A comparative study of patients' preferences and sensory perceptions of three forms of inhalers among Thai asthma and COPD patients.

In 9 study centers, 419 patients with asthma or COPD were randomized to receive two forms of salbutamol metered-dose-inhalers (MDIs), i.e. CFC-driven MDI, non-CFC (HFA) MDI and one salbutamol dry powder inhaler (DPI), in a multi-center, comparative, cross-over and randomized study, performed to facilitate the formulation of a strategic plan to phase out CFC MDIs. After having received all three forms of test products, the patients completed an evaluation questionnaire indicating their preferences, likelihood of treatment compliance on each product and the easiest one to use. Statistical analysis showed that the CFC MDI was significantly less irritating (p < 0.014) but lower in its overall appeal (p < 0.0001). The "most preferred form to be prescribed" was DPI at 47.5% followed by non-CFC at 32.5% and CFC MDI at 20.1%. Concerning the ease of use among the three forms of test products, 59.9% of the patients indicated "no difference". Adverse events were mild and occurred in only 8.2%. In conclusion, patients' preference and sensory perception among the three forms of inhalers were comparable except that the CFC MDI was significantly less irritating but lower in its overall appeal. DPI was the most preferred and easiest form to use but also the most expensive. Taking public health into consideration, a non-CFC MDI with a similar market price to the CFC MDI would be the obvious choice in a strategic plan to phase out CFC MDIs with the least difficulty to the consumers.

Clinical characteristics, management in real world practice and long-term survival among COPD patients of Northern Thailand COPD club members.

OBJECTIVE: To assess the baseline clinical characteristics, management, and long-term survival of hospital-based COPD patients in the northern part of Thailand. MATERIAL AND METHOD: One hundred and ninety five hospital-based COPD patients from community and provincial hospitals in the northern part of Thailand were recruited between May and November 2002. They were followed up for 45 months for survival. RESULTS: Most of them (71.3%) were in the advanced stage and 41.8% were undernourished. Only a small fraction of the advanced stage patients (25.7%) estimated their dyspnea severity correctly with the disease stages. The frequency of the exacerbations increases as the disease become more severe. Only 23.7% of the advanced stage patients had received regular bronchodilator therapy. No patients had received pulmonary rehabilitation and long-term oxygen therapy. The 45 months survival was 75.6% in all patients. The severe group with low BMI had significantly lower survival than the one with normal BMI (67.7% vs. 89.8%, p = 0.040). CONCLUSION: Most COPD patients in the northern part of Thailand were in the advanced stage. They were commonly undernourished and exacerbated but still under treated according to standard treatment guidelines. BMI tends to influence the long-term survival of the advanced stage patients.

Actual implementation of the Thai Asthma Guideline.

OBJECTIVE: To determine the clinical impact of Thai Asthma Guideline implementation. MATERIAL AND METHOD: A nationwide written questionnaire survey was used for 365 Thai physicians who were involved in routine asthma practice. The questionnaire consisted of two questions; the first concerning the criteria to define steps of asthma severity (16 parameters) and the second concerning controller use in each step of asthma severity, focusing on the use of inhaled corticosteroids (ICS). RESULTS: Of 272 physicians (74.5%) who responded to the questionnaire; 21, 76 and 175 were chest physicians, general practitioners (internists), and general doctors, respectively. All the non-responders could not provide answers to the questionnaire because they were unable to remember them all. More than 12 out of 16 parameters in the first question were filled out correctly by only 14%, 4% and 5% of chest physicians, general practitioners and general doctors, respectively, whereas fewer than 5 out of 16 parameters were answered correctly by 33%, 66% and 71% of these physicians, respectively. The most common parameters answered incorrectly by general doctors were FEV1 and PEF variability. ICS was the most common controller used in controlling each step of persistent asthma. However, only 46.8% of general doctors prescribed it for the management of mild persistent asthma. CONCLUSION: The Thai Asthma Guideline is impractical for clinical practice implementation, due to complicated severity grading and a very low rate of lung function tests for grading asthma severity. Although ICS is the most common controller prescribed, its use is still far from optimal in Thailand. The authors suggest that the Thai asthma guideline should be simplified and aimed towards optimal ICS use among generalists.

