Bakgrund: Kroniskt obstruktiv lungsjukdom (KOL) är en vanlig sjukdom som drabbar oftast äldre och rökare. Typiska symtom är andnöd, produktiv hosta, trötthet samt återkommande luftvägsinfektioner. Flera olika bidragande orsaker kan leda till att en KOL-patient utvecklar sjukdomen, bland annat rökning, luftföroreningar, socioekonomisk status, astma, genetik, luftvägsinfektioner och dålig kost. KOLpatienter drabbas oftast av försämringsperioder, så kallade KOL-exacerbationer. En KOL-exacerbation kan förekomma i olika grader: som mild, måttlig eller svår. Oavsett svårighetsgraden ges olika läkemedel för att minska frekvensen av exacerbationer och för att förbättra livskvaliteten hos en KOL-patient. Det finns olika tillgängliga läkemedel i dagsläget för att behandla både KOL och KOL-exacerbationer. I detta projektarbete granskades åtta tidigare studier för att undersöka effekten av peroral kortisonkur hos KOL-patienter med mild till måttlig KOL-exacerbation. Även undersöktes om peroral kortisonkur var en effektiv behandling för att minska exacerbationsfrekvens och därmed förbättra livskvaliteten samt hälsostatus hos KOLpatienter. Syfte: Syftet var att undersöka vilken evidens som finns för peroral kortisonkur enligt GOLD 2019s rekommendation vid mild-måttlig KOL-exacerbation hos KOL-patienter i GOLD stadium B. Metod: En systematisk litteraturgenomgång gjordes enligt Statens beredning för medicinsk och social utvärdering (SBU) metoden. Databaserna PubMed och Cochrane library användes för att hitta relevanta artiklar för projektarbetet. Både randomiserade studier och systematiska översikter inkluderades i projektarbetet. Bedömning av relevans och kvalitet av artiklarna gjordes med hjälp av mallar från SBU. Resultat: Åtta artiklar inkluderades, av vilka två av hög kvalitet och resterande sex av godtagbar kvalitet. Artiklarnas resultat visade att det fanns evidens för att ge peroral kortisonkur till KOL-patienter med mild till måttlig KOL-exacerbation. Dessutom ger peroral kortisonkur positiv effekt med avseende på excerbationsfrekvens, andfåddhet, hälsostatus och livskvalitet. Risken/biverkningarna av peroral kortisonkur har inte tagit med i detta arbete. Slutsats: Slutsatsen för projektarbetet var att peroralt prednisolon ger effekt vid mild till måttlig KOL-exacerbation i GOLD stadium B och minskar exacerbationsfrekvens, förbättrar lungfunktion samt livskvalitet. En mer nyanserande evidenssammanställning hade kunnat göras om även riskerna med kortisonbehandling hade beaktats.

Chronic obstructive lung disease is among the leading causes of adult hospital admissions and readmissions in the United States. Preventing acute exacerbations is the primary approach in therapy. Combinations of smoking cessation, pulmonary rehabilitation, vaccinations and inhaled and oral medications may all reduce the overall risk of acute exacerbations. When prevention is unsuccessful, treatment of exacerbations often does not require hospitalization but can be safely executed in the outpatient setting. In the patient who does not require mechanical ventilation or who manifests respiratory acidosis, oxygen supplementation, frequent short-acting inhaled bronchodilators, oral corticosteroids and often antibiotics can abort the decompensation and sometimes return the patient to his or her pre-attack baseline lung function. Several models exist for delivering this care in the ambulatory setting. Follow-up care after an exacerbation has resolved is important, though there are few hard data suggesting which approach is best in this setting.

