Asthma in the Brazilian Unified Health Care System: an epidemiological analysis from 2008 to 2021.

OBJECTIVE: To analyze the number of hospitalizations, the length of hospital stay, and mortality due to asthma, as well as the costs to the Unified Health Care System in Brazil between 2008 and 2021. METHODS: This was a cross-sectional epidemiological study using data from the Information Technology Department of the Brazilian Unified Health Care System. Proportional hospitalization and death rates were estimated per 100,000 population by age, microregion, and year. RESULTS: The number of hospitalizations and deaths due to asthma decreased from 2008 to 2021 (205,392 vs. 55,009 and 822 vs. 327, respectively). In addition, a between-sex difference was observed in asthma-related hospitalizations in 2008, and more men were hospitalized in 2021 (51.8%). Asthma mortality rates were similar for both sexes (50.0% each) in 2008, and a slight increase was observed in women's deaths in 2021 (52.9%). Even so, approximately one death/day and more than 55,000 hospitalizations were observed yearly, with a mean length of hospital stay of three days. Additionally, the Southeast region allocated more financial resources to asthma-related hospitalizations. CONCLUSIONS: Our results showed that the number of deaths and hospitalizations due to asthma substantially declined during the study period.

Postural balance in COPD with obstructive sleep apnoea: a cross-sectional study.

Objective: The aim of this study was to assess the postural balance in COPD patients with obstructive sleep apnoea (OSA). Physical activity, anxiety and depression symptoms, mood, and falls were also assessed in this population. Methods: Moderate to severe COPD patients were assessed for laboratory and clinical postural balance (force platform and mini-balance evaluation systems test (Mini-BESTest)), physical activity (accelerometry), OSA (polysomnography), sleep quality (Pittsburgh Sleep Quality Index), sleepiness (Epworth Sleepiness Scale), anxiety and depression symptoms (Hospital Anxiety and Depression Scale), dyspnoea (modified Medical Research Council), clinical status (COPD Assessment Test) and mood (Brunel Mood Scale). Self-reported falls were recorded for 6 months via phone calls. Results: COPD patients (n=70) were divided according to the polysomnography findings into the no OSA (n=30), mild OSA (n=25), and moderate to severe OSA (n=15) groups. Compared to patients with no OSA, those with moderate to severe OSA (msOSA group) presented median (interquartile range) increased path length (30.5 (23.9-34.5) cm versus 39.0 (30.6-52.6) cm, anteroposterior displacement (1.89 (1.39-2.31) cm versus 2.54 (2.06-2.83) cm and postural adjustment velocity (1.02 (0.80-1.15) cm·s-1 versus 1.30 (1.02-1.76) cm·s-1) (p<0.05). No differences were observed in the Mini-BESTest scores among the groups. The msOSA group presented a greater number of recurrent fallers in the first follow-up trimester. No association was observed between postural balance and age and pulmonary function. Conclusion: Individuals with COPD and moderate to severe OSA present changes in postural balance, including broader oscillation, faster postural adjustments and a greater risk of falls than those with no OSA. Physical activity, anxiety and depression symptoms, and mood are similar between COPD patients with and without OSA.

Effects of constant-load exercise and high-intensity interval training on reliever medication consumption and peak expiratory flow in individuals with asthma: a randomised controlled trial.

Introduction: The effect of aerobic training on reliever medication consumption (short-acting ß2-agonist (SABA)) and peak expiratory flow (PEF) in participants with asthma is poorly known. The comparison between constant-load exercise (CLE) and high-intensity interval training (HIIT) in these outcomes has never been tested. The purpose of the present study was to compare the effects of CLE or HIIT in SABA consumption and PEF improvement during an exercise programme in subjects with asthma. Methods: Clinically stable participants were randomised into CLE (n=27; 70-85% of the maximal load (Wmax)) or HIIT (n=28; 80-140% Wmax). The programme lasted 12 weeks (two sessions per week, 40 min per session), and the intensity was based on cardiopulmonary exercise testing (CPET). PEF was assessed before and after each exercise session. SABA was used if PEF was <70%. Clinical control (Asthma Control Questionnaire (ACQ)-6), CPET and aerobic fitness were also assessed before and after the intervention. Results: Both groups were similar at baseline. CLE and HIIT reduced SABA consumption throughout the intervention (p<0.05). Before training, 14 patients required SABA before exercising, but only one needed it after the intervention. Changes in post-exercise PEF were lower in the CLE group than in the HIIT group (1.6±25.3 versus 10.3±13.7%). Both groups improved aerobic fitness (10.1±12.8% versus 5.7±15.6%) and clinical asthma control; however, only the HIIT group achieved a minimal clinically important difference in the ACQ-6 post-intervention (-0.23±1.06 versus -0.52±0.73 Δ score). Conclusion: CLE and HIIT reduced SABA consumption; however, only HIIT increased PEF and asthma clinical control after the intervention. These results reinforce the importance of exercise training in moderate-to-severe asthma.

Physical Activity and Sedentary Behavior as Treatable Traits for Clinical Control in Moderate-to-Severe Asthma.