Efficacy of weaning protocol in medical intensive care unit of tertiary care center.

OBJECTIVE: To evaluate the efficacy of the protocol-directed weaning from a mechanical ventilator compared to physician-directed weaning. MATERIAL AND METHOD: A comparative study between retrospective studies of physician-directed weaning as controls (N = 198) reviewed from July 2000 to July 2002 and the prospective studies of protocol-directed weaning as intervention (N = 196) enrolled from October 2002 to October 2003 in the medical ICU of Maharaj Nakorn Chiang Mai Hospital, tertiary care center of northern Thailand. Study results were concluded by Fisher's exact test. RESULTS: Baseline characteristics data of both groups including sex, age, illness severity which demonstrated by APACHE II score and PaO2/FiO2 ratio, causes of respiratory failure and mode of mechanical ventilation used were similar. The duration of mechanical ventilation before weaning was 5.89 +/- 3.71 days in the protocol-directed group and 7.41 +/- 5.54 days in the physician-directed group (p < 0.05). Weaning duration in the protocol-directed group was significantly shorter than the physician-directed group (14.58 +/- 16. 98 hours VS 47.09 +/- 38.23 hours; p < 0.05). Kaplan-Meire analysis demonstrated that patients in the protocol-directed group had significantly shorter durations of mechanical ventilation compared to patients in the physician-directed group (p = 0.001, log-rank test). The ICU LOS was significantly shorter in the protocol-directed group (7.91 +/- 4.71 vs 11.53 +/- 7.80 days; p < 0.05). The 28 days mortality rate and the incidence of hospital acquired pneumonia seemed to be less in the protocol-directed group (4.60% vs 6.10% and 5.60% vs 10.10% consecutively) and reintubation rate seemed to be higher in the protocol-directed group (6.1% vs 4.5%) than the physician-directed group but differences were not significant (p > 0. 05). CONCLUSION: Protocol-directed weaning proved to have more efficacy in weaning patients from a ventilator than physician-directed weaning in terms of weaning duration and ICU length of stay without a deteriorating effect to the patients.

Role of bronchial washing in the diagnosis of endoscopically visible lung cancer.

OBJECTIVE: To evaluate the usefulness of bronchial washings in addition to endobronchial biopsies and/or bronchial brushings for the pathological diagnosis of endoscopically visible lung cancer. MATERIAL AND METHOD: A retrospective study of patients diagnosed as lung cancer by bronchoscopy between January 1995 and December 1998. Patients were included in the study if they had 1) endoscopically visible tumors (exophytic mass or irregular mucosa) and 2) bronchial washings (BWs) performed together with either endobronchial biopsies (EBBs) or bronchial brushings (BRs). Patients were classified into 3 groups according to the result of the histocytology as follows: A) positive in both BWs and EBBs/BRs, B) positive in only EBBs/BRs and C) positive in only BWs. A number of patients in each group were analyzed to see the benefit of BWs as an add-on diagnostic tool. The authors also evaluated the benefits of BWs in the subgroup of patients who had necrotic and bleeding tumor Statistical analysis of the data was performed by using the likelihood-ratio chi-square test. RESULTS: Two hundred and twenty-two patients were included in the present study. The number of patients in group A, B and C was 108, 108, and 6, respectively. Therefore, BW was the only diagnostic procedure in 6 patients (2.7%). Those 6 patients all had incurable non-small cell lung cancer The likelihood of a positive BWs in an exophytic mass was no different from irregular mucosa. The likelihood of a positive BWs in a tumor with necrosis was higher than in a tumor without necrosis. In contrast, tumors with active bleeding had a lower likelihood of positive BWs when compared with those without bleeding. The likelihood ratio showed no statistical significance in any of the groups. CONCLUSION: The addition of BWs to either EBBs or BRs is beneficial, but it may not be cost-effective. This procedure may be useful in patients with an endoscopically visible necrotic tumor In contrast, the bronchoscopic finding of a bleeding tumor may be a negative predictor. This procedure may be a suitable approach when performed only in selected cases, such as necrotic tumor or negative initial EBBs/BRs.