Chronic Obstructive Pulmonary Disease in Heart Failure: Challenges in Diagnosis and Treatment for HFpEF and HFrEF.

PURPOSE OF REVIEW: Chronic obstructive pulmonary disease (COPD) is common in heart failure (HF), and it has a significant impact on the prognosis and quality of life of patients. Additionally, COPD is independently associated with lower adherence to first-line HF therapies. In this review, we outline the challenges of identifying and managing HF with preserved (HFpEF) and reduced (HFrEF) ejection fraction with coexisting COPD. RECENT FINDINGS: Spirometry is necessary for COPD diagnosis and prognosis but is underused in HF. Therefore, misdiagnosis is a concern. Also, disease-modifying drugs for HF and COPD are usually safe but underprescribed when HF and COPD coexist. Patients with HF-COPD are poorly enrolled in clinical trials. Guidelines recommend that HF treatment should be offered regardless of COPD presence, but modern registries show that undertreatment persists. Treatment gaps could be attenuated by ensuring an accurate and earlier COPD diagnosis in patients with HF, clarifying the concerns related to pharmacotherapy safety, and increasing the use of non-pharmacologic treatments. Acknowledging the uncertainties, this review aims to provide key clinical resources to support better physician-patient co-decision-making and improve collaboration between health professionals.

Factors Associated with Inhaled Bronchodilator and Oral Corticosteroid Use in Young Children with First Lower Respiratory Tract Infection.

OBJECTIVES: To examine factors associated with claims for and potential overuse of inhaled bronchodilators (IBs) and oral corticosteroids (OCSs) for children <2 years old at first lower respiratory tract infections (LRTIs). STUDY DESIGN: Retrospective cohort study using Colorado All Payer Claims data from 2009 through 2019. Children with asthma were excluded. Primary outcomes were 1) IB and 2) OCS claims within 7 days of index LRTI. Primary predictors were previous IB or OCS claims for each outcome respectively. Covariates included demographics, atopy, family history of asthma, complex chronic conditions, prior inhaled corticosteroid claim, and location of index LRTI. Separate multivariable logistic regression models were used for each outcome. RESULTS: Of 10 194 eligible children, 1468 (14.4%) had an IB and 741 (7.3%) an OCS claim at or within 7 days of index LRTI. Index LRTIs were most often at outpatient visits (64%). Adjusting for covariates, prior IB prescription was associated with the IB outcome (aOR 1.9; 95% CI 1.3, 2.8), and prior OCS prescription was associated with the OCS outcome (AOR 2.2; 95% CI 1.7, 2.9). Other variables associated with either outcome included age, sex, insurance, location, and atopy. Prior inhaled corticosteroid claim, asthma family history, and complex chronic conditions were not associated with either outcome. CONCLUSIONS: This study identifies factors that might serve as opportunities for de-implementation strategies for IB and OCS overuse in young children with LRTI.

Position statement: asthma in Latin America. IS short-acting beta-2 agonist helping or compromising asthma management?

In Latin-America, with 603 million inhabitants, the average prevalence of asthma is estimated at 17%, but with wide fluctuations, ranging from 5% in some cities (Mexico) to 30% in Costa Rica. The risk of severe exacerbations seems to be higher in Latin America compared with other regions. A majority of patients uses daily quick-relief medication, with the belief that it is the most important treatment because of its rapid onset of action; without treating the underlying inflammation. Overuse of short-acting beta2 agonists (SABAs) is associated with increased risk of asthma deaths in a dose-response manner. Beta2 agonists increase the severity of asthma through enhanced bronchial hyperresponsiveness and reduced lung function. Also, it has been shown that overreliance on SABA delays recognition of a potentially life-threatening asthma attack. We believe that overreliance on SABA in asthma is also an important public health issue. The fact that SABA use in GINA is not supported by a randomized trial but by an anonymous paper; makes us guess that we use SABA just because we are used to do so. In 2019 GINA strategy introduces one of the most important changes in the management of Asthma in the past 30 years, highlighting anti-inflammatory reliever therapy. A combination of low dose ICS/fast action bronchodilator will not only treat symptoms, but more importantly the underlying inflammation, protecting patients from preventable asthma attacks. After 50 years of a SABA centric approach in asthma management, it is time to leave behind a treatment based just on the bronchodilation and tackle the inflammation.

Does Bilevel Noninvasive Ventilation Have a Bronchodilating Effect and Alter Respiratory Mechanics in Asthmatic Individuals After Bronchoprovocation? Randomized, Crossover Study.

