asthma is a public health problem worldwide and is one of the most common chronic diseases in childhood . it is highly prevalent , impairs the quality of life of patients and their families , and incurs high costs to the health care system and society . 
 1 the current level of asthma control in latin american countries falls far short of the goals set forth by current international guidelines . 2 
  asthma is one of the twenty most common reasons for primary care visits in brazil , being the third leading cause of hospitalization within the brazilian unified health care system . 
 3 
 4 
  the mean prevalence of asthma among children and adolescents in brazil 5 
  in the state of rio grande do sul , brazil , respiratory diseases are the leading cause of hospitalization in those aged under 19 years , and asthma ranks second among these diseases . 
 4 
  there is as yet no curative treatment for asthma ; the primary goal of treatment is disease control . however , despite advances in asthma treatment and in the implementation of guidelines for asthma management , the disease remains poorly controlled . 6 
  possible explanations for this failure include lack of patient access to health care , lack of diagnosis of asthma , inappropriate treatment , and not taking the prescribed medication properly , whether because of lack of understanding or lack of adherence , despite instruction . 7 
  adherence to treatment is one of the most important factors in ensuring treatment success . many factors , such as knowledge of the disease , cultural standards , socioeconomic factors , lack of perception of asthma symptoms , adverse events , and ability to use inhalers , can influence adherence to treatment and asthma control . 
 8 
  poor adherence is a serious problem among patients with chronic respiratory disease in developing countries , a problem that is often due to limited access to health care ; therefore , in addition to prescription and provision of pharmacological treatment that is appropriate to the level of disease severity , education on self - management is an aspect that must be addressed . 
 8 
  asthma education for patients so that they know all they need about their disease is not only a right but also an effective strategy of asthma control in the short , medium and long term . 9 
  thus , the need to tailor knowledge of asthma education to clinical practice and make it accessible at a public outpatient clinic specializing in asthma motivated the development of the programa infantil de preveno de asma ( pipa , program for the prevention of childhood asthma ) in the city of uruguaiana , brazil , in order to decrease the morbidity and mortality of childhood asthma in that city . the objective of the present study was to present pipa and the characteristics of the patients followed in this program . this was a retrospective study of children ( < 18 years of age ) with asthma or suspected asthma who enrolled in pipa spontaneously or were referred by pediatricians or primary care physicians . pipa was established in april of 2012 in the city of uruguaiana , which has a population of approximately 120,000 inhabitants , in southern brazil . after being admitted to pipa , patients underwent the following treatment protocol : a ) a medical visit ; b ) ancillary tests ; c ) clinical diagnosis ; d ) functional diagnosis ; e ) treatment planning ; f ) follow - up and monitoring of asthma control ; and g ) a nursing visit and nursing instruction . at the medical visit , the parents or legal guardians of the patients completed standardized questionnaires , the use of which depended on patient age and the characteristics of the cross - cultural validation of the questionnaire for use in brazil . for the youngest patients ( those aged up to 3 years , 11 months , and 29 days ) , we used the international study of wheezing in infants ( eisl ) written questionnaire , 
 10 
  whereas for those aged over 4 years , we used the international study of asthma and allergy in childhood ( isaac ) questionnaire 
 11 
  together with the isaac phase ii questionnaire on risk factors , 
 11 
 12 
  in addition to the children 's sleep habits questionnaire , 
 13 
  which began to be used in january of 2014 , for those aged between 2 and 12 years . following the initial interview , patients underwent a detailed physical examination , including assessment of nutritional status ( weight and height ) ) , physical examination of the upper airways , cardiopulmonary auscultation , etc . ancillary tests included blood workup ; quantitative determination of total serum ige ( immunocap rast ; thermo fisher scientific inc . , waltham , ma , usa ) ; determination of 25-hydroxyvitamin d by chemiluminescent microparticle immunoassay ; skin prick tests to airborne allergens ( dermatophagoides pteronyssinus , d. farinae , blomia tropicalis , cockroach mix , alternaria sp . , dog dander , and cat dander ) , 
 14 
  and parasitological examination ( direct method ) . 
 15 
  depending on age and clinical history , patients underwent imaging assessment , which included a chest and/or sinus x - ray . in this phase , the clinical diagnosis of asthma was made in accordance with the global initiative for asthma ( gina ) criteria . 