Many patients are affected by chronic obstructive pulmonary disease (COPD), a progressive lung disease that obstructs air flow, resulting in dyspnea and inability to carry out daily activities. Despite optimal pharmacological management, COPD patients make frequent emergency room visits and are hospitalized due to exacerbations of COPD. Literature has suggested that pulmonary rehabilitation (PR), a nonpharmacological treatment, could help to decrease the symptoms that lead to illness exacerbation, hospital readmissions, and decreased quality of life in patients with COPD. The purpose of the project was to increase the quality of life and reduce admission rates for patients diagnosed with COPD through the development and implementation of patient education material that would increase PR awareness, increase patient motivation, and promote participation. The ACE star model was used to guide the project development, and the theoretical framework of the health belief model was used to enhance patients' perceptions and desires to participate in a PR program. Evaluation of the pretests and posttests revealed significant improvement in various variables, reduction of dyspnea, improved exercise tolerance, and increased knowledge. The evaluation of health-related quality of life using the short form 36 showed significant improvement in some subscales namely: general health, role emotional, with slight significance in bodily pain. There were no readmissions among the participants. The implementation of comprehensive PR has implications for positive social change because it helps patients with COPD to be more knowledgeable about their disease and allows for more independence and a higher quality of life.

No description available.

No description available.

Background: Air pollution has been associated with adverse health effects for all-cause and specific respiratory morbidity and mortality outcomes. Acute exacerbations of COPD (AE-COPD) accelerate the decline in pulmonary function and are associated with greater mortality, morbidity, health care utilization, and reduced quality of life. Since the 1970 Clean Air Act was implemented, important reductions in air pollution have been achieved, but no safe threshold has been identified. Objectives: The study was planned to evaluate associations between exposure to ambient concentrations of five criteria air pollutants (CO, SO2/, NO2/, ozone, PM2.5/) in Philadelphia, Pennsylvania, and visits to Temple University Hospital for AE-COPD, from January 1, 2005 through March 31, 2007. To identify subgroups with greater susceptibility to air pollution, associations were examined according to age, gender, race, residence, and antibiotic prescription. Methods: Average daily air pollutant concentrations were obtained from the EPA's Air Quality Services Data Mart. Air pollutant exposures were evaluated for the day of the visit (lag0), one and two days preceding the visit (lag1 and lag2), and the average concentration over three days (lag012). Poisson regression provided rate ratios (RRs) to estimate associations between air pollution exposures and AE-COPD hospital visits. Results: Of 1546 hospital visits for AE-COPD, 43% were from persons 65 years or older, 50% of each gender, and 90% from Philadelphia. In single pollutant models, increased RRs were present at all lags for NO2/ (e.g., RR = 2.27 [95%CI: 1.52, 3.38] at lag012) and SO2/ (e.g., RR = 1.70 [95%CI: 1.38, 2.08] at lag012). For PM2.5/, the direct effect was present only during the winter at lag1, lag2, and lag012 (RR = 1.79 [95%CI: 1.08, 2.96]). Inverse associations were present for ozone at all lags (e.g., RR = 0.64 [95%CI: 0.53, 0.76] at lag012). Compared to the cohort as a whole, those ≥ 65 years of age were at greater risk of an AE-COPD hospital visit associated with PM2.5/ and CO at lag012, with NO2/ and SO2/ at lag0 and lag012, but there was no difference in ozone effect. Conclusions: Primary gaseous air pollution exposures (SO2/, CO, NO2/) were associated with increased AE-COPD hospital visits among COPD patients at Temple University Hospital. The effects of SO2/, CO, NO2/, and PM2.5 were greater for the subgroup ≥ 65 years of age compared to the cohort as a whole. Inverse associations with ozone were consistent across subgroups. These results suggest that air quality during the study period was insufficient to protect the health of COPD patients, especially those ≥ 65 years old. Further study is needed to understand generalizability to other populations and to evaluate lower ranges of exposure from current levels of air pollution. / Public Health

