Marcos Ribeiro

Air trapping: The major factor limiting diaphragm mobility in chronic obstructive pulmonary disease patients

Background and objective:  Patients with COPD can have impaired diaphragm mechanics. A new method of assessing the mobility of the diaphragm, using ultrasound, has recently been validated. This study evaluated the relationship between pulmonary function and diaphragm mobility, as well as that between respiratory muscle strength and diaphragm mobility, in COPD patients.

Asma e doença pulmonar obstrutiva crônica: uma comparação entre variáveis de ansiedade e depressão

OBJECTIVE: To evaluate the presence and severity of symptoms of anxiety and depression in individuals with asthma or chronic obstructive pulmonary disease. METHODS: In order to evaluate symptoms of anxiety and depression, specific instruments of quantification (the State-Trait Anxiety Inventory and the Beck Depression Inventory, respectively) were administered to patients at an outpatient clinic for the treatment of asthma and chronic obstructive pulmonary disease. The population comprised 189 randomly and prospectively selected patients that were divided into three study groups (each with a different therapeutic objective): 40 patients with controlled asthma, 100 patients with uncontrolled asthma, and 49 patients with chronic obstructive pulmonary disease. Included among the variables studied, as part of the methodology, were symptoms of anxiety and depression. The data obtained were compared taking into consideration demographic and functional aspects, as well as the severity of the symptoms of anxiety and depression. RESULTS: Among the asthma patients, the prevalence of moderate or severe anxiety was significantly higher than that observed among those with chronic obstructive pulmonary disease (p < 0.001). The uncontrolled asthma group presented significantly higher rates of depressive symptoms than did the controlled asthma group (p < 0.05). CONCLUSION: The frequency of symptoms of anxiety and depression is greater among asthma patients than among patients with chronic obstructive pulmonary disease, which can make clinical control difficult.

Avaliação de dois anos de um programa educacional para pacientes ambulatoriais adultos com asma

OBJETIVO: Avaliar o conhecimento da doenca e a melhora clinica de portadores de asma persistente moderada e grave antes e apos a sua participacao em um programa de educacao realizado durante as visitas ambulatoriais de rotina. METODOS: Trata-se de um estudo piloto, prospectivo que envolveu 164 pacientes durante um periodo de dois anos. O programa de educacao, oferecido para pequenos grupos nos dias de consulta, consistiu de aulas expositivas divididas em tres modulos: fisiopatologia, controle ambiental e tratamento, incluindo o treinamento da tecnica inalatoria. Para a avaliacao do programa, foram utilizados questionarios padronizados sobre a melhora clinica e conhecimento da doenca. RESULTADOS: Em um ano, 120 pacientes completaram tres visitas, e 51 pacientes foram reavaliados em dois anos. A media de idade dos pacientes foi de 44 anos, 70% eram do sexo feminino, e 43% tinham ate oito anos de educacao formal. A intervencao educacional aumentou o conhecimento da doenca de forma significativa (p < 0,001) e possibilitou melhora clinica (p < 0,05) com a diminuicao do uso de corticosteroide oral, reducao de visitas ao servico de emergencia e menor numero de faltas ao trabalho ou escola. CONCLUSOES: O programa de educacao expositivo oferecido durante a rotina de atendimento ambulatorial de adultos asmaticos de nosso servico mostrou um crescente e progressivo aprendizado em longo prazo. Paralelamente, promoveu melhora clinica.OBJECTIVE To evaluate the understanding of asthma and the clinical improvement in patients with moderate or severe persistent asthma prior to and after their participation in an educational program presented during the routine outpatient visits. METHODS This was a prospective pilot study involving 164 patients over a two-year period. The educational program, presented to small groups on outpatient visit days, consisted of lectures divided into three parts: pathophysiology; environmental control; and treatment, including training in the inhalation technique. The program was evaluated using standardized questionnaires on clinical improvement and understanding of the disease. RESULTS By the end of the first year, 120 patients had completed three visits, and 51 of those patients were re-evaluated at the end of the second year. The mean age of the patients was 44 years, 70% were female, and 43% had up to eight years of schooling. The educational intervention significantly increased the understanding of the disease (p < 0.001), and allowed greater clinical improvement (p < 0.05) with a decrease in the use of oral corticosteroids, fewer visits to the emergency room and fewer days missed from work or school. CONCLUSIONS The educational program offered during the routine outpatient visits of adult patients with asthma at our clinic resulted in a progressive long-term increase in knowledge, as well as in clinical improvement.