Background: Noninvasive ventilation (NIV) has an additional important effect that does not occur with medicinal therapy: a reduction in the work of breathing. Understanding the mechanical effects of these therapies is of considerable importance and can affect clinical decision making. Objective: Evaluate the effects of NIV compared to albuterol on lung function and respiratory mechanics in asthmatic adolescents and young adults after bronchoprovocation and determine the effects of a hypertonic saline solution on lung function respiratory mechanics. Methods: A randomized crossover study was conducted involving individuals with a diagnosis of asthma. Evaluations were performed with optoelectronic plethysmography (OEP) and spirometry at baseline, after the bronchial provocation test with 4.5% saline solution and after the intervention. The order of the procedures (bilevel NIV and albuterol) was randomized, with the participants crossing over to the other treatment after a 1-week washout period. Inspiratory positive airway pressure (IPAP) 12 and expiratory positive airway pressure (EPAP) 8 cmH2O were set for 10 minutes and the dose of albuterol was 400 µg. Results: Forty individuals were included in the study (mean age: 21.6 ± 4 years; 24 females). The recovery of FEV1% was 87.9% (80.8 ± 35 to 101.1 ± 46.1, p < 0.05) after NIV and 95.9% (84.4 ± 42.4 to 110.3 ± 44.3, p < 0.05) after albuterol. Inspiratory capacity (IC; L) reduced 12% to 15% after bronchoprovocation, with 100% recovery using NIV (2.1 ± 0.7 to 2.42.4 ± 0.6, p < 0.05) and 107.6% using albuterol (2.2 ± 0.8 to 2.8 ± 1.1, p < 0.05). Regarding OEP variables, tidal volume had greater participation in the thoracic compartment. NIV led to an increase in minute volume and a return to the baseline value, which did not occur with albuterol. Conclusion: NIV recovered FEV1 and improves signs of hyperinflation by improving IC. Bronchoprovocation with a hypertonic solution reduced FEV1 by 20% and reduced IC. NIV led to a faster recovery of minute volume and reduced the contraction velocity of the muscles of the rib cage compared to albuterol, although the effects on lung function were less intense.

Impulse oscillometry: pulmonary function assessment in preschool children.

OBJECTIVES: In contrast to spirometry, which requires active participation of the individual and is challenging for the preschool age group, the impulse oscillometry system comprises a test that minimizes the degree of coordination required. The study aimed to compare the results of Impulse Oscillometry System (IOS) in children with and without respiratory symptoms. METHODS: A cross-sectional study was conducted in children aged between 3 and 6 years. A short version of the ATS-DLD-78-C questionnaire validated for Brazilian children was applied to identify two groups: children with and without respiratory symptoms. The IOS analysis was carried out measuring the following parameters in triplicate: resistance at 5 Hz (R5Hz) and 20 Hz (R20Hz), respiratory reactance at 5 Hz (X5Hz), and R5-R20Hz before and after bronchodilator application. RESULTS: A total of 76 preschoolers were selected, 55 (72.4%) of whom had respiratory complaints. The coefficient of variability of R5Hz was ≤17% in 70/76 (92.1%) of the children. Resistances at R5Hz and R5-R20Hz in the children with respiratory complaints reached values higher than those of children without symptoms before bronchodilation. CONCLUSIONS: The results obtained for resistance using IOS in children with respiratory symptoms were higher in the pre-bronchodilator examination for R5Hz and R5-R20Hz compared to those of children without respiratory symptoms. EXPERT OPINION: Prospective investigations suggest that irreversible changes in lung function begin in infancy, before reaching school age. Pulmonary function follow-up in children with recurrent wheezing or asthma is important for confirmation of diagnosis and evaluation of the disease severity. The Impulse Oscillometry System (IOS) can be useful in assessing children's pulmonary function since it requires minimal patient cooperation and can be successfully applied to preschool children being an alternative to individuals who have difficulty performing spirometry.

Conduta terapêutica em pacientes com doença pulmonar obstrutiva crônica: monoterapia ou terapia cominada? / Therapy for chronic obstructive pulmonary disease patients: monotherapy or combination therapy?

Objetivo: Comparar a dupla terapia broncodilatadora com glicopirrônio mais indacaterol à monoterapia com glicopirrônio em pacientes portadores de doença pulmonar obstrutiva crônica. Métodos: Estudo clínico prospectivo, unicêntrico, controlado, cruzado, randomizado e duplo-cego realizado com 14 pacientes com diagnóstico de doença pulmonar obstrutiva crônica grau II. Os participantes receberam cada um dos tratamentos durante 30 dias. Antes de cada terapia, realizou-se período de wash-out por 7 dias, com broncodilador de curta ação. Antes e após cada intervenção, os pacientes passaram por exame de espirometria e responderam ao questionário COPD Assessment Test. Resultados: Observou-se melhora na função pulmonar medida por meio do volume expiratório forçado no primeiro segundo de 19mL (±36) para a monoterapia e 87mL (±33) para a terapia dupla. O ganho foi de 67mL (p=0,042) da associação dos medicamentos em relação ao glicopirrônio isolado. A melhora na qualidade de vida, medida a partir das pontuações do questionário, foi de 4,7 (±8,9) pontos para a monoterapia e 5,2 (±11) pontos para a dupla terapia (p=0,08). Conclusão: Ambos os tratamentos demonstram melhora na função pulmonar dos pacientes.

