Assessment of the effect of implementation of global initiatives for asthma [GINA] guidelines in the outcome of asthma exacerbation in the Emergency Department

Asthma is a continuous significant health problem. Strategies for treating exacerbations are best adapted and implemented at a local level. Severe exacerbations are potentially life threatening, and their treatment requires close supervision. The severity of the exacerbation determines the treatment administered. Indices of severity, particularly peak expiratory flow [PEF], pulse rate, respiratory rate, and pulse oximetry should be monitored during treatment. The aim of this work was to assess the effect of the implementation of the Global Initiative for Asthma [GINA] guidelines in the prognosis and the outcome of asthma exacerbation in the emergency department. The study was conducted on one hundred asthmatic patients. All patients were informed about the study and gave their consents. Patients were subjected to full history taking and clinical evaluation. Investigations were done in the form of peak flow rate [PFR] measurement, pulse oximetry assessment, ABG analysis [for only 17 patients], chest X-ray [it is not routinely recommended] and complete blood count [if needed]. Then patients were classified according to their attacks. All patients were managed according to GINA guidelines. Older patients were significantly suffering from severe to life threatening attacks than younger patients. We found that 12% of patients had occupational related asthma in relation to 88% of patients had non-occupational related asthma. There were no statistical significant differences between classification of severity of current attack and previous emergency department [ED] visits/year. There were no statistical significant differences between the studied groups regarding temperature. Systolic and diastolic blood pressure had statistically significant lower values in patients with severe to life threatening attacks than those with mild to moderate attacks. Severe to life threatening group had respiratory rate higher than mild to moderate group. Mild to moderate group had PEF and SaO2% higher than severe to life threatening group. PEF was statistically higher post treatment than pre treatment. Three patients of 17 had PaCo2 >45 mmHg with hypoxemia and respiratory acidosis and they admitted to the intensive care unit [ICU]. All patients in ED were assisted to determine the severity of asthma concomitant with administration of initial treatment [plan A], which is oxygen to achieve O2 saturation >/= 92%, inhaled B2 adrenergic bronchodilator and an oral or intravenous dose of corticosteroids. Five patients met a good response so they enter in [plan C1]. Seventy-five patients met with the criteria of moderate episode they go to plan B1, 68 patients of them [about 90%] had a good response within 2 h so go to plan C1 and the rest 7 patients [10%] had an incomplete response go to plan C2. Twenty patients met with criteria of severe episode, 17 of them [85%] with incomplete response move to plan C2, and the rest 3 patients [15%] had a poor response and moved to plan C3, no improvement noticed so they were admitted to the ICU. Hospitalization was done to 11 patients who met a poor response [plan C2], 86 patients were discharged from the ED [73 patients from plan C1 and 13 patients from plan C2]. Severe to life threatening group stayed in ED longer than mild to moderate group. All patients presenting in the emergency department with asthma exacerbations should be evaluated and triaged immediately and must be treated according to their severity of classification using GINA guidelines. Measurements of airflow obstruction, using peak expiratory flow, can help to guide therapy for acute asthma. Continuous monitoring of oxyhaemoglobin saturation by pulse oximetry should be undertaken for all patients with acute exacerbation of asthma. We must; educate patients in ED about the nature of asthma and its therapy, educate patients how to use inhalers, encourage patients to use spirometer at home and discharge each patient with ED-asthma discharge plan

use of overnight pluse oximetry and phoniatrics parameters in the screening protocol of obstructive sleep apnea

Obstructive sleep apnea-hypopnea syndrome [OSAHS] is a major public health problem due to its high prevalence rate. Polysomnography is the current golden standard test for diagnosis of OSAHS. The studies with pulse oximetry reveal a high sensitivity and suggest that as a screening tool, these may exclude some patients with negative studies from further work-up for OSAHS. Acoustic analysis of snoring sounds would offer the advantage of a non-invasive technique that would be used to monitor normal sleep. The posterior vocal tract resonances [i.e. F1 and F2] of OSA patients would yield lower frequency values compared to non-OSA individuals. To determine the sensitivity and specificity of overnight oximetry and phoniatrics parameters in evaluation of OSAHS and to compare the results with those obtained from polysomnography [PSG] as the gold standard test. Twenty patients, were presented with presumptive clinical diagnosis of OSAHS, each patient was subjected to: Full history taking: including age, sex, complain and Epworth Sleepiness Scale [ESS]. Systemic examination: Including general examination and body mass index [BMI]. Standard ENT examination and fibroptic pharyngoscopy with Muller maneuver. Polysomnography was done using RESMED Apnea Link screening device. Other tests: Acoustic analysis of voice and acoustic analysis of snoring sounds using computerized speech lab [CSL]. Pulse oximetry: The overnight oximetry was analyzed using the Wrist Pulse Oximeter MD300W. Eighteen patients [90%] were found to have OSAHS and two patients [10%] were simple snorers. The sensitivity of overnight pulse oximetry for an apnea hypopnea index of >5, >15, and >30/h was 66.7%, 80%, and 100% respectively and the specificity was 50%. The formant frequencies of different vowels [i, u and a] in OSA patients and non-OSA snorers revealed that the mean F1 value for the vowel /i/ was significantly lowered in OSA patients. In addition, the mean F2 value of the vowel /i/ and /u/ was markedly lowered in OSA patients. There was significant increase in values of bandwidths [BW1 and BW2] for /i/ and /u/ vowels in OSA patients in comparison to non-OSA snorers. Acoustic analysis of snoring sounds revealed that; in the palatal snorers group, the average pitch was 105 +/- 8 Hz and in the tongue base snorers group the average pitch was 263 +/- 17 Hz; meanwhile the average pitch in the combined group was 160 +/- 14 Hz. The difference was highly significant between the 3 groups. However harmonic to noise ratio was increased in patients with tongue base obstruction. Polysomnography is the current golden standard test for diagnosis and evaluation of degree of OSA. Overnight pulse oximetry offers an inexpensive method of screening for and diagnosing OSAHS. Oximetry alone allowed confident recognition of moderate and severe cases of OSAHS. Acoustic analysis of snoring sounds and voice in patients with snoring and/or OSAHS is useful as a screening or supportive method with other investigations to diagnose the site of upper airway obstruction during sleep