Andreia Kist Fernandes

Characteristics of Acute Asthma Patients Attended Frequently Compared with Those Attended Only Occasionally in an Emergency Department

Asthma patients that depend on emergency department (ED) services are generally considered to have extremely poor disease control and prognosis. It is important to identify characteristics related to poor disease control and frequent visits to the ED to apply appropriate clinical management. This study comprised a cross-sectional survey of consecutive patients with asthma exacerbation (age ≥12 years) presenting at the adult ED of a large, tertiary care, university-affiliated hospital over a 2-month period. The frequent visitors (FV) were defined by ≥3 visits to the ED in the preceding year, and the occasional visitors (OV) by ≤2 visits. Eighty-six patients (61 females and 25 males) were included in the study (mean age 38 ± 18 years). Of these patients, 51.2% were FV and 48.8% were OV. Sixty-nine percent had annual income lower than A

Factors associated with emergency department visits due to acute asthma

3000 and 66.3% had ≤8 years of the formal education. Only 18.6% had used inhaled corticosteroids, 79.1% identified the asthma attack severity, 70.9% increased or initiated inhaled β-agonist, 20.9% increased or initiated steroid therapy, and 55.8% had an asthma action plan for attack. The number of hospital admissions in past year (OR 4.3, P = .02), use of home nebulizer (OR 3.6, P = .05) and the lack of a written asthma action plan (OR 3.3, P = .03) were independently associated with frequent visits to the ED. We conclude that a substantial proportion of the patients that visit the ED are FV. These patients are more likely to have hospital admission in the past year, to use a home nebulizer, and to lack a written asthma action plan. They should be considered the most important target for asthma education.

Early prediction of poor outcome in patients with acute asthma in the emergency room

It is important to identify characteristics related to poor disease control and frequent visits to the emergency department (ED). The objective of the present study was to compare the characteristics of patients attending the adult ED for treatment of asthma exacerbation with those attending an asthma specialist clinic (AC) in the same hospital, and to determine the factors associated with frequent visits to the ED. We conducted a cross-sectional survey of consecutive patients (12 years and older) attending the ED (N = 86) and the AC (N = 86). Significantly more ED patients than AC patients reported ED visits in the past year (95.3 vs 48.8%; P < 0.001) and had difficulty performing work (81.4 vs 49.4%; P < 0.001. Significantly more AC than ED patents had been treated with inhaled corticosteroids (75.6 vs 18.6%; P < 0.001) used to increase or start steroid therapy when an attack was perceived (46.5 vs 20.9%; P < 0.001) and correctly used a metered-dose inhaler (50.0 vs 11.6%; P < 0.001). The history of hospital admissions (odds ratio, OR, 4.00) and use of inhaled corticosteroids (OR, 0.27) were associated with frequent visits to the ED. In conclusion, ED patients were more likely than AC patients to be dependent on the acute use of the ED, were significantly less knowledgeable about asthma management and were more likely to suffer more severe disease. ED patients should be considered an important target for asthma education. Facilitating the access to ambulatory care facilities might serve to reduce asthma morbidity.

Efeito da implantação de um protocolo assistencial de asma aguda no serviço de emergência de um hospital universitário

Early identification of patients who need hospitalization or patients who should be discharged would be helpful for the management of acute asthma in the emergency room. The objective of the present study was to examine the clinical and pulmonary functional measures used during the first hour of assessment of acute asthma in the emergency room in order to predict the outcome. We evaluated 88 patients. The inclusion criteria were age between 12 and 55 years, forced expiratory volume in the first second below 50% of predicted value, and no history of chronic disease or pregnancy. After baseline evaluation, all patients were treated with 2.5 mg albuterol delivered by nebulization every 20 min in the first hour and 60 mg of intravenous methylprednisolone. Patients were reevaluated after 60 min of treatment. Sixty-five patients (73.9%) were successfully treated and discharged from the emergency room (good responders), and 23 (26.1%) were hospitalized or were treated and discharged with relapse within 10 days (poor responders). A predictive index was developed: peak expiratory flow rates after 1 h < or =0% of predicted values and accessory muscle use after 1 h. The index ranged from 0 to 2. An index of 1 or higher presented a sensitivity of 74.0, a specificity of 69.0, a positive predictive value of 46.0, and a negative predictive value of 88.0. It was possible to predict outcome in the first hour of management of acute asthma in the emergency room when the index score was 0 or 2.

