Ministry of Health Clinical Practice Guidelines: Chronic Obstructive Pulmonary Disease

The Ministry of Health (MOH) has updated the Clinical Practice Guidelines on Chronic Obstructive Pulmonary Disease (COPD) to provide doctors and patients in Singapore with evidence-based treatment for COPD. This article reproduces the introduction and executive summary (with recommendations from the guidelines) from the MOH Clinical Practice Guidelines on COPD, for the information of SMJ readers. Chapters and page numbers mentioned in the reproduced extract refer to the full text of the guidelines, which are available from the Ministry of Health website: https://www.moh.gov.sg/content/moh_web/healthprofessionalsportal/doctors/guidelines/cpg_medical.html. The recommendations should be used with reference to the full text of the guidelines. Following this article are multiple choice questions based on the full text of the guidelines.

Trigger factors in asthma and chronic obstructive pulmonary disease: a single-centre cross-sectional survey

<p><b>INTRODUCTION</b>The presence of trigger factors may help to distinguish asthma from chronic obstructive pulmonary disease (COPD). Knowing and avoiding trigger factors for both asthma and COPD can facilitate the design of comprehensive management programmes that can aid disease control. This study aimed to describe the relative frequency and range of various trigger factors in asthma and COPD.</p><p><b>METHODS</b>We conducted a telephone-based survey involving asthma and COPD patients on follow-up at a university hospital in Singapore.</p><p><b>RESULTS</b>A total of 779 asthma patients and 129 COPD patients participated in this study. Among these patients, 93.8% of those with asthma and 42.6% of those with COPD had trigger factors (p < 0.001). The median number of trigger factors was greater among asthma patients than among those with COPD (3 vs. 0, p < 0.001). Trigger factors found to be significantly more prevalent among asthma patients compared to those with COPD include tobacco smoke, alcohol, upper respiratory tract infections, incense smoke, perfume, laughter, a dusty environment, air-conditioning, heavy rain, heavy traffic fumes, citrus fruits, gastro-oesophageal reflux, household pets, flowers/pollen, medications and psychological triggers. Trigger factors that were not previously described, such as bathing, fatigue, insufficient sleep, crowded places and overeating, were also reported.</p><p><b>CONCLUSION</b>Trigger factors, although found in both groups of patients, were more common among asthma patients. Knowledge of these trigger factors may be useful in distinguishing between the two diseases and optimising disease management.</p>

Characteristics of distractions in the intensive care unit: how serious are they and who are at risk?

<p><b>INTRODUCTION</b>Distractions and interruptions of doctor's work, although common and potentially deleterious in the intensive care unit (ICU), are not well studied.</p><p><b>METHODS</b>We used a simple observational method to describe the frequency, sources and severity of such distractions, and explore at-risk situations in the ICU. Independent paired observers separately shadowed eight residents and three fellows for 38 sessions (over 100 hrs) in a 20-bed medical ICU.</p><p><b>RESULTS</b>In total, 444 distractions were noted. Interobserver agreement was excellent at 99.1%. The mean number of distractions/doctor/hr was 4.36 ± 2.27. Median duration of each distraction was 2 mins (interquartile range 2-4 mins; range 1-20 mins). The top three initiators of distractions were other doctors (35.1%), nurses (30.4%) and oneself (18.7%). Of the 444 distractions, 107 (24.1%) were prolonged (lasting ≥ 5 mins), 210 (47.3%) led to a complete pause of current activity and 85 (19.1%) led to complete abandonment of the current activity. On multivariate analysis, physician seniority, time of session and day of week did not predict frequency of distraction. After adjusting for time of session, day of week and type of current activity, urgent distractions (to see another patient, perform immediate procedures or administer medications) and physician juniority were associated with major distractions (complete interruption or termination of current activity), while only urgent distractions were associated with prolonged distractions.</p><p><b>CONCLUSION</b>Distractions are common in the ICU and junior doctors are particularly susceptible to major distractions.</p>

Impact of the Singapore National Asthma Program (SNAP) on preventor-reliever prescription ratio in polyclinics

<p><b>INTRODUCTION</b>The Singapore National Asthma Program (SNAP) was launched in 2001 to address the high burden of asthma in Singapore. One component of the SNAP was directed at improving asthma control in the community by promoting preventive treatment with inhaled corticosteroids. This paper describes the program on prescription patterns of preventor and reliever medication for asthma in the polyclinics.</p><p><b>MATERIALS AND METHODS</b>We monitored the prescription pattern for asthma as the preventor-reliever (PR) drug ratio. The PR ratio was employed both as a positive feedback tool and as a key performance indicator (KPI) for the program. Individual clinics were encouraged to implement locally relevant and effective initiatives to increase the KPI and facilitate this process. The different methods included chronic care models, multidisciplinary teams, enhanced primary care clinics, pre-counselling screening, decision support tools, self-management support, a patient information system and community education.</p><p><b>RESULTS</b>In the course of the program, the case load for asthma in the polyclinics increased by 31%. During the same period, the average PR ratio increased significantly from 0.68 to 1.80 (P <0.001).</p><p><b>CONCLUSIONS</b>A simple audit and positive feedback program based on PR ratios, accompanied by sustained local quality improvement cycles has been associated with a significant shift in the drug treatment of asthma away from episodic quick relief medication towards long-term daily preventive treatment with inhaled steroids in polyclinics.</p>

Use of D-dimer and lower extremity Doppler ultrasound results to obviate the need for computerised tomographic pulmonary angiography

<p><b>UNLABELLED</b>We hypothesise that correct interpretation of other diagnostic tests could reduce the use of computerised tomographic pulmonary angiogram (CTPA) examinations in patients with suspected pulmonary embolism (PE).</p><p><b>MATERIALS AND METHODS</b>We carried out a retrospective analysis of 158 patients in a 928-bed university hospital. These consecutive patients were investigated for suspected PE from May 2001 to February 2002 using CTPA.</p><p><b>RESULTS</b>There were 74 men and 84 women with a mean (+/-SD) age of 57 (+/-19) years. Overall, 56% of patients (89/158) showed clinically significant abnormalities on the CTPA examination. The overall prevalence of PE was 15% (24/158). The D-dimers were assayed in 40% (63/158) and lower limbs were scanned with Doppler ultrasound (US) in 22% (35/158) of patients. None of the 19 patients with negative D-dimer assays had PE. Of the patients who were positively tested on Doppler US, 4 were positive and 1 was negative for PE on the CTPA. None of the patients with positive Doppler US had negative D-dimer test. In retrospect, patient management based on negative D-dimer assays and positive lower extremity Doppler US studies could have reduced the need for further investigation with CTPA by 15% (24/158).</p><p><b>CONCLUSION</b>In patients with suspected PE, correct interpretation of D-dimer and leg Doppler US tests may reduce the demand for CTPAs.</p>