 1 
  for the children aged under 2 years who were referred with suspected asthma , we employed the asthma predictive index ( api ) , 
 16 
  and for those aged over 2 years , we employed the modified api , which includes sensitization to airborne allergens as a prognostic factor of disease progression . 17 
  the diagnosis of allergic rhinitis was made in accordance with the criteria established by the third brazilian consensus on rhinitis 
 18 
  and by the allergic rhinitis and its impact on asthma initiative . 19 
  the children aged over 6 years who were able to perform the expiratory maneuvers required for functional assessment underwent objective measurements of pulmonary function , whether by spirometry or by determination of maximum peak expiratory flow , with the use of a spirolab iii spirometer ( medical international research , rome , italy ) . american thoracic society acceptability criteria - values from at least the three best maneuvers were selected - and reproducibility criteria were used . 20 
  following the initial spirometric assessment , patients underwent bronchodilator testing with albuterol aerosol ( 400 mg ) administered with a valve spacer , and the spirometric parameters were measured again 15 minutes later . 21 
   maximum peak expiratory flow was determined with a mini - wright peak flow meter ( clement clarke international , essex , uk ) , especially in patient follow - up and monitoring of the response to the treatment regimen . 21 
  after completion of the clinical and functional assessment and before establishment of a treatment plan , patients were classified with respect to level of asthma control , as well as to the presence of acute exacerbation , as recommended by gina . 
 1 
  on that basis , patients received a written treatment plan for maintenance control and possible exacerbations , as recommended by gina 
 1 
  and by the brazilian thoracic association guidelines for asthma management . 
 3 
  the medications available through pipa are as follows : albuterol ( metered dose inhaler ; 100 mg / puff ) ; and beclomethasone ( metered dose inhaler ; 250 mg / puff ) ; both of which are distributed free of charge at all " aqui tem farmcia popular " facilities of the brazilian popular pharmacy program . 22 
  for patients with moderate or severe asthma , montelukast ( tablets of 5 and 10 mg ) and the combination of albuterol ( 25 mg / puff ) and fluticasone dipropionate ( 125 mg or 250 mg / puff ) metered dose inhaler or dry powder inhaler ( diskus 50 mg/250 mg ) are available free of charge through the uruguaiana city hall . after being admitted to pipa , patients were followed and reassessed over 1 - 3 months , as determined by asthma severity and control . 
 1 
  in addition to medical follow - up , patients were followed by nurses who are specialists in asthma care and who are part of the team of professionals involved in pipa , as recommended by other groups and by international consensus guidelines . 23 
 24 
  the responsibilities of these nurses included the following : a ) administer quality - of - life questionnaires at the first nursing visit and 6 months later to assess patient 's response to treatment 
 25 
 ; b ) emphasize , to family members , the importance of identifying symptoms of uncontrolled disease early ; c ) always review the ( written ) action plan 
 26 
  with the following aims-1 ) recognition of asthma - related symptoms ; 2 ) treatment adjustment based on the medical prescription ; and 3 ) identification of when and where to seek medical attention , for patients with poor disease control with the initial treatment 
 25 
 -d ) check proper use of inhaled medication at all visits ; e ) encourage adherence to maintenance treatment and provide instruction regarding the difference between treatment of asthma attacks and maintenance treatment ; f ) address aspects of environmental control , habits such as smoking , and other triggers ; and g ) encourage regular visits ( every 3 months ) even if the patient is asymptomatic . 1 
  the study was approved by the research ethics committee of the uruguaiana municipal department of health , brazil . since the creation of pipa , 646 patients have been enrolled , all of whom were being followed at this writing . most of the patients aged up to 3 years ( > 80% ) had a history of recurrent wheezing ( three or more episodes ) , which had started early , before 6 months of age . episodes of severe wheezing were identified in nearly 30% of these patients , more than half of whom had been hospitalized for wheezing . of all patients aged up to 3 years , 26.5% had physician - diagnosed asthma , 53.0% had been born by cesarean section , and only 29.0% had been exclusively breastfed for at least 6 months ( table 1 ) . passive exposure to tobacco smoke was reported by 39.5% of the parents / legal guardians of these patients , with exposure occurring during pregnancy in 15.4% of the cases and the smoker being the mother in 18.7% ( table 1 ) . attending day care was identified in 38.2% of the cases , presence of household mold was identified in 44.6% , and presence of pets in the household was identified in 73.0% ( mainly dogs ) . a maternal education level of less than 8 years was identified in 35.6% of the cases ( table 1 ) . table 1.patients followed in the programa infantil de preveno  asma ( pipa , program for the prevention of childhood asthma ) since its establishment , by clinical characteristics and age group - uruguaiana , brazil , 2014 . characteristic 

 follow - up patients 

  3 years 

 > 3 years 

 ( n = 298 ) 

 ( n = 348 ) 
 wheezing ever298 ( 100.0)336 ( 96.5)wheezing in the first year of life256 ( 86.0)-recurrent wheezing in the first year of life 
 181 ( 60.7)-wheezing in the previous 12 months-308 ( 88.7)first episode before 6 months of age247 ( 82.8)-more than 4 attacks of wheezing in the previous year-155 ( 44.5)wakes up at night because of wheezing-200 ( 57.5)severe wheezing88 ( 29.5)158 ( 45.4)hospitalization for wheezing / asthma50 ( 16.7)28 ( 8.0)physician - diagnosed asthma79 ( 26.5)286 ( 82.2)rhinoconjunctivitis-259 ( 74.4)pneumonia 58 ( 28.5)-hospitalization for pneumonia42 ( 14.0)90 ( 25.8)exclusive breastfeeding until 6 months of age86 ( 29.0)218 ( 62.6)at least one smoker in the household117 ( 39.5)127 ( 36.4)maternal smoking56 ( 18.7)50 ( 14.6)maternal smoking during pregnancy46 ( 15.4)61 ( 17.5)birth by cesarean section158 ( 53.0)141 ( 40.5)attended day care in the first year of life114 ( 38.2)206 ( 59.1)exposure to household mold133 ( 44.6)168 ( 48.2)exposure to pets217 ( 73.0)275 ( 79.0)dogs190 ( 64.0)163 ( 47.0)cats71 ( 23.8)21 ( 6.0)maternal education level of less than 8 years106 ( 35.6)168 ( 48.4 ) 
 values expressed as n ( % ) . more than three episodes . 


