Erica Ferraz

Técnica e compreensão do uso dos dispositivos inalatórios em pacientes com asma ou DPOC

OBJECTIVE To evaluate knowledge of and techniques for using prescribed inhalation devices among patients with asthma or COPD treated at a tertiary teaching hospital. METHODS Patients were assessed after medical visits, and their physicians were blinded to this fact. Patients were asked to demonstrate their inhaler technique and were then interviewed regarding their knowledge of inhalation devices, control of the disease and instructions received during medical visits. RESULTS We included 120 volunteers: 60 with asthma and 60 with COPD. All of the asthma patients and 98.3% of the COPD patients claimed to know how to use inhaled medications. In the sample as a whole, 113 patients (94.2%) committed at least one error when using the inhalation device. Patients committed more errors when using metered-dose inhalers than when using the dry-powder inhalers Aerolizer (p < 0.001) or Pulvinal (p < 0.001), as well as committing more errors when using the Aerolizer inhaler than when using the Pulvinal inhaler (p < 0.05). Using the metered-dose, Pulvinal and Aerolizer inhalers, the COPD group patients committed more errors than did the asthma group patients (p = 0.0023, p = 0.0065 and p = 0.012, respectively). CONCLUSIONS Although the majority of the patients claimed to know how to use inhalation devices, the fact that 94.2% committed at least one error shows that their technique was inappropriate and reveals a discrepancy between understanding and practice. Therefore, it is not sufficient to ask patients whether they know how to use inhalation devices. Practical measures should be taken in order to minimize errors and optimize treatment.

Investigação de fatores associados à asma de difícil controle

OBJECTIVE To determine the prevalence of factors associated with difficult-to-control asthma. METHODS Patients with severe asthma were selected from the outpatient asthma clinic of the Ribeirão Preto School of Medicine Hospital das Clínicas. The patients were divided into two groups: controlled severe asthma and difficult-to-control severe asthma. After new attempts to optimize the severe asthma treatment, a questionnaire was applied, and additional tests for factors associated with difficult-to-control asthma, such as environmental and occupational exposure, smoking history, social factors, rhinitis/sinusitis, gastroesophageal reflux disease (GERD), obstructive sleep apnea, congestive heart failure (CHF), pulmonary embolism, cystic fibrosis, vocal cord dysfunction, alpha-1 antitrypsin deficiency, and Churg-Strauss syndrome, were performed. RESULTS 77 patients with severe asthma were selected, of which 47 suffered from hard-to-control asthma, being 68.1% female, with mean age of 44.4 years (+/-14.4), and forced expiratory volume in one second of 54.7% (+/-18.3). The most factors most often associated with difficult-to-control asthma were noncompliance with treatment (68%), rhinitis/sinusitis (57%), GERD (49%), environmental exposure (34%), occupational exposure (17%), smoking history (10%), obstructive sleep apnea (2%), and CHF (2%). At least one of these factors was identified in every case. CONCLUSIONS Noncompliance with treatment was the factor most often associated with difficult-to-control asthma, underscoring the need to investigate comorbidities in the evaluation of patients with this form of the disease.

Comparison of 4 AM and 4 PM Bronchial Responsiveness to Hypertonic Saline in Asthma

Bronchial responsiveness to methacholine or histamine increases at night and may contribute to the mechanisms of nocturnal asthma. Hypertonic saline (HS) is a more clinically relevant stimulus for the diagnosis and assessment of the severity of asthma, but the circadian variation in bronchial responsiveness to hypertonic challenges has not been addressed. The aim of this study was to compare the responsiveness to hypertonic saline at 4:00 AM and at 4:00 PM. Eighteen diurnally active patients (11 women) with asthma, 31 ± 9 years of age (mean ± SD) and with a forced expiratory volume in 1 s (FEV1) of 79.11% ± 12.85%, underwent two challenge tests (4:00 AM and 4:00 PM) in random sequence separated by an interval of 7 days. The challenge test consisted of inhalations of 4.5% saline with increasing doses by doubling the duration of nebulization (0.5, 1, 2, 4, and 8 min). The inhalation continued until a drop of 20% in FEV1 was achieved or total time of 15.5 min. The provocative dose that caused the 20% drop in FEV1 (PD20) was calculated. Differences were found between 4:00 PM and 4:00 AM values for inhalation times [3.80 ± 3.57 min and 2.19 ± 2.42 min (p = 0.001), respectively] and for PD20 [4.94 ± 6.77 ml and 2.93 ± 4.74 ml (p = 0.002), respectively]. Eight patients with a home-assessed nocturnal peak expiratory flow (PEF) drop of more than 15% formed the nocturnal asthma group. The behavior of these patients was similar to that of the non-nocturnal asthma group. We conclude that the bronchial responsiveness to HS increases at night.

