Avaliação diagnóstica e resposta terapêutica ao corticosteróide inalatório em pacientes com diagnóstico clínico de tosse crônica de causa inaparente
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Data
2003
Autores
Ribeiro, Marcos [UNIFESP]
Orientadores
Silva, Clystenes Odyr Soares [UNIFESP]
Tipo
Tese de doutorado
Título da Revista
ISSN da Revista
Título de Volume
Resumo
Introdução: Tosse crônica sem causa aparente é comum e decorre de afecção de vias aéreas superiores, de hiperresponsividade brônquica ou de refluxo gastroesofageano em mais de 90% dos casos. Testes de broncoprovocação (TBP) são aplicados para avaliação desta condição com valor preditivo positivo e negativo insuficiente. Objetivo: Realizar uma
avaliação diagnóstica através de um questionário respiratório, de testes broncoprovocação e de testes cutâneos e a resposta a um ensaio terapêutico com corticosteróide inalatório em pacientes com diagnóstico clínico de tosse crônica de causa inaparente. Métodos: Foram avaliados após exclusão de causas extrapulmonares como rinossinusite e refluxo gastroesofágico 64 pacientes de forma prospectiva, aleatorizada, duplocega e paralela por 14 dias. Foi utilizado tratamento com beclometasona
inalatória 1500mg/dia para 44 pacientes (Grupo1) e placebo na forma inalatória para 20 pacientes (Grupo 2). Questionário respiratório, TBP com adenosina e metacolina, curvas inspiratórias e expiratórias e teste cutâneo foram comparados nos dois grupos e a resposta ao tratamento foi avaliada através de dois diários de sintomas. Resultados: Não houve diferenças
para o questionário respiratório, os TBP, testes cutâneos e o ensaio terapêutico tanto para o Grupo 1 quanto para o Grupo 2. Posteriormente os pacientes que utilizaram tratamento com corticosteróide (Grupo 2) foram separados em : Grupo 3 ou não respondedores ao tratamento (n=8) e Grupo 4 ou respondedores ao tratamento (n=36). O questionário respiratório não mostrou correlação com a resposta favorável ao tratamento para a maioria das perguntas nos Grupos 3 e 4. Entretanto a duração da tosse em meses (p < 0,032) e o uso de medicamentos nas últimas semanas ou meses (p < 0,001) no Grupo 4 foram significativamente menores. Os testes de broncoprovocação,
independentemente da substancia utilizada, foram semelhantes quanto ao resultado na identificação dos casos. Nos pacientes com TBP positivo, ou seja, nos portadores de tosse variante de asma, houve melhora dos sintomas em 95% (n=21) dos casos com o tratamento. Por outro lado, nos pacientes com teste de broncoprovocação negativo, ou seja, nos possíveis portadores de bronquite eosinofílica houve resposta ao tratamento em 68%
(n=15) dos casos. Quando analisamos apenas a resposta ao tratamento, independentemente da doença subjacente (tosse variante de asma ou possível bronquite eosinofílica) obtivemos uma melhora em 82% (n=36) dos pacientes que utilizaram corticosteróide inalatório. Após 1 ano houve o desenvolvimento de asma em 27% (n=12) de quarenta e cinco pacientes analisados.
Conclusões: Excluídas condições como drenagem retronasal e doença do refluxo gastroesofágico, o questionário respiratório não tem valor preditivo para a avaliação de pacientes com tosse variante de asma e possível bronquite eosinofílica. O valor preditivo positivo do TBP foi de 95% para os casos de tosse variante de asma e 68% para os casos de possível bronquite
eosinofílica. O ensaio terapêutico com corticosteróide inalatório mostrou excelente resposta com resolução completa da tosse em 82% dos pacientes, sendo 95% nos pacientes com tosse variante de asma e 68% nos pacientes com possível bronquite eosinofílica.
