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Matsuura H, Kishida M. Monitor-related changes consistent with paradoxical pulse. Am J Med Sci 2024:S0002-9629(24)01349-1. [PMID: 39025431 DOI: 10.1016/j.amjms.2024.07.014] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Revised: 02/02/2024] [Accepted: 07/03/2024] [Indexed: 07/20/2024]
Affiliation(s)
- Hiroki Matsuura
- Department of Emergency Medicine, Okayama City Hospital; Department of General Internal Medicine, Okayama City Hospital.
| | - Masayuki Kishida
- Department of Emergency Medicine, Okayama City Hospital; Department of General Internal Medicine, Okayama City Hospital
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Agarwal D. Pediatrician’s Viewpoint. Indian Pediatr 2022. [DOI: 10.1007/s13312-022-2672-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
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Kharasch SJ, Jansson P, Liteplo AS, Gouker S, Longacre M, Shokoohi H, Schleifer J. The Use of Point-of-Care Ultrasound to Evaluate Pulsus Paradoxus in Children With Asthma. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2020; 39:625-632. [PMID: 31971275 DOI: 10.1002/jum.15226] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Pulsus paradoxus (PP) is defined as a fall of systolic blood pressure of greater than 10 mm Hg during the inspiratory phase of respiration. Measurement of PP is recommended by national and international asthma guidelines as an objective measure of asthma severity but is rarely used in clinical practice. Cardiac point-of-care ultrasound with pulsed wave Doppler imaging measuring respiratory-phasic changes of mitral valve inflow velocities is well described in cardiac tamponade as "sonographic" PP. We present 10 cases of acute asthma presenting to an emergency department showing the finding of sonographic determined PP in the apical 4-chamber view of the heart on pulsed wave Doppler imaging.
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Affiliation(s)
| | - Paul Jansson
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Stacey Gouker
- Massachusetts General Hospital, Boston, Massachusetts, USA
| | | | - Hamid Shokoohi
- Massachusetts General Hospital, Boston, Massachusetts, USA
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Pologe JA, Wolley KL, Arnold DH. Respiratory waveform variation can prevent pulsus paradoxus measurement by sphygmomanometry. J Asthma 2019; 56:687-692. [PMID: 29972658 PMCID: PMC6395523 DOI: 10.1080/02770903.2018.1490959] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2017] [Revised: 05/07/2018] [Accepted: 06/15/2018] [Indexed: 10/28/2022]
Abstract
BACKGROUND Pulsus paradoxus (PP) represents increased fluctuation of systolic pressure during the respiratory cycle. PP increases in pathologic conditions, including asthma and other obstructive airways diseases. Respiratory waveform variation (RWV) represents arterial-waveform baseline variability resulting from intra-pleural pressure changes during the respiratory cycle in the presence of airway obstruction. It is not known whether RWV influences manual PP measurement using a sphygmomanometer and stethoscope. METHODS We performed an observational study in six healthy adults. Participants performed tidal-breathing through a breathing apparatus with pre-determined inspiratory (0-45.6 cm H2O) and expiratory (0-24.4 cm H2O) resistance levels for a total of 23 data sets per participant. PP was measured from continuous radial artery pressure recordings as the absolute difference between maximum and minimum systolic pressure levels during a complete respiratory cycle. RESULTS In this study, PP values measured without applied airway resistance exceeded 10 mmHg, the traditional definition of PP, in five of the six participants. Manual measurement of PP would not be possible at greater RWV because the maximum diastolic pressure exceeded minimum systolic pressure during RWV. CONCLUSIONS PP in normal adults may exceed 10 mmHg, and RWV may be of sufficient magnitude to preclude manual PP measurement.
