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Background: Physical activity and sedentary behavior are treatable traits that may impact asthma control in distinct manners, but this impact remains poorly understood., Objective: To evaluate the influence of physical activity and sedentary behavior on clinical control in adults with moderate-to-severe asthma., Methods: This cross-sectional, multicentric study included 426 individuals with moderate-to-severe asthma. Assessments included physical activity and sedentary time (actigraphy), clinical asthma control (Asthma Control Questionnaire [ACQ]), quality of life (Asthma Quality of Life Questionnaire), anxiety and depression symptoms (Hospital Anxiety and Depression Scale), anthropometric data, and lung function. Participants were grouped according to physical activity levels and sedentary behavior., Results: Participants who walked ≥7500 steps/day presented better ACQ scores than those who walked <7500 steps/day (P < .05), independent of sedentary status. The percentage of patients with controlled asthma was higher in the active/sedentary (43.9%) and active/nonsedentary (43.8%) groups than in the inactive/sedentary (25.4%) and inactive/nonsedentary (23.9%) groups (P < .02). The likelihood of having uncontrolled asthma according to the treatable traits of physical inactivity (odds ratio [95% confidence interval]: 2.36 [1.55-3.59]), higher anxiety (2.26 [1.49-3.42]), and depression symptoms (1.95 [1.28-2.95]) was significant (P ≤ .002). Obesity and sedentary time were not associated with asthma control., Conclusions: Our results show that ≥7500 steps/day is associated with better asthma control independent of sedentary time in adults with moderate-to-severe asthma. Physical inactivity, anxiety, and depression symptoms are associated with higher odds of uncontrolled asthma. These results suggest that interventions should mainly focus on increasing physical activity rather than reducing sedentary time., (Copyright © 2024 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Objective: To analyze the number of hospitalizations, the length of hospital stay, and mortality due to asthma, as well as the costs to the Unified Health Care System in Brazil between 2008 and 2021., Methods: This was a cross-sectional epidemiological study using data from the Information Technology Department of the Brazilian Unified Health Care System. Proportional hospitalization and death rates were estimated per 100,000 population by age, microregion, and year., Results: The number of hospitalizations and deaths due to asthma decreased from 2008 to 2021 (205,392 vs. 55,009 and 822 vs. 327, respectively). In addition, a between-sex difference was observed in asthma-related hospitalizations in 2008, and more men were hospitalized in 2021 (51.8%). Asthma mortality rates were similar for both sexes (50.0% each) in 2008, and a slight increase was observed in women's deaths in 2021 (52.9%). Even so, approximately one death/day and more than 55,000 hospitalizations were observed yearly, with a mean length of hospital stay of three days. Additionally, the Southeast region allocated more financial resources to asthma-related hospitalizations., Conclusions: Our results showed that the number of deaths and hospitalizations due to asthma substantially declined during the study period.

Objective: The aim of this study was to assess the postural balance in COPD patients with obstructive sleep apnoea (OSA). Physical activity, anxiety and depression symptoms, mood, and falls were also assessed in this population., Methods: Moderate to severe COPD patients were assessed for laboratory and clinical postural balance (force platform and mini-balance evaluation systems test (Mini-BESTest)), physical activity (accelerometry), OSA (polysomnography), sleep quality (Pittsburgh Sleep Quality Index), sleepiness (Epworth Sleepiness Scale), anxiety and depression symptoms (Hospital Anxiety and Depression Scale), dyspnoea (modified Medical Research Council), clinical status (COPD Assessment Test) and mood (Brunel Mood Scale). Self-reported falls were recorded for 6 months via phone calls., Results: COPD patients (n=70) were divided according to the polysomnography findings into the no OSA (n=30), mild OSA (n=25), and moderate to severe OSA (n=15) groups. Compared to patients with no OSA, those with moderate to severe OSA (msOSA group) presented median (interquartile range) increased path length (30.5 (23.9-34.5) cm versus 39.0 (30.6-52.6) cm, anteroposterior displacement (1.89 (1.39-2.31) cm versus 2.54 (2.06-2.83) cm and postural adjustment velocity (1.02 (0.80-1.15) cm·s -1 versus 1.30 (1.02-1.76) cm·s -1 ) (p<0.05). No differences were observed in the Mini-BESTest scores among the groups. The msOSA group presented a greater number of recurrent fallers in the first follow-up trimester. No association was observed between postural balance and age and pulmonary function., Conclusion: Individuals with COPD and moderate to severe OSA present changes in postural balance, including broader oscillation, faster postural adjustments and a greater risk of falls than those with no OSA. Physical activity, anxiety and depression symptoms, and mood are similar between COPD patients with and without OSA., Competing Interests: Conflict of interest: The authors declare that they have no conflicts of interest to disclose., (Copyright ©The authors 2024.)

Introduction: The effect of aerobic training on reliever medication consumption (short-acting β 2 -agonist (SABA)) and peak expiratory flow (PEF) in participants with asthma is poorly known. The comparison between constant-load exercise (CLE) and high-intensity interval training (HIIT) in these outcomes has never been tested. The purpose of the present study was to compare the effects of CLE or HIIT in SABA consumption and PEF improvement during an exercise programme in subjects with asthma., Methods: Clinically stable participants were randomised into CLE (n=27; 70-85% of the maximal load (W max )) or HIIT (n=28; 80-140% W max ). The programme lasted 12 weeks (two sessions per week, 40 min per session), and the intensity was based on cardiopulmonary exercise testing (CPET). PEF was assessed before and after each exercise session. SABA was used if PEF was <70%. Clinical control (Asthma Control Questionnaire (ACQ)-6), CPET and aerobic fitness were also assessed before and after the intervention., Results: Both groups were similar at baseline. CLE and HIIT reduced SABA consumption throughout the intervention (p<0.05). Before training, 14 patients required SABA before exercising, but only one needed it after the intervention. Changes in post-exercise PEF were lower in the CLE group than in the HIIT group (1.6±25.3 versus 10.3±13.7%). Both groups improved aerobic fitness (10.1±12.8% versus 5.7±15.6%) and clinical asthma control; however, only the HIIT group achieved a minimal clinically important difference in the ACQ-6 post-intervention (-0.23±1.06 versus -0.52±0.73 Δ score)., Conclusion: CLE and HIIT reduced SABA consumption; however, only HIIT increased PEF and asthma clinical control after the intervention. These results reinforce the importance of exercise training in moderate-to-severe asthma., Competing Interests: Conflict of interest: The authors declare no conflicts of interest related to the contents of the manuscript., (Copyright ©The authors 2024.)

