Bronchial asthma and self-management education: implementation of Guidelines by an interdisciplinary programme in health network.

UNLABELLED: Asthma is a chronic disease generating very high costs even for Switzerland. Self-management education (SME) is effective and recommended as an integral part of management in the most recent guidelines on asthma treatment. Its aim is to reduce morbidity [hospitalisations (H), lost workdays (LW), emergency consultations (EC)] and improve quality of life (QOL) in these patients. METHOD: Integrated programme with educational platforms (two-language booklet), SME in 66 patients (30 m, 36 f) with interdisciplinary quality team (pneumologists, primary care physicians, pharmacists, specialised nursing staff), QOL questionnaire. Measurement of morbidity parameters 12 months before and after SME. Measurement of QOL before and 12 months after SME. RESULTS: Hospitalisations fell from 35 to 8%*, EC from 88 to 53%*. and LW from 39 to 14%* (*p <0.001). Overall, SME resulted in a health cost saving of CHF 202,510 in terms of LW and CHF 131,200 in terms of days in hospital, i.e. a total of CHF 333,710. Costs saved per patient were CHF 5,056 per year. QOL improved with the following scores: overall QOL 4.5 +/- 0.9 to 5.2 +/- 0.9*; activities 4.5 +/- 0.9 to 5.2 +/- 0.9*; symptoms 4.2 +/- 1.1 to 5.2 +/- 1.1*; emotions 4.9 +/- 1.1 to 5.6 +/- 1*; environment 4.5 +/- 1.4 to 4.9 +/- 1.3* (*p <0.001). CONCLUSION: SME by interdisciplinary health network is effective. It brings a steep fall in costs for asthma treatment by cutting back hospitalisations and lost workdays and by improving the asthmatics' quality of life. It should be recognised and better supported by the health system.

[Isocyanate-induced alveolitis in a furniture manufacture worker]. / Alvéolite aux isocyanates chez une couturière.

A 41-year-old woman who worked in a furniture plant was admitted to hospital for acute dyspnea that had developed a few hours she marked pieces of "Alcantara" material with a heated metallic blade. The chest x-ray showed a restrictive syndrome. The lymphocyte count was high in the bronchioalveolar lavage fluid with a CD4/CD8 ratio of 0.11, leading to the diagnosis of alveolitis. Investigations at the work place allowed identification and evaluation of the causal agent. Alcantara is a synthetic fabric composed of 70% polyurethane fibers, which when burned produces isocyanate monomers. After eliminating exposure and institution of corticosteroid therapy, the outcome was good with complete recovery. The risk was eliminated by changing the work procedure. This risk has not been reported earlier for furniture manufacture.

Predictors of participation and attendance in a new asthma patient self-management education program.

BACKGROUND: Low participation limits the effectiveness of patient education interventions. In this study, the characteristics of patients who agreed to participate in a clinical trial of disease self-management education for asthma were compared to the characteristics of those who declined, and among the former group patients who actually attended were compared to those who did not. METHODS: The education program, implemented at the Geneva University Hospitals between 1996 and 1998, consisted of three interactive sessions spread over 3 weeks. Only 131 of 253 eligible patients (52%) agreed to participate in the trial, and only 83 patients (63%) attended two to three educational sessions. All eligible patients filled out baseline questionnaires and were interviewed by a trained physiotherapist. RESULTS: Lower confidence in the patient's own current treatment regimen and a more severe baseline asthma attack were independently associated with participation in the trial. Among those who agreed to participate in the study, a university education, longer asthma duration, older age, and a higher level of asthma management knowledge were associated with higher attendance. Quality-of-life scores were not associated with higher course attendance. Among all eligible participants, persons with lower knowledge of asthma management (which was assessed by what to do during an asthma attack and knowledge of the correct use of a peak expiratory flowmeter and inhalers) were less likely to enroll in the trial and to attend the educational training sessions. CONCLUSIONS: Strategies need to be developed to motivate patients with lower disease self-management knowledge to participate in asthma education programs.

[Diagnostic evaluation of dyspnea]. / Evaluation diagnostique de la dyspnée.