BACKGROUND: Physical activity and sedentary behavior are treatable traits that may impact asthma control in distinct manners, but this impact remains poorly understood. OBJECTIVE: To evaluate the influence of physical activity and sedentary behavior on clinical control in adults with moderate-to-severe asthma. METHODS: This cross-sectional, multicentric study included 426 individuals with moderate-to-severe asthma. Assessments included physical activity and sedentary time (actigraphy), clinical asthma control (Asthma Control Questionnaire [ACQ]), quality of life (Asthma Quality of Life Questionnaire), anxiety and depression symptoms (Hospital Anxiety and Depression Scale), anthropometric data, and lung function. Participants were grouped according to physical activity levels and sedentary behavior. RESULTS: Participants who walked ≥7500 steps/day presented better ACQ scores than those who walked <7500 steps/day (P < .05), independent of sedentary status. The percentage of patients with controlled asthma was higher in the active/sedentary (43.9%) and active/nonsedentary (43.8%) groups than in the inactive/sedentary (25.4%) and inactive/nonsedentary (23.9%) groups (P < .02). The likelihood of having uncontrolled asthma according to the treatable traits of physical inactivity (odds ratio [95% confidence interval]: 2.36 [1.55-3.59]), higher anxiety (2.26 [1.49-3.42]), and depression symptoms (1.95 [1.28-2.95]) was significant (P ≤ .002). Obesity and sedentary time were not associated with asthma control. CONCLUSIONS: Our results show that ≥7500 steps/day is associated with better asthma control independent of sedentary time in adults with moderate-to-severe asthma. Physical inactivity, anxiety, and depression symptoms are associated with higher odds of uncontrolled asthma. These results suggest that interventions should mainly focus on increasing physical activity rather than reducing sedentary time.

Tobacco exposure, but not aging, shifts the frequency of peripheral blood B cell subpopulations.

Several disturbances in T-cell mediated immunity have been described during aging, but immunosenescence of the B-cell compartment is less well elucidated. The peripheral blood B-cell compartment (CD19+) can be split into six main subpopulations according to the cell surface markers IgD, CD27, CD24, and CD38: Transitional, naïve, unswitched, switched, double negative and plasmablasts. We thus aimed to verify whether shifts in these subsets occur during healthy and pathological aging. We recruited three groups of aged people (> 60 years old), healthy, COPD patients, and smokers without altered pulmonary function test, and a fourth group of individuals 18-40 years old (youngs). Total B-cells percentage and absolute number were similar among the healthy aged, COPD patients, and youngs, but the smokers showed significantly higher absolute numbers. While all six B-cell subset percentages were comparable among the healthy aged, COPD patients, and youngs, smokers showed significantly higher percentages of switched B-cells and reduced naïve B-cells than the other three groups, resulting in an inverted naive:switched ratio. Analysis of the cell subset absolute numbers showed a similar trend. Overall, our results suggest that aging drives milder alterations in the distribution of peripheral blood B-cell subpopulations than in the T-cell compartment. We suggest that it is the T-cell immunosenescence that most contributes to the poor humoral immune responses in the elderly, vaccine responses included. Surprisingly it was the smokers who showed significant alterations when compared with the youngs, healthy aged, and aged COPD patients, probably as a result of the chronic immune stimulation described in active smoking subjects.

Asthma in the Brazilian Unified Health Care System: an epidemiological analysis from 2008 to 2021

ABSTRACT Objective: To analyze the number of hospitalizations, the length of hospital stay, and mortality due to asthma, as well as the costs to the Unified Health Care System in Brazil between 2008 and 2021. Methods: This was a cross-sectional epidemiological study using data from the Information Technology Department of the Brazilian Unified Health Care System. Proportional hospitalization and death rates were estimated per 100,000 population by age, microregion, and year. Results: The number of hospitalizations and deaths due to asthma decreased from 2008 to 2021 (205,392 vs. 55,009 and 822 vs. 327, respectively). In addition, a between-sex difference was observed in asthma-related hospitalizations in 2008, and more men were hospitalized in 2021 (51.8%). Asthma mortality rates were similar for both sexes (50.0% each) in 2008, and a slight increase was observed in women's deaths in 2021 (52.9%). Even so, approximately one death/day and more than 55,000 hospitalizations were observed yearly, with a mean length of hospital stay of three days. Additionally, the Southeast region allocated more financial resources to asthma-related hospitalizations. Conclusions: Our results showed that the number of deaths and hospitalizations due to asthma substantially declined during the study period.

Characteristics of individuals with moderate to severe asthma who better respond to aerobic training: a cluster analysis / Características de indivíduos com asma moderada a grave que melhor respondem a treinamento aeróbio: análise de conglomerados

ABSTRACT Objective: To determine the characteristics of individuals with asthma who are responsive to aerobic training. Methods: This post hoc analysis of pooled data from previous randomized controlled trials involved 101 individuals with moderate to severe asthma who underwent aerobic training. Participants underwent a maximal cardiopulmonary exercise test and completed the Asthma Control Questionnaire and the Asthma Quality of Life Questionnaire before and after a 24-session aerobic training program. Better and worse responders to aerobic training were identified by cluster analysis. Results: Two clusters were identified according to the improvement in peak VO2 after aerobic training (better and worse responders). Characteristics of the better responder group were being older, being female, having higher BMI, and having higher cardiac reserve at baseline when compared with the worse responder group. Also, better responders had worse clinical control, worse quality of life, and lower physical capacity at baseline. After training, worse responders, in comparison with better responders, showed half the improvement in Δpeak VO2 (7.4% vs. 13.6%; 95% CI, −12.1 to −0.92%; p < 0.05) and worse asthma control. A weak, negative, but significant association (r = −0.35; p < 0.05) was observed between clinical control and aerobic fitness only in the better responder group. Both groups showed significant improvement in quality of life. Conclusions: Obese individuals with worse exercise capacity, clinical control, and quality of life showed improvement with aerobic training. Moreover, worse responders also improved with training, but to a lesser extent.