Objective: To compare dual bronchodilator therapy (Glycopyrronium with Indacaterol) versus Glycopyrronium monotherapy in patients with chronic obstructive pulmonary disease. Methods: This was a prospective, unicentric, controlled, crossover, randomized, and double-blind clinical trial with 14 patients diagnosed with grade II chronic obstructive pulmonary disease. The participants received each treatment during the period of 30 days. Before each therapy, a 7-day wash-out period with a short-acting bronchodilator was instituted. Before and after each intervention, the patients underwent spirometry and answered the COPD Assessment Test questionnaire. Results: An improvement in pulmonary function measured by forced expiratory volume during the first second of 19mL (±36) for monotherapy, and 87mL (±33) for dual therapy was observed. The gain was of 67mL (p=0.042) in the association of the drugs in relation to Glycopyrronium alone. The mean improvement in quality of life measured from the questionnaire scores was 4.7 (±8.9) points for monotherapy and 5.2 (± 11) points for dual therapy (p=0.08). Conclusion: Both treatments show improvement in the patients' pulmonary function.

The Importance of Inhaler Adherence to Prevent COPD Exacerbations.

It has been shown that the better outcomes of chronic obstructive pulmonary disease (COPD) are closely associated with adherence to drug therapy, independent of the treatment administered. The clinical trial Towards a Revolution in COPD Health (TORCH) study clearly showed in a three year follow up that patients with good adherence to their inhaler treatment presented a longer time before the first exacerbation, a lower susceptibility to exacerbation and lower all-cause mortality. The Latin American Study of 24-hour Symptoms in Chronic Obstructive Pulmonary Disease (LASSYC), a real-life study, evaluated the self-reported inhaler adherence in COPD patients in seven countries in a cross-sectional non-interventional study and found that approximately 50% of the patients had good adherence, 30% moderate adherence and 20% poor adherence. Adherence to inhaler may be evaluated by the specific inhaler adherence questionnaire, the Test of Adherence to Inhalers (TAI). Several factors may predict the incorrect use of inhalers or adherence in COPD outpatient, including the number of devices and the daily dosing frequency. Ideally, patient education, simplicity of the device operation, the use of just one device for multiple medications and the best adaptation of the patient to the inhaler should guide the physician in prescribing the device.

Broncodilatadores en pacientes con bronquiolitis / Bronchodilators for bronchiolitis

La bronquiolitis es una infección respiratoria aguda baja de causa viral, de aparición invernal, que es común en bebés de 0a 12 meses de edad. Conduce a que las vías respiratorias pequeñas se inflamen y se llenen de desechos, obstruyéndose.El bebé tiene una tos fuerte, secreción nasal, generalmente fiebre y puede presentar sibilancias dificultad respiratoria ydesaturación de oxígeno. Tras la presentación de un caso en la guardia se generó una controversia científica sobre lautilidad de los broncodilatadores en pacientes con bronquiolitis. Luego de realizar una búsqueda bibliográfica y seleccionarla evidencia más reciente y de mejor calidad, se concluye que la evidencia no apoya el uso de broncodilatadores enpacientes con bronquiolitis.(AU)

Bronchiolitis is a low acute respiratory lower respiratory tract infection of viral origin, winter appearance, which is commonin babies from 0 to 12 months of age. It causes the small airways in the lungs to become inflamed and fill with debris. Theinfant has a harsh cough, runny nose, usually fever and may have wheezing, respiratory distress and oxygen desaturation.After the presentation of a case in the emergency department, a scientific controversy was generated about the usefulnessof bronchodilators in patients with bronchiolitis. After conducting a literature search and selecting the most recent and bestquality evidence, it is concluded that evidence does not support the use of bronchodilators in patients with bronchioliTIS.(AU)

[When education in asthma is crucial. About a case]. / Cuando la educación en asma es crucial. A propósito de un caso.