L’asthme est l’une des pathologies chroniques les plus fréquemment rencontrées durant la grossesse, affectant environ 8% des femmes enceintes. Les lignes directrices pour le traitement de l’asthme affirment que le risque d’un développement non optimal du fœtus dû à un asthme mal maîtrisé est supérieur au risque associé à la prise de médicaments pour le traitement de l’asthme durant la grossesse. Des questions persistent par contre sur l’innocuité des hautes doses de corticostéroïdes inhalés (CSI) et très peu de données sont publiées pour les bêta2-agonistes à longue action (BALA). Un programme de recherche en deux volets a été développé afin de répondre à certaines de ces questions. Dans un premier volet, une cohorte de femmes asthmatiques accouchant au Québec de 1998 à 2008 a été assemblée à partir des bases de données de la Régie de l’assurance maladie du Québec et de MED-ÉCHO afin d’évaluer l’impact de la prise de CSI ou de BALA sur la prévalence de faible poids à la naissance (FPN), de prématurité et de bébé petit pour l’âge gestationnel (PAG). La cohorte était composée de 7376 grossesses dont 56,9% étaient exposées aux CSI et 8,8% aux BALA. Dans cette cohorte, l’utilisation de BALA n’était pas associée à des prévalences plus élevées de FPN (OR=0,81, IC95%:0,58–1,12), prématurité (OR=0,84, IC95%:0,61–1,15) ou PAG (OR=0,92, IC95%:0,70–1,20). Lors de la comparaison des BALA (salmétérol comparé au formotérol comme référence) la différence la plus importante était pour le PAG (OR=1,16, IC95%:0,67–2,02). Pour les CSI, une tendance à une augmentation de FPN, prématurité et PAG a été observée avec l’augmentation des doses. Le OR le plus élevé était pour une dose > 500 ug/jour (équivalent fluticasone) pour le FPN: (OR=1,57, IC95%:0,86–2,87). La comparaison des CSI les plus utilisés (fluticasone comparé au budésonide comme référence) montre des différences non statistiquement significatives avec la différence maximale observée pour le PAG (OR=1,10, IC95%:0,85–1,44). Dans un second volet, une sous-cohorte de femmes asthmatiques avec visites médicales pour exacerbation d’asthme au Centre hospitalier universitaire de Sherbrooke (CHUS) a été constituée pour comparer le traitement des exacerbations durant et hors grossesse. Les résultats montrent que le traitement par CS était moins fréquent et différé pour les femmes enceintes comparées aux femmes non-enceintes. Le traitement de maîtrise de l’asthme (CSI et/ou BALA) dans l’année précédant l’exacerbation était sous-optimal. Les résultats présentés dans cette thèse démontrent l’innocuité des BALA et des doses faibles à modérées de CSI pendant la grossesse pour les issues de FPN, prématurité et PAG alors que des études supplémentaires sont nécessaires afin d’évaluer l’innocuité des hautes doses de CSI. Une innocuité comparable entre les CSI (budésonide, fluticasone) et les BALA étudiés (formotérol, salmétérol) a également été démontrée. Les résultats montrent également un recours moindre aux CS pour le traitement des exacerbations d’asthme durant la grossesse comparativement à hors grossesse. Ces résultats sont un ajout important aux évidences permettant aux cliniciens et aux femmes enceintes asthmatiques de faire les meilleurs choix pour optimiser le traitement pharmacologique durant la grossesse. / Asthma is one of the most common chronic medical conditions encountered during pregnancy, affecting approximately 8% of pregnant women. Current asthma treatment guidelines emphasize the importance and safety of the use of asthma medications during pregnancy compared to the risk of poorly controlled asthma for the fetus. In the evaluation of the safety of asthma medications during pregnancy, the literature review shows that questions persist, amongst others, on the safety of high inhaled corticosteroids (ICSs) doses and that there is a paucity of data on the safety of long-acting beta2-agonists (LABAs). A two components research program was developed to answers some of these questions. In the first component, a cohort of asthmatic women giving birth from 1998 to 2008 was constructed from the Régie de l’assurance maladie du Québec (RAMQ) et de MED-ÉCHO databases to assess the impact of the use of long-acting β2-agonists (LABAs) and the dose of inhaled corticosteroids (ICSs) during pregnancy on the prevalence of low birth weight (LBW), preterm birth (PB), and small for gestational age (SGA). The cohort included 7,376 pregnancies: 8.8% exposed to LABAs and 56.9% exposed to ICSs. LABA use was not found to be associated with increased prevalence of LBW (OR=0.81; 95%CI: 0.58–1.12), PB (OR=0.84; 95%CI: 0.61–1.15), or SGA (OR=0.92; 