Objective: To evaluate the effects of an outpatient education program in patients with uncontrolled asthma. Methods: This was an uncontrolled study evaluating an educational intervention and involving patients with uncontrolled asthma ≥ 14 years of age. The participants completed a questionnaire designed to assess the level of asthma control, the inhalation technique, and quality of life. All of the patients underwent pulmonary function testing, after which they participated in an education program consisting of one 45-min face-to-face session, followed by phone interviews at two, four, and eight weeks. The participants were reevaluated after three months. Results: Sixty-three patients completed the study. There was a significant improvement in the level of asthma control (p < 0.001). Of the 63 patients, 28 (44.4%) and 6 (9.5%) were classified as having partially controlled asthma and controlled asthma, respectively. The mean FEV1 was 63.0 ± 20.0% and 68.5 ± 21.2% of the predicted value prior to and after the educational intervention, respectively (p = 0.002), and all of the quality of life scores improved (p < 0.05 for all). The same was true for the proportion of patients prior to and after the educational intervention using the proper inhalation technique when using metered dose inhalers (15.4% vs. 46.2%; p = 0.02) and dry powder inhalers (21.3% vs. 76.6%; p < 0.001). The logistic regression analysis revealed that an incorrect inhalation technique identified during the first evaluation was independently associated with a favorable response to the educational intervention. Conclusions: This study suggests that an outpatient education program for asthma patients improves the level of asthma control, lung function parameters, and quality of life. An incorrect inhalation technique identified during the first evaluation was predictive of a favorable response to the educational intervention.

Keywords: Asthma/prevention and control; Quality of life; Respiratory function tests; Ambulatory care; Health education.

Objective: To evaluate the effects that a hand hygiene education program has on the compliance of health professionals in an ICU. Methods: This was a quasi-experimental study with an interrupted time-series design, conducted over a 12-month period: the 5 months preceding the implementation of a hand hygiene education program (baseline period); the 2 months of the intensive (intervention) phase of the program; and the first 5 months thereafter (post-intervention phase). Hand hygiene compliance was monitored by one of the researchers, unbeknownst to the ICU team. The primary outcome measure was the variation in the rate of hand hygiene compliance. We also evaluated the duration of mechanical ventilation (MV), as well as the incidence of ventilator-associated pneumonia (VAP) at 28 days and 60 days, together with mortality at 28 days and 60 days. Results: On the basis of 959 observations, we found a significant increase in hand hygiene compliance rates-from 31.5% at baseline to 65.8% during the intervention phase and 83.8% during the post-intervention phase, corresponding to prevalence ratios of 2.09 and 2.66, respectively, in comparison with the baseline rate (p < 0.001). Despite that improvement, there were no significant changes in duration of MV, VAP incidence (at 28 or 60 days), or mortality (at 28 or 60 days). Conclusions: Our findings indicate that a hand hygiene education program can increase hand hygiene compliance among ICU professionals, although it appears to have no impact on VAP incidence, duration of MV, or mortality.

Keywords: Hand disinfection; Health personnel; Pneumonia, ventilator-associated; Respiration, artificial; Guideline adherence.

Objective: To evaluate respiratory muscle strength and six-minute walk test (6MWT) variables in patients with uncontrolled severe asthma (UCSA). Methods: This was a cross-sectional study involving UCSA patients followed at a university hospital. The patients underwent 6MWT, spirometry, and measurements of respiratory muscle strength, as well as completing the Asthma Control Test (ACT). The Mann-Whitney test was used in order to analyze 6MWT variables, whereas the Kruskal-Wallis test was used to determine whether there was an association between the use of oral corticosteroids and respiratory muscle strength. Results: We included 25 patients. Mean FEV1 was 58.8  21.8% of predicted, and mean ACT score was 14.0  3.9 points. No significant difference was found between the median six-minute walk distance recorded for the UCSA patients and that predicted for healthy Brazilians (512 m and 534 m, respectively; p = 0.14). During the 6MWT, there was no significant drop in SpO2. Mean MIP and MEP were normal (72.9  15.2% and 67.6  22.2%, respectively). Comparing the patients treated with at least four courses of oral corticosteroids per year and those treated with three or fewer, we found no significant differences in MIP (p = 0.15) or MEP (p = 0.45). Conclusions: Our findings suggest that UCSA patients are similar to normal subjects in terms of 6MWT variables and respiratory muscle strength. The use of oral corticosteroids has no apparent impact on respiratory muscle strength.