Influence of Nocturnal Asthma on Chronotype

Individual differences in circadian rhythm have been studied since the past century. Chronotypes are a chronobiology classification based on the preferential times for beginning and ending activities throughout the day. Chronotypes can be classified as definitely morning, moderately morning, indifferent, moderately evening, and definitely evening. We aim to assess the distribution of chronotypes in asthmatics and the relationship of chronotype to the presence of nocturnal symptoms. Two hundred subjects were evaluated, 100 asthmatics and 100 non-asthmatics. The Morningness/Eveningness questionnaire was applied for chronotype determination. The asthmatics were subdivided according to the presence or absence of nocturnal symptoms. The chronotype distribution did not differ significantly between asthmatics and non-asthmatics. Thirty-five percent of the asthma group reported nocturnal symptoms. There was a significant difference in chronotype distribution between asthmatics with and without nocturnal worsening. The asthmatics with nocturnal symptoms had a lower prevalence of morning types and had a greater predominance of indifferent chronotype compared to asthmatics without nocturnal symptoms (p = 0.011). In conclusion, asthmatics with nocturnal symptoms present deviation from the chronotype distribution curve when compared to asthmatics without nocturnal symptoms. This is the first study to show the effect of a disease on chronotypes.

Development and validation of an asthma knowledge questionnaire for use in Brazil

OBJECTIVE To develop and validate an asthma knowledge questionnaire for use in adult asthma patients in Brazil. METHODS A 34-item self-report questionnaire was constructed and administered to adult asthma patients and adult controls. The maximum total score was 34. RESULTS The questionnaire was shown to be discriminatory, with good reliability and reproducibility. The mean score for asthma patients and controls was, respectively, 21.47 +/- 4.11 (range: 9-31) and 17.27 +/- 5.11 (range: 7-28; p < 0.001). The Kaiser-Meyer-Olkin measure of sampling adequacy was 0.53, and the Bartletts test of sphericity demonstrated a satisfactory suitability of the data to factor analysis (p < 0.001). There was no significant difference between the total scores obtained in the first and in the second application of the questionnaire within a two-week interval (p = 0.43). The internal consistency reliability (KR-20 coefficient) was 0.69. CONCLUSIONS This study has validated an asthma knowledge questionnaire for use in Brazil.

Laboratory animals and respiratory allergies: The prevalence of allergies among laboratory animal workers and the need for prophylaxis

OBJECTIVE: Subjects exposed to laboratory animals are at a heightened risk of developing respiratory and allergic diseases. These diseases can be prevented by simple measures such as the use of personal protective equipment. We report here the primary findings of the Laboratory Animals and Respiratory Allergies Study regarding the prevalence of allergic diseases among laboratory animal workers, the routine use of preventive measures in laboratories and animal facilities, and the need for prevention programs. METHODS: Animal handlers and non-animal handlers from 2 Brazilian universities (University of São Paulo and State University of Campinas) answered specific questionnaires to assess work conditions and symptoms. These subjects also underwent spirometry, a bronchial challenge test with mannitol, and skin prick tests for 11 common allergens and 5 occupational allergens (rat, mouse, guinea pig, hamster, and rabbit). RESULTS: Four hundred fifty-five animal handlers (32±10 years old [mean±SD], 209 men) and 387 non-animal handlers (33±11 years old, 121 men) were evaluated. Sensitization to occupational allergens was higher among animal handlers (16%) than non-animal handlers (3%, p<0.01). Accessibility to personal protective equipment was measured at 85% (median, considering 73 workplaces of the animal handler group). Nineteen percent of the animal handlers indicated that they wear a respirator at all times while handling animals or working in the animal room, and only 25% of the animal handlers had received an orientation about animal-induced allergies, asthma, or rhinitis. CONCLUSION: In conclusion, our data indicate that preventive programs are necessary. We suggest providing individual advice to workers associated with institutional programs to promote a safer work environment.