95%CI: 0.70–1.20). In the LABAs comparison (salmeterol compared to formoterol as reference), the most important difference was observed for PAG (OR=1.16, 95%CI: 0.67–2.02). For the ICSs, increasing doses were associated with a trend of increased LBW, PB, and SGA. The maximal observed OR was for a dose > 500 ug/day (fluticasone-equivalent) for LBW: (OR=1.57, 95%CI: 0.86–2.87). The comparison of the most frequently used ICSs (fluticasone compared to budesonide as reference) revealed non-statistically significant differences with a maximal difference observed for SGA (OR=1.10, 95%CI: 0.85–1.44). In the second component, a sub-cohort of asthmatic women with medical visits for asthma exacerbations was constructed to compare the treatment of exacerbations during and outside of pregnancy. The results show a reduced and delayed use of systemic corticosteroids for the treatment of asthma exacerbations in women when pregnant than when non-pregnant. The preventive treatment of asthma (ICSs and/or BALAs) could also be optimized. The results presented in this thesis support the safety of the use during pregnancy of LABAs and low to moderate doses of ICSs for the outcomes of LBW, PB and SGA and point to the need for additional data on the safety of high ICS doses. A comparable safety between studied ICSs (budesonide and fluticasone) and BALAs (formoterol and salmeterol) was also demonstrated. We also observed a reduced and delayed use of systemic corticosteroids for the treatment of asthma exacerbations in women when pregnant than when non-pregnant.

La BPCO se traduit rapidement par l'apparition d'une susceptibilité aux infections liées aux atteintes des mécanismes de défense du poumon. Les travaux antérieurs de l’équipe montrent qu'une altération de la réponse IL-17/IL-22 et de la fonction des cellules dendritiques (DC) participe au développement de l’exacerbation de la BPCO par les bactéries. Les mécanismes responsables de ce défaut de réponse ne sont pas élucidés. Au cours de cette thèse, nous nous sommes intéressés aux points suivants :1-Mécanismes cellulaires responsables du défaut de production d'IL-17 et d'IL-22 au cours de l'infection.Les cellules présentatrices d'antigène (APC) et en particulier, les DC jouent un rôle essentiel dans la réponse antimicrobienne, par leur fonction de phagocytes et par l’activation et la polarisation de cellules immunitaires innées et adaptatives. Sur des modèles murins d’exacerbation de la BPCO par Streptococcus pneumoniae ou Haemophilus influenzae non typable (NTHi), nous avons réalisé des tris de macrophages, DC et monocytes inflammatoires du poumon par cytométrie en flux. Ces analyses montrent que les cellules APC pulmonaires présentent des altérations fonctionnelles aboutissant à une limitation de leur capacité à polariser la réponse Th17 de Lymphocytes T CD4+. Une analyse transcriptomique est également effectuée sur les ARN des APC triées afin de préciser les altérations fonctionnelles de ces cellules par rapport aux souris contrôles.2-Rôle des cytokines IL-20 dans la susceptibilité à l'infection et l'exacerbation de la BPCO Myles et al ont montré en 2013 que les cytokines IL-20 (IL-19, IL-20 et IL-24) jouent un rôle délétère dans la réponse immunitaire cutanée contre Staphylococcus aureus par un mécanisme impliquant une inhibition indirecte d’IL-17 produite par les cellules T. La fonction des DC peut être affecté par l'environnement cytokinique. Comme les cytokines IL-20 sont surexprimées chez les souris BPCO, notre objectif a été de définir leur rôle au cours de l'exacerbation de la BPCO et l'impact de ces cytokines sur les DC dans ce contexte.Dans notre modèle d’exacerbation de la BPCO, nous avons bloqué cette voie en neutralisant l'IL-20RB qui est commune aux 2 récepteurs de ces cytokines afin d’étudier leur impact sur l'exacerbation et sur la réponse immune associée, notamment la réponse IL-17/IL-22. En parallèle, nous avons analysé la modulation de la fonction des DC humaines par ces cytokines dans un contexte d'infection bactérienne. Nos résultats montrent que le traitement avec l'anticorps bloquant anti-IL-20RB permet de bloquer le développement de l'exacerbation de la BPCO en diminuant la charge bactérienne et l'inflammation associée. Cet effet est associé à une diminution importante de la mobilisation des DC dans le poumon mais sans affecter sur la réponse IL-17/IL-22. In vitro, les cytokines IL-20 sont produites par les DC dans un contexte infectieux. De plus, ces cytokines sont capables de diminuer l'activation des ces cellules par les bactéries et de réduire leur capacité à activer les Lymphocytes T