Suzie Hyeona Kang

Effect of clinical pathways on the management of acute asthma in the emergency department: Five years of evaluation

There is a wide variability in clinical practice for treating acute asthma (AA) in the emergency department (ED), interfering in the quality of care. The purpose of this study was to evaluate the impact of a clinical pathway on the management of AA in the ED. We conducted a prospective before-after study of patients presenting with AA to the adult ED, during five separate periods (from January to March): in 2001 (pre-protocol group), 2002, 2003, 2004, and 2005 (6 months without educational reinforcement). We evaluated the effects of the recommendations on objective assessment of severity, diagnostic resource utilization, use of recommended and non-recommended therapy, and outcomes. The 2001, 2002, 2003, 2004, and 2005 groups comprised, respectively: 108, 96, 97, 98, and 101 patients. There was a significant increase in the use of pulse oximetry (8.3%, 77.1%, 88.7%, 95.9%, and 97.0%, respectively; p < 0.001). There was an increase in the use of peak expiratory flow rate from 2001 to 2004 (4.6%, 20.8%, 28.9%, and 48.0%) and a decrease after a period without educational efforts (29.7%, p < 0.001). Although the overall use of systemic corticosteroids was not changed, there was a significant increase in the use of oral steroids (p < 0.001). There was a decrease in aminophylline utilization (p = 0.005). Length of stay in the ED was significantly reduced (p = 0.04). There was no effect on hospital admission or emergency discharge (p = 0.193). The AA clinical pathway applied in the ED was associated with a positive effect on improving the quality of care.

Avaliação prognóstica precoce da asma aguda na sala de emergência

OBJETIVO: Estudar medidas clinicas e funcionais pulmonares utilizadas nos primeiros quinze minutos de manejo da asma aguda em um servico de emergencia, para predicao prognostica. METODOS: Estudo de coorte, prospectivo, que incluiu pacientes consecutivos com asma aguda, com idades entre doze e 55 anos e medida do pico de fluxo expiratorio menor ou igual a 50% do previsto. Realizaram-se avaliacoes na admissao, aos quinze minutos e em quatro horas apos o inicio do tratamento. O tratamento incluiu salbutamol e ipratropio, administrados por aerossol dosimetrado com espacador, e 100 mg de hidrocortisona intravenosa. O desfecho favoravel foi definido pelo pico de fluxo expiratorio maior ou igual a 50% do previsto apos a quarta hora de tratamento, e o desfecho desfavoravel pelo pico de fluxo expiratorio menor que 50% do previsto. RESULTADOS: Tiveram desfecho favoravel 27 pacientes e desfavoravel 24. A analise multivariada identificou o pico de fluxo expiratorio em porcentagem do previsto aos quinze minutos como variavel mais preditiva. O pico de fluxo expiratorio maior ou igual a 40% aos quinze minutos mostrou significativa contribuicao em predizer desfecho favoravel (sensibilidade = 0,74, especificidade = 1,00 e valor preditivo positivo = 1,00). O pico de fluxo expiratorio menor que 30% aos quinze minutos contribuiu para predizer desfecho desfavoravel (sensibilidade = 0,54, especificidade = 0,93 e valor preditivo positivo = 0,87). CONCLUSAO: O estudo sugeriu que a medida do pico de fluxo expiratorio aos quinze minutos do manejo da asma aguda em um servico de emergencia e um instrumento util para avaliacao prognostica.

Factors associated with emergency department visits due to acute asthma

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.

Chronic rhinosinusitis and nasal polyposis in cystic fibrosis: update on diagnosis and treatment

Although cystic fibrosis (CF) is an irreversible genetic disease, advances in treatment have increased the life expectancy of CF patients. Upper airway involvement, which is mainly due to pathological changes in the paranasal sinuses, is prevalent in CF patients, although many are only mildly symptomatic (with few symptoms). The objective of this literature review was to discuss the pathophysiology and current therapeutic management of chronic rhinosinusitis (CRS) in CF patients. The review was based on current evidence, which was classified in accordance with the Oxford Centre for Evidence-Based Medicine criteria. When symptomatic, CRS with nasal polyps can affect quality of life and can lead to pulmonary exacerbations, given that the paranasal sinuses can be colonized with pathogenic bacteria, especially Pseudomonas aeruginosa. Infection with P. aeruginosa plays a crucial role in morbidity and mortality after lung transplantation in CF patients. Although clinical treatment of the upper airways is recommended as initial management, this recommendation is often extrapolated from studies of CRS in the general population. When sinonasal disease is refractory to noninvasive therapy, surgery is indicated. Further studies are needed in order to gain a better understanding of upper airway involvement and improve the management of CRS in CF patients, with the objective of preserving lung function and avoiding unnecessary invasive procedures.

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

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.

Sinonasal alterations in computed tomography scans in cystic fibrosis: a literature review of observational studies

Almost all cystic fibrosis (CF) patients reveal upper airway involvement in computed tomography (CT) scans. Sinonasal pathology has become a challenging issue because there are few studies to guide appropriate management. The objective of this study was to provide information about paranasal sinus CT manifestations in CF patients, mainly in adulthood.