Narrative review: should teaching of the respiratory physical examination be restricted only to signs with proven reliability and validity?

A Proposed Decision Making Framework for the Translation of In-Person Clinical Care to Digital Care: A Tutorial

UNSTRUCTURED

The continued demand for digital health requires that providers adapt thought processes to enable sound clinical decision making in digital settings. Providers report that lack of training is a barrier to providing digital healthcare. Physical exam techniques and hands-on interventions must be adjusted in safe, reliable and feasible ways to digital care and decision making may be impacted by modifications made to these techniques. We have proposed a framework for determining if a procedure can be modified to obtain a comparable result in a digital environment or if a referral to in-person care is required. The decision making framework developed using program outcomes of a digital physical therapy platform, and aims to alleviate provider barriers to providing digital care. This paper describes the unique considerations a provider must make when collecting background information, selecting procedures, executing procedures, assessing results, and determining if they can proceed with clinical care in digital settings.

Telehealth Clinical Appropriateness and Quality

Contrary to common perception, telehealth is not simply a substitute for in-person care. With an array of modalities-live audio-video, asynchronous patient communication, and remote patient monitoring, to name a few-telehealth creates entirely new avenues of care delivery (Table 1). Although our current care model is reactive-relying on episodic visits to an office or hospital-telehealth allows us to be proactive, filling in the gaps to provide a continuum of care. Widespread uptake of telehealth has created fertile ground for long-overdue health system reform. In this study, we describe essential next steps: redefine telehealth clinical appropriateness, evolve payment models, provide necessary training, and reimagine the patient-physician interaction.

Thoracic ultrasound influences physiotherapist's clinical decision-making in respiratory management of critical care patients: a multicentre cohort study

BACKGROUND

The potential influence of thoracic ultrasound on clinical decision-making by physiotherapists has never been studied. The aim of this study was to assess the impact of thoracic ultrasound on clinical decision-making by physiotherapists for critical care patients.

METHODS

This prospective, observational multicentre study was conducted between May 2017 and November 2020 in four intensive care units in France and Australia. All hypoxemic patients consecutively admitted were enrolled. The primary outcome was the net reclassification improvement (NRI), quantifying how well the new model (physiotherapist's clinical decision-making including thoracic ultrasound) reclassifies subjects as compared with an old model (clinical assessment). Secondary outcomes were the factors associated with diagnostic concordance and physiotherapy treatment modification.

RESULTS

A total of 151 patients were included in the analysis. The NRI for the modification of physiotherapist's clinical decisions was-40% (95% CI (-56 to -22%), p=0.02). Among the cases in which treatment was changed after ultrasound, 41% of changes were major (n=38). Using a multivariate analysis, the physiotherapist's confidence in their clinical diagnosis was associated with diagnostic concordance (adjusted OR=3.28 95% CI (1.30 to 8.71); p=0.014). Clinical diagnosis involving non-parenchymal conditions and clinical signs reflecting abolished lung ventilation were associated with diagnostic discordance (adjusted OR=0.06 95% CI (0.01 to 0.26), p<0.001; adjusted OR=0.26 95% CI (0.09 to 0.69), p=0.008; respectively).

CONCLUSION

Thoracic ultrasound has a high impact on the clinical decision-making process by physiotherapists for critical care patients.

TRIAL REGISTRATION NUMBER

NCT02881814; https://clinicaltrials.gov.

Training medical students in physical examination and point-of-care ultrasound: An assessment of the needs and barriers to acquiring skills in point-of-care ultrasound

BACKGROUND:

With growth of the use of point of care ultrasound (PoCUS) around the world, some medical schools have incorporated this skill into their undergraduate curricula. However, because of epidemiology of disease and regional differences in approaches to patient care, global application of PoCUS might not be possible. Before creating a PoCUS teaching course, it is critical to perform a needs analysis and recognize the training obstacles.

MATERIALS AND METHODS:

A validated online questionnaire was given to final-year medical students at our institution to evaluate their perceptions of the applicability of specific clinical findings, and their own capability to detect these signs clinically and with PoCUS. The skill insufficiency was assessed by deducting the self-reported clinical and ultrasound skill level from the perceived usefulness of each clinical finding.