dans ce contexte.3-Capacité d'un immunostimulant à restaurer la réponse IL-17/IL-22, et à limiter le développement de l'exacerbation.L’utilisation d’immunostimulant dont la flagelline (agoniste du TLR-5, principale composante du flagelle bactérien) est souvent proposé comment pouvant promouvoir la réponse immunitaire des muqueuses et en particulier la réponse IL-17/IL-22. Nous avons analysé la capacité de cet agoniste du TLR-5 à améliorer la réponse à S. pneumoniae et NTHi dans notre modèle d’exacerbation de la BPCO.Le traitement par la flagelline permet de limiter les conséquences de l'infection bactérienne chez les souris BPCO en diminuant l'inflammation et les lésions pulmonaires associées. L'effet de ce ligand de TLR est au moins en partie dépendant de la production d'IL-22._A terme, ces données permettent d'envisager de nouvelles options thérapeutiques pour le traitement des exacerbations de la BPCO. / Patients with COPD often presented a susceptibility to respiratory infections. Previous works in our lab have showed that a defect of IL-17/IL-22 response and an altered dendritic cell (DC) function is involved in COPD exacerbation with bacteria. However, the mechanism responsible for this defect is not elucidated yet. In order to better define these mechanisms and to develop new therapeutic approaches against COPD exacerbation, we focused on the following points during this PhD project:1-Cellular mechanisms responsible of the defect of IL-17 and IL-22 production during infection in COPD.Antigen presenting cells (APC) particularly, DC are essential in antimicrobial immune response since they are professional phagocytes able to engulf and kill bacteria, but also by their essential role in the polarization of innate and adaptive immune responses. We worked on COPD exacerbation mice model infected with Streptococcus pneumoniae or Nontypeable Haemophilus influenzae (NTHi). APC including macrophages, DC and inflammatory monocytes were sorted by flow cytometry for phenotype and functional analysis. We found an altered function of these lung APC showing limited capacity of Th17 polarization. Transcriptional analysis on total RNA from sorted APC is performed to decipher the mechanisms involved in this functional alteration regarding to control mice.2-The role of IL-20 cytokines in the susceptibility to infection during COPD exacerbation.Myles et al showed in 2013 that IL-20 cytokines (IL-19, IL-20 and IL-24) are deleterious in skin immune response against Staphylococcus aureus. Indeed, these IL-20 cytokines indirectly inhibited IL-17 produced by T cells. The function of DC is also controlled by the presence of cytokines in the microenvironment. Because IL-20 cytokines are overexpressed in COPD, we aimed to determine their role during COPD exacerbation and the impact on DC.We used IL-20RB (common subunits of the 2 receptors) neutralizing antibodies to blocked IL-20 cytokines in COPD exacerbation mice model. We analyzed the impact of this treatment on the immune response, more particularly IL-17/IL-22 response. In addition, we analyzed the modulation of human monocyte derived DC (MDDC) function by IL-20 cytokines in the context of bacterial infection.Our results shows that treatment with IL-20 RB neutralizing antibodies limited COPD exacerbation by reducing the bacterial burden and the associated inflammatory response. This process was associated to reduced number of DC in the lung without impacting IL-17 and IL-22 production. In vitro, MDDC produced IL-20 cytokines upon bacterial infection. Additionally, these cytokines impaired MDDC activation following bacterial infection, which was associated to a reduced capacity of MDDC to activate T lymphocytes.3-The possibility to restore IL-17 and IL-22 response with immuno-stimulants in order to limit the development of COPD exacerbation.Flagellin (a TLR-5 agonist, the main component of bacterial flagellum) is an immuno-stimulant often used to promote mucosal immune response. This activity is related to its ability to promote IL-17 and IL-22 production. In this PhD work, we analyzed the capacity of this TLR-5 agonist to improve the immune response during S. pneumoniae and NTHi infection in COPD exacerbation mice model.Flagellin treatment reduced the bacterial burden and limited the consequences of bacterial infection in COPD mice, by lowering the inflammation and the associated lung remodeling. We also found that the immunomodulatory effect of flagellin was at least partially IL-22 dependent.Finally, these data allow to identify new therapeutic tools potentially useful for the treatment of COPD exacerbations.

