Asma bronquial: característiques clíniques, grau de control i aguditzacions

Abstract

Bronchial asthma is a common disease with a prevalence of 10-13% of population. A 27% of the asthmatic population required to be attended in the outpatient settings in the last year. This last report is, in part, due to the clinical control deficiency of the asthmatic population. Asthmatic exacerbations (AE) could be an epiphenomenon of this bad control, or likely due to the presence of one or many triggering agents, such as viruses or allergens. At present, patients do not always receive an accurate treatment and report that their disease is poorly controlled. This unsatisfactory control gives rise to a greater personal discomfort and it is also a risk for the patient, since asthma is a potentially mortal threat; besides, it is also a greater economic burden on the heath system, which significantly increases health care assistance due to exacerbations. For these reasons, we decided to evaluate this situation in our settings and to outline a few clinical behaviour and measures to be followed so that patients improved their control rate of asthma symptoms. First study: Monitoring of asthma outpatients after adapting treatment to meet international guidelines (ASMACAP I). Objective: Poor control of asthma treated in outpatient settings has been demonstrated. The aim of this study was to perform a short intervention, readily replicable in everyday practice, to try to improve control of asthma symptoms. Patients and Methods: Two primary health care clinics made appointments with asthma patients to administer a questionnaire and adapt their treatment to the guidelines of the GINA (Global Initiative for Asthma). Patients also received an explanation of the disease lasting not more than 5 minutes. The protocol was repeated at a second visit 4 months later. Health care parameters were compared with those from the previous visit. Results: The characteristics of the 180 patients were as follows: 70% were women, 17% were smokers, 8% were illiterate, 46% had only primary education, 45% were in contact with cleaning products, and 63% had extrinsic asthma. The asthma severity was as follows: mild in 73%, moderate in 23%, and severe in 4%. Twenty-two percent had received previous explanations of the disease, 50% had a written treatment plan, 14% had a plan for exacerbations, and 54% were taking inhaled corticosteroids. The second appointment was kept by 110 (61%) of the patients, who showed differences with respect to the previous visit 4 months earlier in the percentage taking inhaled corticosteroids (78%, p . 001), the number of visits to the physician (p . 01), visits to the physician due to exacerbations (p . 001), emergency visits to the outpatient clinic (p . 002), and disease severity (p . 02). Conclusions: This minimal clinical intervention reduced the need for visits to health care centers and improved the clinical control of the disease. Second study: Rate and characteristics of asthma exacerbations: The ASMAB I Study. Objective: The aim of this study was to determine the incidence and clinical characteristics of asthma exacerbations seen by emergency services in Barcelona, Spain (the ASMAB-I study). Patients and methods: The emergency services considered in the study served a population of 1. 203. 598 inhabitants aged over 14 years. Episodes treated in hospital emergency departments and by emergency services called to patients' homes over a period of 129 days were included in the study. Results: In total, 831 episodes of exacerbation were identified; 523 were seen in 3 university hospitals, 113 in secondary hospitals, and 195 by emergency services at the patient's home. Twenty of the patients seen at home were subsequently taken to hospital. The mean frequency was 6. 4 episodes per day, corresponding to a daily incidence of 0. 53 exacerbations per 100. 000 inhabitants (95% confidence interval, 0. 46-0. 56 exacerbations/100. 000 inhabitants) and 8. 2 per 100. 000 asthmatic patients (95% confidence interval, 6. 89-8. 41 exacerbations/100. 000 asthmatic patients). Of the 276 episodes treated between Monday to Thursday in university hospitals, 66 patients (24%) reported acute onset and 14 (5%) sudden onset. Only 85 patients (31%) regularly used inhaled corticosteroids and only 33 (12%) added oral corticosteroids in the 12 hours prior to consulting emergency services. In 16% of cases the episode was classified as severe and in 3% near fatal. Eighty-two patients (30%) were ultimately admitted to hospital: 12% of mild exacerbations, 39% of moderate exacerbations, 62% of severe episodes, and 100% of near-fatal episodes. The Charlson comorbidity index was higher in patients admitted to hospital (p . 001). In the 28 patients readmitted to hospital (10%), antibiotics (p . 001) and ipratropium bromide (p . 0001) had been prescribed less often at the time of discharge after the first hospital admission. Conclusions: The rate of asthma exacerbation established in this study may be a useful indicator of the degree of control of the disease and may serve as a reference to confirm future short-term or lasting increases in asthma exacerbations. Rapid onset (acute or sudden) is common and many patients are not receiving appropriate treatment prior to hospital admission. Severe exacerbation is common in our practice setting. Hospital admission is related to severity and comorbidity. Patients who are readmitted to hospital had less often received antibiotic treatment and ipratropium bromide when discharged previously.

Date of Award	30 Oct 2008
Original language	Catalan
Supervisor	Ferran Morell Brotad (Director) & Javier Mundet Tuduri (Director)