RESUMO Objetivo: Determinar as características de indivíduos com asma responsivos a treinamento aeróbio. Métodos: Esta análise post hoc de dados agrupados provenientes de ensaios clínicos controlados randomizados anteriores envolveu 101 indivíduos com asma moderada a grave submetidos a treinamento aeróbico. Os participantes foram submetidos a um teste de exercício cardiopulmonar máximo e responderam ao Asthma Control Questionnaire e ao Asthma Quality of Life Questionnaire antes e depois de um programa de treinamento aeróbio de 24 sessões. Melhores e piores respondedores ao treinamento aeróbio foram identificados por análise de conglomerados. Resultados: Foram identificados dois conglomerados de acordo com a melhora do VO2 de pico após o treinamento aeróbio (melhores e piores respondedores). As características do grupo melhor respondedor foram maior idade, sexo feminino, IMC mais elevado e maior reserva cardíaca basal em comparação com o grupo pior respondedor. Os melhores respondedores também apresentavam pior controle clínico, pior qualidade de vida e menor capacidade física basal. Após o treinamento, os piores respondedores, em comparação com os melhores respondedores, apresentaram metade da melhora no ΔVO2 de pico (7,4% vs. 13,6%; IC95%: -12,1 a -0,92%; p < 0,05) e pior controle da asma. Observou-se uma associação negativa fraca, mas significativa (r = −0,35; p < 0,05) entre controle clínico e aptidão aeróbia apenas no grupo melhor respondedor. Ambos os grupos apresentaram melhora significativa da qualidade de vida. Conclusões: Os indivíduos obesos com pior capacidade de exercício, controle clínico e qualidade de vida apresentaram melhora com o treinamento aeróbio. Além disso, os piores respondedores também melhoraram com o treinamento, mas em menor grau.

Frequência de fenestração do canal mandibular em imagens de tomografia computadorizada multidetectores / Frequency of mandibular canal fenestration in multislice computerized tomography images

Introdução: o conhecimento das variações anatômicas que podem acometer o canal mandibular (CM) é importante, pois, para a realização de procedimentos cirúrgicos mandibulares a presença dessas variantes pode comprometer o sucesso do procedimento. A fenestração do CM é uma variação anatômica caracterizada pela exposição do feixe neurovascular inferior (FNVI) por ausência da cortical óssea, sem estar associada a processos patológicos, consequentemente, ampliando os riscos de danos ao mesmo quando de procedimentos cirúrgicos na região. Objetivo: avaliar por meio de tomografia computadorizada (TC) multidetectores a frequência de fenestração nas corticais ósseas da mandíbula, no percurso do CM e relacioná-la à idade, sexo e lado afetado. Metodologia: a amostra foi constituída por 150 exames de TC da mandíbula, num total de 300 CM avaliados. Como critério de inclusão, o exame deveria permitir a observação de toda a extensão do CM. Foram excluídos os exames que apresentavam doenças ósseas ou artefatos metálicos que dificultassem a observação da área de interesse. Todos os exames foram analisados por um avaliador por duas vezes com o intervalo mínimo de uma semana entre as avaliações, e os resultados foram submetidos à análise estatística descritiva. Resultados: Dos 300 CM analisados 1% da amostra, o que equivale a três casos, apresentou fenestração do CM, sendo todas localizadas no lado esquerdo da mandíbula. Em dois casos, a fenestração estava associada a terceiros molares inclusos em posição horizontal. Conclusão: a fenestração do CM foi uma variação anatômica rara na amostra avaliada, porém esteve mais frequentemente associada a terceiros molares impactados em posição horizontal.

Introduction: knowledge of the anatomical changes that affect the mandibular canal (MC) is important, as it is for performing mandibular surgical procedures and the presence of these variables can compromise or be successful in the procedure. MC fenestration is a variation characterized by the exposure of the inferior alveolar neurovascular bundle (IANC) due to lack of bone cortical, without being associated with pathological processes, consequently, increasing the risks and damage and the same when surgical procedures in the region. Objective: to analyze by means of multidetector computed tomography (CT) the frequency of fenestration in the cortical of the mandible, in the course of the MC and to relate with age, sex and affected side. Methodology: the sample consisted of 150 CT examinations of the mandible, in a total of 300 MC evaluated. As an inclusion criterion, the exam should allow the observation of the entire length of the MC. Examinations that presented bone diseases or metallic artifacts that made it difficult to observe the area of interest were excluded. All examinations were reviewed by an evaluator twice with a minimum interval of 1 week between evaluations, and the results were analyzed by descriptive statistical analysis. Results: of the 300 MC analyzed, 1% of the sample, which is equivalent to three cases, presented fenestration of the MC, all of which were located on the left side of the mandible. In two cases, fenestration was associated with third molars included in a horizontal position. Conclusion: CM fenestration was a rare anatomical variation in the evaluated sample, but it was more frequently associated with impacted third molars in a horizontal position.