  among the older patients ( those aged over 3 years ) , it is of note that wheezing in the previous year was reported in 88.7% of the cases , wheezing was severe in 45.4% , and hospitalization for wheezing was required in 8.0% ( table 1 ) . physician - diagnosed asthma was identified in 82.2% of the cases , and , in most of them , asthma had been classified as uncontrolled . exclusive breastfeeding for at least 6 months was reported in 62.6% of the cases ; however , passive exposure to tobacco smoke and maternal smoking during pregnancy were reported in 36.4% and 17.5% of the cases , respectively ( table 1 ) . nearly 60.0% of the patients attended day care in the first year of life , and presence of pets in the household was reported in 79.0% of the cases ( most often dogs ) . a maternal education level of less than 8 years was reported by 48.4% of the respondents ( table 1 ) . the high prevalence rates of asthma in children ( 9 to 11 years of age ) and recurrent wheezing in infants ( 12 to 15 months of age ) identified in uruguaiana by the isaac 
 12 
  and by the international study of wheezing in infants 
 27 
  prompted the local managers to establish pipa . as can be seen in table 1 , most of the children aged up to 3 years followed in the program experienced symptom onset in the first year of life , and the first episode of wheezing occurred before 6 months of age , as reported by other researchers . 28 
  in addition , a significant number of children in the two groups studied had severe wheezing . recent studies have increasingly shown that copd has its origins in severe childhood asthma ; therefore , identifying these children and the risk factors leading to more severe asthma is of the utmost importance for public health . 
 29 
  pre- and postnatal exposure to cigarette smoke has been identified as one of the most important risk factors for the development of wheezing in infants and asthma in older children . 30 
  among the patients enrolled in pipa , the prevalence of passive smoking was significant , since , in approximately 40% of the cases , there was at least one smoker in the household , and , in approximately 15% , the smoker was the mother . to this we must add prenatal exposure to tobacco smoke , which was identified in more than 15% of the cases . knowledge of these factors and of their magnitude is very important , because exposure so early in life can cause epigenetic changes in lung development that may extend to future generations . 31 
  a recent study also pointed out that exposure to tobacco smoke during pregnancy increases the risk of asthma and wheezing in adolescence , and that pulmonary function changes in these children would be related to potential epigenetic effects of tobacco smoke rather than to immune function changes or atopy . another finding worthy of note in this population was the large number of children who had been born by cesarean section , which is identified as a risk factor for developing asthma later in life , especially if associated with a family history of asthma . 