RESULTS:

The levels of expertise and knowledge in the 229 students who participated were not up to the expected standard. The applicability of detection of abdominal aortic aneurysm (AAA) (3.9 ± standard deviation [SD] 1.4) was the highest. However, detection of interstitial syndrome (3.0 ± SD 1.1) was perceived as the least applicable. The deficit was highest in the detection of AAA (mean 0.95 ± SD 2.4) and lowest for hepatomegaly (mean 0.57 ± SD 2.3). Although the majority agreed that training of preclinical and clinical medical students would be beneficial, 52 (22.7%) showed no interest, and 60% (n = 136) reported that they did not have the time to develop the skill.

CONCLUSION:

Although medical students in Saudi Arabia claim that PoCUS is an important skill, there are significant gaps in their skill, indicating the need for PoCUS training. However, a number of obstacles must be overcome in the process.

Interclinician agreement on the recognition of selected respiratory clinical signs in dogs and cats with abnormal breathing patterns

In humans, classification of abnormal breathing patterns (ABP) and recognition of ancillary respiratory signs are difficult, as reflected by poor-to-moderate interclinician agreement. The aims of this study were to assess interclinician agreement for respiratory sign recognition in dogs and cats and evaluate the influence of clinical experience on agreement. Dogs and cats with ABP were recruited from three hospitals. Included animals were evaluated by three clinicians at each hospital before therapeutic intervention. Consensual definitions for each respiratory clinical sign were provided to all clinicians. Interclinician agreement was measured via Fleiss' kappa and intraclass correlation coefficient statistics. Influence of clinical experience on interobserver agreement was studied via mixed-effects logistic regression. One-hundred and fifteen dogs and 49 cats with ABP were recruited. Out of 12 clinical signs evaluated, only stertor (kappa, 0.80), stridor (kappa, 0.64), attenuation of heart/lung sounds (kappa, 0.60), and goose honking (kappa, 0.84) in dogs, and stertor (kappa, 0.65) and open-mouth breathing (kappa, 0.75) in cats, were considered sufficiently reliable among clinicians. Agreement on respiratory rate estimation was good in both species (intraclass correlation coefficient, 0.75). The greater the difference in clinical experience between two clinicians, the lower the odds of agreement between the two clinicians' respiratory physical examination findings. Interclinician agreement was demonstrated to be poor for recognition of most respiratory clinical signs in dogs and cats. Teaching and clinical experience acquisition should be encouraged to improve respiratory clinical sign recognition.

The use of spectrograms improves the classification of wheezes and crackles in an educational setting

Chest auscultation is a widely used method in the diagnosis of lung diseases. However, the interpretation of lung sounds is a subjective task and disagreements arise. New technological developments like the use of visSual representation of sounds through spectrograms could improve the agreement when classifying lung sounds, but this is not yet known. In this study, we tested if the use of spectrograms improves the agreement when classifying wheezes and crackles. To do this, we asked twenty-three medical students at UiT the Arctic University of Norway to classify 30 lung sounds recordings for the presence of wheezes and crackles. The sample contained 15 normal recordings and 15 with wheezes or crackles. The students classified the recordings in a random order twice. First sound only, then sound with spectrograms. We calculated kappa values for the agreement between each student and the expert classification with and without display of spectrograms and tested for significant improvement between these two coefficients. We also calculated Fleiss kappa for the 23 observers with and without the spectrogram. In an individual analysis comparing each student to an expert annotated reference standard we found that 13 out of 23 students had a positive change in kappa when classifying wheezes with the help of spectrograms. When classifying crackles 16 out of 23 showed improvement when spectrograms were used. In a group analysis we observed that Fleiss kappa values were k = 0.51 and k = 0.56 (p = 0.63) for classifying wheezes without and with spectrograms. For crackles, these values were k = 0.22 and k = 0.40 (p = <0.01) in the same order. Thus, we conclude that the use of spectrograms had a positive impact on the inter-rater agreement and the agreement with experts. We observed a higher improvement in the classification of crackles compared to wheezes.

Time to Say Goodbye to Bronchiolitis, Viral Wheeze, Reactive Airways Disease, Wheeze Bronchitis and All That

