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Histological changes such as mucosal secretion changes, thickening of the basal membrane of the lung epithelium, decreased alveolar space, a higher degree of fibrosis, centrolobular emphysema, and pulmonary microangiopathy have been reported in patients with diabetes.<a class="elsevierStyleCrossRef" href="#bib0005"><span class="elsevierStyleSup">1</span></a> Multiple observational studies have shown impaired lung function, usually as modest restrictive changes.<a class="elsevierStyleCrossRef" href="#bib0010"><span class="elsevierStyleSup">2</span></a> Such changes, attributed to a greater rigidity of the lung parenchyma and the chest wall or to the microvascular damage induced by diabetes, have to date been of little clinical relevance, although it should be borne in mind that, in diabetic patients, a 10% reduction in forced expiratory volume in the first second (FEV1) has been associated with an increased overall mortality.<a class="elsevierStyleCrossRef" href="#bib0015"><span class="elsevierStyleSup">3</span></a> This secondary clinical role is largely due to the nonexistent therapeutic implications derived from this knowledge to date, in contradistinction to the impact of other target organs of diabetes such as the kidney, retina, peripheral nervous system, or cardiovascular system. However, the relationship between endocrinologists and pneumologists is being redefined as a result of improved understanding of the harmful effects of diabetes not only on lung parenchyma, but also on the mechanisms involved in the control of ventilation and the maintenance of upper airway patency.</p><p id="par0010" class="elsevierStylePara elsevierViewall">In parallel to the increase in the prevalence of obesity and type 2 diabetes mellitus in recent decades, there has been a great increase in the number of patients referred to sleep units for studies of the obstructive sleep apnea syndrome (OSAS), for which obesity is the main determinant factor. OSAS is characterized by the occurrence of repeated episodes of upper airway obstruction (apnea) during sleep leading to sleep fragmentation, as well as changes in intrathoracic pressure and intermittent hypoxia. Evidence from clinical series<a class="elsevierStyleCrossRef" href="#bib0020"><span class="elsevierStyleSup">4</span></a> and population studies<a class="elsevierStyleCrossRef" href="#bib0025"><span class="elsevierStyleSup">5</span></a> relating OSAS to an increased cardiovascular morbidity and mortality has gradually accumulated.</p><p id="par0015" class="elsevierStylePara elsevierViewall">Intermittent hypoxia, a feature which is virtually exclusive to sleep respiratory disorders, plays a central role in the increase cardiovascular risk of OSAS. It is known to exert its effects partly through its metabolic consequences, promoting dyslipidemia<a class="elsevierStyleCrossRef" href="#bib0030"><span class="elsevierStyleSup">6</span></a> and altering glucose metabolism. Intermittent hypoxia increases insulin resistance and decreases insulin secretion. Various pathophysiological mechanisms have been implicated in these effects, including sympathetic activation, activation of lipid synthesis at the liver, induction of inflammation, changes in adipokine synthesis, and activation of the hypothalamus–adrenal axis.<a class="elsevierStyleCrossRef" href="#bib0035"><span class="elsevierStyleSup">7</span></a> As a result, OSAS is associated with insulin resistance in non-diabetic subjects,<a class="elsevierStyleCrossRef" href="#bib0040"><span class="elsevierStyleSup">8</span></a> and also acts as a risk factor for the occurrence of type 2 diabetes mellitus in the general population.<a class="elsevierStyleCrossRefs" href="#bib0045"><span class="elsevierStyleSup">9,10</span></a> The clinical relevance of these findings is supported by observations which suggest an improved control of diabetes when OSAS is treated.