Incorrect Application Technique of Metered Dose Inhalers by Internal Medicine Residents : Impact of Exposure to a Practical Situation

We evaluated residents regarding maintenance treatment of asthma and the technique for using metered dose inhalers. Methods. Residents were asked to prescribe a treatment for a patient with poorly controlled persistent asthma and to demonstrate the use of metered dose inhaler (MDI) medication. Results. 76% of 239 residents correctly identified the medication indicated for the case; only 30% of them adequately performed the inhalation technique (49% from HCFMUSP vs. 19% from other institutions; p < 0.001). Conclusions. The results demonstrate that, when seeing a typical patient with uncontrolled persistent asthma, most residents are able to correctly identify the drugs indicated for treatment but not adequately instruct the MDI technique use.

Determinação de escore e nota de corte do módulo de asma do International Study of Asthma and Allergies in Childhood para discriminação de adultos asmáticos em estudos epidemiológicos

OBJECTIVE: To validate, for use in asthma prevalence studies, the asthma module of the standardized written questionnaire developed for use in the International Study of Asthma and Allergies in Childhood, establishing the score and cut-off point that would identify asthmatic adults. METHODS: We interviewed 78 adult outpatients (40 adult asthmatics and 38 age-matched and gender-matched controls) using the asthma module of the International Study of Asthma and Allergies in Childhood questionnaire, which is composed of questions related to eight dichotomous features of asthma. We determined the score and cut-off point required to accurately identify asthmatic adults, calculating sensitivity, specificity and Youden index. The method was validated against the clinical and functional diagnosis of asthma. The reproducibility of individual questions was evaluated by conducting second interviews with half of the patients some weeks later. RESULTS: The score ranged from 0 to 14 points. A score = 5 allowed patients with asthma to be distinguished from those without (sensitivity = 93%; specificity = 100%; Youden index = 0.93). Most questions presented satisfactory reproducibility in the second interviews conducted after 48.2 ± 11.1 days (kappa and weighted kappa ranging from 0.43 to 1.00 for individual questions). CONCLUSION: For studies of adult asthma prevalence, the determination/validation of a cut-off point allows an alternative interpretation of the information gathered through the application of the asthma module of the International Study of Asthma and Allergies in Childhood, taking into account the totality of the data rather than responses to individual questions.

Prevalence and Risk of Asthma Symptoms Among Firefighters in Sao Paulo, Brazil : A Population-Based Study

UNLABELLED The firefighters are at increased risk of respiratory disease as a result of exposure to smoke and dust. The aim of this study was to determine the prevalence and risk associated with respiratory symptoms among city firefighters in São Paulo, Brazil. METHODS A cross-sectional study utilizing the European Community Respiratory Health Survey (ECRHS) questionnaire was administered to firefighters and police officers, in order to evaluate their respiratory symptoms. RESULTS Complete respiratory data were obtained from 1,235 firefighters and 1,839 police officers. Among the firefighters, there were 55.5% never-smokers, 22.4% current smokers and 18.2% former smokers (P < 0.05). Among the police officers, there were 63.4%, 18.6%, and 9.6% who were never-smokers, current smokers and former smokers (P < 0.05), respectively. Compared to police, firefighters experienced an increase in wheezing [OR = 1.63 (95% CI: 1.43-1.87)], wheezing with breathlessness [OR = 1.34 (95% CI: 1.10-1.64)], wheezing without a cold [OR = 1.60 (95% CI: 1.32-1.95)], waking with tightness in the chest [OR = 1.20 (95% CI: 1.02-1.42)], and rhinitis [OR = 1.12 (95% CI: 1.03-1.22)]. The prevalence of adult-onset asthma in never-smokers was 9.3% and 6.7% for firefighters and police officers [OR = 1.23 (95% CI: 1.01-1.56)]. An independent association was observed between years employed, smoking, history of rhinitis, and work as a firefighter and respiratory and nasal symptoms. We observed a high prevalence of asthma-like symptoms in firefighters who presented respiratory symptoms beginning immediately after firefighting. CONCLUSION These results suggest that the prevalence of respiratory symptoms and asthma in firefighters is higher than those in police officers. Work-as a firefighter, rhinitis and years employed were risk factors for respiratory symptoms of asthma.