Dyspnea is a very common symptom and is mostly a benign condition. However certain pathologies could lead to the death of the patient. In such cases the general practitioner plays an important role in the prompt diagnosis and management. Although other conditions may contribute, the cardiac and pulmonary organ system is the main causes of dyspnea. A careful history and physical examination can lead to a clear diagnosis or a right suspicion. After the emergency call the physician will be also involved in the majority of the cases in the long term follow-up. This article tries to give cues of diagnosis, indications when to hospitalize and keys points for the follow-up.

Objectives, methods and content of patient education programmes for adults with asthma: systematic review of studies published between 1979 and 1998.

BACKGROUND: Education programmes for adults with asthma vary widely. Such variability suggests a lack of consensus on what works and what does not. The objectives of this paper are to describe asthma education programmes and assess their variability. METHODS: A systematic review of reports published between 1979 and 1998 was conducted. Medline, the CINAHL database, the PsycINFO database, the Cochrane collaboration database, the Dissertation Index database, and cross referencing were used to identify educational interventions; 77 projects including 94 interventions that involved 7953 patients were analysed. A standard form was used to record characteristics of studies (design, setting, size, year, and country of publication), projects (theoretical framework, objectives), and education (methods, duration, intensity, educator, and content). RESULTS: Most reports did not specify the general (56%) and educational objectives (60%) of the intervention. Important training characteristics were often not available: duration of education (45%) and number of sessions (22%), who delivered education (15%), whether training was conducted in groups or was individualised (28%). When this information was available there were wide variations in training methods and content: training duration ranged from 0 (self-education) to 58 hours and the number of sessions from 0 to 36; training tools such as peak flow meters, diary cards or books were used in various proportions of interventions (19%, 27%, and 23%, respectively). The content of education also differed widely between programmes. CONCLUSIONS: Insufficient documentation of asthma education programmes for adults precludes their replication. This, together with excessive variability, reduces the possibility of identifying their most effective components. A more systematic description of asthma training programmes should be promoted.

Electronic monitoring of adherence to treatment in the preventive chemotherapy of tuberculosis.

SETTING: Non-adherence to treatment is a frequent problem in the preventive chemoprophylaxis of tuberculosis. OBJECTIVE: To evaluate the usefulness of the Medication Event Monitoring System (MEMS) for following and improving patient adherence to 6-month treatment with isoniazid. DESIGN: Three methods of monitoring compliance, MEMS, pill count and a urine test for isoniazid, were compared prospectively in 30 patients. The efficacy of a combined intervention by the physician and the pharmacist was evaluated in non-compliant patients. RESULTS: According to the MEMS data, overall adherence to isoniazid therapy was 91.5%, and 86% of the patients were considered compliant throughout the period of observation. The pill count and the urine test tended to overestimate the overall compliance when compared to the MEMS. The combined intervention of the physician and pharmacist allowed drug adherence to be enhanced in non-compliant patients, but the effect was only transient if this was not repeated every month. CONCLUSION: Our results suggest that the MEMS system is a useful approach for monitoring and improving compliance with preventive chemotherapy for tuberculosis.

Sniff nasal inspiratory pressure in patients with chronic obstructive pulmonary disease.

In subjects with normal lung mechanics, inspiratory muscle strength can be reliably and easily assessed by the sniff nasal inspiratory pressure (SNIP), which is the pressure measured in an occluded nostril during a maximal sniff performed through the contralateral nostril. The aim of this study was to assess the validity of the SNIP in patients with chronic obstructive pulmonary disease (COPD), where pressure transmission from alveoli to upper airways is likely to be dampened. Twenty eight patients with COPD were studied (mean forced expiratory volume in one second (FEV1) = 36% of predicted). The SNIP and the sniff oesophageal pressure (sniff Poes) were measured simultaneously during maximal sniffs, and were compared to the maximal inspiratory pressure obtained against an occlusion (MIP). All measurements were performed from functional residual capacity in the sitting position. The ratio SNIP/sniff Poes was 0.80, and did not correlate with the degree of airflow limitation. The ratio MIP/sniff Poes was 0.87, and the ratio SNIP/MIP was 0.97. Inspiratory muscle weakness, as defined by a low sniff Poes, was present in 17 of the 28 patients. A false diagnosis of weakness was made in eight patients when MIP was considered alone, in four when SNIP was considered alone, and in only three patients when MIP and SNIP were combined. We conclude that both the sniff nasal inspiratory pressure and the maximal inspiratory pressure moderately underestimate sniff oesophageal pressure in chronic obstructive pulmonary disease. Although suboptimal in this condition, the sniff nasal inspiratory pressure appears useful to complement the maximal inspiratory pressure for assessing inspiratory muscle strength in patients with chronic obstructive pulmonary disease.