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Affiliation(s)
| | - Kara Lynn Wolley
- b Department of Integrative Physiology , Kestrel Labs, Inc. , Boulder , CO , USA
| | - Donald H Arnold
- c Divison of Emergency Medicine, Vanderbilt University School of Medicine, Vanderbilt Children's Hospital , Nashville , TN , USA
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Schmidt M, Schumann A, Müller J, Bär KJ, Rose G. ECG derived respiration: comparison of time-domain approaches and application to altered breathing patterns of patients with schizophrenia. Physiol Meas 2017; 38:601-615. [DOI: 10.1088/1361-6579/aa5feb] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
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Arnold DH, Wang L, Hartert TV. Pulse Oximeter Plethysmograph Estimate of Pulsus Paradoxus as a Measure of Acute Asthma Exacerbation Severity and Response to Treatment. Acad Emerg Med 2016; 23:315-22. [PMID: 26727986 DOI: 10.1111/acem.12886] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2015] [Revised: 10/09/2015] [Accepted: 10/10/2015] [Indexed: 10/22/2022]
Abstract
OBJECTIVES Pulsus paradoxus is one of the few objective bedside measures of acute asthma exacerbation severity but is difficult to measure in tachypneic and tachycardic patients and in noisy clinical environments. Our primary objective was to examine whether pulse oximeter plethysmograph estimate of pulsus paradoxus (PEP) is associated with physiologic and symptom measures of acute exacerbation severity (airway resistance by impulse oscillometry [%IOS] and the Acute Asthma Intensity Research Score [AAIRS]). Secondary objectives were to validate the previous association of PEP with percent predicted forced expiratory volume in 1 second (%FEV1 ) and to examine associations of change of PEP with change of these outcomes after 2 hours of treatment. METHODS This was a secondary analysis of data from a prospective observational study of patients aged 5-17 years with acute asthma exacerbations. The predictor variable, PEP, was measured using a dedicated pulse oximeter and waveform analysis program. Outcome measures included the AAIRS, %IOS, and %FEV1 at baseline and after 2 hours of treatment. We examined associations of PEP with %IOS and the AAIRS at baseline using multiple linear regression models adjusted for age, sex, and race. As secondary analyses we similarly examined the association of PEP with %FEV1 at baseline and change of PEP with change of %IOS, the AAIRS, and %FEV1 after 2 hours of treatment using multiple linear regression models adjusted for the baseline value of the outcome measure and the AAIRS. RESULTS Among 684 participants (61% males; 61% African American) there were associations of baseline PEP with %IOS, the AAIRS, and %FEV1 (p < 0.001). Change of PEP after 2 hours of treatment was associated with change of %FEV1 (p < 0.001) and change of the AAIRS (p = 0.01) but not with change of %IOS (p = 0.60). CONCLUSIONS PEP demonstrates criterion validity in predicting baseline %IOS, the AAIRS, and %FEV1 , and responsiveness to change of the AAIRS and %FEV1 . Data contained in the oximeter plethysmograph waveform might be utilized as a continuous, objective measure of acute asthma exacerbation severity and real-time response to treatment.
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Affiliation(s)
- Donald H. Arnold
- Department of Pediatrics; Division of Emergency Medicine; Vanderbilt University School of Medicine; Nashville TN
- Center for Asthma Research; Vanderbilt University School of Medicine; Nashville TN
| | - Li Wang
- Department of Biostatistics; Vanderbilt University School of Medicine; Nashville TN
| | - Tina V. Hartert
- Department of Medicine; Division of Allergy, Pulmonary & Critical Care Medicine; Vanderbilt University School of Medicine; Nashville TN
- Center for Asthma Research; Vanderbilt University School of Medicine; Nashville TN