Study of risk factors for atopic sensitization, asthma, and bronchial hyperresponsiveness in animal laboratory workers

Study of risk factors for atopic sensitization, asthma, and bronchial hyperresponsiveness in animal laboratory workers: Christian Silva Simoneti, et al. Department of Medicine, Medical School of Ribeirão Preto, University of São Paulo, Brazil

Asthma Self-Management Model: Randomized Controlled Trial.

Information for patients provided by the pharmacist is reflected in adhesion to treatment, clinical results and patient quality of life. The objective of this study was to assess an asthma self-management model for rational medicine use. This was a randomized controlled trial with 60 asthmatic patients assigned to attend five modules presented by a pharmacist (intervention group) and 59 patients in the control group. Data collection was performed before and after this 4-month intervention and included an evaluation of asthma knowledge, lifestyle, inhaler techniques, adhesion to treatment, pulmonary function and quality of life. An economic viability analysis was also performed. The intervention group obtained an increase in asthma knowledge scores of 58.3-79.5% (P < 0.001). In this group, there was also an increase in the number of individuals who practiced physical exercise (36-43%), in the number of correct replies regarding the use of inhalers, in the percentage of adherent patients, and in quality of life scores for all domains. We concluded that this asthma self-management model was effective in improving the quality of life of asthma patients.

Bronchial provocation tests in clinical practice

Bronchial hyperresponsiveness, which consists of an exaggerated response of the airways to bronchoconstrictor stimuli, is one of the main characteristics of asthma, presented in nearly all asthmatic patients. Bronchial hyperresponsiveness may also be present in other diseases, such as allergic rhinitis, chronic obstructive pulmonary disease, cystic fibrosis, heart failure and respiratory infection, and with some medications, such as β-blockers. Bronchial provocation tests (also known as bronchial challenges) are used to evaluate bronchial responsiveness. These tests have become increasingly used over the last 20 years, with the development and validation of accurate, safe and reproducible tests, and with the publication of well-detailed protocols. Several stimuli can be used in a bronchial challenge, and they are classified as direct and indirect stimuli. There are many indications for a bronchial challenge. In this review, we discuss the main differences between direct and indirect stimuli, and the use of bronchial challenges in clinical practice, especially for confirming diagnoses of asthma, exercise-induced bronchoconstriction and cough-variant asthma, and for use among elite-level athletes.

Atopy risk factors at birth and in adulthood

OBJECTIVE To study the association between atopy and variables such as weight, length, and socioeconomic level at birth and in young adulthood. METHODS A total of 2,063 subjects were investigated in a prospective birth cohort study of individuals born in Ribeirão Preto, Brazil, in 1978/1979, and examined at the age of 23-25 years. Skin prick tests (SPT) for eight common allergens in Brazil were performed. Subjects with a wheal reaction ≥ 3 mm to one or more of the eight allergens tested were considered to be atopic. We used the log-binomial model (generalized linear model) in order to assess the association between atopy and birth or adult variables. RESULTS The prevalence of positive SPT was 47.6%. Male gender was associated with an increased risk of atopy (relative risk [RR] = 1.18; 95% confidence interval [95%CI] 1.07-1.30). Low level of schooling was a protective factor against atopy, with a RR = 0.74; 95%CI 0.62-0.89. Living with a smoker in childhood was also associated with lower risk of atopy (RR = 0.87; 95%CI 0.79-0.96). Birth weight, length and order, maternal age, and intrauterine growth restriction were not associated with positive SPT. CONCLUSIONS This study showed that male gender was associated with an increased risk of atopy. Low socioeconomic status, assessed by low level of schooling, was a protective factor against atopy. These data agree with the hygiene hypothesis.