention. Conclusion: The knowledge about spirometry is minimal and poorly used in the primary care of our country. Possible causes are a lack of continuous training and infrastructure. After a short training, there is a significant improvement in the learning of the test, which is held months later and is reinforced with a second training of longer duration. However, after a year of follow-up, new staff replaced the original one in a large percentage. What makes it necessary to establish more cost-effective educational modalities as tele-education.

Resumen: Introducción: La espirometría forzada es una herramienta diagnóstica y pronóstica en asma y en la enfermedad pulmonar obstructiva crónica. El poco uso de esta prueba es un problema persistente, en particular en el primer nivel de atención, lo que genera subdiagnóstico y diagnóstico inadecuado de enfermedades respiratorias obstructivas. El aprendizaje de la maniobra espirométrica y su interpretación no son obligatorios en los programas académicos de las facultades de medicina en muchos países incluyendo México. Objetivo: Evaluar los posibles motivos del poco uso de la espirometría en el primer nivel de atención en México y el impacto de un programa educativo en el aprendizaje declarativo y procedimental de la prueba. Material y métodos: Se desarrolló un entrenamiento presencial de seis horas dirigido al personal de primer nivel perteneciente a los centros con mayor prevalencia de infecciones respiratorias agudas en México (fase I). Los participantes resolvían una encuesta sobre el uso de la espirometría antes de acudir al curso. Se aplicó una evaluación de 13 preguntas y un ejercicio de interpretación gráfica antes y después del curso. Se instruyó a los participantes sobre el envío de controles biológicos al Instituto Nacional de Enfermedades Respiratorias para poder continuar en el proyecto y ser invitados al curso de certificación de fase II, basado en los estándares del Instituto Nacional para la Seguridad y Salud Ocupacional (NIOSH). Se analizaron los puntajes pre- y posintervención del curso de fase I, así como del curso de fase II en aquellos participantes que continuaron activos. Resultados: 579 sujetos realizaron el entrenamiento de fase I, de los cuales, 397 (68.6%) contestaron la encuesta inicial, en la cual 83.9 y 78.9% reportaron atender más de un paciente con el diagnóstico de asma o enfermedad pulmonar obstructiva crónica, respectivamente. El 53.8% de los encuestados no solicita ninguna espirometría al mes. Entre los motivos destacan el desconocimiento sobre la ejecución de la prueba (39.7%) y falta de equipo para realizarla (30.5%). Después del curso se observó una mejoría significativa en el conocimiento declarativo, comparado con la evaluación diagnóstica 53.85 (RIC 38.46-69.23) versus 23.08 (RIC 7.69-30.77), respectivamente. Después de 10 meses (7.17-14.5) sólo 77 sujetos tomaron el curso de Certificación en Espirometría (18 horas) o fase II, demostrando estabilidad en la puntuación teórica a pesar del tiempo transcurrido y puntuaciones de buena calidad en las evaluaciones (teóricas y prácticas) posteriores a la segunda intervención. Conclusión: El conocimiento sobre espirometría es pobre en el primer nivel de atención de nuestro país. Las posibles causas son la falta de formación e infraestructura continuas. Tras un breve entrenamiento, se produce una mejora significativa en el aprendizaje de la prueba, que se mantiene meses después y se refuerza con un segundo entrenamiento de mayor duración. Sin embargo, el personal nuevo reemplaza al original en un gran porcentaje, lo que hace necesario establecer modalidades educativas rentables como la teleeducación.

Abstract: Mexico experiences great challenges in public health and its health system. Demographic transition combines the coexistence of infectious and chronic-degenerative diseases. Respiratory diseases are some of the major public health problems and have been aggravated by the advent of respiratory pandemics: Influenza A H1N1 in 2009 and COVID-19 by SARS-CoV-2 during 2020. In this period, the National Institute of Respiratory Diseases (INER), the main training center for specialized human resources in Mexico, like other centers for the specialty of pulmonary medicine, has undergone a profound transformation towards the healthcare integration of respiratory and critical care medicine. Nevertheless, the great lack of specialized human resources in this area has become more evident during the current epidemiological emergency. It confirms that the proposal to integrate pulmonary and critical care medicine into a single specialty may be one of the compelling and effective responses to match some of the greatest challenges of medicine in our country.

Resumen: México experimenta grandes retos de salud poblacional y de su sistema de salud. La transición demográfica combina la coexistencia de enfermedades infecciosas y crónico-degenerativas. Las enfermedades respiratorias son algunos de los principales problemas de salud pública y se han agudizado con el surgimiento de las pandemias respiratorias: influenza A H1N1 en 2009 y COVID-19 por el virus SARS-CoV-2 durante el año 2020. En este período, el Instituto Nacional de Enfermedades Respiratorias (INER), el principal centro formador de recursos humanos especializados en México, al igual que otras sedes de la especialidad de neumología, ha experimentado una profunda transformación hacia la integración asistencial de la medicina respiratoria y la medicina crítica. Sin embargo, la gran carencia de recursos humanos especializados en la materia se ha hecho más evidente durante la actual emergencia epidemiológica. Esto viene a confirmar que la propuesta de integración de neumología y medicina crítica en una sola especialidad puede ser una de las respuestas obligadas y efectivas a la altura de algunos de los mayores desafíos de la medicina en nuestro país.