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Mourad ST, Elganady AA, Mohamed EE, Elgammal AM. Assessment of the effect of implementation of global initiatives for asthma (GINA) guidelines in the outcome of asthma exacerbation in the emergency department. EGYPTIAN JOURNAL OF CHEST DISEASES AND TUBERCULOSIS 2012. [DOI: 10.1016/j.ejcdt.2012.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
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Rodrigo GJ, Plaza Moral V, Forns SB, Castro-Rodríguez JA, de Diego Damiá A, Cortés SL, Moreno CM, Nannini LJ, Neffen H, Salas J. [ALERTA 2 guidelines. Latin America and Spain: recommendations for the prevention and treatment of asmatic exacerbations. Spanish Pulmonology and Thoracic Surgery Society (SEPAR). Asthma Department of the Latinamerican Thoracic Association (ALAT)]. Arch Bronconeumol 2011; 46 Suppl 7:2-20. [PMID: 21320808 DOI: 10.1016/s0300-2896(10)70041-7] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Gustavo J Rodrigo
- Departamento de Emergencia, Hospital Central de las Fuerzas Armadas, Montevideo, Uruguay
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Arnold DH, Jenkins CA, Hartert TV. Noninvasive assessment of asthma severity using pulse oximeter plethysmograph estimate of pulsus paradoxus physiology. BMC Pulm Med 2010; 10:17. [PMID: 20350320 PMCID: PMC2855526 DOI: 10.1186/1471-2466-10-17] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/20/2009] [Accepted: 03/29/2010] [Indexed: 12/01/2022] Open
Abstract
Background Pulsus paradoxus estimated by dynamic change in area under the oximeter plethysmograph waveform (PEP) might provide a measure of acute asthma severity. Our primary objective was to determine how well PEP correlates with forced expiratory volume in 1-second (%FEV1) (criterion validity) and change of %FEV1 (responsiveness) during treatment in pediatric patients with acute asthma exacerbations. Methods We prospectively studied subjects 5 to 17 years of age with asthma exacerbations. PEP, %FEV1, airway resistance and accessory muscle use were recorded at baseline and at 2 and 4 hours after initiation of corticosteroid and bronchodilator treatments. Statistical associations were tested with Pearson or Spearman rank correlations, logistic regression using generalized estimating equations, or Wilcoxon rank sum tests. Results We studied 219 subjects (median age 9 years; male 62%; African-American 56%). Correlation of PEP with %FEV1 demonstrated criterion validity (r = - 0.44, 95% confidence interval [CI], - 0.56 to - 0.30) and responsiveness at 2 hours (r = - 0.31, 95% CI, - 0.50 to - 0.09) and 4 hours (r = - 0.38, 95% CI, - 0.62 to - 0.07). PEP also correlated with airway resistance at baseline (r = 0.28 for ages 5 to 10; r = 0.45 for ages 10 to 17), but not with change over time. PEP was associated with accessory muscle use (OR 1.16, 95% CI, 1.11 to 1.21, P < 0.0001). Conclusions PEP demonstrates criterion validity and responsiveness in correlations with %FEV1. PEP correlates with airway resistance at baseline and is associated with accessory muscle use at baseline and at 2 and 4 hours after initiation of treatment. Incorporation of this technology into contemporary pulse oximeters may provide clinicians improved parameters with which to make clinical assessments of asthma severity and response to treatment, particularly in patients who cannot perform spirometry because of young age or severity of illness. It might also allow for earlier recognition and improved management of other disorders leading to elevated pulsus paradoxus.
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Affiliation(s)
- Donald H Arnold
- Departments of Pediatrics and Emergency Medicine, Vanderbilt University School of Medicine, Nashville, TN, USA.
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Hodder R, Lougheed MD, Rowe BH, FitzGerald JM, Kaplan AG, McIvor RA. Management of acute asthma in adults in the emergency department: nonventilatory management. CMAJ 2010; 182:E55-67. [PMID: 19858243 PMCID: PMC2817338 DOI: 10.1503/cmaj.080072] [Citation(s) in RCA: 80] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Rick Hodder
- Division of Pulmonary Medicine, University of Ottawa, Ottawa, Ontario.