Introduction and Objectives: The elastic tape (ET) is a novel intervention that acutely improves exercise capacity in laboratory tests; however, its effect on a patient's daily life remains unknown. This randomized controlled trial evaluated the effects of ET on daily life physical activity (DLPA), dyspnea symptoms, health status, and health-related quality of life (HRQoL) in individuals with COPD., Methods: Fifty males with moderate to very severe COPD were randomly assigned to an intervention group (ETG, n = 25), receiving ET on the chest wall and abdomen, or a control group (CG, n = 25). The intervention was for 14 days. DLPA (accelerometry; steps per day, and sedentary time), dyspnea symptoms (transition dyspnea index, TDI; and modified Medical Research Council, mMRC), health status (COPD assessment test, CAT), and health-related quality of life (HRQoL, CRQ) were evaluated at baseline and on Day 21 after the intervention., Results: No change in the DLPA was observed in between-group comparison. CG presented a reduction in step counts after 21days (-707,p <0.05) while ETG. maintained (-114,p > 0.94). However, ET reduced dyspnea symptoms in all TDI domains (functional, task, and effort) and on the mMRC scale after 14 days compared with CG (p < 0.01). Also, the ETG improved CAT score compared to the CG, reaching minimal clinical important difference (MCID) (-4.4 score, p <0.01). The ETG also improved in most CRQ domains reaching MCID after 21 days., Conclusions: ET does not modify DLPA but reduces dyspnea and improves health status and HRQoL in nonobese males with moderate to very severe COPD in the short term. This novel and low-cost intervention improves COPD symptoms., Competing Interests: Declaration of competing interest The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2023. Published by Elsevier Ltd.)

Cerebrovascular responses were compared between COPD and non-COPD participants. The association between COPD severity and cognitive function was also investigated. Cerebral blood velocity in the middle cerebral artery, blood pressure, and end-tidal CO 2 were recorded at rest, followed by a brain activation paradigm, and an inhaled gas mixture (5% CO 2 ) to assess cerebral autoregulation (CA), neurovascular coupling (NVC) and cerebrovascular reactivity to carbon dioxide (CVR CO2 ), respectively. Pulmonary function, blood gas analysis (COPD) and cognitive function (MoCA test) were also performed. No difference in baseline (systemic and cerebral parameters) and CA was found between 20 severe COPD and 21 non-COPD. Reduced NVC and CVR CO2 test were found in the COPD group. Lower pulmonary function was positively correlated with CA, NVC and CVR CO2 in COPD patients. Cognitive impairment (MoCA<26) was associated with lower NVC responses (COPD and non-COPD) and lower pulmonary function (COPD). Both mechanisms, CVR CO2 and NVC, were lower in COPD patients. Moreover, disease severity and cognitive impaired were associated with worse cerebrovascular regulation., (Copyright © 2023 Elsevier B.V. All rights reserved.)

Background: Previous research has suggested that most adults improve their asthma control after a short-term behavioral intervention program to increase physical activity in daily life (PADL). However, the characteristics of individuals who respond and do not respond to this intervention and the medium-term response remain unknown., Objective: This study aims to (1) identify the characteristics of adult responders and nonresponders with asthma to a behavioral intervention to increase physical activity and (2) evaluate the functional and clinical benefits in the medium term., Methods: This prospective pragmatic study will include adults with moderate to severe asthma who enroll in a behavioral intervention. All individuals will receive an educational program and an 8-week intervention to increase PADL (1 time/wk; up to 90 min/session). The educational program will be conducted in a class setting through group discussions and video presentations. Behavioral interventions will be based on the transtheoretical model using counseling, incentives, and individual feedback aiming to increase participation in physical activity. Motivational interviewing and guidelines for overcoming barriers will be used to stimulate individuals to reach their goals. Pre- and postintervention assessments will include the following: PADL (triaxial accelerometry), body composition (octopolar bioimpedance), barriers to PADL (questionnaire), clinical asthma control (Asthma Control Questionnaire), quality of life (Asthma Quality of Life Questionnaire), anxiety and depression levels (Hospital Anxiety and Depression Scale), and exacerbations. "Responders" to the intervention will be defined as those who demonstrate an increase in the number of daily steps (≥2500)., Results: In December 2021, the clinical trial registration was approved. Recruitment and data collection for the trial is ongoing, and the results of this study are likely to be published in late 2024., Conclusions: The intervention will likely promote different effects according to the clinical characteristics of the individuals, including asthma control, age, anxiety and depression levels, obesity, and several comorbidities. Identifying individuals who respond or do not respond to behavioral interventions to increase PADL will help clinicians prescribe specific interventions to adults with asthma., Trial Registration: ClinicalTrials.gov NCT05159076; https://clinicaltrials.gov/ct2/show/NCT05159076., International Registered Report Identifier (irrid): DERR1-10.2196/49032., (©Fabiano Francisco de Lima, Adriana Claudia Lunardi, David Halen Araújo Pinheiro, Regina Maria Carvalho-Pinto, Rafael Stelmach, Pedro Giavina‑Bianchi, Rosana Câmara Agondi, Celso RF Carvalho. Originally published in JMIR Research Protocols (https://www.researchprotocols.org), 31.08.2023.)

Objective: To determine the characteristics of individuals with asthma who are responsive to aerobic training., Methods: This post hoc analysis of pooled data from previous randomized controlled trials involved 101 individuals with moderate to severe asthma who underwent aerobic training. Participants underwent a maximal cardiopulmonary exercise test and completed the Asthma Control Questionnaire and the Asthma Quality of Life Questionnaire before and after a 24-session aerobic training program. Better and worse responders to aerobic training were identified by cluster analysis., Results: Two clusters were identified according to the improvement in peak VO2 after aerobic training (better and worse responders). Characteristics of the better responder group were being older, being female, having higher BMI, and having higher cardiac reserve at baseline when compared with the worse responder group. Also, better responders had worse clinical control, worse quality of life, and lower physical capacity at baseline. After training, worse responders, in comparison with better responders, showed half the improvement in Δpeak VO2 (7.4% vs. 13.6%; 95% CI, -12.1 to -0.92%; p < 0.05) and worse asthma control. A weak, negative, but significant association (r = -0.35; p < 0.05) was observed between clinical control and aerobic fitness only in the better responder group. Both groups showed significant improvement in quality of life., Conclusions: Obese individuals with worse exercise capacity, clinical control, and quality of life showed improvement with aerobic training. Moreover, worse responders also improved with training, but to a lesser extent.

Background: The Brazilian Cohort of Asthma São Paulo (BRASASP) had a well-characterized severe asthmatic in Brazil, with 12 years of follow-up under standard treatment., Methods: Sequential assessment of patients with uncontrolled asthma from BRASASP cohort was carried out with 12 years of follow-up, performing exams and comparing with previous measurements., Results: 50 from the 60 initial patients were reevaluated. Twelve years later, FEV1 and the FEV1/FVC ratio have significantly decreased, with a rate of loss of lung function of 11.8 and 14%, respectively, and worsening in small airway parameters such as RV/TLC. BMI, The Asthma Control Test (ACT) and Asthma Control Questionnaire (ACQ) scores haven't changed. However, exacerbations decreased by 56%. Mean daily inhaled corticosteroid use was similar over time, but daily oral corticosteroid use decreased, in addition to a significant reduction in induced sputum eosinophilic and neutrophilic profile and serum IgE. Rhinitis, sinusitis, and GERD were the main comorbidities. In quality of life according to respiratory questionnaire SGRQ, total score showed a huge improvement (62% of patients)., Conclusions: There was significant decrease in FEV1 and FEV1/FVC. Data of pulmonary functional small airway characteristics show globally affected airways. Although higher doses of medications, patients were still uncontrolled, but with reduction of exacerbations, daily use of oral corticosteroid, less eosinophils and neutrophils in induced sputum and lower levels of IgE. Improvement in quality of life in 62% of patients.