BACKGROUND: Childhood asthma causes frequent hospitalizations and visits to the emergency room because of exacerbations that could be avoided if the disease is managed properly. CLINICAL CASE: A 6-year-old girl who has had asthma since her first 16 months of life. She had been taken 130 times to the emergency room; she had been hospitalized 22 times, and she had received numerous medical consultations for asthma. She had never received structured health education, therefore, she was misusing the inhalation devices, and the controller treatment for bronchial inflammation was clearly below the dose according to the level of severity of the disease. There was an intervention focused on health education, an increase in the dose of anti-inflammatory drugs to treat bronchial asthma, and instruction in the proper use of inhaled medications. Since the intervention was made, the patient achieved better control without requiring visits to the emergency room, hospital admissions, or systemic corticosteroids after two years of follow-up. CONCLUSION: The lack of health education about asthma causes insufficient control of the disease. In the therapeutic approach to patients with severe uncontrolled asthma, it is essential to apply structured procedures of health education.

Antecedentes: El asma infantil ocasiona frecuentes hospitalizaciones y visitas a urgencias por exacerbaciones que podrían ser evitadas con el manejo apropiado de la enfermedad. Caso clínico: Niña de seis años con asma desde los 16 meses de vida. Fue llevada 130 veces al servicio de urgencia, 22 veces fue hospitalizada y recibió otras numerosas consultas médicas por asma. Nunca había recibido educación sanitaria estructuradamente, de manera que utilizaba los dispositivos de inhalación inadecuadamente y el tratamiento controlador de la inflamación bronquial estaba claramente por debajo de la dosis correspondiente al grado de gravedad de su asma. Se realizó una intervención centrada en la educación sanitaria, incremento de la dosis de medicamentos antiinflamatorios bronquiales e instrucción en el uso adecuado de la medicación inhalada. A partir de la intervención, la paciente alcanzó un mejor control sin requerir nuevamente visitas a urgencias, ingresos hospitalarios ni corticoides sistémicos, tras dos años de seguimiento. Conclusiones: La falta de educación sanitaria en asma ocasiona control insuficiente de la enfermedad. En el acercamiento terapéutico al paciente con asma grave no controlada resulta imprescindible aplicar procedimientos estructurados de educación sanitaria.

El uso de broncodilatadores en la bronquiolitis / The use of bronchodilators in bronchiolitis

INTRODUCCIÓN: La bronquiolitis es una patología frecuente en la práctica clínica pediátrica. Constituye una de las principales entidades clínicas dentro de las infecciones respiratorias agudas bajas (IRAB). Se define como el primer episodio de sibilancias con manifestaciones clínicas de infección viral en un niño menor de dos años y afecta principalmente a lactantes menores de 6 meses. El tratamiento es fundamentalmente de soporte con oxigenoterapia e hidratación, quedando el resto de las terapéuticas bajo una profunda controversia acerca de su real efectividad. METODOLOGÍA: Desde la exposición de un escenario clínico se planteó una pregunta estructurada para luego realizar una búsqueda bibliográfica con el fin de dar respuesta a la pregunta sobre la efectividad en el tratamiento del bronquiolitis con broncodilatadores. Se realizó una búsqueda en PubMed utilizando los Mesh (Medical Subject Headings) "bronchodilators AND bronchiolitis", se aplicaron distintos filtros, tras lo cual se llegó al número final de 23 artículos. Tras una lectura de los títulos y resúmenes de los artículos, se escogió el artículo "Bronchodilators for bronchiolitis". ANÁLISIS DEL ARTÍCULO: Nos hemos centrado las siguientes variables con el fin de responder a la pregunta clínica: la mejoría en el score clínico, la reducción de la tasa de internación y la saturometría de oxígeno. Realizamos luego un análisis secundario de los datos de las distintas variables con el fin de definir los valores de riesgo relativo (RR), reducción de riesgo absoluto (RRA), reducción del riesgo relativo (RRR) y el número necesario a tratar (NNT) con sus respectivos intervalos de confianza del 95% (IC 95%). También se llevó a cabo un análisis estadístico para evaluar la variable de saturación de oxígeno. RECOMENDACIÓN FINAL: No está recomendado el uso de broncodilatadores en el manejo del bronquiolitis, ya que no mejoran ninguna de las variables analizadas. Los broncodilatadores no sólo no tienen eficacia, sino que suponen un gasto y presentan efectos adversos indeseables. (AU)

INTRODUCTION: Bronchiolitis is a frequent pathology in pediatric clinical practice. It constitutes one of the main clinical entities within acute lower respiratory infections. It is defined as the first episode of wheezing with clinical manifestations of viral infection in a child younger than two years and mainly affects infants under 6 months. The treatment is fundamentally support with oxygen therapy and hydration, leaving the rest of the therapeutic under a deep controversy about its real effectiveness. METHODOLOGY: From the exposition of a clinical scenario, a structured question was presented for a bibliographic search in order to answer the question about the effectiveness in the treatment of bronchiolitis with bronchodilators. A PubMed search was performed using the Mesh (Medical Subject Headings) "Bronchodilators AND Bronchiolitis", different filters were applied, and we reached the final number of 23 articles. After a reading of the titles and summaries of the articles, the article "Bronchodilators for Bronchiolitis" was chosen. ANALYSIS OF THE ARTICLE: We have focused the following variables in order to answer the clinical question: the improvement in the clinical score, the reduction of the hospitalization rate and oxygen saturation. Then, we performed a secondary analysis of the data of the different variables in order to define the values of relative risk, absolute risk reduction, relative risk reduction, and the number needed to treat, with their respective 95% Confidence Intervals. We also carried out the statistical analysis needed to evaluate the oxygen saturation. Recommendation: The use of bronchodilators in the management of bronchiolitis is not recommended because none of the analyzed variables improve. Bronchodilators not only do not have efficacy, but they suppose an expense and present undesirable adverse effects. (AU)