2020 Brazilian Thoracic Association recommendations for the management of asthma / Recomendações para o manejo da asma da Sociedade Brasileira de Pneumologia e Tisiologia - 2020

ABSTRACT The pharmacological management of asthma has changed considerably in recent decades, as it has come to be understood that it is a complex, heterogeneous disease with different phenotypes and endotypes. It is now clear that the goal of asthma treatment should be to achieve and maintain control of the disease, as well as to minimize the risks (of exacerbations, disease instability, accelerated loss of lung function, and adverse treatment effects). That requires an approach that is personalized in terms of the pharmacological treatment, patient education, written action plan, training in correct inhaler use, and review of the inhaler technique at each office visit. A panel of 22 pulmonologists was invited to perform a critical review of recent evidence of pharmacological treatment of asthma and to prepare this set of recommendations, a treatment guide tailored to use in Brazil. The topics or questions related to the most significant changes in concepts, and consequently in the management of asthma in clinical practice, were chosen by a panel of experts. To formulate these recommendations, we asked each expert to perform a critical review of a topic or to respond to a question, on the basis of evidence in the literature. In a second phase, three experts discussed and structured all texts submitted by the others. That was followed by a third phase, in which all of the experts reviewed and discussed each recommendation. These recommendations, which are intended for physicians involved in the treatment of asthma, apply to asthma patients of all ages.

RESUMO O manejo farmacológico da asma mudou consideravelmente nas últimas décadas, com base no entendimento de que a asma é uma doença heterogênea e complexa, com diferentes fenótipos e endótipos. Agora está claro que o objetivo do tratamento da asma deve ser alcançar e manter o controle da doença e evitar riscos futuros (exacerbações, instabilidade da doença, perda acelerada da função pulmonar e efeitos adversos do tratamento). Isso implica em uma abordagem personalizada, incluindo tratamento farmacológico, educação do paciente, plano de ação por escrito, treinamento para uso do dispositivo inalatório e revisão da técnica inalatória a cada visita ao consultório. Um painel de 22 pneumologistas brasileiros foi convidado a revisar criticamente evidências recentes de tratamento farmacológico da asma e a preparar esta recomendação, um guia de tratamento adaptado à nossa realidade. A escolha dos tópicos ou questões relacionadas às mudanças mais significativas nos conceitos e, consequentemente, no manejo da asma na prática clínica foi realizada por um painel de especialistas. Foi solicitado a cada especialista que revisasse criticamente um tópico ou respondesse a uma pergunta, com base em evidências, para estas recomendações. Numa segunda fase, três especialistas discutiram e estruturaram todos os textos submetidos pelos demais e, na última fase, todos revisaram e discutiram cada recomendação. As presentes recomendações se aplicam a adultos e crianças com asma e destinam-se a médicos envolvidos no tratamento da doença.

The patient profile of individuals with Alpha-1 antitrypsine gene mutations at a referral center in Brazil / Perfil dos pacientes com mutação no gene da alfa-1 antitripsina em um centro de referência no Brasil

ABSTRACT Objective: The clinical, functional, radiological and genotypic descriptions of patients with an alpha-1 antitrypsin (A1AT) gene mutation in a referral center for COPD in Brazil. Methods: A cross-sectional study of patients with an A1AT gene mutation compatible with deficiency. We evaluated the A1AT dosage and genotypic, demographic, clinical, tomographic, and functional characteristics of these patients. Results: Among the 43 patients suspected of A1AT deficiency (A1ATD), the disease was confirmed by genotyping in 27 of them. The A1AT median dosage was 45 mg/dL, and 4 patients (15%) had a normal dosage. Median age was 54, 63% of the patients were male, and the respiratory symptoms started at the age of 40. The median FEV1 was 1.37L (43% predicted). Tomographic emphysema was found in 77.8% of the individuals. The emphysema was panlobular in 76% of them and 48% had lower lobe predominance. The frequency of bronchiectasis was 52% and the frequency of bronchial thickening was 81.5%. The most common genotype was Pi*ZZ in 40.7% of participants. The other genotypes found were: Pi*SZ (18.5%), PiM1Z (14.8%), Pi*M1S (7.4%), Pi*M2Z (3.7%), Pi*M1I (3.7%), Pi*ZMnichinan (3.7%), Pi*M3Plowell (3.7%), and Pi*SF (3.7%). We did not find any significant difference in age, smoking load, FEV1, or the presence of bronchiectasis between the groups with a normal and a reduced A1AT dosage, neither for 1 nor 2-allele mutation for A1ATD. Conclusions: Our patients presented a high frequency of emphysema, bronchiectasis and bronchial thickening, and early-beginning respiratory symptoms. The most frequent genotype was Pi*ZZ. Heterozygous genotypes and normal levels of A1AT also manifested significant lung disease.

