Management of asthma in hospital: a prospective audit

Abstract

with bicarbonate fluid (p<005). Mean arterial blood pressure fell at a mean rate of 3 9 (0 90) mm Hg/hour during dialysis with acetate fluid (p<001) and 1-4 (0 52) mm Hg/hour during dialysis with bicarbonate fluid (p<005). The rate of fall was significantly greater during dialysis with acetate than with bicarbonate fluid (p<0 02). The index of venous tone rose at a mean rate of 0-23 (0-05) ml/dl over 40 mm Hg/hour during dialysis with acetate fluid (p<001) and 0-20 (0 05) ml/dl over 40 mm Hg/hour during dialysis with bicarbonate fluid (p<001). Vascular resistance in the forearm increased at a mean rate of [3][4][5][6] (1-12) units/hour during dialysis with acetate fluid (p<002) and 4-5 (1-48) units/hour during dialysis with bicarbonate fluid (p<0 01). There were no significant differences in the changes in venous tone or vascular resistance between dialysis with acetate and bicarbonate fluid. DiscussionThe results of this study point to important abnormalities of the control of the peripheral circulation during dialysis that may contribute to the development of hypotension. The normal responses to a reduction in plasma volume such as that occurring during dialysis are venoconstriction and an increase in peripheral vascular resistance.7 Both of these mechanisms help to prevent a fall in blood pressure. The venoconstriction compensates for the reduced central plasma volume and maintains cardiac filling pressures and thereby cardiac output. The increase in peripheral vascular resistance helps maintain blood pressure despite a fall in cardiac output. Our patients showed a normal increase in peripheral vascular resistance during dialysis, but paradoxically their veins dilated. This venodilatation would accentuate the fall in central blood volume and lead to a fall in cardiac filling pressures and cardiac output and then to hypotension. Evidence supporting this as the mechanism of hypotension during dialysis is that an infusion of fluid often corrects the hypotension.The reason for the abnormal dilatation of the venous bed is unclear. It occurred equally during both types of dialysis and therefore is not due to the vasodilating properties of acetate. It does not seem to be due to autonomic dysfunction as there were appropriate changes in heart rate and peripheral resistance during dialysis, and the veins actively dilated. It is more likely that the correction of the metabolic derangements of renal failure withdrew a stimulus to venoconstriction. Whatever the mechanism, simple measures-for example, wearing support stockings-aimed at reducing pooling of blood in peripheral veins may prevent hypotension induced by dialysis.

Management of acute childhood asthma: a prospective multicentre study

“…Previous studies have tended to be either retrospective in nature [2, 10±12] or prospective but with relatively small numbers of patients [13,14]. A multicentre study was therefore initiated to compare practices and outcome for admissions for childhood asthma in the UK.…”

Proposta de indicadores e padrões para a avaliação de qualidade da atenção hospitalar: o caso da asma brônquica

“…Bucknall et al (1988), através de entrevistas realizadas com pacientes asmáticos duas semanas após a alta de um hospital da Escócia, observaram falhas significativas na educação dos pacientes, acerca da compreensão e gerência da asma. Verificaram que pouquíssimos pacientes possuíam o medidor de fluxo expiratório para uso em sua moradia, embora 32% tivessem história de ataques repentinos e crises graves.…”

“…Como padrão mínimo, espera-se que 100% dos pacientes acima de cinco anos de idade e que não apresentem problemas físicos que impeçam a realização do exame sejam submetidos a pelo menos uma avaliação objetiva durante a internação, sendo a espirometria o exame de preferência pela sua maior precisão. Esse indicador é importante visto que diversos autores enfatizaram a sua subutilização (Daley et al, 1991;Spevetz et al, 1992;BTA, 1982;Johnson et al, 1984;Bucknall et al, 1988;Lazarus, 1989;Oliveira, 1988).…”

“…A necessidade de educação do paciente asmá-tico vem sendo bastante enfatizada pela literatura, principalmente em artigos de revisões de óbitos (Collins-Williams et al, 1981), nos protocolos de atenção à asma já citados, nos de avaliação da assistência hospitalar (Fitzgerald & Hargreave, 1989;Bucknall et al, 1988), e em artigos de revisão do tratamento realizados por especialistas (Higenbottam & Hay, 1990;Campos, 1994;Serafini, 1992). Por ser a asma uma doença crônica, o seu adequado controle pressupõe uma boa compreensão da doença e de seu manejo pelo paciente e/ou familiares, pois muitos dos desfechos trágicos têm ocorrido devido à desinformação.…”

“…Portanto, após a internação, há necessidade de monitoração até a cura completa, para que não reste resíduo de obstrução brônquica que, com o tempo, possa tornar-se irreversível (Barnes, 1989;Brown et al, 1984). Torna-se, portanto, recomendável que o paciente tenha alta do hospital com uma consulta agendada dentro da semana seguinte à alta hospitalar (BTS, 1990;Bucknall et al, 1988).…”