[Evaluation of the inspiratory muscle strength using the nasal pressure of the sniff]. / Evaluation de la force musculaire inspiratoire par la pression nasale lors du sniff.

The measurement of oesophageal pressure during maximal sniffs (Poes sniff) is useful to assess inspiratory muscle strength. The aim of this study was to develop a noninvasive test of inspiratory muscle strength based on the sniff manoeuvre. The sniff nasal inspiratory pressure (SNIP) was measured through a plug occluding one nostril during sniffs performed through the contralateral nostril. In 10 normal subjects and in 12 patients with neuromuscular or skeletal disorders, the SNIP reliably reflected the Poes sniff. Nasal mucosa congestion was induced in four normal subjects by nebulization of increasing doses of histamine. The SNIP accurately reflected Poes sniff when nasal congestion was moderate, but failed to do so when congestion was severe. Reference values of SNIP were established in a group of 160 healthy subjects aged 20-80 years. For both men and women, SNIP was negatively correlated with age, and was similar in the sitting and in the supine positions. SNIP was higher than maximal inspiratory pressure (P1 max) in most subjects, but the wide limits of agreement showed that these two methods are not interchangeable but complementary. The SNIP represents a useful noninvasive test of inspiratory muscle strength.

Differences in PO2 and PCO2 between arterial and arterialized earlobe samples.

Arterialized ear lobe blood samples have been described as adequate to gauge gas exchange in acute and chronically ill patients. It is a safe procedure, usually performed by medical technicians. We have conducted a prospective study to verify the validity of this method. One hundred and fifteen consecutive adult patients were studied. Blood samples were drawn simultaneously from arterialized earlobe and radial artery. Values of partial pressure of oxygen (PO2) and of carbon dioxide (PCO2) were measured by means of blood gas electrodes. The correlation coefficients between the two samples were 0.928 for PO2 and 0.957 for PCO2 values. In spite of a highly significant correlation, the limits of agreement between the two methods were wide for PO2. Earlobe values of PO2 were usually lower than arterial values, with larger differences in the range of normal arterial PO2. On the other hand, the error and the limits of agreement were smaller for PCO2. We conclude that, in adult patients, arterialized earlobe blood PO2 is not a reliable mirror of arterial PO2.

Maximal values of sniff nasal inspiratory pressure in healthy subjects.

BACKGROUND: Inspiratory muscle strength is often better reflected by oesophageal pressure during a maximal sniff (sniff POES) than by maximal inspiratory pressure (PImax). Sniff POES can be estimated non-invasively by measuring the sniff nasal inspiratory pressure (SNIP). The aim was to establish maximal normal values for the SNIP and to compare them with PImax. METHODS: One hundred and sixty healthy subjects (80 men) aged 20-80 years were recruited. All subjects had a forced vital capacity (FVC) of > 80%, a forced expiratory volume in one second (FEV1)/FVC of > 85% predicted value, and a body mass index of 18-31 kg/m2. Because PImax is known to be reduced in the supine posture, the SNIP was measured in both the sitting and the supine positions. PImax sustained over one second was measured from functional residual capacity (FRC) in the sitting position with a standard flanged mouthpiece during four manoeuvres. SNIP was measured from FRC in the sitting and supine positions using a catheter through a plug occluding one nostril during 10 maximal sniffs through the contralateral nostril. For each test the largest pressure measured in cm H2O was taken into account. RESULTS: For both men and women maximal SNIP was negatively correlated with age, and was similar in the sitting and the supine positions. In the sitting position maximal SNIP was greater or equal to PImax in 107 of 160 subjects. The mean (SD) ratio SNIP/PImax was 1.08 (0.22) in men and 1.17 (0.29) in women. CONCLUSIONS: Normal values of maximal SNIP can be predicted from age and sex. Maximal SNIP is similar in the sitting and the supine position and is significantly higher than PImax in healthy subjects. The low level of agreement between maximal SNIP and PImax indicates that the two manoeuvres are not interchangeable but complementary.