Relationship Between Peak Expiratory Flow Rate and Shoulders Posture in Healthy Individuals and Moderate to Severe Asthmatic Patients

Introduction. Asthma overloads respiratory muscles causing changes in posture. Objectives. To evaluate shoulder position in asthmatics and its correlation to the peak expiratory flow rate (PEFR). Methods. A cross-sectional study involving 19 asthmatics (study group) and 20 healthy volunteers (control group). Assessment of PEFR was used to determine airway obstruction. Shoulder position was quantified as the ratio between the front and back measurements, in centimeters, of the distance between the two outermost points of each scapula. Shoulder position measurement (SPM) ratio data from both groups were compared and correlated to PEFR. Results. The asthmatics presented lower PEFR (279 ± 64 L/min) and SPM (0.88: range 0.83–0.9) than did control subjects (555 ± 100 L/min and 0.97: range 0.95–1, respectively) (p < 0.001). There was a correlation between PEFR and SPM (asthmatics r = 0.8; controls r = 0.5). Conclusion. Determining SPM ratios allowed us to identify those postural alterations that correlated with pulmonary function in asthmatics and in healthy individuals. Further investigation is needed before SPM can be used as a tool for clinical evaluation of asthma patients.

Validation of the Brazilian-Portuguese Version of the European Community Respiratory Health Survey in Asthma Patients

Background. The European Community Respiratory Health Survey (ECRHS) questionnaire was planned to answer questions about the distribution of asthma. Our objective was to determine the cultural equivalence of the ECRHS into the Brazilian-Portuguese language. Methods. We translated the ECRHS according to international criteria. Results. Small cultural adaptations were necessary. Among the 80 participating patients, the Cronbach indices were higher (0.98–1.00) and the Kappa indices varied from 0.77 to 1.00. Conclusion. The study suggests that the Brazilian version of the ECRHS is conceptually equivalent to the original and similarly reliable and may be used in international studies involving Portuguese-speaking respiratory patients.

Method for evaluating subjective states of awareness that accompany recognition: adaptation for use in Portuguese-speaking patients with schizophrenia

OBJECTIVE Memory is composed of several systems and processes, and recognition can be accompanied by two subjective states of consciousness: autonoetic awareness, which characterizes conscious recollection; and noetic (or semantic) awareness, related to feelings of familiarity. The objective of this study was to describe the adaptation to Portuguese of an experiential procedure for investigation of states of awareness that accompany recognition. METHODS Development of the material (word list and instructions permitting manipulation of the level of information processing); translation/adaptation of the original instructions to Portuguese; and application of the procedure in healthy volunteers and patients with schizophrenia. Manipulation of the level of processing consisted in requiring, during the learning phase, that subjects form a phrase or count the number of letters of the words presented. The level of processing, documented in healthy volunteers, should be expressed by greater conscious recollection of words used to form phrases than of words for which letters were counted. In addition, there should be no change in the proportion of recognition based on feelings of familiarity. RESULTS The procedure was first applied in six healthy volunteers, in whom the processing level effect was clearly reproducible. Subsequently, it was used in patients with schizophrenia, who understood and followed the instructions perfectly. There was also a clear processing level effect in the patient group. CONCLUSION The Portuguese version of this method can be used in our milieu, even in patients with schizophrenia, allowing the study of memory alterations accompanying this mental disorder.