 33 
  maternal education level , especially in populations in developing countries , has been associated with the development of asthma . a significant proportion of the patients evaluated here had a mother who had had less than 8 years of schooling . previous studies conducted in brazil have related a low level of education to an increased risk of asthma or wheezing in children aged under 5 years . 34 
  this is possibly due to poor understanding of the disease by mothers , unawareness of the possibility of obtaining free controller medications , poor adherence to the asthma action plan , and , in particular , the lack of a bond between mothers and a specific facility where they can feel supported and welcomed if their children experience an acute asthma exacerbation .   for greater success in establishing an asthma program , the following should be taken into consideration : a ) get to know the local situation , through a local or regional epidemiological survey , so as to properly adjust the health policies needed for optimal care of the target population ; b ) build the foundations of the program upon the major consensus guidelines on the different aspects to be addressed in an asthma program 
 1 
 3 
 24 
 28 
 35 
 ; c ) get different categories of professionals , such as primary care physicians , nurses , physical therapists , social workers , physical education teachers , and community health agents , involved in the program , 
 36 
  thus preventing the program from being focused on a single person 
 9 
 ; d ) pharmaceutical care should be seen as a set of tasks performed by the pharmacist and other health professionals , in which medications are the essential material and which involve selecting , scheduling , purchasing , distributing , and dispensing medications , as well as ensuring the quality of the products and services and the follow - up and assessment of their use , with a view to achieving concrete results and improving the quality of life of the population 
 37 
 -understanding this concept is of paramount importance , since , often times , medications are distributed regardless of the fulfillment of the necessary criteria for the rational and safe use of these products 
 38 
 ; e ) get the population involved through the use of advisory boards , associations , and the media ; f ) get managers 
 9 
 36 
  involved and keep them permanently informed about the results of the program ; and g ) make the asthma program known through the media , television , or new communication tools ( such as the internet ) , which offer innovations in physician - patient communication and in knowledge and recommendations about the disease . 38 
  pipa has a page on facebook through which it has achieved greater communication and integration with patients and their families , as well as allowing the general public to get acquainted with the activities of the program . in conclusion , considering that brazil is a country with many " types of asthma " , 
 39 
  the establishment of regional asthma programs , based on epidemiological and environmental differences , would facilitate the implementation of appropriately targeted prevention , early diagnosis , and treatment measures , so as to allow proper allocation of financial resources , as occurs in other successful programs in brazil for adults . 40 
  therefore , there would be appropriate disease follow - up from symptom onset and a consequent reduction in the number of emergency room visits and hospitalizations , especially in patients with undiagnosed , undertreated , or poorly controlled asthma , thus preventing pulmonary changes that could lead to copd in adulthood . : apresentar o programa infantil de preveno de asma ( pipa ) , assim como as caractersticas dos pacientes nele acompanhados . : o pipa , implantado em uruguaiana ( rs ) , tem como populao alvo crianas e adolescentes com asma ou suspeita de asma , menores de 18 anos , referidos por pediatras , mdicos de ateno primria ou por procura espontnea . nesse grupo de pacientes , houve sibilncia recorrente em 60,7% e o primeiro episdio de sibilncia ocorreu nos primeiros seis meses de vida em 86,0% . sibilncia grave foi apontada em 29,5% e 45,4% nas crianas com  3 anos e com > 3 anos , respectivamente . na amostra total , a prevalncia de exposio passiva ao fumo foi elevada ( > 36% ) , ocorrendo durante a gestao em > 15% ; o nmero de nascimentos por cesariana foi > 40% , e o nvel educacional materno foi inferior a 8 anos em 30% . : um programa de preveno para atendimento de crianas com asma  uma estratgia eficaz para o controle da doena . o conhecimento das caractersticas epidemiolgicas e ambientais da populao local  primordial para que haja a reduo das formas graves da asma , melhor utilizao dos recursos de sade e possvel preveno de alteraes pulmonares que possam levar a dpoc no adulto . a asma  um problema de sade pblica em todo mundo e  uma das doenas crnicas mais frequentes na infncia . tem prevalncia elevada , causa comprometimento da qualidade de vida dos pacientes e de seus familiares , assim como determina um alto custo aos servios de sade e  sociedade . 1 
  os nveis atuais de controle da asma em pases da amrica latina ainda esto muito distantes dos objetivos preconizados pelos protocolos internacionais atuais . 
 2 
  a asma  um dos vinte principais motivos de consulta em ateno primria , sendo a terceira causa de internao do sistema nico de sade no brasil . 3 
 4 
  estima - se que a mdia de prevalncia de asma entre crianas e adolescentes no brasil seja de 20% . 
 5 
  no estado do rio grande do sul ( rs ) , as doenas respiratrias constituem o primeiro grupo de causas de internao em menores de 19 anos , sendo a asma o segundo nesse grupo . 4 
  ainda no dispomos de um tratamento curativo para a asma ; a meta principal do seu tratamento  o seu controle . entretanto , apesar dos avanos no tratamento e na implementao de diretrizes para o manejo da mesma , a asma continua sendo pouco controlada . 
 6 
  essa deficincia pode ser decorrente de vrias causas , tais como falta de acesso dos pacientes ao sistema de sade , falta de diagnstico da doena , tratamento da forma inadequada ou a no utilizao da medicao prescrita de forma correta , quer por falta de entendimento , quer por falta de aderncia , apesar da orientao recebida . 
 7 
  a aderncia ao tratamento  um dos fatores mais importantes que garantem o sucesso do tratamento . muitos fatores podem influenciar a aderncia ao tratamento e o controle da asma , tais como o conhecimento da doena , padres culturais , fatores socioeconmicos , falta de percepo dos sintomas da asma , eventos adversos e habilidade no uso de dispositivos de inalao . 
 8 
  a m aderncia  um problema srio entre pacientes com doenas respiratrias crnicas em pases em desenvolvimento , muitas vezes devido ao acesso limitado aos cuidados de sade ; por isso , alm da prescrio e da disponibilizao adequadas do tratamento farmacolgico de acordo com a gravidade da doena , a educao sobre o automanejo  um aspecto indispensvel de ser abordado . 