Background and Objective: Individuals with asthma are more likely to develop sleep-disordered breathing. Exercise training improves sleep; however, the effect of physical activity (PA) on improving sleep quality remains unknown. This study had two objectives: (i) to evaluate the effect of a behavioural intervention to increase physical activity in daily living (PADL) on sleep quality in adults with asthma; (ii) to verify the association between a change in sleep quality, quality of life, anxiety, depression and asthma symptoms., Methods: This randomized controlled clinical trial included adults physically inactive with asthma. Participants were randomized into the control (CG; n = 25) and intervention groups (IG; n = 24). IG was submitted to a behavioural intervention to increase PADL, and CG received the usual care. Pre- and post-intervention assessments of sleep quality (by actigraphy and questionnaire), PADL level (by accelerometry), asthma control, health-related quality of life and anxiety and depression levels were conducted., Results: Both groups were similar at baseline. After the intervention, IG increased daily steps and moderate to vigorous PA levels. IG also improved sleep efficiency and latency as well as increased asthma-symptom-free days compared to CG. In addition, a greater proportion of participants in the IG had improved sleep quality after the intervention. Lastly, IG presented clinical improvement in the asthma-related quality of life questionnaire and a reduction in anxiety symptoms., Conclusion: Our results demonstrate that a behavioural intervention can increase PA, enhance behavioural sleep quality, efficiency and quality of life and reduce asthma and anxiety symptoms., (© 2022 Asian Pacific Society of Respirology.)

Advances in the understanding that severe asthma is a complex and heterogeneous disease and in the knowledge of the pathophysiology of asthma, with the identification of different phenotypes and endotypes, have allowed new approaches for the diagnosis and characterization of the disease and have resulted in relevant changes in pharmacological management. In this context, the definition of severe asthma has been established, being differentiated from difficult-to-control asthma. These recommendations address this topic and review advances in phenotyping, use of biomarkers, and new treatments for severe asthma. Emphasis is given to topics regarding personalized management of the patient and selection of biologicals, as well as the importance of evaluating the response to treatment. These recommendations apply to adults and children with severe asthma and are targeted at physicians involved in asthma treatment. A panel of 17 Brazilian pulmonologists was invited to review recent evidence on the diagnosis and management of severe asthma, adapting it to the Brazilian reality. Each of the experts was responsible for reviewing a topic or question relevant to the topic. In a second phase, four experts discussed and structured the texts produced, and, in the last phase, all experts reviewed and approved the present manuscript and its recommendations.

Asthma is a heterogeneous and complex disease, and a description of asthma phenotypes based on extrapulmonary treatable traits has not been previously reported.The objective of this study was to identify and characterise clusters based on clinical, functional, anthropometrical and psychological characteristics in participants with moderate-to-severe asthma.This was a cross-sectional multicentre study involving centres from Brazil and Australia. Participants (n=296) with moderate-to-severe asthma were consecutively recruited. Physical activity and sedentary time, clinical asthma control, anthropometric data, pulmonary function and psychological and health status were evaluated. Participants were classified by hierarchical cluster analysis and the clusters compared using ANOVA, Kruskal--Wallis and Chi-squared tests. Multiple logistic and linear regression models were performed to evaluate the association between variables.We identified four clusters: 1) participants with controlled asthma who were physically active; 2) participants with uncontrolled asthma who were physically inactive and more sedentary; 3) participants with uncontrolled asthma and low physical activity, who were also obese and experienced anxiety and/or depression symptoms; and 4) participants with very uncontrolled asthma who were physically inactive, more sedentary, obese and experienced anxiety and/or depression symptoms. Higher levels of sedentary time, female sex and anxiety symptoms were associated with increased odds of exacerbation risk, while being more active showed a protective factor for hospitalisation. Asthma control was associated with sex, the occurrence of exacerbation, physical activity and health status.Physical inactivity, obesity and symptoms of anxiety and/or depression were associated with worse asthma outcomes, and closely and inextricably associated with asthma control. This cluster analysis highlights the importance of assessing extrapulmonary traits to improve personalised management and outcomes for people with moderate and severe asthma., Competing Interests: Conflict of interest: P.D. Freitas has nothing to disclose. Conflict of interest: R.F. Xavier has nothing to disclose. Conflict of interest: V.M. McDonald has nothing to disclose. Conflict of interest: P.G. Gibson has nothing to disclose. Conflict of interest: L. Cordova-Rivera has nothing to disclose. Conflict of interest: K.C. Furlanetto has nothing to disclose. Conflict of interest: J.M. de Oliveira has nothing to disclose. Conflict of interest: R.M. Carvalho-Pinto has nothing to disclose. Conflict of interest: A. Cukier has nothing to disclose. Conflict of interest: R. Stelmach has nothing to disclose. Conflict of interest: C.R.F. Carvalho has nothing to disclose., (Copyright ©ERS 2021.)

Background: Higher levels of physical activity have been associated with better asthma clinical control., Research Question: Does a behavior change intervention aimed at increasing physical activity change asthma clinical control, physical activity, sedentary time, health-related quality of life (HRQoL), and anxiety and depression symptoms?, Study Design and Methods: This single-blind, randomized controlled trial included participants who were allocated to an intervention group (IG) or to a control group (CG). Both groups received usual care and disease-specific education. Participants in the IG also underwent an 8-week behavior change intervention aimed at increasing physical activity. Prior to and following the intervention period, measures were made of asthma clinical control (Asthma Control Questionnaire [ACQ]), physical activity, sedentary time and sleep quality (ActiGraph), HRQoL (Asthma Quality of Life Questionnaire), and anxiety and depression symptoms (Hospital Anxiety and Depression Scale). Data on asthma exacerbations were recorded 12 months prior to and throughout the intervention period., Results: Fifty-one participants were included (CG, n = 26; IG, n = 25). On completion of the intervention period, compared with the CG, those in the IG exhibited improvements in asthma control (mean difference [95% CI] in ACQ score, -0.8 [-1.1 to -0.4]); in daily step count, 3,605 [1,937 to 8,867] steps/d; in sleep efficiency, 9.2% [-7.1% to 21.9%]; and a reduction in sedentary time, -1.1 [-2.9 to -0.6] h/d). No between-group difference in HRQoL was observed. The percentage of participants who experienced exacerbations during the intervention period was 27% in the IG vs 60% in the CG (P = .04). The change in time spent in moderate-intensity physical activity was inversely associated with change in ACQ (r = -0.60). Compared with the CG, a higher percentage of participants in the IG reported a reduction in anxiety symptoms (43% vs 0%; P < .02)., Interpretation: In adults with moderate to severe asthma, a comprehensive behavior change intervention that increased physical activity also produced improvements in asthma clinical control, sedentary time, sleep quality, and anxiety symptoms., Clinical Trial Registration: ClinicalTrials.gov; No.: NCT03705702; URL: www.clinicaltrials.gov., (Copyright © 2020 American College of Chest Physicians. Published by Elsevier Inc. All rights reserved.)