Current and future pharmacotherapy options for non-cystic fibrosis bronchiectasis.

INTRODUCTION: In recent years, there has been an increasing number of clinical trials investigating the effect of pharmacological treatments on patients with bronchiectasis. Areas covered: This review provides an overview of current drugs used in bronchiectasis patients as well as those that could make a future contribution to the management of this disease. Expert commentary: Bronchiectasis is a very heterogeneous disease, so it can be studied from a phenotypic standpoint and its pathophysiological mechanisms (endotypes) can be defined. This provides an interesting field of research as it enables the identification of patients suitable for inclusion in specific clinical trials on new drugs.

Inhaled Beta Agonist Bronchodilator Does Not Affect Trans-diaphragmatic Pressure Gradient but Decreases Lower Esophageal Sphincter Retention Pressure in Patients with Chronic Obstructive Pulmonary Disease (COPD) and Gastroesophageal Reflux Disease (GERD).

BACKGROUND: Chronic obstructive pulmonary disease (COPD) patients have a high incidence of gastroesophageal reflux disease (GERD) whose pathophysiology seems to be linked to an increased trans-diaphragmatic pressure gradient and not to a defective esophagogastric barrier. Inhaled beta agonist bronchodilators are a common therapy used by patients with COPD. This drug knowingly not only leads to a decrease in the lower esophageal sphincter (LES) resting pressure, favoring GERD, but also may improve ventilatory parameters, therefore preventing GERD. AIMS: This study aims to evaluate the effect of inhaled beta agonist bronchodilators on the trans-diaphragmatic pressure gradient and the esophagogastric barrier. METHODS: We studied 21 patients (mean age 67 years, 57 % males) with COPD and GERD. All patients underwent high-resolution manometry and esophageal pH monitoring. Abdominal and thoracic pressure, trans-diaphragmatic pressure gradient (abdominal-thoracic pressure), and the LES retention pressure (LES basal pressure-transdiaphragmatic gradient) were measured before and 5 min after inhaling beta agonist bronchodilators. RESULTS: The administration of inhaled beta agonist bronchodilators leads to the following: (a) a simultaneous increase in abdominal and thoracic pressure not affecting the trans-diaphragmatic pressure gradient and (b) a decrease in the LES resting pressure with a reduction of the LES retention pressure. CONCLUSION: In conclusion, inhaled beta agonist bronchodilators not only increase the thoracic pressure but also lead to an increased abdominal pressure favoring GERD by affecting the esophagogastric barrier.

Patrones de prescripción de broncodilatadores y corticoides inhalados en pacientes adultos de Colombia / Prescription patterns of bronchodilators and inhaled corticosteroids in adults of Colombia

Introducción: las enfermedades pulmonares obstructivas son frecuentes en pacientes mayores de 40 años y son causa de alta morbimortalidad a nivel mundial. En el presente estudio se describen los patrones de prescripción de medicamentos para su tratamiento en pacientes de Colombia. Material y métodos: estudio descriptivo observacional con pacientes, mayores de 40 años de ambos sexos, afiliados al Sistema General de Seguridad Social en Salud, en tratamiento continuo con broncodilatadores y/o corticoides inhalados entre septiembre y diciembre del año 2013, seleccionados a partir de una base de datos de dispensación de 6.5 millones de personas. Se recolectaron variables sociodemográficas, farmacológicas (fármacos con sus dosis diarias definidas), medicamentos concomitantes y clínicas (comorbilidades). Análisis mediante SPSS 22. Resultados: se incluyeron 6856 pacientes con una edad promedio de 73.8 ± 11.3 años, 54%fueron mujeres. Del total de pacientes 17.2% recibían monoterapia y 82.8% terapia combinada. El 74.3% de sujetos recibía β2-adrenérgicos, la mayoría (81.5%) de corta duración (BDCA), mientras que 33.3% de larga acción (BDLA). El 73.1% recibía anticolinérgicos distribuidos entre ipratropio (87.1%) y tiotropio (16.9%) y 71.7% recibía corticoides inhalados. Los medicamentos prescritos concomitantemente con mayor frecuencia fueron antihipertensivos (68.9%), antiulcerosos (56.1%) e hipolipemiantes (46.2%). Tener entre 40 y 55 o más de 80 años, recibir alguna medicación concomitante, utilizar corticoides inhalados, emplear monoterapia broncodilatadora y ser tratado en Bogotá y Cali, se asociaron de manera estadísticamente significativa con menor riesgo de recibir BDLA. Conclusiones: predomina la prescripción de BDCA, pese al limitado beneficio clínico reportado. La mayoría de broncodilatadores se emplean a dosis superiores a las recomendadas. Se considera necesario establecer estrategias educativas que mejoren los hábitos de prescripción. (Acta Med Colomb 2015; 40: 218-226).