RESUMO Objetivo: Caracterização clínica, funcional, radiológica e genotípica dos pacientes portadores de mutações do gene da alfa-1 antitripsina (A1AT) em um centro de referência em doença pulmonar obstrutiva crônica (DPOC) no Brasil. Métodos: Estudo transversal de pacientes com mutação no gene da A1AT compatível com deficiência. Foram avaliadas características genotípicas, demográficas, clínicas, tomográficas, de função pulmonar, e dosagem de A1AT. Resultados: De 43 pacientes suspeitos para deficiência de alfa-1 antitripsina (DA1AT), a doença foi confirmada por genotipagem em 27. A mediana da dosagem de A1AT foi de 45 mg/dL, e 4 pacientes (15%) apresentavam dosagens normais. A idade mediana foi de 54 anos, 63% dos participantes eram do sexo masculino e a idade do início dos sintomas prevalente foi aos 40 anos. A mediana do volume expiratório forçado no primeiro segundo (VEF1) foi de 1,37 L (43% do previsto). Enfisema tomográfico foi encontrado em 77,8% dos indivíduos, sendo panlobular em 76% e de predomínio em lobos inferiores em 48%. A frequência de bronquiectasias foi de 52%, e a de espessamento brônquico, de 81,5%. O genótipo mais encontrado foi Pi*ZZ (40,7%). Os demais genótipos foram: Pi*SZ (18,5%), Pi*M1Z (14,8%), Pi*M1S (7,4%), Pi*M2Z (3,7%), Pi*M1I (3,7%), Pi*ZMnichinan (3,7%), Pi*M3Plowell (3,7%) e Pi*SF (3,7%). Não encontramos diferença significativa para idade, carga tabágica, VEF1 e presença de bronquiectasias entre os grupos com dosagem de A1AT normal versus alterada, nem entre 1 alelo versus 2 alelos com mutação para DA1AT. Conclusões: Nossos pacientes apresentaram alta frequência de enfisema, bronquiectasias e espessamento brônquico, com início precoce dos sintomas respiratórios. O genótipo mais frequente foi Pi*ZZ, embora genótipos heterozigotos e níveis normais de A1AT também tenham se manifestado com doença pulmonar significativa.

Spirometry in patients screened for coronary artery disease: is it useful? / Espirometria em pacientes submetidos a investigação para detecção de doença arterial coronariana: é útil?

ABSTRACT Objective: To determine the prevalence of spirometric abnormalities in patients screened for coronary artery disease (CAD) and the risk factors for lung function impairment. Methods: Patients referred for cardiac CT underwent spirometry and were subsequently divided into two groups, namely normal lung function and abnormal lung function. The prevalence of spirometric abnormalities was calculated for the following subgroups of patients: smokers, patients with metabolic syndrome, elderly patients, and patients with obstructive coronary lesions. All groups and subgroups were compared in terms of the coronary artery calcium score and the Duke CAD severity index. Results: A total of 205 patients completed the study. Of those, 147 (72%) had normal lung function and 58 (28%) had abnormal lung function. The median coronary artery calcium score was 1 for the patients with normal lung function and 36 for those with abnormal lung function (p = 0.01). The mean Duke CAD severity index was 15 for the former and 27 for the latter (p < 0.01). Being a smoker was associated with the highest OR for abnormal lung function, followed by being over 65 years of age and having obstructive coronary lesions. Conclusions: The prevalence of spirometric abnormalities appears to be high in patients undergoing cardiac CT for CAD screening. Smokers, elderly individuals, and patients with CAD are at an increased risk of lung function abnormalities and therefore should undergo spirometry. (ClinicalTrials.gov identifier: NCT01734629 [http://www.clinicaltrials.gov/])

RESUMO Objetivo: Determinar a prevalência de alterações espirométricas em pacientes submetidos a investigação para detecção de doença arterial coronariana (DAC) e os fatores de risco de comprometimento da função pulmonar. Métodos: Pacientes encaminhados para TC cardíaca foram submetidos a espirometria e, em seguida, divididos em dois grupos: função pulmonar normal e função pulmonar anormal. A prevalência de alterações espirométricas foi calculada em fumantes, pacientes com síndrome metabólica, idosos e portadores de lesões coronárias obstrutivas. Os grupos e subgrupos foram comparados quanto ao escore de cálcio coronariano e ao índice de gravidade de DAC de Duke. Resultados: Completaram o estudo 205 pacientes. Destes, 147 (72%) apresentaram função pulmonar normal e 58 (28%) apresentaram função pulmonar anormal. A mediana do escore de cálcio coronariano foi 1 nos pacientes com função pulmonar normal e 36 naqueles com função pulmonar anormal (p = 0,01). A média do índice de gravidade de DAC de Duke foi = 15 nos pacientes com função pulmonar normal e 27 nos pacientes com função pulmonar anormal (p < 0,01). O tabagismo apresentou a maior OR de função pulmonar anormal, seguido de idade > 65 anos e lesões coronarianas obstrutivas. Conclusões: A prevalência de alterações espirométricas parece ser alta em pacientes submetidos a TC cardíaca para detecção de DAC. O risco de função pulmonar anormal é maior em fumantes, idosos e pacientes com DAC, os quais, portanto, devem ser submetidos a espirometria. (ClinicalTrials.gov identifier: NCT01734629 [http://www.clinicaltrials.gov/])

Validation of scores of use of inhalation devices: valoration of errors / Validação de escores de uso de dispositivos para inalação: valoração dos erros cometidos

AbstractObjective: To validate two scores quantifying the ability of patients to use metered dose inhalers (MDIs) or dry powder inhalers (DPIs); to identify the most common errors made during their use; and to identify the patients in need of an educational program for the use of these devices.Methods: This study was conducted in three phases: validation of the reliability of the inhaler technique scores; validation of the contents of the two scores using a convenience sample; and testing for criterion validation and discriminant validation of these instruments in patients who met the inclusion criteria.Results: The convenience sample comprised 16 patients. Interobserver disagreement was found in 19% and 25% of the DPI and MDI scores, respectively. After expert analysis on the subject, the scores were modified and were applied in 72 patients. The most relevant difficulty encountered during the use of both types of devices was the maintenance of total lung capacity after a deep inhalation. The degree of correlation of the scores by observer was 0.97 (p < 0.0001). There was good interobserver agreement in the classification of patients as able/not able to use a DPI (50%/50% and 52%/58%; p < 0.01) and an MDI (49%/51% and 54%/46%; p < 0.05).Conclusions: The validated scores allow the identification and correction of inhaler technique errors during consultations and, as a result, improvement in the management of inhalation devices.