Background: Aerobic training and breathing exercises are interventions that improve asthma control. However, the outcomes of these 2 interventions have not been compared., Objective: To compare the effects of aerobic training versus breathing exercises on clinical control (primary outcome), quality of life, exercise capacity, and airway inflammation in outpatients with moderate-to-severe asthma., Methods: Fifty-four asthmatics were randomized into either the aerobic training group (AG, n = 29) or the breathing exercise group (BG, n = 25). Both interventions lasted for 24 sessions (2/week, 40 minutes/session). Asthma clinical control (Asthma Control Questionnaire [ACQ]), quality of life (Asthma Quality of Life Questionnaire), asthma symptom-free days (ASFD), airway inflammation, exercise capacity, psychological distress (Hospital Anxiety and Depression Scale), daily-life physical activity (DLPA), and pulmonary function were evaluated before, immediately after, and 3 months after the intervention., Results: Both interventions presented similar results regarding the ACQ score, psychological distress, ASFD, DLPA, and airway inflammation (P > .05). However, participants in the AG were 2.6 times more likely to experience clinical improvement at the 3-month follow-up than participants in the BG (P = .02). A greater proportion of participants in the AG also presented a reduction in the number of days without rescue medication use compared with BG (34% vs 8%; P = .04)., Conclusions: Outpatients with moderate-to-severe asthma who participated in aerobic training or breathing exercise programs presented similar results in asthma control, quality of life, asthma symptoms, psychological distress, physical activity, and airway inflammation. However, a greater proportion of participants in the AG presented improvement in asthma control and reduced use of rescue medication., (Copyright © 2020 American Academy of Allergy, Asthma & Immunology. Published by Elsevier Inc. All rights reserved.)

Subjects with severe and very severe chronic obstructive pulmonary disease (COPD) present thoracoabdominal asynchrony (TAA) that reduces ventilatory efficiency and exercise capacity. However, no therapeutic intervention has focused on reducing TAA. The purpose of this study was to evaluate the effects of elastic tape (ET) on thoracoabdominal mechanics, dyspnea symptoms, exercise capacity, and physical activity level in nonobese male subjects with severe-to-very severe COPD. This crossover, randomized trial included nonobese males with severe to very severe COPD. ET was placed on the chest wall and abdomen to reduce TAA. Subjects were evaluated at three hospital visits, each 7 days apart. At visit 1 , thoracoabdominal kinematic and pulmonary ventilation were evaluated by optoelectronic plethysmography and electrical impedance tomography, respectively, both at rest and during isoload exercise testing. At visit 2 , a cardiopulmonary exercise test (CPET; 10 W/min) was performed until exhaustion. Between the visits, subjects used a physical activity monitor (PAM) (at least 5 days of measurement; 10 h/day). At visit 3 , all the tests were repeated in the opposite order of the previous randomization. During the isoload exercise, subjects with ET presented lower tidal and minute volumes ( P = 0.01) and reduced TAA ( P = 0.02) and dyspnea ( P = 0.04). During the CPET, subjects with ET presented an increase in peak oxygen consumption (V̇o 2peak ; L/min and mL·kg -1 ·min -1 ; P = 0.01), test duration ( P = 0.009), and maximal load ( P = 0.03). Moderate and vigorous physical activity (MVPA), which was evaluated by the PAM, was also increased in subjects with ET ( P = 0.01). ET reduced TAA and dyspnea and increased exercise capacity and the duration of MVPA in nonobese male subjects with severe-to-very severe COPD NEW & NOTEWORTHY Elastic tape can be used as a new and low-cost intervention to reduce thoracoabdominal asynchrony and sedentary behavior as well as improve exercise capacity and physical activity level in nonobese male subjects with severe-to-very severe chronic obstructive pulmonary disease.

Objective: To describe trends of hospital admissions due to asthma from 2008 to 2015 and to evaluate their relationship with trends of inhaled corticosteroids (ICS) provision by the government in Brazil., Methods: We used Brazilian Government data to calculate hospital admission rates due to asthma, number of physicians, number of hospital beds, number of subjects that received ICS per 100,000 inhabitants in Brazil and in each of its municipalities for each year of the study. We performed Poisson Multilevel Regression Analyses to evaluate the relationship between the trends of hospital admission rates due to asthma with the trends of the number of subjects that had been receiving ICS during the study period. The analyses were adjusted for the number of physicians and hospital beds., Findings: The number of patients who received ICS/100,000 inhabitants increased from 2008 to 2015 (943.9-1988.5). Hospital admissions/100,000 inhabitants decreased in patients aged 5-14 years (148.3-110.9) and in patients aged 15-39 years (59.9-32.3); the reduction was greater in municipalities in which ICS provision increased. The number of physicians/100,000 inhabitants increased and the number of hospital beds/100,000 inhabitants decreased in the study period. The increase in the number of physicians and in the number of subjects that received ICS were associated with reduction in hospital admissions., Conclusion: We found that provision of ICS by the Brazilian Government was associated with a decrease of hospital admissions for asthma in the municipalities and country levels from 2008 to 2015., Competing Interests: Declaration of competing interests The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper., (Copyright © 2020 Elsevier Ltd. All rights reserved.)

The pharmacological management of asthma has changed considerably in recent decades, as it has come to be understood that it is a complex, heterogeneous disease with different phenotypes and endotypes. It is now clear that the goal of asthma treatment should be to achieve and maintain control of the disease, as well as to minimize the risks (of exacerbations, disease instability, accelerated loss of lung function, and adverse treatment effects). That requires an approach that is personalized in terms of the pharmacological treatment, patient education, written action plan, training in correct inhaler use, and review of the inhaler technique at each office visit. A panel of 22 pulmonologists was invited to perform a critical review of recent evidence of pharmacological treatment of asthma and to prepare this set of recommendations, a treatment guide tailored to use in Brazil. The topics or questions related to the most significant changes in concepts, and consequently in the management of asthma in clinical practice, were chosen by a panel of experts. To formulate these recommendations, we asked each expert to perform a critical review of a topic or to respond to a question, on the basis of evidence in the literature. In a second phase, three experts discussed and structured all texts submitted by the others. That was followed by a third phase, in which all of the experts reviewed and discussed each recommendation. These recommendations, which are intended for physicians involved in the treatment of asthma, apply to asthma patients of all ages.

Objective: A resolution passed by the government of the Brazilian state of São Paulo established a protocol for requesting free COPD medications, including tiotropium bromide, creating regional authorization centers to evaluate and approve such requests, given the high cost of those medications. Our objective was to analyze the requests received by an authorization center that serves cities in the greater metropolitan area of (the city of) São Paulo between 2011 and 2016., Methods: Data regarding the authorization, return, or rejection of the requests were compiled and analyzed in order to explain those outcomes. Subsequently, the clinical and functional data related to the patients were evaluated., Results: A total of 7,762 requests for dispensing COPD medication were analyzed. Requests related to male patients predominated. Among the corresponding patients, the mean age was 66 years, 12% were smokers, 88% had frequent exacerbations, and 84% had severe/very severe dyspnea. The mean FEV1 was 37.2% of the predicted value. The total number of requests decreased by 24.5% from 2012 to 2013 and was lowest in 2015. Most (65%) of the requests were accepted. The main reasons for the rejection/return of a request were a post-bronchodilator FEV1/FVC ratio > 0.7, a post-bronchodilator FEV1 > 50% of the predicted value, and failure to provide information regarding previous use of a long-acting β2 agonist. During the study period, the total number of requests returned/rejected decreased slightly, and there was improvement in the quality of the data included on the forms., Conclusions: Here, we have identified the characteristics of the requests for COPD medications and of the corresponding patients per region served by the authorization center analyzed, thus contributing to the improvement of local public health care measures.