<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">11,12</span></a></p><p id="par0020" class="elsevierStylePara elsevierViewall">Alternatively, there are observations which suggest a marked impact of the presence of insulin resistance and diabetes on respiratory changes in obese subjects. The Sleep Heart Health Study, a population study, showed a greater severity of OSAS and nocturnal hypoxia in subjects with type 2 diabetes mellitus,<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> supporting some prior clinical observations.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">14</span></a> Although this effect disappeared when the analysis was adjusted for the presence of obesity and other confounding factors, subsequent studies have provided new findings in this regard. In women with morbid obesity, a phenotype with a high prevalence of frequently asymptomatic OSAS,<a class="elsevierStyleCrossRef" href="#bib0075"><span class="elsevierStyleSup">15</span></a> who were carefully matched in accordance with the main variables involved in its occurrence, the presence of type 2 diabetes was an independent risk factor for the development of severe hypoxemia during sleep.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> Several pathophysiological mechanisms may have been involved in these findings. Lung function impairment in these types of patients is mainly characterized by a decreased FEV1 related to the presence of both diabetes<a class="elsevierStyleCrossRef" href="#bib0085"><span class="elsevierStyleSup">17</span></a> and insulin resistance.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">18</span></a> However, it could not be related to nocturnal hypoxia.<a class="elsevierStyleCrossRef" href="#bib0080"><span class="elsevierStyleSup">16</span></a> The reported presence of glucagon-like peptide-1 (GLP-1) receptors in human lung and the fact that experimental administration of GLP-1 to human pneumocytes increases the production of lung surfactant, which is partly responsible for maintaining airway patency suggest another potential pathophysiological mechanism relating type 2 diabetes mellitus to lung function impairment.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">19,20</span></a> Diabetes may also alter central respiratory control mechanisms, as is suggested by the increased number of periodic breathing episodes during sleep associated with it.<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">13</span></a> Diabetic autonomic neuropathy may cause changes in reflex mechanisms responsible for maintaining the patency of the upper airway or may condition, through an increased circulation time due to the presence of autonomic heart disease, a defective response of the peripheral and central chemoreceptors to episodes of intermittent hypoxia. All these factors would result in greater ventilatory instability and would explain the increased number of episodes of obstructive and central apnea in diabetic patients with autonomic neuropathy as compared to those with no neuropathy.<a class="elsevierStyleCrossRefs" href="#bib0105"><span class="elsevierStyleSup">21,22</span></a> The increase in proinflammatory cytokines such as tumor necrosis factor (TNF) alpha induced by obesity or insulin resistance has also been related to impaired lung function<a class="elsevierStyleCrossRef" href="#bib0115"><span class="elsevierStyleSup">23</span></a> or the occurrence of sleep apnea.<a class="elsevierStyleCrossRef" href="#bib0120"><span class="elsevierStyleSup">24</span></a></p><p id="par0025" class="elsevierStylePara elsevierViewall">Not only has the possibility of improved diabetes control when sleep respiratory disorders are treated aroused interest, but the apparent bi-directionality of the relationship has also opened up complementary alternatives of potential clinical relevance. Data from animal experiments have suggested that increases in insulin sensitivity induced by the administration of metformin have beneficial effects on nocturnal apnea episodes.<a class="elsevierStyleCrossRef" href="#bib0125"><span class="elsevierStyleSup">25</span></a> No studies assessing the impact of improved glycemic control on respiratory parameters during sleep in humans are currently available, so we believe that further research is needed on this subject.</p></span>" "pdfFichero" => "main.pdf" "tienePdf" => true "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara">Please cite this article as: Sampol G, Lecube A. Diabetes mellitus tipo 2 y pulmón: una relación bidireccional. 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Year/Month | Html | Total | |