ResumoObjetivo: Validar dois escores para medir a habilidade de pacientes em utilizar inaladores pressurizados (IPs) ou inaladores de pó (IPos), verificar os erros mais comuns na sua utilização e identificar os pacientes que necessitam de um programa educacional para o uso desses dispositivos.Métodos: Este estudo foi realizado em três etapas: validação da confiabilidade dos escores de uso dos dispositivos inalatórios; validação do conteúdo dos escores utilizando-se uma amostra de conveniência; e realização de testes para a validação de critério e a validação discriminante desses instrumentos em pacientes que preenchiam os critérios de inclusão do estudo.Resultados: A amostra de conveniência foi composta por 16 pacientes, e houve discordância interobservador em 19% e 25% para os escores de IPo e IP, respectivamente. Após a análise de expertos no assunto, os escores sofreram modificações e foram aplicados em 72 pacientes. A dificuldade mais relevante no uso de ambos os dispositivos foi a manutenção da capacidade pulmonar total após inspiração profunda. O grau de correlação dos escores por observador foi de 0,97 (p < 0,0001). Houve boa concordância interobservador na classificação dos pacientes como aptos/não aptos para uso de IPo (50%/50% e 52%/58%; p < 0,01) e de IP (49%/51% e 54%/46%; p < 0,05).Conclusões: Os escores validados permitem identificar e corrigir os erros da técnica inalatória ao longo das consultas e, em consequência, melhorar o manejo dos dispositivos para inalação.

Comparison between objective measures of smoking and self-reported smoking status in patients with asthma or COPD: are our patients telling us the truth? / Comparação entre medidas objetivas do tabagismo e tabagismo autodeclarado em pacientes com asma ou DPOC: será que nossos pacientes dizem a verdade?

OBJECTIVE: Smoking prevalence is frequently estimated on the basis of self-reported smoking status. That can lead to an underestimation of smoking rates. The aim of this study was to evaluate the difference between self-reported smoking status and that determined through the use of objective measures of smoking at a pulmonary outpatient clinic. METHODS: This was a cross-sectional study involving 144 individuals: 51 asthma patients, 53 COPD patients, 20 current smokers, and 20 never-smokers. Smoking status was determined on the basis of self-reports obtained in interviews, as well as through tests of exhaled carbon monoxide (eCO) and urinary cotinine. RESULTS: All of the asthma patients and COPD patients declared they were not current smokers. In the COPD and asthma patients, the median urinary cotinine concentration was 167 ng/mL (range, 2-5,348 ng/mL) and 47 ng/mL (range, 5-2,735 ng/mL), respectively (p < 0.0001), whereas the median eCO level was 8 ppm (range, 0-31 ppm) and 5 ppm (range, 2-45 ppm), respectively (p < 0.05). In 40 (38%) of the patients with asthma or COPD (n = 104), there was disagreement between the self-reported smoking status and that determined on the basis of the urinary cotinine concentration, a concentration > 200 ng/mL being considered indicative of current smoking. In 48 (46%) of those 104 patients, the self-reported non-smoking status was refuted by an eCO level > 6 ppm, which is also considered indicative of current smoking. In 30 (29%) of the patients with asthma or COPD, the urinary cotinine concentration and the eCO level both belied the patient claims of not being current smokers. CONCLUSIONS: Our findings suggest that high proportions of smoking pulmonary patients with lung disease falsely declare themselves to be nonsmokers. The accurate classification of smoking status is pivotal to the treatment of lung diseases. Objective measures of smoking could be helpful in improving clinical management ...

OBJETIVO: O tabagismo autodeclarado é usado frequentemente para estimar a prevalência dessa condição. As taxas de tabagismo podem ser subestimadas por esse método. O objetivo deste estudo foi avaliar a diferença entre o tabagismo autodeclarado e o tabagismo determinado pelo uso de medidas objetivas em um ambulatório de doenças respiratórias. MÉTODOS: Estudo transversal realizado em 144 indivíduos: 51 pacientes com asma, 53 pacientes com DPOC, 20 fumantes e 20 não fumantes. O tabagismo foi determinado por meio de autorrelato em entrevistas e medição de monóxido de carbono no ar exalado (COex) e de cotinina urinária. RESULTADOS: Todos os pacientes com asma e DPOC declararam não ser fumantes. Nos pacientes com DPOC e asma, a mediana de concentração de cotinina urinária foi de 167 ng/ml (variação, 2-5.348) e de 47 ng/ml (variação, 5-2.735 ppm), respectivamente (p < 0,0001), enquanto . a mediana de COex foi de 8 ppm (variação, 0-31) e 5,0 ppm (variação, 2-45 ppm), respectivamente (p < 0,05). Em 40 (38%) dos pacientes com asma ou DPOC (n = 104), houve discordâncias entre o tabagismo autodeclarado e a concentração de cotinina urinária (> 200 ng/mL). Em 48 (46%) desses 104 pacientes, o não tabagismo autodeclarado foi refutado por um nível de COex > 6 ppm, considerado indicativo de fumo atual. Em 30 (29%) dos pacientes com asma ou DPOC, a concentração de cotinina urinária e o nível de COex contradisseram o autorrelato desses como não fumantes. CONCLUSÕES: Nossos achados sugerem que altas proporções de pacientes fumantes com doenças respiratórias declaram ser não fumantes. A classificação correta do tabagismo é fundamental no tratamento dessas doenças. Medidas objetivas do tabagismo podem ser úteis na melhora do manejo clínico e no aconselhamento. .