Background: In adults with asthma, physical activity has been associated with several asthma outcomes. However, it is unclear whether changes in physical activity, measured via an accelerometer, have an effect on asthma control. The objective of the present study is, in adults with moderate-to-severe asthma, to investigate the effects of a behaviour change intervention, which aims to increase participation in physical activity, on asthma clinical control., Methods: This is a single-blind (outcome assessor), two-arm, randomised controlled trial (RCT). Fifty-five participants with moderate-to-severe asthma, receiving optimized pharmacological treatment, will be randomly assigned (computer-generated) into either a Control Group (CG) or an Intervention Group (IG). Both groups will receive usual care (pharmacological treatment) and similar educational programmes. In addition to these, participants in the IG will undergo the behaviour change intervention based on feedback, which aims to increase participation in physical activity. This intervention will be delivered over eight sessions as weekly one-on-one, face-to-face 40-min consultations. Both before and following the completion of the intervention period, data will be collected on asthma clinical control, levels of physical activity, health-related quality of life, asthma exacerbation and levels of anxiety and depression symptoms. Anthropometric measurements will also be collected. Information on comorbidities, lung function and the use of asthma medications will be extracted from the participant's medical records., Discussion: If successful, this study will demonstrate that, in adults with asthma, a behavioural change intervention which aims to increase participation in physical activity also affects asthma control., Trial Registration: Clinical Trials.gov PRS (Protocol registration and Results System): NCT-03705702 (04/10/2018)., Competing Interests: Competing interestsThe authors declare that they have no competing interests.

Obese adults with asthma are more likely to develop dynamic hyperinflation (DH) and expiratory flow limitation (EFL) than nonobese asthmatics, and weight-loss seems to improve the breathing mechanics during exercise. However, studies evaluating the effect of weight loss on DH in obese adults with asthma have not been performed. We sought to evaluate the effect of a weight loss program on DH in obese adults with asthma. Forty-two asthma patients were enrolled in a weight loss program (diet, psychological support, and exercise) and were subsequently divided into two groups according to the percentage of weight loss: a ≥5% group ( n = 19) and a <5% group ( n = 23). Before and after the intervention, DH and EFL (constant load exercise), health-related quality of life (HRQoL), asthma control, quadriceps muscle strength and endurance, body composition, and lung function were assessed. Both groups exhibited a decrease of ≥10% in inspiratory capacity (DH) before intervention, and only the ≥5% group showed clinical improvement in DH compared with the <5% group postintervention (-9.1 ± 14.5% vs. -12.5 ± 13.5%, respectively). In addition, the ≥5% group displayed a significant delay in the onset of both DH and EFL and a clinically significant improvement in HRQoL and asthma control. Furthermore, a correlation was observed between reduced waist circumference and increased inspiratory capacity ( r = -0.45, P = 0.05) in the ≥5% group. In conclusion, a weight-loss of ≥5% of the body weight improves DH, which is associated with waist circumference in obese adults with asthma. In addition, the group with greater weight-loss showed a delayed onset of DH and EFL during exercise and improved asthma clinical control and HRQoL. NEW & NOTEWORTHY This is the first study to evaluate dynamic hyperinflation (DH) after a weight loss program in obese patients with asthma. Our results demonstrate that moderate weight loss can improve DH in obese patients with asthma that is associated with a decrease in abdominal fat. Moreover, a minimum of 5% in weight loss delays the onset of DH and expiratory flow limitation besides inducing a clinical improvement in asthma quality of life and clinical control.

Introduction: Obese adults with asthma have an increased number of comorbidities and reduced daily life physical activity (DLPA), which may worsen asthma symptoms. Exercise is recommended to improve asthma outcomes; however, the benefits of exercise for psychosocial comorbidities and physical activity levels in obese adults with asthma have been poorly investigated., Objective: This study aimed to assess the effects of exercise on DLPA, asthma symptoms, and psychosocial comorbidities in obese adults with asthma., Methods: Fifty-five grade II obese adults with asthma were randomly assigned to either a weight loss program + exercise program (WL + E group, n = 28) or a weight loss program + sham (WL + S group, n = 27). The WL + E group incorporated aerobic and resistance muscle training into the weight loss program (nutrition and psychological therapies), whereas the WL + S group performed breathing and stretching exercises. DLPA, asthma symptoms, sleep quality, and anxiety and depression symptoms were quantified before and after treatment., Results: After 3 months, the WL + E group presented a significant increase in daily step counts (3068 ± 2325 vs 729 ± 1118 steps per day) and the number of asthma symptom-free days (14.5 ± 9.6 vs 8.6 ± 11.4 d·month) compared with the WL + S group. The proportion of participants with improvements in depression symptoms (76.4% vs 16.6%) and a lower risk of developing obstructive sleep apnea (56.5% vs 16.3%) was greater in the WL + E group than that in the WL + S group (P < 0.05). Significant improvements in sleep efficiency (6.6% ± 5.1% vs 1.3% ± 4.7%) and latency (-3.7 ± 5.9 vs 0.2 ± 5.6 min) were also observed in the WL + E group., Conclusions: Our results strongly suggest that exercise training plus a weight loss program improves DLPA, sleep efficiency, and depression and asthma symptoms in obese adults with asthma.

Objective: To determine the prevalence of spirometric abnormalities in patients screened for coronary artery disease (CAD) and the risk factors for lung function impairment., Methods: Patients referred for cardiac CT underwent spirometry and were subsequently divided into two groups, namely normal lung function and abnormal lung function. The prevalence of spirometric abnormalities was calculated for the following subgroups of patients: smokers, patients with metabolic syndrome, elderly patients, and patients with obstructive coronary lesions. All groups and subgroups were compared in terms of the coronary artery calcium score and the Duke CAD severity index., Results: A total of 205 patients completed the study. Of those, 147 (72%) had normal lung function and 58 (28%) had abnormal lung function. The median coronary artery calcium score was 1 for the patients with normal lung function and 36 for those with abnormal lung function (p = 0.01). The mean Duke CAD severity index was 15 for the former and 27 for the latter (p < 0.01). Being a smoker was associated with the highest OR for abnormal lung function, followed by being over 65 years of age and having obstructive coronary lesions., Conclusions: The prevalence of spirometric abnormalities appears to be high in patients undergoing cardiac CT for CAD screening. Smokers, elderly individuals, and patients with CAD are at an increased risk of lung function abnormalities and therefore should undergo spirometry. (ClinicalTrials.gov identifier: NCT01734629 [http://www.clinicaltrials.gov/]).