 8 
  educar para que os pacientes possam saber tudo o que precisam sobre sua doena no  somente direito das pessoas , mas tambm porque a interveno educativa resulta numa estratgia eficaz de controle da asma a curto , mdio e longo prazos . 9 
  assim , a necessidade de adaptar o conhecimento sobre educao em asma e torn - lo acessvel na prtica clnica de um ambulatrio especializado em asma e vinculado ao sistema pblico de sade motivou a criao do programa infantil de preveno de asma ( pipa ) na cidade de uruguaiana , rs , com o intuito de reduzir a morbidade e a mortalidade por asma nas crianas do municpio . o objetivo do presente estudo foi apresentar o pipa , assim como as caractersticas dos pacientes nele acompanhados . estudo retrospectivo de crianas com asma ou com suspeita de asma , menores de 18 anos , encaminhados ao pipa por pediatras , mdicos de ateno primria ou por procura espontnea . o pipa foi implantado em abril de 2012 na cidade de uruguaiana , cuja populao  de aproximadamente 120.000 habitantes , na regio sul do brasil . aps sua admisso , os pacientes seguiram o seguinte fluxograma de atendimento : a ) consulta mdica ; b ) avaliao complementar ; c ) diagnstico clnico ; d ) diagnstico funcional ; e ) plano teraputico ; f ) seguimento e acompanhamento do estado de controle ; e g ) consulta e orientao de enfermagem . na consulta mdica , os pais e / ou responsveis pelos pacientes responderam questionrios padronizados , segundo a idade e caractersticas de validao para a cultura brasileira . para os menores ( at 3 anos , 11 meses e 29 dias ) foi utilizado o questionrio escrito do international study of wheezing in infants ( eisl ) , 
 10 
  enquanto , para os maiores de 4 anos , o questionrio do international study of asthma and allergy in childhood ( isaac ) 
 11 
  acompanhados por aquele sobre fatores de risco do isaac fase 2 , 
 11 
 12 
  alm do questionrio de hbitos de sono das crianas 
 13 
  para as crianas com idades entre 2 e 12 anos , utilizado a partir de janeiro de 2014 . em seguida  entrevista inicial , realizou - se exame fsico detalhado , sobretudo no que diz respeito  aferio do estado nutricional ( peso e estatura ) , exame fsico das vias areas superiores , ausculta cardiopulmonar , entre outros . a avaliao complementar incluiu hemograma completo , dosagem quantitativa de ige srica total ( immunocap rast ; thermo fisher scientific inc . , waltham , ma , eua ) , dosagem de 25-hidroxivitamina d por imunoensaio quimioluminescente de micropartculas , testes cutneos de leitura imediata com aeroalrgenos ( dermatophagoides pteronyssinus , d. farinae , blomia tropicalis , mistura de barata , alternaria sp . , epitlio de co e epitlio de gato ) empregando - se a tcnica de punctura 
 14 
  e exame protoparasitolgico ( mtodo direto ) . 
 15 
  na dependncia da idade do paciente e da histria clnica , a avaliao por imagem foi realizada e incluiu radiografia de trax e / ou de seios da face . nessa fase , estabeleceu - se o diagnstico clnico de asma obedecendo - se os critrios da global initiative for asthma ( gina ) . 1 
  para as crianas menores de 2 anos encaminhadas com suspeita de asma , empregou - se o ndice preditivo de asma ( asthma predictive index , api ) 
 16 
  e , para as maiores de 2 anos , o api modificado , que inclui a sensibilizao a aeroalrgenos como fator prognstico evolutivo . 17 
  para o diagnstico de rinite alrgica foram obedecidos os critrios do iii consenso brasileiro sobre rinites 
 18 
  e da iniciativa allergic rhinitis and its impact on asthma . 
 19 
  as crianas maiores de 6 anos de vida e capazes de executarem manobras expiratrias necessrias para a avaliao funcional foram submetidas a medidas objetivas da funo pulmonar , quer por espirometria , quer por determinao do pico de fluxo expiratrio mximo , empregando - se o espirmetro spirolab iii ( medical international research , roma , itlia ) . foram utilizados os critrios de aceitabilidade , selecionando - se os melhores valores obtidos em pelo menos trs determinaes , e os de reprodutibilidade segundo o padronizado pela american thoracic society . 20 
  seguiu - se  avaliao espiromtrica inicial a prova com broncodilatador ( salbutamol spray , 400 mg ) administrado com espaador valvulado e nova aferio dos parmetros espiromtricos aps 15 minutos . 
 21 
  a medida do pico de fluxo expiratrio mximo foi realizada com o mini - wright 
  peak flow meter ( clement clarke international , essex , reino unido ) , sobretudo no seguimento dos pacientes e para o monitoramento da resposta ao esquema teraputico institudo . 21 
  finda a avaliao clnico - funcional e antes de estabelecer - se o plano teraputico para os pacientes , eles foram classificados conforme o controle ou no da asma , assim como a presena de exacerbao aguda , conforme o preconizado pela gina . 