Introduction: obstructive lung diseases are common in patients older than 40 years and cause high morbidity and mortality worldwide. The patterns of drugs prescription for its treatment in Colombian patients are described in this study. Methods: descriptive observational study with patients over 40 years of both sexes, members of the General System of Social Security in Health, in continuous treatment with bronchodilators and / or inhaled steroids between September and December 2013, selected from a dispensing database of 6.5 million people. Sociodemographic and pharmacological variables (drugs with defined daily doses), concomitant medications and co-morbidities were collected. Analysis using SPSS 22. Results: A total of 6856 patients were included with a mean age of 73.8±11.3 years, 54% were women. Of the total of patients, 17.2% received monotherapy and 82.8% combined therapy. 74.3% of subjects received β2-adrenergics, most (81.5%) short-acting bronchodilators, while33.3% long acting bronchodilators. 73.1% received anticholinergics distributed between ipratropium (87.1%) and tiotropium (16.9%) and 71.7% received inhaled steroids. The medications that were most often concomitantly prescribed, were antihypertensive (68.9%), antiulcerants (56.1%) and lipid lowering drugs (46.2%). To be between 40 and 55 or over 80 years, receive any concomitant medication, inhaled corticosteroid use, bronchodilator monotherapy use and being treated in Bogota and Cali, was statistically significantly associated with lower risk of receiving long-acting bronchodilators. Conclusions: the prescription of short-acting bronchodilators predominate despite the limited clinical benefit reported. Most bronchodilators are used at higher than recommended doses. It is necessary to establish educational strategies to improve prescribing habits. (Acta Med Colomb 2015; 40: 218-226).

Doença pulmonar obstrutiva crônica / Chronic obstructive pulmonary disease

A doença pulmonar obstrutiva crônica (DPOC) será abordada quanto ao quadro clínico, critérios diagnósticos e tratamento. Serão ainda discutidas as principais manifestações sistêmicas da doença, bem como a importância da identificação e tratamento destas no seguimento de pacientes portadores de DPOC.

Use of digital media for the education of health professionals in the treatment of childhood asthma / Uso de mídia digital na educação de profissionais de saúde para tratamento da asma infantil

OBJECTIVES: Inhalation therapy is the main treatment for asthma and its adequate use has been a factor responsible for disease control; therefore, the aim of the study was to determine whether a digital media tool, which features portability on mobile phones, modifies the assimilation of the inhalation technique. METHODS: A total of 66 professionals working in the health care area with the pediatric population were selected. They were submitted to a pre-test on their knowledge of inhalation therapy. The professionals were randomized into two groups (A and B). Group A received a media application on their mobile phones showing the steps of inhalation therapy, while group B received the same information in written form only. A post-test was applied after 15 days. The results (pre- and post-) were analyzed by two pediatric pulmonologists. RESULTS: Of the 66 professionals, 87.9% were females. Of a total possible score of ten, the mean score obtained in the pre-test was 5.3 ± 3, and in the second test, 7.5 ± 2 (p < 0.000). There were no significant differences when comparing the two groups (p = 0.726). The nurses had the lowest mean scores in the initial test (2.3 ± 2); however, they were the group that learned the most with the intervention, showing similar means to those of other groups in the second test (6.1 ± 3). CONCLUSION: There was significant improvement in knowledge about inhalation therapy in all professional categories using both methods, demonstrating that education, when available to professionals, positively modifies medical practice. .