Exercise training has been shown to reduce symptoms and exacerbations in COPD patients; however, the exercise effect on patients' immune response is poorly known. We thus verified if an exercise program (EP) impacted on proliferative T cell response of COPD patients. Fourteen non-O 2 dependent COPD patients on standard treatment were studied. EP consisted in 24 sessions of aerobic and muscular training. Peripheral blood mononuclear cells were stimulated with the mitogen phytohemagglutinin and antigens from Haemophilus influenzae and cytomegalovirus, and the lymphocyte proliferative response (LPR) was assessed through the expression of Ki67 before and after the EP. The Quality of life [COPD assessment test (CAT)], dyspnea [(modified Medical Research Council scale (mMRC)], and 6-min walk distance were also assessed. The EP program increased significantly the LPR of TCD4+ lymphocytes to phytohemagglutinin and cytomegalovirus and H. influenzae antigens, but with TCD8+ lymphocytes the increase was less marked. Consistent with this, a higher proportion of TCD8+ than TCD4+ cells did not express the costimulatory molecule CD28. The EP also resulted in improvement of the quality of life, dyspnea, and physical capacity. The improvement in TCD4+ cell function may represent an additional mechanism through which the EP results in less exacerbations and hospitalizations.

Background: Patients with asthma present structural and inflammatory alterations that are believed to play a role in disease severity. However, airway remodeling and inflammation have not been extensively investigated in relation to both symptom control and airflow obstruction in severe asthmatics. We aimed to investigate several inflammatory and structural pathological features in bronchial biopsies of severe asthmatics that could be related to symptom control and airflow obstruction after standardized treatment., Methods: Fifty severe asthmatics received prednisone 40 mg/d for 2 weeks and maintenance therapy with budesonide/formoterol 400/12 μg twice daily + budesonide/formoterol 200/6 μg as needed for 12 weeks. Endobronchial biopsies were performed at the end of 12 weeks. We performed extensive immunopathological analyses of airway tissue inflammation and remodeling features in patients stratified by asthma symptom control and by airflow obstruction., Results: Airway tissue inflammation and remodeling were not associated with symptom control. Asthmatics with persistent airflow obstruction had greater airway smooth muscle (Asm) area with decreased periostin and transforming growth factor beta-positive cells within Asm bundles, in addition to lower numbers of chymase-positive mast cells in the submucosa compared to patients with nonpersistent obstruction., Conclusions: Symptom control in severe asthmatics was not associated with airway tissue inflammation and remodeling, although persistent airflow obstruction in these patients was associated with bronchial inflammation and airway structural changes., (© 2017 EAACI and John Wiley and Sons A/S. Published by John Wiley and Sons Ltd.)

Rationale: Clinical control is difficult to achieve in obese patients with asthma. Bariatric surgery has been recommended for weight loss and to improve asthma control; however, the benefits of nonsurgical interventions have been poorly investigated., Objectives: To examine the effect of exercise training in a weight-loss program on asthma control, quality of life, inflammatory biomarkers, and lung function., Methods: Fifty-five obese patients with asthma were randomly assigned to either a weight-loss program plus exercise (WL + E group, n = 28) or a weight-loss program plus sham (WL + S group, n = 27), where the weight-loss program included nutrition (caloric restriction) and psychological therapies. The WL + E group incorporated aerobic and resistance muscle training, whereas the WL + S group incorporated breathing and stretching exercises., Measurements and Main Results: The primary outcome was clinical improvement in asthma control over 3 months. Secondary outcomes included quality of life, lung function, body composition, aerobic capacity, muscle strength, and inflammatory/antiinflammatory biomarkers. After 3 months, 51 patients were analyzed. Compared with the WL + S group, the WL + E group demonstrated improved clinical control scores (median [25th to 75th percentile], -0.7 [-1.3 to -0.3] vs. -0.3 [-0.9 to 0.4]; P = 0.01) and greater weight loss (mean ± SD, -6.8% ± 3.5 vs. -3.1% ± 2.6; P < 0.001) and aerobic capacity (median [25th to 75th percentile], 3.0 [2.4 to 4.0] vs. 0.9 [-0.3 to 1.3] ml O 2  × kg -1  × min -1 ; P < 0.001). These improvements in the WL + E group were also accompanied by improvements in lung function, antiinflammatory biomarkers, and vitamin D levels, as well as reductions in airway and systemic inflammation., Conclusions: Adding exercise to a short-term weight-loss program should be considered as a useful strategy for achieving clinical control of asthma in obese patients. Clinical trial registered with www.clinicaltrials.gov (NCT 02188940).

Background: Chronic obstructive pulmonary disease (COPD) induces an imbalance in T helper (Th) 17/regulatory T (Treg) cells that contributes to of the dysregulation of inflammation. Exercise training can modulate the immune response in healthy subjects., Objective: We aimed to evaluate the effects of exercise training on Th17/Treg responses and the differentiation of Treg phenotypes in individuals with COPD., Methods: This randomized controlled trial included 50 individuals with severe or very severe COPD who were allocated to the Exercise or Control groups. The Exercise group underwent eight weeks of aerobic and muscle strength training, whereas the Control group received usual care. The primary outcome was the change in the phenotypic characteristics of Tregs and Th17 profile differentiation in systemic inflammation., Results: Exercise training increased the frequency of total and activated Tregs and decreased the frequency of Th17 cells in between-group comparisons. Additionally, Th17/Treg responses were moderately correlated with improvements in the six-minute walking test, muscle strength of the upper and lower limbs, and daily life physical activity levels., Conclusion: Exercise training improved functional exercise capacity, muscle strength, and physical fitness, which was associated with a decrease in the Th17 inflammatory response and an increase in Treg cell phenotypes immunosuppressive activity.

Background: The benefits of aerobic training for the main features of asthma, such as bronchial hyperresponsiveness (BHR) and inflammation, are poorly understood. We investigated the effects of aerobic training on BHR (primary outcome), serum inflammatory cytokines (secondary outcome), clinical control and asthma quality of life (Asthma Quality of Life Questionnaire (AQLQ)) (tertiary outcomes)., Methods: Fifty-eight patients were randomly assigned to either the control group (CG) or the aerobic training group (TG). Patients in the CG (educational programme+breathing exercises (sham)) and the TG (same as the CG+aerobic training) were followed for 3 months. BHR, serum cytokine, clinical control, AQLQ, induced sputum and fractional exhaled nitric oxide (FeNO) were evaluated before and after the intervention., Results: After 12 weeks, 43 patients (21 CG/22 TG) completed the study and were analysed. The TG improved in BHR by 1 doubling dose (dd) (95% CI 0.3 to 1.7 dd), and they experienced reduced interleukin 6 (IL-6) and monocyte chemoattractant protein 1 (MCP-1) and improved AQLQ and asthma exacerbation (p<0.05). No effects were seen for IL-5, IL-8, IL-10, sputum cellularity, FeNO or Asthma Control Questionnaire 7 (ACQ-7; p>0.05). A within-group difference was found in the ACQ-6 for patients with non-well-controlled asthma and in sputum eosinophil and FeNO in patients in the TG who had worse airway inflammation., Conclusions: Aerobic training reduced BHR and serum proinflammatory cytokines and improved quality of life and asthma exacerbation in patients with moderate or severe asthma. These results suggest that adding exercise as an adjunct therapy to pharmacological treatment could improve the main features of asthma., Trial Registration Number: NCT02033122., (Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://group.bmj.com/group/rights-licensing/permissions.)

