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PURPOSE: A Regional Technical Commission was set in 2017 by Veneto region (Italy) to provide opinions and recommendations on drug prescriptions and to implement treatment-pathway guidelines for severe asthma. In this observational study, we describe the first structured, integrated, multidisciplinary, patient-centered outpatient clinic for the care of severe-asthma patients in Italy, and characterize patients referring to the center for specialist visits. PATIENTS AND METHODS: To characterize patients that accessed the outpatient clinic in 2018, data on demographic characteristics, treatments, severity of asthma, phenotypes, and relevant comorbidities by phenotype were collected. Use of biologic agents and indicators of the performance of the outpatient clinic were described. RESULTS: A structured multidisciplinary outpatient pathway for taking charge of patients and for administration and monitoring of biological agents was developed. A total of 146 patients accessed the outpatient clinic in 2018: 62.3% had uncontrolled asthma upon admission and 27.4% were already being treated with biologic agents. Among patients with uncontrolled asthma, 66% had severe uncontrolled asthma, 22% had moderate-severe uncontrolled asthma, and 12% had mild-moderate uncontrolled asthma. Main asthma phenotypes in uncontrolled-asthma patients were allergic (58% of patients), eosinophilic (22%), allergic plus eosinophilic (10%) and non-atopic asthma (10%). Among patients affected by severe asthma, 47% had allergic asthma, 28% had eosinophilic asthma, 13% had allergic plus eosinophilic asthma, and 12% had non-atopic asthma. Nasal polyps were more frequent in eosinophilic and allergic plus eosinophilic asthma, while gastro-esophageal reflux disease was more frequent in non-atopic asthma. CONCLUSION: This structure of an outpatient clinic for the treatment of severe asthma, with its dedicated pathway and multidisciplinary approach, may allow a stricter control of asthma and optimization of therapies, as well as minimization of drug misuse.
RESUMO
BACKGROUND: The role of midazolam in flexible bronchoscopy premedication has been debated. The aim of the present study was to evaluate whether midazolam premedication increases the patient-reported tolerance and the physician-reported or nurse-reported feasibility of bronchoscopy. METHODS: Randomized, double-blinded, placebo-controlled, 3-arm study. The study population included patients undergoing bronchoscopy for appropriate clinical indications. Patients were randomly assigned to receive 0.035 mg/kg intravenous midazolam (low dose), 0.07 mg/kg (high dose), or placebo. Vital parameters were monitored in continuum during the procedure. At the end of the procedure, the operating physician and assisting nurse filled out a questionnaire to score the procedure-related outcomes (satisfaction, feasibility, completeness, and unexpected events). Patients were asked to fill out a specific questionnaire to assess the patient-reported tolerance and satisfaction 2 hours after the bronchoscopy. RESULTS: A total of 100 patients (mean age 58.6±1.0; 57% male) were included in the study (33 in the low-dose midazolam group, 34 in the high-dose midazolam group, and 33 in the placebo group). The patient-reported tolerance score was significantly higher in the high-dose midazolam group than in the placebo group (P<0.01). No differences were found in the 3 groups in terms of the physician-reported feasibility and completeness of the procedure. In the groups of patients premedicated with midazolam, significant oxygen desaturation was recorded (at 10 and 8 min after the introduction of the bronchoscope) compared with the baseline value (P<0.01). CONCLUSIONS: In our study, premedication with midazolam increased the patient-reported tolerance of the bronchoscopy. However, the absence of premedication did not affect the diagnostic yield of the procedure.