Barriers associated with reduced physical activity in COPD patients / Barreiras associadas à menor atividade física em portadores de DPOC

OBJECTIVE: To evaluate the ability of COPD patients to perform activities of daily living (ADL); to identify barriers that prevent these individuals from performing ADL; and to correlate those barriers with dyspnea severity, six-minute walk test (6MWT), and an ADL limitation score. METHODS: In COPD patients and healthy, age-matched controls, the number of steps, the distance walked, and walking time were recorded with a triaxial accelerometer, for seven consecutive days. A questionnaire regarding perceived barriers and the London Chest Activity of Daily Living (LCADL) scale were used in order to identify the factors that prevent the performance of ADL. The severity of dyspnea was assessed with two scales, whereas submaximal exercise capacity was determined on the basis of the 6MWT. RESULTS: We evaluated 40 COPD patients and 40 controls. In comparison with the control values, the mean walk time was significantly shorter for COPD patients (68.5 ± 25.8 min/day vs. 105.2 ± 49.4 min/day; p < 0.001), as was the distance walked (3.9 ± 1.9 km/day vs. 6.4 ± 3.2 km/day; p < 0.001). The COPD patients also walked fewer steps/day. The most common self-reported barriers to performing ADL were lack of infrastructure, social influences, and lack of willpower. The 6MWT distance correlated with the results obtained with the accelerometer but not with the LCADL scale results. CONCLUSIONS: Patients with COPD are less active than are healthy adults of a comparable age. Physical inactivity and the barriers to performing ADL have immediate implications for clinical practice, calling for early intervention measures. .

OBJETIVO: Avaliar a capacidade de portadores de DPOC em realizar atividades de vida diária (AVD), identificar barreiras que impedem a sua realização, e correlacionar essas barreiras com gravidade da dispneia, teste de caminhada de seis minutos (TC6) e um escore de limitação de AVD. MÉTODOS: Nos pacientes com DPOC e controles saudáveis pareados por idade, o número de passos, a distância percorrida e o tempo de caminhada foram registrados por um acelerômetro tridimensional durante sete dias consecutivos. Um questionário de barreiras percebidas e a escala London Chest Activity of Daily Living (LCADL) foram utilizados para identificar os fatores que impedem a realização de AVD. A dispneia foi medida por duas escalas distintas, e a capacidade física submáxima foi determinada com base no TC6. RESULTADOS: Foram avaliados 40 sujeitos com DPOC e 40 controles. Os pacientes com DPOC, comparados aos controles, realizaram menor tempo de caminhada (68,5 ± 25,8 min/dia vs. 105,2 ± 49,4 min/dia; p < 0,001), menor distância caminhada (3,9 ± 1,9 km/dia vs. 6,4 ± 3,2 km/dia; p < 0,001) e menor número de passos/dia. As principais barreiras referidas para realização de AVD foram falta de estrutura, influência social e falta de vontade. A distância caminhada no TC6 correlacionou-se com os resultados do acelerômetro, mas não os resultados da LCADL. CONCLUSÕES: Portadores de DPOC são menos ativos quando comparados a adultos saudáveis com idade comparável. O sedentarismo e as barreiras para a realização de AVD têm implicações imediatas na prática clínica, exigindo medidas precoces de intervenção. .

Deve-se extrapolar o tratamento de bronquiectasias em pacientes com fibrose cística para aqueles com bronquiectasias de outras etiologias? / Should the bronchiectasis treatment given to cystic fibrosis patients be extrapolated to those with bronchiectasis from other causes?

OBJETIVO: Conhecer o perfil de pacientes adultos com bronquiectasias, comparando portadores de fibrose cística (FC) com aqueles com bronquiectasias de outra etiologia, a fim de determinar se é racional extrapolar terapêuticas instituídas em fibrocísticos para aqueles com bronquiectasias de outras etiologias. MÉTODOS: Análise retrospectiva dos prontuários de 87 pacientes adultos com diagnóstico de bronquiectasia em acompanhamento em nosso serviço. Pacientes com doença secundária a infecção por tuberculose corrente ou no passado foram excluídos. Foram avaliados dados clínicos, funcionais e terapêuticos dos pacientes. RESULTADOS: Dos 87 pacientes com bronquiectasias, 38 (43,7 por cento) tinham diagnóstico confirmado de FC através de dosagem de sódio e cloro no suor ou análise genética, enquanto 49 (56,3 por cento) apresentavam a doença por outra etiologia, 34 (39,0 por cento) desses com bronquiectasia idiopática. Os pacientes com FC apresentavam média de idade ao diagnóstico mais baixa (14,2 vs. 24,2 anos; p < 0,05). A prevalência de sintomas (tosse, expectoração, hemoptise e sibilância) foi semelhante entre os grupos. A colonização por Pseudomonas aeruginosa e a por Staphylococcus aureus foram mais comuns nos pacientes com FC (82,4 vs. 29,7 por cento e 64,7 vs. 5,4 por cento, respectivamente). CONCLUSÕES: As causas e as manifestações clínicas das bronquiectasias são heterogêneas, sendo importante a identificação dessas diferenças na abordagem do paciente. Reconhecer estas diferenças é crucial para o desenvolvimento de novas estratégias para o manejo de pacientes com bronquiectasias.