Background: Chronic obstructive pulmonary disease is detrimental to lung mechanics and peripheral muscles. The physical programs developed for this condition are usually targeted to an improvement on aerobics capacity. Programs that approach specifically the changes in thoracic mobility and thoracic muscles are rare. Objective: To assess the effects of a physical exercise program designed to increase chest wall mobility on functional and psychosocial capacity in moderate to severe chronic obstructive pulmonary disease patients. Methods: Thirty patients with moderate to severe chronic obstructive pulmonary disease were studied. They were randomized to 2 groups: control group (CG) and treated group (TG). The CG was submitted to an educational program and the TG was submitted to an educational program plus a physical exercise program aiming to increase chest wall mobility. Variables included spirometry, thoracic mobility, quality of life, anxiety and depression levels and a six minute walk test (6MWT). Results: After 2 months of training, only the TG presented improvements on chest wall mobility (from 4.20 ± 0.58 cm to 5.27 ± 0.58 cm; p = 0.05) and 6MWT (from 469.73 ± 31.99 m to 500.60 ± 27.38 m; p = 0.01). It was also observed that the TG presented improvement on the St. George's Respiratory Questionnaire (SGRQ) score, Chronic Respiratory Questionnaire (CRQ), and Beck's depression scale after 2 months of treatment. Pulmonary function did not improve either in the CG or in the TG group. Conclusion: Our results suggest that exercises aimed to the increasing of chest wall mobility improve thoracic mobility, quality of life, submaximal exercise capacity, and reduce dyspnea and depression symptoms in chronic obstructive pulmonary disease patients.

Keywords: COPD. Thoracic mobility. Quality of life. Capacity of exercise. Dyspnea.

Objective: To evaluate patient profiles and factors associated with successful treatment. Methods: A retrospective study of patients enrolled in the smoking cessation program at the Hospital de Messejana, located in the state of Ceará, Brazil, from October of 2002 to April of 2005. The treatment was evaluated based on patient profile, type of medication prescribed and time on that medication. Results: Of the 320 patients enrolled, 65.5% were women. The mean age at the outset of treatment was 48 years, and the mean duration of the smoking habit was 33 years. More than 90% of the patients had started smoking before the age of 20. Of the 258 individuals who had enrolled in the program at least one year prior, 50.8% had achieved treatment success; 17.8% had relapsed, and 31.4% had not quit smoking. On average, partial success was achieved in the fifth week of the treatment, and relapse occurred predominantly in the fourth month. Approximately 60% of the patients were treated with medication. Conclusion: Quitting smoking was significantly associated with the use of medication, regardless of the profile of the smoker evaluated. In the second year of the program, quitting smoking was more strongly associated with the use of bupropion and nicotine replacement, resulting in a higher success rate and a trend toward a reduction in the relapse rate.

Keywords: Smoking/therapy; Tobacco use cessation; Bupropion; Nicotine

The direct costs incurred in managing patients with poorly controlled asthma are high and educational programs could decrease these costs. Aim: The objectives of this study were to compare the direct cost of the implementation of an educational program for adult asthmatic patients with the cost of the usual care delivered to asthmatics by specialists. Methods: Five years ago, a six-month study demonstrated that an educational program improved clinical outcomes (22 in educational program-E and 20 patients in control group-C). Throughout the educational intervention period all cases of hospitalization, emergency and regular calls involving patients from both groups were recorded. The basis for the values utilized in the calculation of costs was the healthcare database of the Brazilian government (DATASUS). The overall medication cost/patient in both groups was based on the amount of medication taken during the month preceding the last call. The final values were converted into US dollars. Results: The mean direct cost/patient in the educational (E) and control (C) groups and the difference (Δ) between groups were: hospitalizations (C = US$ 183, E = 0, Δ = US$ 183); emergency calls (C = US$ 14, E = US$ 5, Δ = US$ 9); regular calls (C = US$ 10, E = US$ 24, Δ = -US$ 14); medication (C = US$ 124,3, E = US$ 195,6, Δ = -US$ 71,3). The total cost was US$ 33/patient in group C and US$ 224/patient in group E with an average cost saving of US$ 107/patient. Conclusion: The expenses with medication is higher in E group because the regular use of maintenance drugs, however the study suggested that the application of the asthma education program reduced the total direct costs of asthma.