Relação entre alterações funcionais e radiológicas em pacientes com fibrose cística

INTRODUCAO: Existe grande variabilidade de pratica clinica no tratamento da asma aguda na sala de emergencia, o que interfere na qualidade de atendimento. OBJETIVO: Avaliar o efeito da implantacao de um protocolo assistencial de asma aguda no Servico de Emergencia do Hospital de Clinicas de Porto Alegre. METODO: Estudo transversal, antes e apos a implantacao do protocolo assistencial de asma aguda no setor de adultos (idade > 12 anos) do referido servico, avaliando o efeito das recomendacoes sobre a avaliacao objetiva da gravidade, solicitacoes de exames, uso de terapeutica recomendada, uso de terapeutica nao-recomendada e desfechos da crise. RESULTADOS: Na fase pre-implantacao, foram estudados 108 pacientes e, na fase pos-implantacao, 96 pacientes. Houve aumento na utilizacao da oximetria de pulso (de 8% para 77%, p < 0,001) e do pico de fluxo expiratorio (de 5% para 21%, p < 0,001). Ocorreu aumento na utilizacao de recursos radiologicos (de 33% para 66%, p < 0,001) e de hemograma (de 11% para 25%, p = 0,016). Houve aumento no numero de pacientes que receberam as tres nebulizacoes preconizadas para a primeira hora de tratamento (de 22% para 36%, p=0,04). Embora a utilizacao geral de corticoide nao se tenha modificado, houve aumento no uso de corticoide oral (de 8,3% para 28%, p < 0,001). Nao houve alteracao significativa na utilizacao de medidas terapeuticas nao-preconizadas, no tempo de permanencia na sala de emergencia, nem nas taxas de internacoes e de altas. CONCLUSAO: A aplicacao do protocolo assistencial de asma aguda na sala de emergencia obteve efeito positivo, com maior utilizacao de medidas objetivas na avaliacao da gravidade e de medidas terapeuticas recomendadas, porem nao teve repercussao sobre tratamento e desfechos.

Variability of the perception of dyspnea in healthy subjects assessed through inspiratory resistive loading

BACKGROUND: Cystic fibrosis (CF) is a disease marked by airway inflammation and airflow obstruction, resulting in air trapping in the lungs. OBJECTIVE: To assess the associations between airflow limitation, pulmonary volume and X-ray findings in patients with cystic fibrosis. METHOD: A cross-sectional retrospective study. Review of spirometric, plethysmographic, and chest X-ray findings of outpatients (age ³ 16 years). The airflow findings were classified as within normal limits or as airflow obstruction: mild, moderate or severe obstructive alteration. RESULTS: A total of 23 patients (15 male and eight female; mean age, 21 ± 5.9 years) were studied. Six of them were within normal limits, four had a mild, five had a moderate, and eight had a severe obstructive alteration. There was an association between airflow limitation and the increase of residual volume (p = 0.006) and also with the Brasfield score (p = 0.001), but not with the total lung capacity (p = 0.33). There was a correlation between residual volume and Brasfield score (r = 0,73, p = 0,002), but not with the total pulmonary capacity. Moreover, according to X-ray criteria, the air trapping was correlated only with the residual volume (p = 0.006). CONCLUSION: In patients with cystic fibrosis (age ³ 16 years), the progressive airflow limitation is accompanied by an increase in residual volume, while the total pulmonary capacity remains normal or tends to decrease. The X-ray score was associated with airflow limitation and residual volume, but not with total lung capacity.

