National expert consensus on short-acting beta2-agonist overreliance in asthma care in Malaysia.

OBJECTIVE: Inappropriate use of short-acting beta2-agonists (SABA) in asthma has been associated with undesired outcomes. This national expert consensus was developed to increase awareness of SABA overuse and provide recommendations on the ways to eliminate SABA overprescription and overreliance in Malaysia. DATA SOURCES: This expert consensus was developed by searching the PubMed database, using index terms to identify SABA overuse-related burden and recommendations made in asthma guidelines. Consensus recommendations were made via the Delphi method, involving a Malaysian expert committee comprising 13 healthcare professionals (five pulmonologists, four family medicine specialists, two emergency medicine physicians and two pharmacists). STUDY SELECTIONS: The articles reviewed include randomized controlled trials, systematic reviews, meta-analyses, observational studies, guidelines, and surveys, with abstracts in English and published up until June 2023. Relevant recommendations were also sourced from verified websites of medical organizations and societies. RESULTS: Eleven consensus statements were developed, each statement achieving a priori agreement level of at least 70%. The statements reflect SABA overreliance in asthma care, as well as recommendations to eliminate SABA overprescription and overreliance in Malaysia. Supporting evidence in the literature as well as expert committee discussions leading to the development of the finalized statements were elaborated. CONCLUSION: This national expert consensus discussed the burden of SABA overreliance and made specific recommendations to eliminate SABA overprescription and overreliance in the Malaysian context. This consensus document is anticipated to impart better awareness among Malaysian healthcare providers and contribute to the continuous improvement of asthma care in the country.

Management of Asthma Exacerbations in Southeast Asian Tertiary Care.

BACKGROUND: There have been limited reports looking into the care of patients with asthma exacerbations admitted to tertiary hospitals in Southeast Asia. This study aims to determine the extent in which the 2019 Global Initiative for Asthma (GINA) guidelines were being met. METHODS: A retrospective study of patients with asthma exacerbations admitted to the University of Malaya Medical Centre (UMMC) and Pantai Hospital Kuala Lumpur (PHKL), Malaysia from 1 July 2019 to 31 December 2019. RESULTS: There were significant numbers of patients with previous admissions for asthma in both centres, with almost 50% experiencing an exacerbation in the previous year. Approximately 75% of the patients considered their asthma to be controlled when asked, despite many of them having had a history of acute exacerbations in the previous year. When cross-checked, the level of GINA-defined asthma control remained low, with only 6.4% of the patients deemed to have good control, while asthma was partially controlled in 25.6% of the patients and uncontrolled in 68% of the patients. About 72.1% of the patients reported daytime symptoms, 65.1% of the patients reported night-time symptoms, 70.9% of the patients required frequent usage of rescue inhalers and 72.1% of the patients reported some limitation in their activity prior to the current asthma exacerbation. Almost a quarter of the patients who were admitted had severe or life-threatening exacerbations as defined by GINA. These patients had more hospitalizations in a year and were more likely to have previous admissions requiring non-invasive and invasive ventilation. They were also more likely to be on GINA Step 5 treatment, had a lower mean percent predicted FEV1 and a higher baseline blood eosinophil count. Multivariate analysis revealed that baseline eosinophil count were independently associated with severe or life-threatening asthma exacerbations (odds ratio: 1.01, 95% confidence interval: 1.00-1.01, p=0.001). Failure to adhere to daily controller medications was high in this study (37.2%). CONCLUSION: Although the management of asthma exacerbations in tertiary hospitals in Southeast Asia is largely congruous with international guidelines, there is room for improvement. As there is a marked discrepancy between patient-perceived and guideline-defined asthma control, efforts to increase awareness on the dangers of uncontrolled asthma are warranted.

Anemia and performance status as prognostic markers in acute hypercapnic respiratory failure due to chronic obstructive pulmonary disease.

BACKGROUND: In patients with acute hypercapnic respiratory failure (AHRF) during exacerbations of COPD, mortality can be high despite noninvasive ventilation (NIV). For some, AHRF is terminal and NIV is inappropriate. However there is no definitive method of identifying patients who are unlikely to survive. The aim of this study was to identify factors associated with inpatient mortality from AHRF with respiratory acidosis due to COPD. METHODS: COPD patients presenting with AHRF and who were treated with NIV were studied prospectively. The forced expiratory volume in 1 second (FEV1), World Health Organization performance status (WHO-PS), clinical observations, a composite physiological score (Early Warning Score), routine hematology and biochemistry, and arterial blood gases prior to commencing NIV, were recorded. RESULTS: In total, 65 patients were included for study, 29 males and 36 females, with a mean age of 71 ± 10.5 years. Inpatient mortality in the group was 33.8%. Mortality at 30 days and 12 months after admission were 38.5% and 58.5%, respectively. On univariate analysis, the variables associated with inpatient death were: WHO-PS ≥ 3, long-term oxygen therapy, anemia, diastolic blood pressure < 70 mmHg, Early Warning Score ≥ 3, severe acidosis (pH < 7.20), and serum albumin < 35 g/L. On multivariate analysis, only anemia and WHO-PS ≥ 3 were significant. The presence of both predicted 68% of inpatient deaths, with a specificity of 98%. CONCLUSION: WHO-PS ≥ 3 and anemia are prognostic factors in AHRF with respiratory acidosis due to COPD. A combination of the two provides a simple method of identifying patients unlikely to benefit from NIV.