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2024 October | 3 | 3 | 6 |
2024 September | 41 | 16 | 57 |
2024 August | 34 | 20 | 54 |
2024 July | 27 | 4 | 31 |
2024 June | 13 | 1 | 14 |
2024 May | 9 | 2 | 11 |
2024 April | 28 | 6 | 34 |
2024 March | 43 | 6 | 49 |
2024 February | 43 | 6 | 49 |
2024 January | 17 | 5 | 22 |
2023 December | 42 | 6 | 48 |
2023 November | 21 | 9 | 30 |
2023 October | 23 | 5 | 28 |
2023 September | 17 | 6 | 23 |
2023 August | 13 | 4 | 17 |
2023 July | 15 | 6 | 21 |
2023 June | 24 | 2 | 26 |
2023 May | 42 | 10 | 52 |
2023 April | 35 | 2 | 37 |
2023 March | 22 | 5 | 27 |
2023 February | 14 | 9 | 23 |
2023 January | 18 | 4 | 22 |
2022 December | 20 | 5 | 25 |
2022 November | 29 | 14 | 43 |
2022 October | 22 | 6 | 28 |
2022 September | 23 | 9 | 32 |
2022 August | 20 | 7 | 27 |
2022 July | 13 | 12 | 25 |
2022 June | 13 | 8 | 21 |
2022 May | 19 | 12 | 31 |
2022 April | 28 | 8 | 36 |
2022 March | 26 | 10 | 36 |
2022 February | 14 | 8 | 22 |
2022 January | 26 | 12 | 38 |
2021 December | 58 | 12 | 70 |
2021 November | 31 | 13 | 44 |
2021 October | 22 | 12 | 34 |
2021 September | 30 | 10 | 40 |
2021 August | 27 | 8 | 35 |
2021 July | 7 | 12 | 19 |
2021 June | 17 | 13 | 30 |
2021 May | 22 | 15 | 37 |
2021 April | 26 | 36 | 62 |
2021 March | 17 | 8 | 25 |
2021 February | 8 | 10 | 18 |
2021 January | 6 | 8 | 14 |
2020 December | 10 | 12 | 22 |
2020 November | 18 | 3 | 21 |
2020 October | 8 | 7 | 15 |
2020 September | 9 | 10 | 19 |
2020 August | 5 | 7 | 12 |
2020 July | 8 | 12 | 20 |
2020 June | 7 | 7 | 14 |
2020 May | 9 | 6 | 15 |
2020 April | 7 | 3 | 10 |
2020 March | 10 | 8 | 18 |
2020 February | 14 | 4 | 18 |
2020 January | 8 | 6 | 14 |
2019 December | 14 | 13 | 27 |
2019 November | 5 | 8 | 13 |
2019 October | 10 | 6 | 16 |
2019 September | 12 | 8 | 20 |
2019 August | 12 | 10 | 22 |
2019 July | 8 | 8 | 16 |
2019 June | 3 | 9 | 12 |
2019 May | 60 | 44 | 104 |
2019 April | 22 | 3 | 25 |
2019 March | 8 | 5 | 13 |
2019 February | 5 | 6 | 11 |
2019 January | 4 | 2 | 6 |
2018 December | 10 | 2 | 12 |
2018 November | 9 | 7 | 16 |
2018 October | 6 | 7 | 13 |
2018 September | 7 | 2 | 9 |
2018 August | 3 | 1 | 4 |
2018 July | 3 | 1 | 4 |
2018 June | 4 | 3 | 7 |
2018 May | 11 | 1 | 12 |
2018 April | 17 | 5 | 22 |
2018 March | 3 | 1 | 4 |
2018 February | 2 | 2 | 4 |
2018 January | 8 | 0 | 8 |
2017 December | 5 | 0 | 5 |
2017 November | 8 | 0 | 8 |
2017 October | 6 | 1 | 7 |
2017 September | 19 | 4 | 23 |
2017 August | 10 | 1 | 11 |
2017 July | 12 | 4 | 16 |
2017 June | 9 | 2 | 11 |
2017 May | 13 | 3 | 16 |
2017 April | 15 | 1 | 16 |
2017 March | 29 | 33 | 62 |
2017 February | 22 | 3 | 25 |
2017 January | 4 | 0 | 4 |
2016 December | 14 | 6 | 20 |
2016 November | 11 | 2 | 13 |
2016 October | 14 | 2 | 16 |
2016 September | 6 | 3 | 9 |
2016 August | 8 | 4 | 12 |
2016 July | 10 | 4 | 14 |
2016 June | 14 | 4 | 18 |
2016 May | 13 | 12 | 25 |
2016 April | 7 | 3 | 10 |
2016 March | 13 | 6 | 19 |
2016 February | 11 | 8 | 19 |
2016 January | 14 | 7 | 21 |
2015 December | 11 | 4 | 15 |
2015 November | 18 | 4 | 22 |
2015 October | 26 | 5 | 31 |
2015 September | 17 | 2 | 19 |
2015 August | 15 | 12 | 27 |
2015 July | 8 | 4 | 12 |
2015 June | 7 | 0 | 7 |
2015 May | 16 | 3 | 19 |
2015 April | 16 | 6 | 22 |
2015 March | 15 | 2 | 17 |
2015 February | 9 | 1 | 10 |
2015 January | 28 | 7 | 35 |
2014 December | 53 | 11 | 64 |
2014 November | 28 | 0 | 28 |
2014 October | 44 | 8 | 52 |
2014 September | 24 | 2 | 26 |
2014 August | 21 | 0 | 21 |
2014 July | 34 | 3 | 37 |
2014 June | 15 | 2 | 17 |
2014 May | 31 | 7 | 38 |
2014 April | 16 | 1 | 17 |
2014 March | 21 | 2 | 23 |
2014 February | 17 | 3 | 20 |