OBJECTIVE: To profile the characteristics of adult patients with bronchiectasis, drawing comparisons between cystic fibrosis (CF) patients and those with bronchiectasis from other causes in order to determine whether it is rational to extrapolate the bronchiectasis treatment given to CF patients to those with bronchiectasis from other causes. METHODS: A retrospective analysis of the medical charts of 87 patients diagnosed with bronchiectasis and under follow-up treatment at our outpatient clinic. Patients who had tuberculosis (current or previous) were excluded. We evaluated the clinical, functional, and treatment data of the patients. RESULTS: Of the 87 patients with bronchiectasis, 38 (43.7 percent) had been diagnosed with CF, through determination of sweat sodium and chloride concentrations or through genetic analysis, whereas the disease was due to another etiology in 49 (56.3 percent), of whom 34 (39.0 percent) had been diagnosed with idiopathic bronchiectasis. The mean age at diagnosis was lower in the patients with CF than in those without (14.2 vs. 24.2 years; p < 0.05). The prevalence of symptoms (cough, expectoration, hemoptysis, and wheezing) was similar between the groups. Colonization by Pseudomonas aeruginosa or Staphylococcus aureus was more common in the CF patients (82.4 vs. 29.7 percent and 64.7 vs. 5.4 percent, respectively). CONCLUSIONS: The causes and clinical manifestations of bronchiectasis are heterogeneous, and it is important to identify the differences. It is crucial that these differences be recognized so that new strategies for the management of patients with bronchiectasis can be developed.

Efeito de curto prazo do tiotrópio nos portadores de DPOC em tratamento com B2-agonista / Short-term effect of tiotropium in COPD patients being treated with a B2 agonist

OBJETIVO: Avaliar o impacto de curto prazo do uso de tiotrópio em pacientes com DPOC grave e muito grave com queixas de dispneia apesar do tratamento com outros broncodilatadores. MÉTODOS: Estudo prospectivo incluindo pacientes com DPOC grave ou muito grave, com queixa de dispneia de pequenos esforços ou ao repouso. A cada 15 dias, o tratamento broncodilatador foi modificado: salmeterol, tiotrópio e associação salmeterol+tiotrópio. Ao final de cada regime, foram realizados testes de função pulmonar e teste de caminhada de seis minutos (TC6). Também foram avaliados o grau de dispneia e a capacidade de realização de atividades de vida diária. Para a avaliação das atividades de vida diária, foi utilizada a escala London Chest Activity of Daily Living (LCADL) validado para uso no Brasil. RESULTADOS: Foram avaliados 52 pacientes. Desses, 30 completaram o estudo. A introdução de tiotrópio como monoterapia resultou em uma melhora significativa (p < 0,05) da dispneia basal (média do escore da escala do Medical Research Council de 3,0 para 2,5) e ao final do TC6 (média do escore da escala de Borg de 6,1 para 4,5), e as diferenças foram significativas (p < 0,05 para ambos). O uso da associação salmeterol+tiotrópio resultou em um aumento significativo médio de 81 mL no VEF1 e na melhora de 5,7 pontos no escore da escala LCADL. CONCLUSÕES: A introdução de tiotrópio no tratamento de pacientes com DPOC grave a muito grave em uso de β2-agonistas de longa duração causa melhora na função pulmonar e alivio sintomático perceptível pelos pacientes a curto prazo. Esses resultados, obtidos em regime de atendimento de vida real, dão suporte ao uso da associação salmeterol+tiotrópio em protocolos de assistência específicos a esses pacientes.

OBJECTIVE: To evaluate the short-term impact of tiotropium in patients with severe or very severe COPD who complain of dyspnea despite being currently treated with other bronchodilators. METHODS: A prospective study including patients with severe or very severe COPD and complaining of dyspnea at rest or on minimal exertion. Every 15 days, the bronchodilator treatment regimen was altered, from salmeterol to tiotropium to salmeterol+tiotropium. At the end of each regimen, pulmonary function tests and the six-minute walk test (6MWT) were performed. The degree of dyspnea and the ability to perform activities of daily living were also assessed. To evaluate patient ability to perform activities of daily living, we employed the London Chest Activity of Daily Living (LCADL), validated for use in Brazil. RESULTS: We evaluated 52 patients, 30 of whom completed the study. The use of tiotropium in isolation resulted in significant improvement in dyspnea at baseline (mean Medical Research Council scale score reduced from 3.0 to 2.5) and at the end of 6MWT (mean Borg scale score reduced from 6.1 to 4.5), and the differences were significant (p < 0.05 for both). The use of the salmeterol+tiotropium combination resulted in a significant (81 mL) increase in FEV1 and a 5.7 point improvement in the LCADL score. CONCLUSIONS: The introduction of tiotropium into the treatment of patients with severe or very severe COPD and using long-acting β2 agonists improves pulmonary function and provides symptomatic relief, as perceived by patients in the short term. These results, obtained under real life treatment conditions, support the use of the salmeterol+tiotropium combination in specific treatment protocols for these patients.