OBJETIVOS: A inaloterapia representa a principal forma de tratamento da asma e seu uso adequado tem sido fator responsável pelo controle da doença. Desse modo, o objetivo do estudo foi determinar se uma ferramenta de mídia digital, dotada de portabilidade na forma de telefonia móvel, modifica a assimilação da técnica inalatória. MÉTODOS: Foram selecionados 66 profissionais que atuam na área da saúde com população pediátrica e submetidos a um pré-teste sobre seus conhecimentos de inaloterapia. Os profissionais foram randomizados em dois grupos (A e B). O grupo A recebeu em seu telefone móvel um aplicativo de mídia com os passos da inaloterapia, enquanto o grupo B recebeu as mesmas informações apenas de forma escrita. Após 15 dias, fez-se um pós-teste. Os resultados (pré e pós) foram analisados por dois pneumologistas pediátricos. RESULTADOS: Dos 66 profissionais, 87,9% eram do sexo feminino. Num escore total possível de 10, a média das notas obtidas no pré-teste foi de 5,3 ± 3 e as do segundo teste 7,5 ± 2 (p < 0,000). Não houve diferenças significativas na comparação os dois grupos (p = 0,726). Os profissionais de enfermagem apresentaram a menor média nas provas iniciais (2,3 ± 2), porém foi o grupo que aprendeu mais com a intervenção e apresentou média similar aos outros grupos na segunda prova (6,1 ± 3). CONCLUSÃO: Houve melhoria significativa no conhecimento sobre inaloterapia em todas as categorias profissionais com o uso de ambos os métodos. Isso comprovou que a educação, quando oferecida aos profissionais, modifica positivamente a prática médica. .

Use of digital media for the education of health professionals in the treatment of childhood asthma.

OBJECTIVES: Inhalation therapy is the main treatment for asthma and its adequate use has been a factor responsible for disease control; therefore, the aim of the study was to determine whether a digital media tool, which features portability on mobile phones, modifies the assimilation of the inhalation technique. METHODS: A total of 66 professionals working in the health care area with the pediatric population were selected. They were submitted to a pre-test on their knowledge of inhalation therapy. The professionals were randomized into two groups (A and B). Group A received a media application on their mobile phones showing the steps of inhalation therapy, while group B received the same information in written form only. A post-test was applied after 15 days. The results (pre- and post-) were analyzed by two pediatric pulmonologists. RESULTS: Of the 66 professionals, 87.9% were females. Of a total possible score of ten, the mean score obtained in the pre-test was 5.3 ± 3, and in the second test, 7.5 ± 2 (p<0.000). There were no significant differences when comparing the two groups (p=0.726). The nurses had the lowest mean scores in the initial test (2.3 ± 2); however, they were the group that learned the most with the intervention, showing similar means to those of other groups in the second test (6.1 ± 3). CONCLUSION: There was significant improvement in knowledge about inhalation therapy in all professional categories using both methods, demonstrating that education, when available to professionals, positively modifies medical practice.

Dispositivos inalatórios broncodilatadores em terapia intensiva / Bronchodilators and inhalers devices in ICU

A densidade de uso de ventilação mecânica em Terapia Intensiva varia de 10% a 100%, apesar de na média ficar entre 20 – 40% nas Unidades Intensivas Gerais. Uma parcela substancial dos pacientes em ventilação mecânica é formada por pacientes portadores de distúrbios ventilatórios obstrutivos, nos quais o uso de broncodilatadores inalatórios é um dos eixos centrais de tratamento. O objetivo desta classe de medicamentos em pacientes com doença pulmonar obstrutiva crônica (DPOC) ou asma e sob ventilação mecânica seria reduzir a hiperinsuflação dinâmica, a resistência de vias aéreas e o trabalho ventilatório, favorecendo desmame precoce.Este artigo tem por objetivo atualizar sobre as apresentações dos mais variados broncodilatadores inalatórios bem como as técnicas de uso das medicações em um cenário de alta prevalência de doentes sob ventilação mecânica...

The use of mechanical ventilation in Intensive Care Units ranges from 10% to 100%, although the average stays between 20-40% in the General Intensive Unit. A substantial portion of mechanical ventilation in patients consists of patients with obstructive lung disease, in which the use of inhaled bronchodilators is a central strategy of treatment. The purpose of this therapy in patients with chronic obstructive pulmonary disease (COPD) or asthma on mechanical ventilation is to reduce dynamic hyperinflation, increased airway resistance and excessive respiratory workload, favoring early weaning. This article aims to update on the indications, and techniques of inhaled bronchodilation in a substantial group of patients on mechanical ventilation...