The diagnosis and management of infants and children with a significant viral lower respiratory tract illness remains the subject of much debate and little progress. Over the decades various terms for such illnesses have been in and fallen out of fashion or have evolved to mean different things to different clinicians. Terms such as "bronchiolitis," "reactive airways disease," "viral wheeze," and many more are used to describe the same condition and the same term is frequently used to describe illnesses caused by completely different dominant pathologies. This lack of clarity is due, in large part, to a failure to understand the basic underlying inflammatory and associated processes and, in part, due to the lack of a simple test to identify a condition such as asthma. Moreover, there is a lack of insight into the fact that the same pathology can produce different clinical signs at different ages. The consequence is that terminology and fashions in treatment have tended to go around in circles. As was noted almost 60 years ago, amongst pre-school children with a viral LRTI and airways obstruction there are those with a "viral bronchitis" and those with asthma. In the former group, a neutrophil dominated inflammation response is responsible for the airways' obstruction whilst amongst asthmatics much of the obstruction is attributable to bronchoconstriction. The airways obstruction in the former group is predominantly caused by airways secretions and to some extent mucosal oedema (a "snotty lung"). These patients benefit from good supportive care including supplemental oxygen if required (though those with a pre-existing bacterial bronchitis will also benefit from antibiotics). For those with a viral exacerbation of asthma, characterized by bronchoconstriction combined with impaired b-agonist responsiveness, standard management of an exacerbation of asthma (including the use of steroids to re-establish bronchodilator responsiveness) represents optimal treatment. The difficulty is identifying which group a particular patient falls into. A proposed simplified approach to the nomenclature used to categorize virus associated LRTIs is presented based on an understanding of the underlying pathological processes and how these contribute to the physical signs.

Treatment update: Outpatient management of community-acquired pneumonia

Pneumonia is a leading cause of morbidity and mortality in the US and a primary cause of hospitalization nationwide. A recent guideline update from the American Thoracic Society and Infectious Diseases Society of America provides evidence-based recommendations for managing adults with community-acquired pneumonia in the outpatient setting.

Mini review shows that structured light plethysmography provides a non-contact method for evaluating breathing patterns in children

AIM

Structured light plethysmography (SLP) is a novel light-based method that captures chest wall movements to evaluate tidal breathing. We carried out a narrative mini review of the clinical use of SLP in paediatrics.

METHODS

PubMed and Google Scholar were searched for papers published in English up to December 2018. This identified a methodology paper published in 2010 and eight full papers, including three paediatric studies and one paediatric case report. We also included data from ten conference abstracts and one clinical case study.

RESULTS

We found data that validated the ability of SLP to differentiate airway obstruction from tidal breathing parameters and bronchodilator responsiveness for children aged two years and over. Non-contact measurement of regional chest wall movement was a unique feature. Feasibility data were scarce and more studies are needed, especially in infants. Preliminary studies suggest that SLP has the potential to be used in cases of dysfunctional breathing and neuromuscular diseases and as a follow-up tool after lung infections or surgery.

CONCLUSION

Structured light plethysmography has been validated to demonstrate lung function abnormality in paediatric asthma, but further studies are needed to demonstrate its benefits over current practice and how it can be used for other conditions.

'Dry' and 'wet' cough: how reliable is parental reporting?

Introduction

Chronic cough in childhood is common and causes much parental anxiety. Eliciting a diagnosis can be difficult as it is a non-specific symptom indicating airways inflammation and this may be due to a variety of aetiologies. A key part of assessment is obtaining an accurate cough history. It has previously been shown that parental reporting of 'wheeze' is frequently inaccurate. This study aimed to determine whether parental reporting of the quality of a child's cough is likely to be accurate.

Methods

Parents of 48 'new' patients presenting to a respiratory clinic with chronic cough were asked to describe the nature of their child's cough. They were then shown video clips of different types of cough using age-appropriate examples, and their initial report was compared with the types of cough chosen from the video.

Results

In a quarter of cases, the parents chose a video clip of a 'dry' or 'wet' cough having given the opposite description. In a further 20% parents chose examples of both 'dry' and 'wet' coughs despite having used only one descriptor.

Discussion

While the characteristics of a child's cough carry important information that may be helpful in reaching a diagnosis, clinicians should interpret parental reporting of the nature of a child's cough with some caution in that one person's 'dry' cough may very well be another person's 'wet' cough.

Asthma and Chronic Rhinosinusitis: Diagnosis and Medical Management

Asthma is a prevalent inflammatory condition of the lower airways characterized by variable and recurring symptoms, reversible airflow obstruction, and bronchial hyperresponsiveness (BHR). Symptomatically, these patients may demonstrate wheezing, breathlessness, chest tightness, and coughing. This disease is a substantial burden to a growing population worldwide that currently exceeds 300 million individuals. This is a condition that is frequently encountered, but often overlooked in the field of otolaryngology. In asthma, comorbid conditions are routinely present and contribute to respiratory symptoms, decreased quality of life, and poorer asthma control. It is associated with otolaryngic diseases of the upper airways including allergic rhinitis (AR) and chronic rhinosinusitis (CRS). These conditions have been linked epidemiologically and pathophysiologically. Presently, they are considered in the context of the unified airway theory, which describes the upper and lower airways as a single functional unit. Thus, it is important for otolaryngologists to understand asthma and its complex relationships to comorbid diseases, in order to provide comprehensive care to these patients. In this article, we review key elements necessary for understanding the evaluation and management of asthma and its interrelatedness to CRS.