 1 
  a partir da , os pacientes receberam um plano de tratamento , por escrito , para manuteno e possveis exacerbaes conforme o preconizado pela gina 
 1 
  e pelas diretrizes da sociedade brasileira de pneumologia e tisiologia para o manejo da asma . 3 
  os medicamentos disponibilizados pelo pipa so os seguintes : salbutamol ( inalador pressurizado ; 100 mg / jato ) e beclometasona ( inalador pressurizado ; 250 mg / jato ) , que so de distribuio gratuita nas unidades do " aqui tem farmcia popular " . 
 22 
  para pacientes com asma moderada ou grave , so disponibilizados gratuitamente pela prefeitura do municpio de uruguaiana montelucaste ( comprimidos de 5 e 10 mg ) , e a associao salmeterol ( 25 mg / jato ) e dipropionato de fluticasona ( 125 mg ou 250 mg / jato ) inalador pressurizado ou sob a forma de inalador de p ( diskus 50 mg/250 mg ) . aps a admisso , os pacientes foram seguidos e reavaliados em prazo varivel de 1 - 3 meses , segundo a intensidade e o controle da doena . 1 
  alm do acompanhamento mdico , os pacientes foram seguidos por enfermeiras especializadas em asma e que compem o corpo de profissionais envolvidos com o pipa ,  semelhana do preconizado por outros grupos e consensos internacionais . 23 
 24 
  foram responsabilidades dessas profissionais : a ) aplicar os questionrios de qualidade de vida na primeira consulta de enfermagem e 6 meses aps para avaliar a evoluo do paciente com o tratamento institudo 
 25 
 ; b ) reforar , entre os familiares , a importncia da identificao precoce dos sintomas de descontrole da doena ; e c ) revisar sempre o plano de ao 
 26 
  ( escrito ) visando - 1 ) reconhecimento dos sintomas relacionados  asma ; 2 ) ajustar o tratamento baseado na prescrio mdica ; e 3 ) identificar o momento de procurar atendimento mdico e onde , nas situaes de falta de controle com o tratamento inicial 
 25 
  - d ) verificar o uso correto da medicao inalatria em todas as consultas ; e ) estimular a adeso ao tratamento de manuteno e orientar sobre a diferena entre o tratamento de crise e de manuteno ; f ) reforar aspectos de controle ambiental , de hbitos como o tabagismo e outros fatores desencadeantes ; e g ) estimular consultas regulares mesmo que o paciente esteja assintomtico ( a cada 3 meses ) . 
 1 
  o estudo foi aprovado pelo comit de tica em pesquisa da secretaria de sade do municpio de uruguaiana , rs . desde a sua criao , foram matriculados e esto em seguimento 646 pacientes , dos quais 46,1% tm at 3 anos de idade ( tabela 1 ) . a maioria dos pacientes com at 3 anos ( > 80% ) apresentara um quadro de sibilncia recorrente ( trs ou mais episdios ) , que iniciou de modo precoce , antes dos 6 meses de vida . episdios de sibilncia grave foram apontados em quase 30% dos pacientes , sendo que mais da metade deles foram hospitalizados por sibilncia . do total de pacientes com at 3 anos , 26,5% receberam diagnstico mdico de asma , 53,0% nasceram de parto cesreo , e apenas 29,0% receberam aleitamento materno exclusivo por no mnimo 6 meses ( tabela 1 ) . a exposio passiva  fumaa de tabaco foi referida por 39,5% dos pais / responsveis pelos pacientes , sendo que , em 18,7% , o fumante era a me , e 15,4% foram expostos ao fumo durante a gestao ( tabela 1 ) . frequentar creche foi apontado em 38,2% dos casos ; a presena de mofo no domiclio , em 44,6% ; e a presena de animais no domiclio , em 73,0% ( principalmente ces ) . o nvel educacional materno inferior a 8 anos foi apontado em 35,6% dos casos ( tabela 1 ) . tabela 1.pacientes acompanhados no programa infantil de preveno  asma ( pipa ) desde a sua instalao , segundo caractersticas clnicas e faixa etria - uruguaiana ( rs ) , 2014 . caractersticas 

 pacientes em acompanhamento 

  3 anos 

 > 3 anos 

 ( n = 298 ) 

 ( n = 348 ) 
 sibilncia alguma vez na vida298 ( 100,0)336 ( 96,5)sibilncia no primeiro ano de vida256 ( 86,0)-sibilncia recorrente no primeiro ano de vida 