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Arnold DH, Gebretsadik T, Minton PA, Higgins S, Hartert TV. Clinical measures associated with FEV1 in persons with asthma requiring hospital admission. Am J Emerg Med 2007; 25:425-9. [PMID: 17499661 DOI: 10.1016/j.ajem.2006.09.006] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2006] [Revised: 08/30/2006] [Accepted: 09/05/2006] [Indexed: 10/23/2022] Open
Abstract
OBJECTIVE We sought to determine the association of select clinical measures of asthma severity with percent predicted forced expiratory volume in one-second (%FEV1). METHODS We studied a prospective cohort of adult subjects (N = 129) with asthma exacerbations requiring hospital admission. Clinical data was acquired, including medical and social history, symptoms, vital signs, physical assessment, and spirometry. Predictor variables for this study included manually determined pulsus paradoxus (PP), percent predicted peak expiratory flow rate (%PEFR) and accessory muscle use. The outcome measure was %FEV1. Multiple linear regression analyses were performed to determine the independent associations between predictor variables and %FEV1. RESULTS In univariate analysis, %PEFR correlated with %FEV1 (rho = 0.77, P < .001) and PP correlated negatively with %FEV1 (rho = - 0.384, P < .001). %FEV1 was significantly lower in participants with accessory muscle use (Median %FEV1 = 37.5%, IQR: 27.0-49.0) than in those without accessory muscle use (Median %FEV1= 55.0%, IQR: 39.0-69.0), (P = .004). In multivariable analysis including the covariates %PEFR, accessory muscle use, PP, age, sex, heart rate and respiratory rate, %PEFR (P < .0001) and accessory muscle use (P = .003) remained significantly associated with %FEV1, whereas PP did not (P = .52).
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Affiliation(s)
- Donald H Arnold
- Department of Emergency Medicine, Vanderbilt University School of Medicine, Nashville, Tennessee 37232, USA.
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Affiliation(s)
- G. Bandinelli
- Department of Emergency Medicine, S. Maria Nuova Hospital, Florence, Italy
| | - A. Lagi
- Department of Emergency Medicine, S. Maria Nuova Hospital, Florence, Italy
| | - P. A. Modesti
- Clinical Medicine and Cardiology, Department of Critical Care Medicine and Surgery, University of Florence, Viale Morgagni 85, I-50134 Florence, Italy
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Rayner J, Trespalacios F, Machan J, Potluri V, Brown G, Quattrucci LM, Jay GD. Continuous noninvasive measurement of pulsus paradoxus complements medical decision making in assessment of acute asthma severity. Chest 2006; 130:754-65. [PMID: 16963672 DOI: 10.1378/chest.130.3.754] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
BACKGROUND Pulsus paradoxus (PP) is a pathophysiologic parameter that is indicative of asthma severity. The ability of PP to categorize acutely asthmatic patients in accordance with the earlier National Asthma Education and Prevention Program (NAEPP) expert panel report 1 guidelines was determined. METHODS An arterial tonometric BP monitor, which was interfaced to an analog-digital converter, executed a periodic amplitude analysis algorithm, which computed PP in real time. The PP measurement was compared to the criterion standard of emergency physicians in determining the hospital admission vs hospital discharge disposition following the NAEPP standardized treatment. Receiver operating characteristics (ROCs) were calculated, and the PP threshold, which maximized sensitivity and specificity, was identified. In a separate laboratory investigation, PP was induced in a healthy volunteer by inspiration through a fixed resistance. Plethysmographic waveform changes, induced by PP, were measured by a second analog-to-digital converter that was connected to a pulse oximeter. RESULTS A total of 79 patients were enrolled in the study, of whom 63 met a priori inclusion criteria and had uninterrupted data acquisition. The mean PP for patients who were appropriately discharged from the hospital was 9.1 mm Hg (95% confidence interval [CI], 7.3 to 10.9 mm Hg) and differed from the PP of 17.6 mm Hg (95% CI, 13.5 to 21.8; p < 0.001) for patients admitted to the hospital/relapsed. The sensitivity and specificity for physician disposition were 0.83 and 0.89, respectively, and for PP values were 0.78 and 0.78, respectively. The Wilcoxon area under the ROC curve was 0.82 (95% CI, 0.64 to 0.99) following treatment. The risk ratio was 5.32 for hospital admission among patients with a PP of > 11.3 mm Hg. Changes in the photoplethysmography peak height were correlated to PP from the BP monitor by a regression line with a slope of 0.01 V/mm Hg. CONCLUSIONS Continuous PP can aid in determining disposition among emergency department (ED) patients with acute asthma. ED physicians equipped with a PP monitor would be able to objectify the work of breathing and would more closely adhere to NAEPP guidelines. The possibility that a PP detection algorithm could reside in a pulse oximeter warrants further investigation.
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Affiliation(s)
- James Rayner
- Department of Emergency Medicine, Brown Medical School, Providence, RI, USA
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