Objective: To validate two scores quantifying the ability of patients to use metered dose inhalers (MDIs) or dry powder inhalers (DPIs); to identify the most common errors made during their use; and to identify the patients in need of an educational program for the use of these devices., Methods: This study was conducted in three phases: validation of the reliability of the inhaler technique scores; validation of the contents of the two scores using a convenience sample; and testing for criterion validation and discriminant validation of these instruments in patients who met the inclusion criteria., Results: The convenience sample comprised 16 patients. Interobserver disagreement was found in 19% and 25% of the DPI and MDI scores, respectively. After expert analysis on the subject, the scores were modified and were applied in 72 patients. The most relevant difficulty encountered during the use of both types of devices was the maintenance of total lung capacity after a deep inhalation. The degree of correlation of the scores by observer was 0.97 (p < 0.0001). There was good interobserver agreement in the classification of patients as able/not able to use a DPI (50%/50% and 52%/58%; p < 0.01) and an MDI (49%/51% and 54%/46%; p < 0.05)., Conclusions: The validated scores allow the identification and correction of inhaler technique errors during consultations and, as a result, improvement in the management of inhalation devices.

Objective: Smoking prevalence is frequently estimated on the basis of self-reported smoking status. That can lead to an underestimation of smoking rates. The aim of this study was to evaluate the difference between self-reported smoking status and that determined through the use of objective measures of smoking at a pulmonary outpatient clinic., Methods: This was a cross-sectional study involving 144 individuals: 51 asthma patients, 53 COPD patients, 20 current smokers, and 20 never-smokers. Smoking status was determined on the basis of self-reports obtained in interviews, as well as through tests of exhaled carbon monoxide (eCO) and urinary cotinine., Results: All of the asthma patients and COPD patients declared they were not current smokers. In the COPD and asthma patients, the median urinary cotinine concentration was 167 ng/mL (range, 2-5,348 ng/mL) and 47 ng/mL (range, 5-2,735 ng/mL), respectively (p < 0.0001), whereas the median eCO level was 8 ppm (range, 0-31 ppm) and 5 ppm (range, 2-45 ppm), respectively (p < 0.05). In 40 (38%) of the patients with asthma or COPD (n = 104), there was disagreement between the self-reported smoking status and that determined on the basis of the urinary cotinine concentration, a concentration > 200 ng/mL being considered indicative of current smoking. In 48 (46%) of those 104 patients, the self-reported non-smoking status was refuted by an eCO level > 6 ppm, which is also considered indicative of current smoking. In 30 (29%) of the patients with asthma or COPD, the urinary cotinine concentration and the eCO level both belied the patient claims of not being current smokers., Conclusions: Our findings suggest that high proportions of smoking pulmonary patients with lung disease falsely declare themselves to be nonsmokers. The accurate classification of smoking status is pivotal to the treatment of lung diseases. Objective measures of smoking could be helpful in improving clinical management and counseling.

Objective: To evaluate the ability of COPD patients to perform activities of daily living (ADL); to identify barriers that prevent these individuals from performing ADL; and to correlate those barriers with dyspnea severity, six-minute walk test (6MWT), and an ADL limitation score., Methods: In COPD patients and healthy, age-matched controls, the number of steps, the distance walked, and walking time were recorded with a triaxial accelerometer, for seven consecutive days. A questionnaire regarding perceived barriers and the London Chest Activity of Daily Living (LCADL) scale were used in order to identify the factors that prevent the performance of ADL. The severity of dyspnea was assessed with two scales, whereas submaximal exercise capacity was determined on the basis of the 6MWT., Results: We evaluated 40 COPD patients and 40 controls. In comparison with the control values, the mean walk time was significantly shorter for COPD patients (68.5 ± 25.8 min/day vs. 105.2 ± 49.4 min/day; p < 0.001), as was the distance walked (3.9 ± 1.9 km/day vs. 6.4 ± 3.2 km/day; p < 0.001). The COPD patients also walked fewer steps/day. The most common self-reported barriers to performing ADL were lack of infrastructure, social influences, and lack of willpower. The 6MWT distance correlated with the results obtained with the accelerometer but not with the LCADL scale results., Conclusions: Patients with COPD are less active than are healthy adults of a comparable age. Physical inactivity and the barriers to performing ADL have immediate implications for clinical practice, calling for early intervention measures.

Studies on the effects of weight loss in patients with asthma are scarce. No studies have been performed in patients with severe asthma. Therefore, the aim of the present study was to assess the impact of weight loss in patients with severe asthma associated with obesity. This was an open, prospective, randomised study of two parallel groups, in patients with severe uncontrolled asthma and moderate obesity. The primary outcome was the level of asthma control 6 months after initiation of the weight reduction programme, quantified using the Asthma Control Questionnaire (ACQ). We evaluated clinical parameters, lung function, markers of airway inflammation and circulating cytokines. 22 patients were randomised to undergo treatment for obesity and 11 to the control group. The weight reduction programme was associated with significant improvements in asthma control (mean ± se ACQ score 3.02 ± 0.19 to 2.25 ± 0.28 in the treatment group versus 2.91 ± 0.25 to 2.90 ± 0.16 in the controls, p=0.001). This improvement was not accompanied by changes in markers of airway inflammation or bronchial reactivity, but by an increase in forced vital capacity. Our results suggest that weight reduction in obese patients with severe asthma improves asthma outcomes by mechanisms not related to airway inflammation.

Background: Currently, there are no studies of well-characterized severe asthmatics in Brazil. We aimed to study a population of severe treated asthmatics still uncontrolled to characterize them and define possible phenotypes., Methods: Descriptive cross-sectional outpatient study of severe asthmatics, evaluating functional and inflammatory markers, health-related quality of life, anxiety and depression symptoms, clinical control status, and characteristics related to atopy, age of asthma onset, induced sputum eosinophil levels, and airflow limitation. We also grouped the subgroups characteristics to identify phenotypes. The study is registered on ClinicalTrial.gov NCT 01089322., Results: From 128 eligible patients with severe/uncontrolled asthma, 74 fulfilled the inclusion criteria. The cohort was comprised of 85% women, frequently with a body mass index higher than 31 kg m(-2), atopy (60%), early-onset disease (50%), sputum eosinophilia (80%), comorbidities, and reduced quality of life. Nonatopics had significant higher asthma onset (19 y.a.) and twice level of induced sputum eosinophil. Late-onset patients had significantly less atopy (57%) and higher levels of induced sputum eosinophils. Non-eosinophilics had lower levels of inflammatory markers. Patients with airflow limitation had more intensive care unit admissions (56%) and 1.5 times more airway resistance. Subgroups characteristics identified a priori four well-characterized phenotypes, with 55% presenting sputum eosinophilia., Conclusion: Our data emphasize the high burden of disease, the persistence of inflammation and the existence of clinical possible phenotypes population sharing common features with published cohorts. Despite the necessity of further investigation into pathogenic mechanisms, this study with clinically difficult patient group may help to improve future asthma care., (Copyright © 2011 Elsevier Ltd. All rights reserved.)