Keywords: Asthma. Cost-benefit. Patient education.

Abstract Objectives: To determine the frequency of adverse effects related to the use of the tuberculosis treatment regimen designated Regimen I and the need for regimen alterations due to these effects. Methods: A retrospective analysis of 329 medical charts of patients who were treated with Regimen I and discharged after cure between March 2000 and April 2006 was carried out at the Tuberculosis Outpatient Clinic, Department of Pulmonology of the Santa Casa de Misericórdia de São Paulo Hospital in the city of São Paulo, Brazil. Adverse effects and the timing of their appearance, as well as subsequent modifications in the treatment regimen, were investigated. Results: We included 297 patients, 146 (49.1%) of whom presented one or more adverse effects related to antituberculosis medications. The frequency of minor side effects was 41.1%, and that of major side effects was 12.8%. The most common reactions were those involving the gastrointestinal tract (40.3%) and the skin (22.1%). Adverse effects were more common in the first and second months of treatment (58.4%). Modification of the treatment regimen was necessary in 11 cases (3.7% of the total sample). Drug-induced hepatitis was the adverse effect that demanded the most regimen changes. Conclusions: In this group of patients, the frequency of adverse effects related to treatment with Regimen I was 49.1%. However, in most of the cases, it was not necessary to modify the treatment regimen due to side effects.

Keywords: Tuberculosis/therapy; Antitubercular agents/adverse effects; Hepatitis, toxic.

Objective: To evaluate the understanding of asthma and the clinical improvement in patients with moderate or severe persistent asthma prior to and after their participation in an educational program presented during the routine outpatient visits. Methods: This was a prospective pilot study involving 164 patients over a two-year period. The educational program, presented to small groups on outpatient visit days, consisted of lectures divided into three parts: pathophysiology; environmental control; and treatment, including training in the inhalation technique. The program was evaluated using standardized questionnaires on clinical improvement and understanding of the disease. Results: By the end of the first year, 120 patients had completed three visits, and 51 of those patients were revaluated at the end of the second year. The mean age of the patients was 44 years, 70% were female, and 43% had up to eight years of schooling. The educational intervention significantly increased the understanding of the disease (p < 0.001), and allowed greater clinical improvement (p < 0.05) with a decrease in the use of oral corticosteroids, fewer visits to the emergency room and fewer days missed from work or school. Conclusions: The educational program offered during the routine outpatient visits of adult patients with asthma at our clinic resulted in a progressive long-term increase in knowledge, as well as in clinical improvement.

Keywords: Asthma; Adult; Patient education as topic.

To describe and characterize local adverse effects (in the oral cavity, pharynx, and larynx) associated with the use of inhaled corticosteroids (ICSs) in patients with moderate or severe asthma. Methods: This was a cross-sectional study involving a convenience sample of 200 asthma patients followed in the Department of Pharmaceutical Care of the Bahia State Asthma and Allergic Rhinitis Control Program Referral Center, located in the city of Salvador, Brazil. The patients were ≥ 18 years of age and had been using ICSs regularly for at least 6 months. Local adverse effects (irritation, pain, dry throat, throat clearing, hoarseness, reduced vocal intensity, loss of voice, sensation of thirst, cough during ICS use, altered sense of taste, and presence of oral candidiasis) were assessed using a 30-day recall questionnaire. Results: Of the 200 patients studied, 159 (79.5%) were women. The mean age was 50.7 ± 14.4 years. In this sample, 55 patients (27.5%) were using high doses of ICS, with a median treatment duration of 38 months. Regarding the symptoms, 163 patients (81.5%) reported at least one adverse effect, and 131 (65.5%) had a daily perception of at least one symptom. Vocal and pharyngeal symptoms were identified in 57 (28.5%) and 154 (77.0%) of the patients, respectively. The most commonly reported adverse effects were dry throat, throat clearing, sensation of thirst, and hoarseness. Conclusions: Self-reported adverse effects related to ICS use were common among the asthma patients evaluated here.