Submitted by Luciana Ferreira (lucgeral@gmail.com) on 2015-04-23T14:59:21Z No. of bitstreams: 2 Tese - Lusmaia Damaceno Camargo Costa - 2014.pdf: 1127224 bytes, checksum: 0d8abb81e39218ff98c2ffb7471822f8 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Approved for entry into archive by Luciana Ferreira (lucgeral@gmail.com) on 2015-04-23T15:01:32Z (GMT) No. of bitstreams: 2 Tese - Lusmaia Damaceno Camargo Costa - 2014.pdf: 1127224 bytes, checksum: 0d8abb81e39218ff98c2ffb7471822f8 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) / Made available in DSpace on 2015-04-23T15:01:32Z (GMT). No. of bitstreams: 2 Tese - Lusmaia Damaceno Camargo Costa - 2014.pdf: 1127224 bytes, checksum: 0d8abb81e39218ff98c2ffb7471822f8 (MD5) license_rdf: 23148 bytes, checksum: 9da0b6dfac957114c6a7714714b86306 (MD5) Previous issue date: 2014-04-25 / Fundação de Amparo à Pesquisa do Estado de Goiás - FAPEG / Objective: to describe the prevalence of respiratory viruses in children with asthma during exacerbation and compare with those non-exacerbated and nonasthmatic children during acute respiratory infection. Methods: In this cross-sectional study nasopharyngeal aspirate/swab from children (4-14 years) was collected between August-2012 and August-2013 in a city (Goiânia) in Center-Brazil. There were 92 with exacerbated asthma (EA), 72 non-asthmatic with acute respiratory infection (ARI) in emergency room, and 61 non exacerbated asthmatic (NEA) treated in specialized clinics. The samples were tested to indirect immunofluorescence using the Respiratory Panel I (Chemicon. MA, USA) and RT-PCR kit rhinovirus. The study was approved by the ethics committee of the HC / UFG and statistical analysis performed with the SPSS v.20 software (SPSS Inc., Chicago, IL). The chi-square test was used to compare categorical variables and Kruskal-Wallis test to compare medians, pvalue< 0.05 was considered significant. Results: the sample consisted of 225 children, mostly male (59.5%) with median age of seven years. The viral prevalence was 91.1% and rhinovirus was the most commonly detected (67.6%), with no significant difference in incidence among all groups. Other viruses were identified: influenza A (13.2%), adenovirus (7.5%), influenza B (3.5%), respiratory syncytial virus (2.8%), parainfluenza 2 (2.8%) and parainfluenza 1 (2.5%). Adenovirus were more frequent in ARI (p=0.25). The EA group compared to the NEA group had cough at night (p<0.01), symptoms on exertion (p<0.01), medical visits (p<0.01) and hospitalizations for asthma (p<0.01) in the last 12 months and less use of medication (8.6%) for asthma control (p<0.01). Conclusions: the prevalence of viral detection was high (90.1%) in all patients (EA, NEA and ARI) and rhinovirus was the most prevalent agent, without differences between groups while adenovirus was more common in nonasthmatic children. Children with exacerbated asthma had parameters of uncontrolled disease in the last 12 months. Asthmatic children with nonexacerbated disease had no exacerbation although most of them had viruses in their nasopharynx, probable because of the regular use of inhaled corticosteroids. / Objetivo: descrever a prevalência de vírus respiratórios em crianças asmáticas durante exacerbação e comparar com grupo de crianças asmáticas não exacerbadas e crianças não asmáticas durante episódio de infecção respiratória aguda. Métodos: Em um estudo transversal foram realizadas coletas de aspirado/swabnasofaríngeo de crianças com idade entre 4 e 14 anos no período de agosto/2012 a agosto/2013, na cidade de Goiânia. Foram estudados 92 asmáticas exacerbadas (AE) e 72 crianças não asmáticas com