Pituitary Adenylate Cyclase Activating Peptide (1-38) and its analog (Acetyl-[Ala15, Ala20] PACAP 38-polyamide) reverse methacholine airway hyperresponsiveness in rats

The aim of this study was to investigate both functionally and structurally bronchodilator effects of Pituitary adenylate cyclase activating peptide (PACAP38) and acetyl-[Ala15, Ala20] PACAP38-polyamide, a potent PACAP38 analog, in rats challenged by methacholine (MeCh). Male Wistar rats were divided randomly into five groups. Groups 1 and 2 inhaled respectively aerosols of saline or increasing doses of MeCh (0.5, 1, 2.12, 4.25, 8.5, 17, 34 and 68mg/L). The other groups received terbutaline (Terb) (250 µg/rat) (10-6 M), PACAP38 (50 µg/rat) (0.1 mM) or PACAP38 analog (50 µg/rat) associated to MeCh from the dose of 4.25 mg/L. Total lung resistances (RL) were recorded before and 2 min after MeCh administration by pneumomultitest equipment. MeCh administration induced a significant and a dose-dependent increase (p<0.05) of RL compared to control rats. Terb, PACAP38 and PACAP38 analog reversed significantly the MeCh-induced bronchial constriction, smooth muscle (SM) layer thickness and bronchial lumen mucus abundance. PACAP38 analog prevents effectively bronchial smooth muscle layer thickness, mucus hypersecretion and lumen decrease. Therefore, it may constitute a potent therapeutic bronchodilator.

O objetivo deste estudo foi investigar funcionalmente e estruturalmente efeito broncodilatador do peptídeo ativador da adenilato ciclase pituitária (PACAP1-38) e da acetil-[Ala15, Ala20]PACAP 38-poliamida, potente análogo do PACAP-38, nos ratos desafiados pelo metacolina (MeCh). Ratos Wistar machos foram aleatoriamente divididos em cinco grupos. Grupos 1 e 2, inalando aerossóis de solução salina ou doses crescentes de MeCh (0,5, 1, 2,12, 4,25, 8,5, 17, 34 e 68 mg/L). Os outros grupos recebendo terbutalina (Terb) (250 µg/rato) (10-6M), PACAP-38 (50 µg/rato) (0.1 mM) ou análogo do PACAP-38 (50 µg/rato) associados a MeCh na dose de 4,25 mg/L. A resistência pulmonar total (RL) foi registrada antes e 2 min após a administração de Mech pelo equipamento pneumomultiteste. A administração MeCh induziu aumento significativo e dose dependente (p<0,05) de RL em comparação com ratos do grupo controle. Terb e PACAP1-38 e análogo do PACAP-38 reverteram, significativamente, a constrição brônquica induzida por Mech, a espessura do músculo liso (SM) e abundância de muco do lume brônquico. O análogo PACAP-38 do mesmo modo que a Terb impediu a responsividade brônquica a MeCh e pode se constituir em um importante regulador no desenvolvimento da doença inflamatório pulmonar. Contudo, o uso do peptídeo nativo para aplicações terapêuticas é limitado por sua baixa estabilidade metabólica. Consequentemente, o análogo metabolicamente estável representa ferramenta promissora no tratamento de doenças pulmonares inflamatórias.

Asma bronquial en la población infantil de 5 a 14 años de un área de salud de Santiago de Cuba / Bronchial asthma in children 5 to14 years from a health area of Santiago de Cuba

Se realizó un estudio observacional de 158 niños con asma bronquial -- seleccionados mediante un muestreo por conglomerado bietápico --, dispensarizados por dicha afección en el área de salud del Policlínico Docente "José Martí Pérez" de Santiago de Cuba, durante el 2011, a fin de estimar la prevalencia de las principales características clinicoepidemiológicas en ellos. En la investigación se obtuvo homogeneidad del sexo femenino en todos los grupos etarios, a pesar de un ligero predominio de los varones de 10 a 14 años de edad, así como primacía de la afección entre los precedentes patológicos personales y la conjuntivitis alérgica como antecedente familiar. Igualmente, el asma persistente grave tuvo un mayor porcentaje y los agentes desencadenantes de las crisis asmáticas fueron, en orden descendente de frecuencia, los alergenos domiciliarios, el humo del cigarro, las infecciones, los ejercicios, los contaminantes de tipo doméstico y los medicamentos. El tratamiento más empleado se basó en broncodilatadores y el menos habitual, en cromonas; en tanto el hacinamiento fue el factor desfavorable más observado en los hogares de estos niños y el control de la enfermedad resultó generalmente parcial.

An observational study was carried in 158 children with bronchial asthma -- selected by a two-stage cluster sampling -- attended and monitored by this disease in the health area from "José Martí Pérez" Teaching Polyclinic of Santiago de Cuba during 2011, in order to estimate the prevalence of the main clinical and epidemiological characteristics in them. In the study homogeneity of the female sex was observed in all age groups, in spite of a slight predominance of males 10 to 14 years, as well as primacy of the disease between past medical history and allergic conjunctivitis as family history. Likewise, severe persistent asthma had a higher percentage and triggers of asthma attacks were, in decreasing order of frequency, household allergens, cigarette smoke, and infections, exercises, domestic pollutants and medications. The most common treatment was based on bronchodilators and the less common on chromones; as long as the overcrowding was the most observed adverse factor in the homes of these children and the control of disease was usually partial.