Keywords: Asthma; Glucocorticoids; Administration, inhalation; Pharmaceutical services.

Objective: Duchenne muscular dystrophy (DMD) is the most common form of muscular dystrophy in children, and children with DMD die prematurely because of respiratory failure. We sought to determine the efficacy and safety of yoga breathing exercises, as well as the effects of those exercises on respiratory function, in such children. Methods: This was a prospective open-label study of patients with a confirmed diagnosis of DMD, recruited from among those followed at the neurology outpatient clinic of a university hospital in the city of São Paulo, Brazil. Participants were taught how to perform hatha yoga breathing exercises and were instructed to perform the exercises three times a day for 10 months. Results: Of the 76 patients who entered the study, 35 dropped out and 15 were unable to perform the breathing exercises, 26 having therefore completed the study (mean age, 9.5  2.3 years; body mass index, 18.2  3.8 kg/m2). The yoga breathing exercises resulted in a significant increase in FVC (% of predicted: 82.3  18.6% at baseline vs. 90.3  22.5% at 10 months later; p = 0.02) and FEV1 (% of predicted: 83.8  16.6% at baseline vs. 90.1  17.4% at 10 months later; p = 0.04). Conclusions: Yoga breathing exercises can improve pulmonary function in patients with DMD.

Keywords: Respiratory therapy; Forced expiratory volume; Vital capacity; Muscular dystrophy, Duchenne; Complementary therapies.

Objective: To present the Programa Infantil de Prevenção de Asma (PIPA, Program for the Prevention of Childhood Asthma) and the characteristics of the patients followed in this program. Methods: Implemented in the city of Uruguaiana, Brazil, PIPA has as its target population children and adolescents (< 18 years of age) with asthma or suspected asthma. Patients either enroll in PIPA spontaneously or are referred by pediatricians or primary care physicians. In this retrospective study, we use a standardized protocol to assess PIPA patients. Results: By the end of the study period, 646 patients were being followed. Of those, 298 (46.1%) were ≤ 3 years of age. In this group of patients, recurrent wheezing was identified in 60.7%, and the first episode of wheezing occurred in the first six months of life in 86.0%. Severe wheezing was identified in 29.5% and 45.4% in the children ≤ 3 and > 3 years of age, respectively. Physician-diagnosed asthma was reported in 26.5% and 82.2%, respectively. In the sample as a whole, the prevalence of passive smoking was high (> 36%), occurring during pregnancy in > 15%; > 40% of the patients had been born by cesarean section; and 30% had a mother who had had < 8 years of schooling. Conclusions: A prevention program for children with asthma is an effective strategy for controlling the disease. Knowledge of local epidemiological and environmental characteristics is essential to reducing the prevalence of the severe forms of asthma, to improving the use of health resources, and to preventing pulmonary changes that could lead to COPD in adulthood.

Keywords: Asthma/prevention and control; Asthma/epidemiology; Patient care.

Objective: To determine the clinical characteristics and the predictors of hospital admission due to asthma among children and adolescents with asthma under treatment at a referral center. Methods: A retrospective cohort study comprising 151 children and adolescents with asthma, referred from the Unified Health Care System and enrolled in the Asthma and Allergic Rhinitis Control Program in the city of Feira de Santana, Brazil, followed for a period of 12 months and receiving asthma medication at no cost. The chi-square test was used in order to determine the associations between the studied variables and the occurrence of hospital admissions, whereas the Mann-Whitney test was used for the comparison between the groups of hospitalized patients and nonhospitalized patients. The level of significance was set at p < 0.05. Univariate analysis with logistic regression was performed in order to determine the predictors of hospital admission. Results: Of the 151 patients evaluated, 8 (5.2%) were hospitalized, in a total of 12 hospital admissions. In the univariate analysis, the only variable found to be a predictive factor was greater asthma severity (OR = 13.3; 95% CI: 2.55-70.1). Conclusions: The fact that, in our study sample, the principal predictor of hospital admission was greater asthma severity, calls for special attention being given to the care of these patients.

Keywords: Asthma; Hospitalization; Health services.