sintomas de infecção respiratória aguda (IRA), atendidas em unidades de emergência em Goiânia-GO. No mesmo período, foram coletadas amostras de 61 crianças asmáticas não exacerbadas (ANE) atendidas em ambulatório especializado. As amostras foram submetidas à reação de imunofluorescência indireta utilizando o kit RespiratoryPanel I (Chemicon. MA, USA) para os vírus influenza A e B, parainfluenza 1 a 3, adenovírus e vírus sincicial respiratório e o RT-PCR para o rinovírus. O trabalho foi aprovado pelo comitê de ética do HC/UFG. A análise estatística foi realizada com o auxílio do software SPSS v.20 (SPSS Inc.; Chicago, IL) e o STATA v 12.0 (StataCorp, CollegeStation, TX, EUA). O teste qui-quadrado foi utilizado para comparar variáveis categóricas e aquelas com p<0,10 foram submetidas à análise de regressão logística. O teste de Kruskal-Wallis foi utilizado para comparar as medianas de idade. Para todos os testes, o valor de p<0,05 foi considerando significativo. Resultados: a amostra final foi constituída por 225 crianças, a maioria do sexo masculino (59,5%) e a mediana de idade foide sete anos. A prevalência de detecção viral foi 91,1% e o rinovírus foi o mais frequente (67,6%), sem diferença significativa entre os três grupos. Outros vírus identificados foram: influenza A (13,2%), adenovírus (7,5%), influenza B (3,5%), sincicial respiratório (2,8%), parainfluenza2 (2,8%) e parainfluenza 1 (2,5%). O adenovírus foi mais frequente no grupo com IRA (p=0,25). O grupo AE quando comparado ao grupo ANE apresentou mais tosse noturna (p<0,01), sintomas aos esforços (p<0,01), consultas (p<0,01) e internações por asma (p<0,01) nos últimos 12 meses e menor uso de medicamento (8,6%) para controle da asma (p<0,01). Após análise de regressão, os parâmetros consulta prévia (≥3) no último ano (p= 0,42) e ausência de uso de corticosteróide inalatório (p<0,01) permaneceram significativamente associados à exacerbação. Conclusões: prevalência de identificação viral foi elevada (91,1%) de forma homogênea entre os pacientes (AE, ANE e IRA) e o rinovírus foi o agente mais prevalente, em todos os grupos. O adenovírus esteve mais presente nas crianças não asmáticas com sintomas de infecção respiratória (IRA). As crianças exacerbadas apresentavam parâmetros de não controle da doença e menor uso de corticosteroide inalatório, enquanto as não exacerbadas, apesar de apresentarem o vírus na secreção nasofaríngea, não apresentaram exacerbação, possivelmente pelo uso regular de corticosteroide inalatório.

Abstract Hospital treatment of chronic obstructive pulmonary disease in primary and secondary health care and changes in treatment from 1972 to 2004 were examined by means of the treatment register and the register of deaths. During the study period, the patients with a principal diagnosis of chronic obstructive pulmonary disease (COPD) underwent 356,066 treatment periods. In 1980–1984, 44.3% of the patients hospitalized the first time for COPD died within five years after their treatment period, and in 1990–1994, 50.9% died after their treatment period. According to Cox’s age-adjusted regression model, mortality increased among both men (Hazard Ratio 1.093, 95% CI 1.055–1.133) and women (HR 1.138, 95% CI 1.061–1.221). The number of long-term, over-90-day periods of inpatient treatment of COPD patients in university and central hospitals decreased 97.6% and the number of days of treatment decreased 98.4% between 1972–1976 and 1997–2001. Correspondingly, these treatment periods increased 7.6% in primary care hospitals and the number of days of treatment decreased 47.6%. In 1995–2001 the number of inpatient periods due to