 181 ( 60,7)-sibilncia nos ltimos 12 meses-308 ( 88,7)primeiro episdio antes dos 6 meses247 ( 82,8)-mais de 4 crises de chiado no ltimo ano-155 ( 44,5)acorda  noite por chiado-200 ( 57,5)sibilncia grave88 ( 29,5)158 ( 45,4)hospitalizao por chiado / asma50 ( 16,7)28 ( 8,0)diagnstico mdico de asma79 ( 26,5)286 ( 82,2)rinoconjuntivite -259 ( 74,4)pneumonia 58 ( 28,5)-hospitalizao por pneumonia 42 ( 14,0)90 ( 25,8)leite materno exclusivo at 6 ms 86 ( 29,0)218 ( 62,6)fumante no domiclio117 ( 39,5)127 ( 36,4)me tabagista56 ( 18,7)50 ( 14,6)me fumou durante gestao46 ( 15,4)61 ( 17,5)parto cesreo158 ( 53,0)141 ( 40,5)frequentou creche no primeiro ano de vida114 ( 38,2)206 ( 59,1)exposio a mofo no domiclio133 ( 44,6)168 ( 48,2)exposio a animais217 ( 73,0)275 ( 79,0)ces190 ( 64,0)163 ( 47,0)gatos71 ( 23,8)21 ( 6,0)nvel educacional materno inferior a 8 anos106 ( 35,6)168 ( 48,4 ) 
 valores expressos em n ( % ) . entre os pacientes mais velhos ( com mais de 3 anos de idade ) , destacamos que houve relatos de sibilncia no ltimo ano em 88,7% dos casos , sendo essa grave em 45,4% , havendo necessidade de hospitalizao por esse quadro em 8,0% ( tabela 1 ) . o diagnstico mdico de asma foi apontado em 82,2% dos casos , na maioria deles como asma no controlada , e referiu - se rinoconjuntivite associada em 74,4% dos casos . o aleitamento materno exclusivo por no mnimo 6 meses foi relatado em 62,6% dos casos ; entretanto , a exposio passiva ao fumo do tabaco e o fumo materno durante a gestao foram relatados em 36,4% e 17,5% dos casos , respectivamente ( tabela 1 ) . de vida e , em 79,0% , referiu - se a presena de animais no domiclio , ( mais frequentemente ces ) . o nvel de educao materna inferior a 8 anos foi referido por 48,4% dos entrevistados ( tabela 1 ) . as prevalncias elevadas de asma em crianas ( de 9 a 11 anos ) e de sibilncia recorrente em lactentes ( 12 a 15 meses ) apontadas pelo isaac 
 12 
  e pelo international study of wheezing in infants , 
 27 
  realizados em uruguaiana , sensibilizaram os gestores locais para a implantao do pipa . como podemos ver na tabela 1 , a maioria das crianas com at 3 anos acompanhadas no programa teve o incio de sintomas j no primeiro ano de vida , e o primeiro episdio de sibilncia aconteceu antes do sexto ms de vida ,  semelhana do relatado por outros pesquisadores , 
 28 
  e , alm disso , um nmero significativo de crianas , nos dois grupos estudados , teve sibilncia grave . estudos recentes apontam cada vez mais que a origem da dpoc tem incio na asma grave da infncia ; assim , a identificao dessas crianas e dos fatores de risco que levam ao desenvolvimento de asma mais agressiva  tarefa de suma importncia para a sade pblica . 29 
  a exposio pr- e ps - natal  fumaa de cigarro tem sido identificada como um dos fatores de risco mais importantes para o desenvolvimento de sibilncia em lactentes e de asma nas crianas maiores . 30 
  entre os pacientes do pipa , a exposio passiva ao tabaco foi significativa , posto que aproximadamente em 40% dos casos , havia ao menos um fumante no domiclio e , em cerca de 15% , esse indivduo era a prpria me . a isso devemos acrescentar a exposio pr - natal ao fumo de tabaco , que foi apontada em mais de 15% dos casos . o conhecimento desses fatores e da sua magnitude  muito importante , pois a exposio em poca to precoce da vida pode ocasionar alteraes epigenticas no desenvolvimento pulmonar que podero se estender a geraes futuras . 
 31 
  um estudo recente destaca ainda que a exposio ao fumo de tabaco durante a gestao aumenta o risco de asma e sibilncia na adolescncia e que as alteraes na funo pulmonar dessas crianas no teriam relao com alteraes da funo imunolgica ou atopia , mas sim com possveis efeitos epigenticos do tabaco . 32 
  outro dado que nos chama  ateno nessa populao foi o grande nmero de crianas nascidas por parto cesreo , identificado como fator de risco para se desenvolver asma em uma poca mais tardia na vida , sobretudo se associado  histria familiar de asma . 
 33 
  o nvel de escolaridade materna , sobretudo em populaes de pases em desenvolvimento , tem sido associado ao desenvolvimento de asma . entre os pacientes aqui avaliados , uma parcela significativa de mes no havia atingido os 8 anos de escolaridade bsica . estudos anteriores em nosso meio relacionam a baixa escolaridade a um maior risco de asma / doena sibilante em menores de 5 anos . 