Objective: To report demographic and clinical characteristics of patients with asthma who evolved to death, as well as to describe the conditions related to this outcome in a subgroup of patients admitted to the Program for the Control of Asthma and Rhinitis in Bahia (ProAR). Methods: A descriptive, retrospective, observational study. Data from clinical charts and death certificates of 16 patients of 930 subjects with severe asthma monitored at the ProAR Central Reference Center from December 2003 to June 2006 were reviewed. Results: Of the 930 patients participating in the program, 16 (1.72%) died. Of these, there were 10 males and 6 females, ranging in age from 39 to 74 years (median, 55 years); 12 (75%) of the patients were black. Time since diagnosis ranged from 1 to 68 years (median, 30 years). In 43.8 and 53.8%, respectively, there was a personal or family history of atopy. Ex-smokers (<10 pack-years) accounted for 37.5% of the cases. Causes of death listed on the death certificates were as follows: asthma or asthma exacerbations in 8 (50%); respiratory failure in 3 (18.75%); acute heart infarction in 2 (12.5%); hepatitis in 1 (6.25%); hypovolemic shock in 1 (6.25%); and cardiorespiratory arrest in 1 (6.25%). Of the 16 deaths, 13 (81.25%) occurred inside hospitals. Conclusion: Asphyxia and cardiovascular diseases were the most common atributed causes of mortality in this subgroup of patients with severe asthma. Hospital-based mortality, male gender, advanced age, long-term disease and fixed airflow obstruction were the aspects most frequently observed in the cases studied.

Keywords: Mortality; Rhinitis/treatment; Asthma/treatment; Cardiovascular diseases.

Objective: Preoperative functional evaluation is central to optimizing the identification of patients with non-small cell lung cancer (NSCLC) who are candidates for surgery. The minute ventilation/carbon dioxide output (VE/VCO2) slope has proven to be a predictor of surgical complications and mortality. Pulmonary rehabilitation programs (PRPs) could influence short-term outcomes in patients with COPD undergoing lung resection. Our objective was to evaluate the effects of a PRP on the VE/VCO2 slope in a cohort of patients with COPD undergoing lung resection for NSCLC. Methods: We retrospectively evaluated 25 consecutive patients with COPD participating in a three-week high-intensity PRP prior to undergoing lung surgery for NSCLC, between December of 2015 and January of 2017. Patients underwent complete functional assessment, including spirometry, DLCO measurement, and cardiopulmonary exercise testing. Results: There were no significant differences between the mean pre- and post-PRP values (% of predicted) for FEV1 (61.5 ± 22.0% vs. 62.0 ± 21.1%) and DLCO (67.2 ± 18.1% vs. 67.5 ± 13.2%). Conversely, there were significant improvements in the mean peak oxygen uptake (from 14.7 ± 2.5 to 18.2 ± 2.7 mL/kg per min; p < 0.001) and VE/VCO2 slope (from 32.0 ± 2.8 to 30.1 ± 4.0; p < 0.01). Conclusions: Our results indicate that a high-intensity PRP can improve ventilatory efficiency in patients with COPD undergoing lung resection for NSCLC. Further comprehensive prospective studies are required to corroborate these preliminary results.

Keywords: Carcinoma, non-small-cell lung; Pulmonary disease, chronic obstructive/rehabilitation; Carbon dioxide/metabolism; Oxygen consumption/physiology; Risk assessment.

Introduction: Silicosis is the most prevalent pneumoconiosis in Brazil, with most of the registered cases occurring in the State of Minas Gerais. Although it is a preventable disease, silicosis is still epidemic in some areas. Objective: To describe the profile of workers seen at the Clinics Hospital of the Federal University of Minas Gerais. Patients and methods: 300 medical records of silica-exposed workers in different occupations, seen between 1989-2000, were reviewed. Clinical and occupational information, radiographic and spirometric data were analyzed. Statistical methods included univariate analyses with chi-square and t tests. Results and conclusion: The mean age of the exposed patients was 51 years, with mean exposure duration of 15.6 years. 126/300 (42%) were radiologically classified as cases of silicosis. Increasing grades of profusion were associated with lower spirometric indices and more frequent associations with tuberculosis and chronic airflow limitation. Most of the workers were regularly registered employees and the main occupational activity was mining, accounting for the exposure of 197 (66%) workers. Non-registered workers presented more severe radiological grades of silicosis, suggesting, possibly, worse conditions of silica exposure in this group of workers.