Targeted Antibiotic Prophylaxis for Lung Transplantation in Cystic Fibrosis Patients Colonised with Pseudomonas aeruginosa Using Multiple Combination Bactericidal Testing.

Early infection is a recognised complication after lung transplantation in patients with cystic fibrosis (CF). Our centre uses multiple combination bactericidal testing (MCBT) when determining appropriate peritransplant prophylactic regimens. To evaluate our strategy, we compared the incidence of posttransplant infection in patients whose peritransplant antimicrobial regimens were determined using MCBT versus standard sensitivity testing. Patients with CF who were infected with Pseudomonas aeruginosa and underwent lung transplantations between 2000 and 2010 were included. Data was collected from clinical records and our microbiology database. Microorganisms cultured were mapped against antibiotic resistance, method of sensitivity testing, and antibiotics administered peritransplant. 129 patients were identified (mean age 28, male : female, 63 : 66). Fifty patients (38.8%) had antibiotics determined by MCBT. Two patients in the MCBT group developed septicaemia, 13 in the conventional group (P ≤ 0.05, 2-tailed Fisher's test). Sepsis was attributable to P. aeruginosa in one patient from the MCBT group and seven patients in the conventional group (P = 0.15). P. aeruginosa was recovered from the posttransplant pleural fluid of one patient who received MCBT-guided prophylaxis, six patients in the conventional group (P = 0.25). Patients given antibiotics based on MCBT had significantly lower rates of septicaemia and lower rates of empyema.

Pulmonary hypertension and lung transplantation: Thorax publication activity review 2008-2010.

A review is presented on articles published in Thorax between 2008 and 2010 relating to lung transplantation and pulmonary hypertension.

Recurrent breast cancer and endobronchial ultrasound-transbronchial needle aspiration.

A 67 years old female with previous breast cancer and a 40-pack year smoking history presented with recurrent lower respiratory tract infections on a background of chronic obstructive pulmonary disease. Despite a normal chest X-ray, the history of recurrent infections led to a high resolution computed tomography scan to exclude structural lung disease. This showed subcarinal lymphadenopathy, multiple nodules in the right lung and suggestion of lymphangitis. She proceeded to have EBUS-TBNA of the enlarged paratracheal and subcarinal lymph nodes. Cytology was consistent with the diagnosis of recurrent metastatic breast carcinoma. The patient went on to receive Letrozole and radiotherapy. EBUS-TBNA is typically used to both diagnose and stage suspected lung cancer, usually in a solitary procedure. However, it is also useful in patients with undiagnosed mediastinal and hilar lymphadenopathy. This case adds to the paucity of literature whereby EBUS-TBNA was used as a quick and effective tool by which recurrent breast cancer was diagnosed.

Predicting end-of-life in patients with an exacerbation of COPD by routine clinical assessment.

UNLABELLED: The purpose of this study was to determine if routine clinical assessment could reliably predict in-hospital death in patients admitted with acute exacerbation of COPD (AECOPD). METHODS: In a case-crossover study the case records of AECOPD related deaths were reviewed. Clinical and laboratory variables including performance status (WHO-PS) and a composite physiological score (early warning score, EWS) at initial clinical assessment on final admission (FA) and penultimate admission (PA) for AECOPD were compared. RESULTS: Sixty patients included in study, female 60%, mean age (SD) 75 (8.7) years. 98% had ≥2 admissions for AECOPD. On univariate analysis variables associated with death were: Charlson score, WHO-PS, EWS, pH<7.35, Urea and CRP. On multivariate analysis predictors of mortality were: WHO-PS (OR 95% CI: 4.9 (1.06-22.61); p=0.04) and EWS (OR 95% CI: 3.39 (1.56-7.41); p=0.002). ROC analysis of relationship between combined WHO-PS/EWS score and death gave AUC 0.86; a total score≥6 had sensitivity 78% and specificity 86.2% and on multivariate analysis OR (95% CI) for death was 19.3 (4.3-86.2); p<0.0005. CONCLUSION: In-hospital deaths from AECOPD may be predicted by assessment of WHO-PS and EWS on admission to hospital.