acute exacerbations of COPD increased 10.9%, but the number of days of treatment decreased 8.5%. The growth in age-adjusted treatment periods was 0.8% among men and 18.5% among women. The number of treatment periods increased 36.8% in general practice wards and 17.8% in wards for respiratory diseases, while they decreased 22.3% in internal medicine wards. General practitioners sent 5.1% of patients admitted to a primary care hospital with acute exacerbation of COPD to a secondary care hospital. The age- and gender-adjusted risk of death of patients managed by a general practitioner was 0.83 (95% CI 0.75–0.91) compared with those managed by a pulmonary specialist. Patients treated in primary care had a 1.74 times greater risk of being readmitted within a week after being released from inpatient treatment for acute exacerbations of COPD compared with patients treated in secondary care. The strategic policies of the 1980s, changes in the service structure, the national guidelines for the prevention and treatment of COPD issued in 1998, the valid treatment recommendation, and new treatments and medication have made treatment of COPD patients more effective. The emphasis has shifted to outpatient care and primary health care, where sufficient resources and education must be insured in order to guarantee good quality. / Tiivistelmä Tutkimuksessa selvitettiin hoitoilmoitus- ja kuolinsyyrekisterin avulla keuhkoahtaumataudin sairaalahoitoa ja sen muutoksia perusterveydenhuollossa ja erikoissairaanhoidossa vuosina 1972–2004. Tutkimusaikana oli 356 066 hoitojaksoa niillä potilailla, joiden päädiagnoosi oli keuhkoahtaumatauti (KAT). Vuosina 1980–1984 olleen ensimmäisen KAT:sta aiheutuneen sairaalahoitojakson jälkeen potilaista kuoli viiden vuoden kuluessa 44,3 % ja vastaavasti vuosien 1990–1994 hoitojakson jälkeen 50,9 %. Coxin regressiomallilla iän ollessa vakioituna kuolleisuus lisääntyi sekä miehillä (Hazard Ratio 1,093, 95 % CI 1,055–1,133) että naisilla (HR 1,138, 95 % CI 1,061–1,221). Pitkäaikaiset, yli 90 hoitopäivää jatkuneet, sairaalahoitojaksot vähenivät KAT-potilailla yliopisto- ja keskussairaaloissa 97,6 % ja hoitopäivät 98,4 % ajanjaksojen 1972–1976 ja 1997–2001 välillä. Vastaavasti terveyskeskussairaaloissa nämä hoitojaksot lisääntyivät 7,6 % ja hoitopäivät vähenivät 47,6 %. Vuosina 1995–2001 olleiden KAT:n akuuttien pahenemisvaiheiden sairaalajaksojen määrä kasvoi 10,9 %, mutta hoitopäivien määrä väheni 8,5 %. Ikävakioitujen hoitojaksojen kasvu miehillä oli 0,8 % ja naisilla 18,5 %. Hoitojaksot lisääntyivät yleislääketieteen erikoisalan osastoilla 36,8 % ja keuhkosairauksien osastoilla 17,8 %, kun taas sisätautien osastoilla ne vähenivät 22,3 %. Yleislääkäri lähetti erikoissairaanhoitoon 5,1 % terveyskeskuksen vuodeosastolle otetuista akuuteista KAT:n pahenemisvaiheen potilaista. Yleislääkärin hoitovastuulla olleiden potilaiden ikä- ja sukupuolivakioitu kuoleman riskisuhde oli 0,83 (95 % CI 0,75–0,91) verrattuna keuhkolääkärin vastuulla olleisiin potilaisiin. Perusterveydenhuollossa hoidetuilla potilailla oli 1,74 kertainen riski joutua uudelleen sairaalahoitoon viikon kuluessa KAT:n akuutin pahenemisvaiheen sairaalahoidon jälkeen verrattuna erikoissairaanhoidossa hoidettuihin potilaisiin. 1980-luvun strategiset linjaukset, palvelurakennemuutokset ja kansalliset ohjeet keuhkoahtaumataudin ennaltaehkäisystä ja hoidosta vuodelta 1998 ja Käypä hoito -suositus sekä uudet hoitomuodot ja lääkkeet ovat tehostaneet keuhkoahtaumapotilaan hoitoa. Painopiste on siirtynyt avohoitoon ja perusterveydenhuoltoon, jossa on huolehdittava riittävästä resursoinnista ja koulutuksesta hyvän laadun varmistamiseksi.