Introduction: Chronic cough without apparent cause is common and it comes from problems of the upper airways, bronchial hyperresponsiveness or gastroesophagel reflux in more than 90% of the cases. Bronchoprovocation tests (BPTs) are applied for evaluation of this condition with positive and negative predicts value insufficient. Purpose: To accomplish diagnostic evaluation through a respiratory questionnaire, bronchoprovocation tests, cutaneous tests and to monitor the response to a clinical trial with inhaled corticosteroids in patients with a clinical diagnosis of chronic cough without apparent cause. Methods: Sixty four patients were appraised in a randomized, double-blind and parallel group study for 14 days. forty four patients were treated with inhaled beclometasone 1500mg/day (group 1) and twenty patients by placebo in the inhaled form (group 2). Respiratory questionnaire, BPTs with adenosine and methacoline, inspiratory and expiratory curves and cutaneous tests were compared in the two groups and the response to the treatment was evaluated through two diaries of symptoms. Results: There were no differences in the respiratory questionnaire, BPTs, cutaneous tests and the clinical trial for either group. Patients that had treatment with corticosteroids (group 2) were separate into two groups: non-responders - group 3 (n=8) and responders - group 4 (n=36). For most of the questions (respiratory questionnaire) there was no correlation with the favorable response in treatment. However, the duration of the cough in months (p < 0,032) and the use of medicines in the last weeks or months (p < 0,001) in group 4 were significantly. The broncoprovocation tests, independently of the substances used, were similar for identification of cases. The patients with positive BPT (those with cough variant asthma) were treated and there was an improvement of the symptoms in 95% (n=21) of the cases. On the other hand, in the patients with negative bronchoprovocation test results (possible eosinophilic bronchitis) responsed to the treatment in 68% (n=15) of the cases. When analyzing only the response to treatment, independently of the underlying disease (cough variant asthma and eosinophilic bronchitis), we obtained an improvement in 82% (n=36) of the patients that used inhaled corticosteroids. After one year there was asthma development in 27% (n=12) of forty-five patients analyzed. Conclusions: After excluding conditions such as retronasal drainage and gastroesophageal reflux, we found that the questionnaire has no value as a tool in predicting cough variant asthma and possible eosinophilic bronchitis. The BPTs was effecting in predicting cough variant asthma (95% of the time). The corticosteroids trial showed an excellent response with complete resolution of coughing in 82% of the patients being 95% in the patients with cough variant asthma and 68% in the patients with possible eosinophilic bronchitis.
Introduction: Chronic cough without apparent cause is common and it comes from problems of the upper airways, bronchial hyperresponsiveness or gastroesophagel reflux in more than 90% of the cases. Bronchoprovocation tests (BPTs) are applied for evaluation of this condition with positive and negative predicts value insufficient. Purpose: To accomplish diagnostic evaluation through a respiratory questionnaire, bronchoprovocation tests, cutaneous tests and to monitor the response to a clinical trial with inhaled corticosteroids in patients with a clinical diagnosis of chronic cough without apparent cause. Methods: Sixty four patients were appraised in a randomized, double-blind and parallel group study for 14 days. forty four patients were treated with inhaled beclometasone 1500mg/day (group 1) and twenty patients by placebo in the inhaled form (group 2). Respiratory questionnaire, BPTs with adenosine and methacoline, inspiratory and expiratory curves and cutaneous tests were compared in the two groups and the response to the treatment was evaluated through two diaries of symptoms. Results: There were no differences in the respiratory questionnaire, BPTs, cutaneous tests and the clinical trial for either group. Patients that had treatment with corticosteroids (group 2) were separate into two groups: non-responders - group 3 (n=8) and responders - group 4 (n=36). For most of the questions (respiratory questionnaire) there was no correlation with the favorable response in treatment. However, the duration of the cough in months (p < 0,032) and the use of medicines in the last weeks or months (p < 0,001) in group 4 were significantly. The broncoprovocation tests, independently of the substances used, were similar for identification of cases. The patients with positive BPT (those with cough variant asthma) were treated and there was an improvement of the symptoms in 95% (n=21) of the cases. On the other hand, in the patients with negative bronchoprovocation test results (possible eosinophilic bronchitis) responsed to the treatment in 68% (n=15) of the cases. When analyzing only the response to treatment, independently of the underlying disease (cough variant asthma and eosinophilic bronchitis), we obtained an improvement in 82% (n=36) of the patients that used inhaled corticosteroids. After one year there was asthma development in 27% (n=12) of forty-five patients analyzed. Conclusions: After excluding conditions such as retronasal drainage and gastroesophageal reflux, we found that the questionnaire has no value as a tool in predicting cough variant asthma and possible eosinophilic bronchitis. The BPTs was effecting in predicting cough variant asthma (95% of the time). The corticosteroids trial showed an excellent response with complete resolution of coughing in 82% of the patients being 95% in the patients with cough variant asthma and 68% in the patients with possible eosinophilic bronchitis.
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Citação
RIBEIRO, Marcos. Avaliação diagnóstica e resposta terapêutica ao corticosteróide inalatório em pacientes com diagnóstico clínico de tosse crônica de causa inaparente. 2003. Tese (Doutorado em Ciências) - Escola Paulista de Medicina, Universidade Federal de São Paulo (UNIFESP), São Paulo, 2003.