Dyspnea perception in cystic fibrosis patients

Objective: Few studies have evaluated the variability of the perception of dyspnea in healthy subjects. The objective of this study was to evaluate the variability of the perception of dyspnea in healthy subjects during breathing against increasing inspiratory resistive loads, as well as to assess the association between the level of perception of dyspnea and the level of physical activity. Methods: This was a cross-sectional study involving healthy individuals 16 years of age or older. Subjects underwent inspiratory resistive loading testing, in which the level of perception of dyspnea was quantified with the modified Borg scale. We also determined body mass indices (BMIs), assessed maximal respiratory pressures, performed pulmonary function tests, applied the international physical activity questionnaire (IPAQ)-long form, and conducted six-minute walk tests (6MWTs). The level of perception of dyspnea was classified as low (Borg score < 2), intermediate (Borg score, 2-5), or high (Borg score > 5). Results: We included 48 healthy subjects in the study. Forty-two subjects completed the test up to a load of 46.7 cmH2O/L/s. The level of perception of dyspnea was classified as low, intermediate, and high in 13, 19, and 10 subjects, respectively. The level of perception of dyspnea was not significantly associated with age, gender, BMI, IPAQ-long form score, maximal respiratory pressures, or pulmonary function test results. Conclusions: The scores for perceived dyspnea induced by inspiratory resistive loading in healthy subjects presented wide variability. The perception of dyspnea was classified as low in 31% of the subjects, intermediate in 45%, and high in 24%. There was no association between the level of perception of dyspnea and the level of physical activity (IPAQ or six-minute walk distance).

Repeatability of the Evaluation of Perception of Dyspnea in Normal Subjects Assessed Through Inspiratory Resistive Loads

We evaluated dyspnea perception in cystic fibrosis patients compared with normal subjects, during an inspiratory resistive loading test and 6-min walk test. We also evaluated the correlation between dyspnea scores induced by resistive loads and by the 6-min walk test. In this prospective, cross-sectional study, 31 patients with cystic fibrosis (≥15 years of age) and 31 age-, gender-, and ethnicity-matched healthy volunteers (20 females and 11 males per group) underwent inspiratory resistive loading, spirometry, and the 6-min walk test. As the magnitude of the inspiratory loads increased, dyspnea scores increased (P<0.001), but there was no difference between groups in dyspnea score (P=0.654). Twenty-six (84%) normal subjects completed all the resistive loads, compared with only 12 (39%) cystic fibrosis patients (P<0.001). Dyspnea scores were higher after the 6-min walk test than at rest (P<0.001), but did not differ between groups (P=0.080). Post-6-min walk test dyspnea scores correlated significantly with dyspnea scores induced by resistive loads. We conclude that dyspnea perception induced in cystic fibrosis patients by inspiratory resistive loading and by 6-min walk test did not differ from that induced in normal subjects. However, cystic fibrosis patients discontinued inspiratory resistive loading more frequently. There were significant correlations between dyspnea perception scores induced by inspiratory resistance loading and by the 6-min walk test. This study should alert clinicians to the fact that some cystic fibrosis patients fail to discriminate dyspnea perception and could be at risk for delay in seeking medical care.

Acute lung injury and acute respiratory distress syndrome at the intensive care unit of a general university hospital in Brazil An epidemiological study using the American-European Consensus Criteria

Purpose: Study the repeatability of the evaluation of the perception of dyspnea using an inspiratory resistive loading system in healthy subjects. Methods: We designed a cross sectional study conducted in individuals aged 18 years and older. Perception of dyspnea was assessed using an inspiratory resistive load system. Dyspnea was assessed during ventilation at rest and at increasing resistive loads (0.6, 6.7, 15, 25, 46.7, 67, 78 and returning to 0.6 cm H2O/L/s). After breathing in at each level of resistive load for two minutes, the subject rated the dyspnea using the Borg scale. Subjects were tested twice (intervals from 2 to 7 days). Results: Testing included 16 Caucasian individuals (8 male and 8 female, mean age: 36 years). The median scores for dyspnea rating in the first test were 0 at resting ventilation and 0, 2, 3, 4, 5, 7, 7 and 1 point, respectively, with increasing loads. The median scores in the second test were 0 at resting and 0, 0, 2, 2, 3, 4, 4 and 0.5 points, respectively. The intra-class correlation coefficient was 0.57, 0.80, 0.74, 0.80, 0.83, 0.86, 0.91, and 0.92 for each resistive load, respectively. In a generalized linear model analysis, there was a statistically significant difference between the levels of resistive loads (p<0.001) and between tests (p=0.003). Dyspnea scores were significantly lower in the second test. Conclusion: The agreement between the two tests of the perception of dyspnea was only moderate and dyspnea scores were lower in the second test. These findings suggest a learning effect or an effect that could be at least partly attributed to desensitization of dyspnea sensation in the brain.