Asthma Protocols

EDITORIAL

Asthma Protocols

Mílton de Arruda Martins

Faculdade de Medicina da Universidade de São Paulo, SP

Medical practice has changed considerably over the past few years, and one of the most significant aspects of these changes is the increasing amount of information generated by clinical research. In order to help physicians make decisions based on scientific evidence, guidelines and protocols are being created in ever greater numbers. In Brazil, the “Projeto Diretrizes” coordinated by the Brazilian Medical Association should be highlighted. The objective of this project is to create medical guidelines based on the best scientific evidence available, and various medical specialty societies are involved. A medical practice that keeps apace with current knowledge from well-designed studies is believed to be beneficial to society.

In the elaboration of guidelines and protocols, it is important to prioritize diseases and health risks that have a major impact on society, taking into consideration prevalence, mortality, negative impact on the quality of life, social costs, and intervention options. Asthma is a logical choice for such focus. The incidence of asthma is high and increasing, resulting in significant personal costs and requiring considerable expenditure of public resources for both emergency and long-term follow-up treatment.

The implementation of protocols based on international guidelines may have a major impact on asthmatic patient care. Cabral et al.⁽¹⁾ studied the effect of the implementation of an international guidelines-based program for children and adolescents with asthma. The study was carried out in a specialized clinic of a non-university hospital for children that serves a low-income population. The authors reported that most asthmatic children admitted in this clinic had been receiving inadequate treatment from their physicians and that the adoption of well-defined guidelines considerably reduced the number of emergency room visits and hospitalizations. However, this study was carried out in a specialized clinic with a highly motivated medical staff. Adherence to protocols has been more difficult to achieve in larger clinics with greater numbers of physicians on staff. Results have often been inferior to those expected by the group responsible for implementation of the protocol.

In this issue of the Jornal Brasileiro de Pneumologia, Rocha et al.⁽²⁾ report the results of the implementation of a protocol for adults presenting with asthma attacks to the emergency room of a university hospital. The authors evaluated the quality of care prior to and after protocol implementation, including accuracy of attack severity assessment, solicitation of exams, use of approved versus unapproved therapies, and outcomes. Although there was no significant difference in length of emergency room visits or admission and discharge rates, there was an increase in the use of pulse oximetry, peak expiratory flow determination, administration of the recommended three nebulizations in the first hour and oral corticosteroid therapy. Braga et al.⁽³⁾ had similar results in another Brazilian university hospital, studying the effect of a training program for asthma treatment in the emergency room. The authors reported a significant post-implementation increase in the number of patients for whom oral corticosteroids were prescribed at discharge, although some patients were still discharged without corticosteroid prescription.

Well-conducted studies such as that carried out by Rocha et al. are important to the evaluation of the real effects of protocol implementation. Such studies should be accompanied by a serious evaluation of what the best strategies for protocol implementation are and how we can increase physician adherence, since these protocols may have a positive impact on the quality of patient care.

References

1. Cabral ALB, Carvalho WAF, Chinen M, Barbiroto RM, Boueri FMV, Martins MA. Are international asthma guidelines effective for low-income Brazilian children with asthma. Eur Respir J 1998;12:35-40.

2. Rocha PM, Fernandes AK, Nogueira F, Piovesan DM, Kang S, Franciscatto E, et al. Efeito da implantação de um protocolo assistencial de asma aguda no serviço de emergência de um hospital universitário. J Bras Pneumol 94-101

3. Braga VCM, Caramez MPR, Morano SR, Velasco IT, Martins MA. The effect of a training program on the quality of care of asthma patients by resident and attending physicians in an emergency department of a teaching hospital. Am J Respir Crit Care Med 2000;161:A457.

Publication Dates

• Publication in this collection
  15 June 2004
• Date of issue
  Apr 2004