Abstract: Introduction: Underdiagnosis and misdiagnosis of asthma and COPD is enormous worldwide. This is partly explained by a poor accessibility and medical use of spirometry. The aim of this study was to describe the impact of a 5-hour workshop on medical competence regarding use and interpretation of spirometry. Method: Topic sessions, a technical video and 16-real spirometries workshop were developed for the project. Medical professionals from 31 states completed a residential course with initial and final evaluation. Results: A total of 1,343 professionals, 71.3% general practitioners and family physicians, completed the workshop and examination. Only 37% were able to recognized post-bronchodilator spirometry as the recommended diagnostic test for COPD and 11% correctly diagnosed severe airflow obstruction in the baseline evaluation. After the workshop, there was a significant improvement in all items of the examination and 81.2 % correctly recognized severe airflow obstruction. Conclusion: In this study medical knowledge and competence for using and interpreting spirometry in general practice is clearly insufficient, but a few-hours workshop may be highly efficient for training medical competence in continuous medical education programs.

Resumen: Introducción: El subdiagnóstico y error diagnóstico del asma y la enfermedad pulmonar obstructiva crónica es muy grande en todo el mundo, en parte, debido al pobre acceso y el uso médico de la espirometría. El objetivo fue evaluar el impacto de un curso-taller presencial en la competencia médica para el uso y la interpretación de la espirometría. Método: Se desarrolló un curso de cinco horas que comprendió conferencias, un video técnico y un taller de interpretación de 16 espirometrías reales. Profesionales médicos de 31 estados completaron el curso y sus evaluaciones inicial y final. Resultados: Un total de 1,343 profesionales, 71.3% médicos generales y familiares, completaron el curso. Sólo 37% de los participantes reconocieron de manera correcta a la espirometría con broncodilatador como la prueba de elección diagnóstica y 11.1% fueron capaces de diagnosticar obstrucción al flujo aéreo grave. Después del curso, se observó una mejoría significativa en los conocimientos y 81.2% diagnosticaron de forma acertada la obstrucción grave. Conclusión: El nivel de conocimientos y competencia médica para el uso e interpretación de la espirometría fue claramente insuficiente; sin embargo, un curso-taller de cinco horas fue bastante eficiente para fines de capacitación dirigida a la competencia médica.

Abstract: Cigarette smoking has hazardous effects on cardiovascular health and represents a worldwide great concern that demands further attention. We conducted a systematic review using PubMed database of the literature concerning cardiovascular effects of cigarette smoking reported in meta-analyses published in the last 10 years. 12 studies determined a significant association between cigarette smoking and the incidence of cardiovascular diseases, 6 of them demonstrated a substantial decline in the morbimortality after tobacco control policies were implemented. There is a need for the governments and the health care providers to strengthen their actions in order to reduce the prevalence of tobacco smoking and protect the general population from smoking attributable diseases, affecting multiple organs and systems and generating patients with multiple comorbidities.

Resumen: El consumo de tabaco tiene consecuencias adversas en la salud cardiovascular y representa un problema de salud pública a nivel mundial que demanda atención integral. Se realizó una revisión sistemática en PubMed de la literatura concerniente al impacto del tabaquismo sobre la salud cardiovascular reportada en metaanálisis publicados en los últimos 10 años. Doce estudios determinaron una asociación significativa entre el tabaquismo y la incidencia de enfermedades cardiovasculares, de los cuales seis demostraron una disminución importante de la morbimortalidad tras la implementación de políticas para el control del tabaco. Es necesario fortalecer las acciones de los gobiernos y los profesionales de la salud para disminuir la prevalencia de consumo de tabaco y proteger a la población general de las enfermedades asociadas con este producto, que afectan a todo el cuerpo y que tienden a generar enfermos con múltiples comorbilidades que se tienen que investigar.

Abstract Chronic obstructive pulmonary disease (COPD) is a major cause of chronic morbidity and mortality worldwide. While the cut-off point to define airflow obstruction has been controversial, it is widely accepted that the spirometry test is vital, as well as performing it after using a bronchodilator. The 6-second spirometry and the forced expiratory volume in 1 second/forced expiratory volume in 6 seconds (FEV1/FEV6) have demonstrated validity for defining obstruction, and it would be advisable to incorporate them in the definitions of obstruction. Another relevant issue is that spirometry with borderline obstruction can vary over time, changing to above or below the cut-off point. Thus, surveillance should be considered over time, repeating the spirometry to have a greater certainty in the diagnosis. The objective of this article was to conduct an in-depth review of the controversies in the diagnosis of COPD. During the past years, COPD definition has been updated in different times; however, it is now considered more as a complex syndrome with systemic participation, requiring a multidimensional assessment, and not only a spirometry.

Abstract Electronic cigarettes, handheld devices that generate an aerosol that may contain nicotine by heating a solution or e-liquid, have been increasingly used especially in the young population. The aerosol’s composition is determined by temperature, and by the substances contained in the heated liquid: glycerin, propylene glycol, nicotine in variable concentrations, flavoring agents, and other non-nicotine compounds. >80 compounds (including known toxics, e.g., formaldehyde, acetaldehyde, metallic nanoparticles, and acrolein) have been found in e-liquid and aerosols. Airway irritation, mucus hypersecretion, and inflammatory response, including systemic changes, have been observed after the exposure to e-cigarettes, leading to an increase in respiratory symptoms and changes in respiratory function and the host defense mechanisms. E-cigarette has been linked with an increase of symptoms in individuals with asthma, cystic fibrosis, and chronic obstructive pulmonary disease. One of the major concerns in public health is the rise in e-cigarette experimentation among never-smokers, especially children and adolescents, which leads to nicotine addiction and increases the chances of becoming with time a conventional smoker. There is an urgent need to regulate e-cigarettes and electronic nicotine delivery systems, at least with the same restrictions to those applied to tobacco products, and not to consider them as harmless products.