 34 
  possivelmente isso decorra do menor entendimento sobre a doena por parte das mes , da falta de conhecimento sobre a possibilidade de usar medicamentos de preveno gratuitos , da falta de aderncia ao plano de ao estipulado para o controle da doena e , principalmente , da falta de vnculo com um local especfico onde possam se sentir mais amparadas e acolhidas caso haja uma exacerbao aguda da asma em seus filhos . para um maior sucesso na implantao de um programa de asma devemos levar em conta as seguintes consideraes : a ) conhecer a realidade local , pelo levantamento epidemiolgico local ou de regies prximas , para adequar de forma mais correta as polticas de sade necessrias para o melhor atendimento da populao alvo ; b ) fundamentar as bases do programa nos principais consensos que orientam os diferentes aspectos a serem abordados num programa de asma 
 1 
 3 
 24 
 28 
 35 
 ; c ) envolver , no programa , profissionais de outras categorias , como mdicos de ateno primria , enfermeiros , fisioterapeutas , assistentes sociais , professores de educao fsica e agentes comunitrios , 
 36 
  evitando , dessa maneira , um programa centrado numa nica pessoa 
 9 
 ; d ) a assistncia farmacutica deve ser entendida como um conjunto de aes desenvolvidas pelo farmacutico e por outros profissionais de sade , tendo o medicamento como insumo essencial , o que envolve a seleo , a programao , a aquisio , a distribuio e a dispensao dos medicamentos , assim como a garantia da qualidade dos produtos e servios e o acompanhamento e avaliao da sua utilizao , tendo em perspectiva a obteno de resultados concretos e a melhoria da qualidade de vida da populao , 
 37 
  visto que a compreenso desse conceito  de suma importncia , uma vez que , com frequncia , ocorre a distribuio de medicamentos sem os necessrios critrios que assegurem o uso racional e seguro desses produtos 
 38 
 ; e ) envolver a populao atravs dos conselhos de sade , associaes e mdias ; f ) envolver gestores 
 9 
 36 
  e mant - los informados permanentemente sobre os resultados do programa ; e g ) divulgar o programa de asma na mdia , televiso ou por meio de novas ferramentas de comunicao ( como a internet ) , que oferecem inovaes na comunicao mdico - paciente e nos conhecimentos e recomendaes sobre a doena . 
 38 
  o pipa possui uma pgina no facebook , com a qual tem conseguido uma maior comunicao e integrao com os pacientes e seus familiares , alm de possibilitar ao pblico em geral um maior conhecimento sobre as atividades do programa . em concluso , considerando - se que o brasil  um pas de muitos " tipos de asma " , 
 39 
  a implantao de programas regionais de asma , respeitando - se as diferenas epidemiolgicas e ambientais , facilitaria a instalao de medidas preventivas , de diagnstico precoce e de tratamento mais bem direcionadas , visando o uso dos recursos financeiros de forma mais adequada  realidade , a exemplo de outros programas bem - sucedidos no pas em populaes adultas . 
 40 
  assim , haveria um melhor acompanhamento da doena desde o incio dos sintomas , diminuindo a procura pelos servios de urgncia e as hospitalizaes , especialmente nos pacientes com asma no diagnosticada , subtratada ou mal controlada , evitando assim o aparecimento de alteraes pulmonares que possam levar ao desenvolvimento de dpoc na fase adulta .
objective : to present the programa infantil de preveno de asma ( pipa , program for the prevention of childhood asthma ) and the characteristics of the patients followed in this program . 
 methods : implemented in the city of uruguaiana , brazil , pipa has as its target population children and adolescents ( < 18 years of age ) with asthma or suspected asthma . patients 
 either enroll in pipa spontaneously or are referred by pediatricians or primary care physicians . in this retrospective study 
 , we use a standardized protocol to assess pipa patients . 
 results : by the end of the study period , 646 patients were being followed . 
 of those , 298 ( 46.1% ) were  3 years of age . in this group of patients , 
 recurrent wheezing was identified in 60.7% , and the first episode of wheezing occurred in the first six months of life in 86.0% . 
 severe wheezing was identified in 29.5% and 45.4% in the children  3 and > 3 years of age , respectively . 
 physician - diagnosed asthma was reported in 26.5% and 82.2% , respectively . in the sample as a whole , 
 the prevalence of passive smoking was high ( > 36% ) , occurring during pregnancy in > 15% ; > 40% of the patients had been born by cesarean section ; and 30% had a mother who had had < 8 years of schooling . 
 conclusions : a prevention program for children with asthma is an effective strategy for controlling the disease . 
 knowledge of local epidemiological and environmental characteristics is essential to reducing the prevalence of the severe forms of asthma , to improving the use of health resources , and to preventing pulmonary changes that could lead to copd in adulthood .