Alan Kaplan

Canadian Thoracic Society Recommendations for Management of Chronic Obstructive Pulmonary Disease – 2008 Update – Highlights for Primary Care

Chronic obstructive pulmonary disease (COPD) is a major respiratory illness in Canada that is preventable and treatable but unfortunately remains underdiagnosed. The purpose of the present article from the Canadian Thoracic Society is to provide up-to-date information so that patients with this condition receive optimal care that is firmly based on scientific evidence. Important summary messages for clinicians are derived from the more detailed Update publication and are highlighted throughout the document. Three key messages contained in the update are: use targeted screening spirometry to establish a diagnosis and initiate prompt management (including smoking cessation) of mild COPD; improve dyspnea and activity limitation in stable COPD using new evidence-based treatment algorithms; and understand the importance of preventing and managing acute exacerbations, particularly in moderate to severe disease.

Canadian clinical practice guidelines for acute and chronic rhinosinusitis

This document provides healthcare practitioners with information regarding the management of acute rhinosinusitis (ARS) and chronic rhinosinusitis (CRS) to enable them to better meet the needs of this patient population. These guidelines describe controversies in the management of acute bacterial rhinosinusitis (ABRS) and include recommendations that take into account changes in the bacteriologic landscape. Recent guidelines in ABRS have been released by American and European groups as recently as 2007, but these are either limited in their coverage of the subject of CRS, do not follow an evidence-based strategy, or omit relevant stakeholders in guidelines development, and do not address the particulars of the Canadian healthcare environment.Advances in understanding the pathophysiology of CRS, along with the development of appropriate therapeutic strategies, have improved outcomes for patients with CRS. CRS now affects large numbers of patients globally and primary care practitioners are confronted by this disease on a daily basis. Although initially considered a chronic bacterial infection, CRS is now recognized as having multiple distinct components (eg, infection, inflammation), which have led to changes in therapeutic approaches (eg, increased use of corticosteroids). The role of bacteria in the persistence of chronic infections, and the roles of surgical and medical management are evolving. Although evidence is limited, guidance for managing patients with CRS would help practitioners less experienced in this area offer rational care. It is no longer reasonable to manage CRS as a prolonged version of ARS, but rather, specific therapeutic strategies adapted to pathogenesis must be developed and diffused.Guidelines must take into account all available evidence and incorporate these in an unbiased fashion into management recommendations based on the quality of evidence, therapeutic benefit, and risks incurred. This document is focused on readability rather than completeness, yet covers relevant information, offers summaries of areas where considerable evidence exists, and provides recommendations with an assessment of strength of the evidence base and degree of endorsement by the multidisciplinary expert group preparing the document.These guidelines have been copublished in both Allergy, Asthma & Clinical Immunology and the Journal of Otolaryngology-Head and Neck Surgery.

Diagnosis of asthma in adults

Sara is a 41-year-old secretary in an autobody shop who comes to see you for evaluation of intermittent episodes of wheeze and shortness of breath that have progressed over the past 2 years. She feels that she has more “colds” than her workplace colleague, each of which lasts for 2–3 weeks,

Management of acute asthma in adults in the emergency department: nonventilatory management

Peter, a 26-year-old man with chronic, poorly controlled asthma, presents to a walk-in clinic reporting increasing asthma symptoms over a period of one week. He has been needing up to 20 puffs of salbutamol per day. An acute exacerbation of asthma is diagnosed, and the patient is immediately

Montelukast as an alternative to low-dose inhaled corticosteroids in the management of mild asthma (the SIMPLE trial): An open-label effectiveness trial

OBJECTIVE To evaluate the effectiveness of montelukast as monotherapy for patients with mild asthma who remain uncontrolled or unsatisfied while on inhaled corticosteroid (ICS) monotherapy. DESIGN A multicentre, open-label study. Patients (six years of age or older) had ICS therapy discontinued and were treated with orally administered montelukast once daily for six weeks. MAIN OUTCOME MEASURES The primary outcome measure was the rate at which asthma symptom control was achieved or maintained after six weeks of treatment. The secondary outcome measures were to compare compliance and physician satisfaction, and to further assess the safety and tolerability of montelukast. RESULTS Of the 534 patients enrolled, 481 (90.1%) completed the study. Mean (+/- SD) age was 27.8+/-19.0 years. The number of patients with uncontrolled symptoms decreased from 455 (85.2%) at baseline to 143 (26.8%) at week 6 (P<0.001), and mean Asthma Control Questionnaire score decreased from 1.4+/-0.8 to 0.6+/-0.6 (P<0.001), representing a clinically significant improvement. Of the 79 patients with controlled asthma symptoms at baseline, 73.4% maintained asthma control at week 6. Compliance to asthma therapy increased from 41% at baseline for ICS to 88% at week 6 for montelukast (P<0.001). Physician satisfaction with treatment increased from 43% to 85% (P<0.001) and patient satisfaction increased from 45% at baseline to 94% at week 6. No serious adverse events were reported over the course of the study. CONCLUSION Montelukast is an effective and well-tolerated alternative to ICS treatment in patients with mild asthma who are uncontrolled or unsatisfied with low-dose ICS therapy.

Management of acute asthma in adults in the emergency department: assisted ventilation.

Jordan, a 32-year-old man with chronic, poorly controlled asthma, has been in the emergency department for 1 hour with only partial response to aggressive bronchodilator therapy and a single intravenous dose of corticosteroids. He is considered to be at high risk for potentially fatal asthma because

Management of asthma in adults

Sara is a 41-year-old secretary in an autobody shop who comes to see you for evaluation of intermittent episodes of wheezing and shortness of breath that have progressed over the past 2 years. She feels that she has more “colds” than her workplace colleague. Each episode lasts for 2–3 weeks,

Contemporaneous international asthma guidelines present differing recommendations: An analysis.

Background. Several international groups develop asthma guidelines. Conflicting recommendations across guidelines have been described in several disease areas and may contribute to practice variability. Accordingly, we compared the latest Canadian Thoracic Society (CTS) asthma guideline with contemporaneous international asthma guidelines to evaluate conflicting recommendations and their causes. Methods. We identified the latest CTS asthma guideline update (2012) and the following societies which also updated their guidelines in 2012: the British Thoracic Society and Scottish Intercollegiate Guidelines Network and the Global Initiative for Asthma. We compared these three guidelines on (1) key methodological factors and (2) adult pharmacotherapy recommendations. Results. Methods used and documentation provided for literature search strategy and dates, evidence synthesis, outcomes considered, evidence appraisal, and recommendation formulation varied between guidelines. Criteria used to define suboptimal asthma control varied widely between guidelines. Inhaled corticosteroid dosing recommendations diverged, as did recommendations surrounding use of budesonide/formoterol as a reliever and controller and recommendations in the subsequent step. Conclusions. There are important differences between recommendations provided in contemporaneous asthma guidelines. Causes include differences in methods used for interpreting evidence and formulating recommendations. Adopting a common set of valid and explicit methods across international societies could harmonize recommendations and facilitate guideline implementation.