Background: Tuberculosis is an ancient disease, which still remains one of the major ills faced by mankind in the 21st century. In recent decades, new technologies employing the knowledge gained from molecular biology studies have allowed for more accurate detection of tuberculosis and increased investigation of the etiology and epidemiology of the disease. Aim: Evaluating the degree of similarity among strains of Mycobacterium tuberculosis provided by the Phthisiology Sector of Centro de Saúde Navegantes (Navegantes Health Clinic) in Porto Alegre, RS, Brazil. Method: A retrospective study was performed involving RFLP typing of 55 sputum samples from outpatients examined at the Centro de Saúde Navegantes. The results of the genotyping were correlated to the conventional epidemiology data. Results: A single pattern was seen in 39 (70.9%) of the isolates, whereas 16 isolates (29.1%) showed clustering patterns and were grouped into 8 clusters of 2 patients each. An epidemiological link was found for 6 (37.5%) of the 16 patients in the clusters. Conclusion: The appropriate combination of conventional epidemiology and genotyping of M. tuberculosis contributes to a better understanding of the dynamics of tuberculosis transmission even when such a study is performed in a single, isolated health clinic.

Keywords: Mycobacterium tuberculosis. Transmission. Polymorphism, Restriction Fragment Length. Epidemiology.

Objective: To investigate the effects of airway obstruction on albuterol-mediated variations in the resistive and elastic properties of the respiratory system of adult patients with asthma. Methods: This study comprised 24 healthy controls and 69 patients with asthma, all of whom were nonsmokers. The patients were divided into three groups according to the severity of airway obstruction (mild, moderate or severe). Each of the three groups was divided into two subgroups according to the bronchodilator response (BR): positive (BR+) or negative (BR−). These measurements were conducted before and after albuterol use (300 µg). Airway obstruction was determined by means of spirometry, and the resistive and elastic properties were determined by means of the forced oscillation technique. Results: The resistance at the intercept (R0) presented greater reductions in the groups with higher obstruction. This reduction was more evident in the BR+ subgroups than in the BR− subgroups (p < 0.02 and p < 0.03, respectively). There was a significant difference between the control group and the BR+ subgroup with severe obstruction (p < 0.002). The reductions in dynamic elastance (Edyn) were significantly greater in proportion to the degree of obstruction, in the BR− subgroups (p < 0.03), and in the BR+ subgroups (p < 0.003). The reductions in Edyn were significantly greater in the BR− subgroup with moderate obstruction (p < 0.008) and in the BR+ subgroup with severe obstruction (p < 0.0005) than in the control group. Conclusions: In patients with asthma, increased airway obstruction results in greater reductions in R0 and Edyn after albuterol use. These reductions are greater among BR+ patients than among BR− patients.

Keywords: Asthma; Bronchodilator agents; Respiratory mechanics; Spirometry; Albuterol.

Objective: To determine whether a low level of education is a risk factor for uncontrolled asthma in a population of patients who have access to pulmonologists and to treatment. Methods: This was a cross-sectional study involving outpatients > 10 years of age diagnosed with asthma who were followed by a pulmonologist for at least 3 months in the city of Jundiai, located in the state of São Paulo, Brazil. The patients completed a questionnaire specifically designed for this study, the 6-item Asthma Control Questionnaire (to assess the control of asthma symptoms), and a questionnaire designed to assess treatment adherence. Patients underwent spirometry, and patient inhaler technique was assessed. Results: 358 patients were enrolled in the study. Level of education was not considered a risk factor for uncontrolled asthma symptoms (OR = 0.99; 95% CI: 0.94-1.05), spirometry findings consistent with obstructive lung disease (OR = 1.00; 95% CI: 0.99-1.01), uncontrolled asthma (OR = 1.03; 95% CI: 0.95-1.10), or the need for moderate/high doses of inhaled medication (OR = 0.99; 95% CI: 0.94-1.06). The number of years of schooling was similar between the patients in whom treatment adherence was good and those in whom it was poor (p = 0.08), as well as between those who demonstrated proper inhaler technique and those who did not (p = 0.41). Conclusions: Among asthma patients with access to pulmonologists and to treatment, a low level of education does not appear to be a limiting factor for adequate asthma control.

Keywords: Asthma; Educational status; Spirometry; Treatment adherence and compliance.