BACKGROUND: Proper structural foundations for asthma care at primary health care centers [PHCCs], are of essential importance, regarding its management. OBJECTIVE: To assess the adherence of PHCCs to the recommended structural foundation for asthma care. MATERIALS AND METHODS: 35 PHCCs were selected in a cluster random fashion. A questionnaire for structural standards was designed, based on the Saudi national protocol for the management of asthma (SNPMA). A physician and a nurse, each from PHCC, were trained for data collection. Structural facilities deficiency was arbitrarily classified into: least deficient (>75%), moderate to severe deficient (25-75%) and most deficient (<25%). RESULTS: The total population registered, was 131190 [urban: 85701 (65.4%), rural: 45489 (34.6%)]. Total registered asthmatics was 4093 [urban: 2585 (63.1%), rural: 1508 (36.9%)]. The asthma prevalence rate did not differ significantly between urban (3%) and rural (3.3%) areas . Structural facilities distribution for asthma care, did not significantly vary among urban and rural PHCCs and none of them fulfilled 100% of the desired standards. The least deficient, were the availability of asthma register and salbutamol, in its various forms. The moderately to severely deficient were the SNPMA, peak flow meter (PFM), nebulizer system, Theophylline and systemic corticosteroid. However, they were most deficient in trained doctors and nurses, record charts for Peak flow meter, spacer, educational material and inhalers of corticosteroid or cromoglycate. CONCLUSION: Proper structural foundations for asthma care at PHCCs, at AL-Qassim region, were below the desired national standards. They were most deficient in trained doctors and nurses, record charts for PFM, spacers, educational material and anti-inflammatory inhalers. Future health directorate strategies have to provide such beneficial interventions for proper asthma care.

STUDY OBJECTIVE: To compare between Abrams and Cope needles pleural biopsy, as regard their diagnostic yield and complications in pleural effusions. STUDY DESIGN: Retrospective chart analysis SETTING: 140 bed community chest hospital, ministry of health, affiliated with teaching hospitals in Riyadh area. MATERIALS AND METHODS: 57 patients (44 males and 13 females), with a mean age of 37.9 years (range, 17-80 years), who were admitted through July 1994 to June 1995, for management of pleural effusion. INTERVENTION: Pleural biopsy was performed for all patients, using either cope needle (group 1: 22 patients), or Abrams needle (group 2: 35 patients). MEASUREMENT: We recorded the type of pleural biopsy needle, final diagnosis and complications. RESULTS: The overall diagnostic sensitivity in pleural effusions for Cope needle was 82% (18/22), compared to 54% (19/35) for Abrams needle. The diagnostic sensitivity in TB pleurisy for Cope needle was 85% (17/20), compared to 57.5 (19/33)% for Abrams needle ( P = 0.08). The incidence of pneumothorax was 18% (4/22) with cope needle, compared to 8% (3/35) with Abrams needle ( P = 0.5) no other complications occurred with both needles. CONCLUSION: Cope needle demonstrates a diagnostic sensitivity equal to that of Abrams needle, without increase in the incidence of pneumothorax.

BACKGROUND: Six minutes walk test (6MWT), is a sub-maximal exercise test, used as a clinical indicator of the functional capacity, in patients with cardiopulmonary diseases. Its safety, validity, reliability and its correlation with several physiological instruments, are well studied. However, there are no published data on 6MWT, in the Saudi population. We are reviewing our experience with 6MWT and assessing its safety and its correlation with pulmonary function variables, in patients with pulmonary diseases, in our local population. MATERIALS AND METHODS: We consecutively studied patients with pulmonary diseases, who underwent 6MWT and pulmonary function test in King Khalid University Hospital, from June 2003 to December 2004. The 6MWTs were conducted according to the American Thoracic Society guidelines. Spirometry, lung volumes and diffusion capacity measurements were correlated with the absolute walked distance. RESULTS: One hundred and twenty nine tests were performed. All patients were of the Saudi community (59% female), with mean age of 43±15 years. Out of 129 patients, 65 patients had proven respiratory diagnosis. In all patients, the test were performed with no serious complications. The six minute walk distance (6MWD) had correlation with patient's height (r=+0.40, P <0.001), but not with patients' weight, BMI, borg scale, or oxygen saturation. The 6MWD correlated significantly with Dlco (r=+0.52, P <0.01), FVC (r=+0.46, r<0.001) and had a weaker relation with FEV1 (r=+0.31, P <0.05). The test had no significant correlation with lung volumetric parameters (TLC, FRC and RV). CONCLUSION: 6MWT is simple and safe test in evaluating patients with chronic pulmonary diseases in the Saudi population. In our study, 6MWD showed correlation with spirometric parameters and diffusion capacity. Further studies are needed to evaluate 6MWT in a more homogenous patients' population.

