VIII. Management of Exacerbations of Asthma

Survey of asthma practice among emergency physicians

PURPOSE

The National Asthma Education and Prevention Program (NAEPP) published guidelines for asthma management in 1991. The purpose of this study is to assess the concordance between emergency physicians' practice and the guidelines.

DESIGN

Survey mailed to emergency physicians. Non-respondents were mailed a second copy of the survey.

PARTICIPANTS

Eight hundred randomly selected active members of the American College of Emergency Physicians.

INTERVENTIONS

None.

MEASUREMENTS

Participants were asked questions regarding training, current asthma practices, and sources of information on asthma management.

RESULTS

Eight hundred questionnaires were mailed, of which 416 (52%) were returned. Sixty-four percent of respondents administer beta-agonists consistent with the NAEPP guidelines. Seventy-five percent of respondents administer corticosteroids in similar accord, while 75% prescribed outpatient corticosteroids in concordance with those recommendations. Forty-seven percent report measuring pretreatment pulmonary function more than half the time and only 38% report checking pulmonary function prior to disposition more than half the time.

CONCLUSIONS

Most emergency physicians surveyed use beta-agonists and steroids at least as often as recommended. A minority of emergency physicians reported utilizing pulmonary function testing in the manner recommended by the NAEPP.

Accuracy of the clinical examination in detecting hypoxemia in infants with respiratory illness

OBJECTIVES

To evaluate the diagnostic accuracy of the clinical examination in detecting hypoxemia in infants with lower respiratory tract illness.

DESIGN

Cross-sectional study.

SETTING

Three university pediatric outpatient departments and one private pediatric practice.

PATIENTS

Healthy infants less than 1 year of age seen between December and March 1989 and 1990, with symptoms suggesting acute lower respiratory tract illness.

MAIN OUTCOME MEASURES

The test characteristics of 27 elements of the clinical examination, as well as the accuracy of the overall examination and the components of the examination in detecting oxygen saturation < 95% measured by pulse oximetry. Reliability of clinical examination findings.

RESULTS

None of the 27 clinical findings had sensitivities that would make them useful diagnostic tests for hypoxemia. By combining all the clinical findings, however, we found good diagnostic accuracy (area under the receiver operator characteristic curve 0.90). Three groups of clinical findings--social interactiveness, respiratory effort, and physical appearance--accounted for much of the diagnostic accuracy of the examination. Auscultatory findings contributed little. In these three groups, five clinical findings accounted for almost all the accuracy: attentiveness, consolability, respiratory effort, color, and movement. Together, these findings also had good accuracy (area under the receiver operator characteristic curve 0.95).

CONCLUSIONS

A small number of clinical observations may be mostly responsible for the diagnostic value of the clinical examination of infants with symptoms of LRI. Concentrating on a limited group of findings appears to enhance the accuracy of the examination in detecting hypoxemia.