Objective: Chronic rhinosinusitis (CRS) is a risk factor for asthma exacerbations and is associated with greater clinical severity. Discrepancies may exist between CRS clinical diagnosis and data from paranasal sinus (PS) X-ray or computed tomography (CT) scans. The objective was to compare PS involvement using low-dose CT and plain X-ray in allergic asthmatic patients with rhinitis., Methods: Patients underwent PS radiography in the frontal and mentonian positions and low-dose CT consisting of six to eight coronal scans performed on the central region of the sphenoidal, ethmoidal, maxillary, and frontal sinuses. Possible results for each sinus were a normal aspect or the presence of mucosal thickening, opacification, and/or air-fluid level., Results: Eighty-five (93.4%) of 91 study patients had radiological changes on radiography or CT. In only six (6.6%) were both tests normal. The maxillary was the most involved sinus by both methods. Simultaneous PS abnormalities were observed in 40.5% on X-ray and 56.7% on CT. For the frontal, ethmoidal, and sphenoidal sinuses, the proportion of normal results differed significantly between X-ray and CT: 80.2% versus 89%, 76.9% versus 63.7% and 96.7% versus 70.3%, respectively (p <.05). Agreement was over 70% for the maxillary and frontal sinuses. CT also provided a better diagnosis of air-fluid level changes than X-ray., Conclusions: Low-dose CT significantly showed larger number of normal PS results and diagnosed more severe PS lesions. As the determination of true sinus severity lesion impacts in asthma control, low-dose CT may replace PS plain X-ray and conventional CT to support better clinical decisions.

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 re-evaluated 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.

1. Studies in asthmatic subjects have reported conflicting results about the arrhythmogenic effects of beta agonist and theophylline. The purpose of the present study was to evaluate the effects of the combination of these drugs in patients with chronic obstructive pulmonary disease (COPD). 2. Twelve COPD patients (FEV1 = 1.2 +/- 0.3 L; PaO2 = 65.7 +/- 9.0 mmHg) were evaluated by 24-h Holter monitoring on three different days. The first evaluation was done after the patient had been without any treatment for at least 24 h, the second after sustained-release theophylline for one week and the third after oral beta agonist (albuterol) and theophylline for one week. 3. Mean serum level of theophylline was 1.9, 15.6 and 11.7 micrograms/ml, and mean heart rate was 78.3, 82.0 and 84.5 beats/min for the first, second and third period, respectively. Four patients showed more than 10 premature atrial contractions/h in the baseline Holter, and this rate did not increase after either treatment. Three patients had more than 10 premature ventricular contractions/h (PVC) at baseline, with no increase while receiving theophylline or the combination of theophylline and albuterol. However, one patient did have worsening of the arrhythmia while taking both drugs. There were 5 single PVCs/h at baseline and 150 single and 9 coupled PVCs/h plus 1 episode of non-sustained ventricular tachycardia during combined therapy. 4. We conclude that the combination of theophylline and a beta agonist (albuterol) may increase the premature ventricular contraction rate and the complexity of ectopic activity in COPD patients.

The role of the concurrent use of theophylline and beta-adrenergic agents for relief of bronchial obstruction is controversial. For this reason, we studied the lung function of 9 patients with chronic obstructive pulmonary disease, whose ages ranged from 51 to 69 (average 60.6 +/- 6.6) years, after the oral administration of theophylline and theophylline plus salbutamol. After withdrawal of all bronchodilators for 24 hours, the basal values of forced vital capacity (FVC) and forced expiratory volume in one second (FEV1) were obtained. Oral slow release theophylline (600 mg/day) was then administered for 7 days, followed by 7 days of the concurrent use of the same dose of theophylline plus salbutamol (16 mg/day). Spirometry was reevaluated at the end of each week. Pretreatment FVC ranged from 0.85 to 2.57 (average 1.78 +/- 0.64) liters, FEV1 from 0.70 to 1.64 (average 1.15 +/- 0.30) liters and theophylline serum levels from 0.1 to 3.1 (average 1.81 +/- 1.01) micrograms/ml. At the end of the first week, FVC was 1.38 to 3.26 (average 2.03 +/- 0.65) liters, FEV1 0.85 to 1.73 (average, 1.40 +/- 0.29) liters and theophylline serum levels 8.1 to 21.0 (average 13.40 +/- 4.18) micrograms/ml. With the concurrent use of theophylline and salbutamol FVC ranged from 1.24 to 2.57 (average 1.90 +/- 0.50) liters and FEV1 from 0.96 to 1.90 (average 1.46 +/- 0.33) liters, values not statistically different from theophylline alone.

Several drugs interfere with theophylline pharmacokinetics, inducing changes on it's serum levels. With the purpose of determining a possible influence of oral administered beta-2-adrenergics agents on theophylline serum levels ten patients with bronchial obstruction, whose ages ranged from 51 to 69 (average 59.90 +/- 6.67) years, were analysed. After a period of 24 hours without any medication, the patients received 600 mg of oral slow release theophylline per day, for 7 days, followed by 7 days of the same dose of theophylline combined with 16 mg of oral salbutamol. Blood samples were drawn after the 24 hours without medication and at the 4th hour after the morning dose of theophylline, at the end of each week. The serum levels were, respectively, 2.08 +/- 1.20 micrograms/ml, 15.18 +/- 6.87 micrograms/ml and 11.45 +/- 5.15 micrograms/ml. The levels of the phase (theophylline alone) were significantly higher than those obtained after the concurrent use of theophylline and salbutamol. It can be concluded that this association interferes on theophylline pharmacokinetics. We suggest that in patients taking these drugs the serum levels of theophylline shall be measured to permit an eventual correction of the dose of theophylline being administered.

Amiodarone is an amphiphilic drug that penetrates easily through the plasmatic membrane and can induce the production of lysosome lamellar bodies in virtually all cells of the organism, independently of toxic effects. This study determines the value of searching for lamellar bodies in peripheric leucocytes as a method of prevention of pulmonary toxic effects in long term amiodarone treated patients. The rate of leucocytes with lamellar bodies was determined in three groups of patients. The group I was composed of 8 patients with amiodarone induced pneumonia who were taking the drug for an average of 16.88 months (average of 386.60 mg a day). The group II was composed of 19 patients not presenting any toxic effects, and who were taking amiodarone for an average of 38.32 months (average of 260.62 mg a day). The group III consisted by 8 healthy volunteers. The leucocyte layer was sampled from centrifuged peripheric blood and examined by transmission electron microscopy. The average percentage of leucocytes with lamellar bodies was 1.82 in group I, 1.65 in group II and 3.47 in group III. The lamellar inclusions were seen in all groups. There were no significant qualitative or quantitative differences between the groups. The inclusions couldn't be differentiated from other previously described non amiodarone lamellar bodies, such as artifacts and those produced by cellular degeneration. Although lamellar bodies can be observed in leucocytes of patients taking amiodarone, the determination of the rate of affected leucocytes is of no help for predicting amiodarone pulmonary toxicity.

Occupational lung disease is uncommon in workers of abrasive industries. Twenty-two workers of these industries presenting radiological lung lesions were analysed. All were males with ages ranging from 29 to 59 years. Nineteen worked in the production of silicon carbide, three in the production of aluminum dioxide and one in both for a period of 8 to 27 years. In 20 patients the predominant radiological changes (ILO-80) were small opacities. Association of small and large opacities was observed in one case and isolated large opacities in another one. The small opacities were predominantly round and diffuse. The large opacities in both patients were classified as being of category B. It is concluded that the workers in abrasive industries are at a higher risk of developing occupational lung disease produced by silicon carbide.