OBJECTIVE: To evaluate the impact of an extensive education campaign for physicians, in effecting positive changes, in their asthma prescription practice, in line with the 'Saudi protocol for diagnosis and management of asthma'. MATERIALS AND METHODS : An extensive campaign on asthma management for physicians in Saudi Arabia was conducted in 1995-1996, based on the 'Saudi protocol for asthma diagnosis and management'. During this campaign, one day courses-cum-workshops were held in 19 different cities, for over 2500 physicians (8% of all physicians in the kingdom). To evaluate the changes in asthma prescription, we retrospectively reviewed the charts of 98 asthmatic patients in 1994 and 100 patients in 1997, attending the outpatient department of two tertiary care hospitals, with over 500 beds, each in Riyadh and Jeddah. Data on demographic profile of the patients, Pulmonary function test and medications prescribed, were analysed and compared between the two groups. RESULTS: The mean age and severity of asthma was similar in both the groups.The prescription rate of inhaled steroids and inhaled beta-agonists increased significantly, with decrease in the use of oral beta-agonists, oral steroids, Theophylline, sodium cromoglycate and ketotifen. Conclusion: The use of inhaled steroids and inhaled beta agonists, considerably improved after the asthma education campaign for physicians in Saudi Arabia. Education campaign for physicians may be effective and could help in the improvement of clinical practice towards a specific disease.

We report a young lady, who was labeled as a case of refractory asthma for a few years, based on history of shortness of breath on minimal exertion, noisy breathing and normal chest radiograph. Repeated upper airway exam by an otolaryngologist and computerized tomography scan, were normal. On presentation to our hospital, she was diagnosed to have fixed upper airway obstruction, based on classical flow-volume loop findings. Fibroptic bronchoscopy revealed a web-shaped subglottic stenosis. The histopathology of a biopsy taken from that area, showed non-specific inflammation. No cause for this stenosis could be identified. The patient was managed with rigid bronchoscopy dilatation, without recurrence. We report this case as idiopathic subglottic stenosis, that was misdiagnosed as refractory bronchial asthma, stressing the importance of performing spirometry in the clinic.

Despite the availability of many diagnostic modalities and the advent of new tests, the diagnosis of pulmonary embolism (PE) remains a challenge. Clinical manifestations can be notoriously deceptive and there is not a single test, that can be relied on solely, to exclude PE. Although it has been regarded as the gold standard test, pulmonary angiography has not been tested against a reference standard and thromboembolic events have been reported after a normal study. Therefore the diagnosis of PE depends on judicious utilization of the available tests in the right clinical setting, as the accuracy of the results of the investigations, depends largely on the pretest clinical probability. Simple investigations such as chest radiograph, electrocardiogram and arterial blood gas, are used to enhance the clinical probabilities, rather than confirming or refuting the diagnosis of PE. On the other hand, Perfusion ventilation (VQ) scan and computerized tomographic pulmonary angiography (CTPA), are the main screening tests used for patients with suspected PE. Recently CTPA has largely replaced VQ scan, in many centres. As both VQ scan and CTPA have their limitations, other diagnostic modalities, such as D-dimer and Compression ultrasound of the legs (CUS), are used as adjunctive diagnostic investigations. High probability and normal VQ scan, especially when combined with the concordant clinical probability, has a high positive and negative predicative value, respectively. On the other hand, CTPA is more sensitive and specific than VQ scan, though it has to be combined with CUS and clinical probability, to reduce the chance of missing PE. Although many diagnostic algorithms have been advocated, the discretion of the clinician and clinical experience, still has a major role to play in the diagnosis of PE. In this article, we try to come with a plausible approach to the diagnosis of PE, based on the current literature.

Bronchiectasis is a chronic lung disease, defined pathologically as irreversible dilatation of the bronchi. The clinical course of the disease is chronic and progressive and in most cases, causes lung damage over many years. There is usually an initial event, which causes impairment of mucociliary clearance of the bronchial tree. The respiratory tract becomes colonized by bacteria that inhibit the ciliary function and promote further lung damage. The hallmark of bronchiectasis, is a chronic cough with mucopurulent or purulent sputum, lasting for months to years and may progress to chronic respiratory failure. Diagnosis of bronchiectasis is suspected on the basis of clinical manifestations. In order to confirm the diagnosis and underlying causes, appropriate investigations must be performed. In this comprehensive review, we discuss the etiology, pathogenesis, clinical presentation, appropriate investigations and management of bronchiectasis.