Derivation and Validation of an Objective Effort of Breathing Score in Critically Ill Children

OBJECTIVES

To derive and validate a score that correlates with an objective measurement of a child's effort of breathing.

DESIGN

Secondary analysis of a previously conducted observational study.

SETTING

The pediatric and cardiothoracic ICUs of a quaternary-care children's hospital.

PATIENTS

Patients more than 37 weeks gestational age to age 18 years who were undergoing extubation.

INTERVENTIONS

Effort of breathing was measured in patients following extubation using esophageal manometry to calculate pressure rate product. Simultaneously, members of a multidisciplinary team (nurse, physician, and respiratory therapist) assessed respiratory function using a previously validated tool. Elements of the tool that were significantly associated with pressure rate product in univariate analysis were identified and included in a multivariate model. An Effort of Breathing score was derived from the results of the model using data from half of the subjects (derivation cohort) and then validated using data from the remaining subjects (validation cohort) by calculating the area under the receiver operator characteristic curve for pressure rate product greater than 90th percentile and for the need for reintubation.

MEASUREMENTS AND MAIN RESULTS

Among 409 subjects, the median age was 5 months, and nearly half were cardiac surgery patients (49.1%). Retractions, stridor, and pulsus paradoxus were included in the Simple Score. Area under the receiver operator characteristic curve for pressure rate product greater than 90th percentile was 0.8359 (95% CI, 0.7996-0.8722) in the derivation cohort and 0.7930 (0.7524-0.8337) in the validation cohort. Area under the receiver operator characteristic curve for reintubation was 0.7280 (0.6807-0.7752) when all scores were analyzed individually and was 0.7548 (0.6644-0.8452) if scores from three clinicians from different disciplines were summated. Results were similar regardless of provider discipline or training.

CONCLUSIONS

A scoring system was derived and validated, performed acceptably to predict increased effort of breathing or need for advanced respiratory support and may function best when used by a team.

Traditional and ultrasound physical examinations: a hybrid approach to improve clinical care

Point-of-care ultrasonography, which is performed at the bedside by physicians who are not specialists in imaging, has become possible thanks to recent technological advances that have allowed for a device with greater portability while maintaining image quality. The increasing use of point-of-care ultrasonography in different specialties has made it possible to expand physical examinations, make timely decisions about the patients and allows the performance of safer medical procedures. In this review, three cases from our experience are presented that highlight the use of point-of-care ultrasonography by clinicians. Bedside ultrasonography is a convenient modality used in a clinical setting to aid in early diagnosis of several common conditions. It is suggested that a hybrid approach of physical examination and point-of-care ultrasonography in the everyday clinical practice is an inevitable change of paradigm that is improving quality of care in a variety of clinical settings.

Undiagnosed tuberculosis in patients with HIV infection who present with severe anaemia at a district hospital

Background

Tuberculosis (TB) is a major cause of severe anaemia in patients with human immunodeficiency virus (HIV) infection in South Africa. However, TB can be difficult to diagnose as it may be extra pulmonary and paucibacillary.

Aim

The aim of this study was to investigate undiagnosed TB in patients with HIV infection and severe anaemia and to identify the optimal investigations for diagnosing TB.

Setting

Mthatha General Hospital, a district hospital.

Methods

The study was a case series.

Results

Haemoglobin levels ranged from 3.6 g/dL to 7.9 g/dL, the mean CD4 count was 176 cells/μL and 80% of patients had a positive TB symptom screen. Forty-three (86%) patients had either clinical or bacteriologically proven TB of whom 33 had pulmonary TB, 34 had extra pulmonary TB and 24 had both types. The diagnostic yield for TB was: chest X-ray (CXR) 91%; ultrasound (US) abdomen pericardium and lower chest 62%; sputum Xpert MTB/RIF 35%; TB blood culture 21% and TB urine culture 15%. Blood and urine cultures did not identify any additional cases over those identified by CXR and US. The laboratory turnaround times were as follows: sputum Xpert, 1.6 days; blood culture, 20 days and urine culture, 28 days. CXR and US were done within one day of initial patient assessment.

Conclusions

The majority of HIV patients with severe anaemia had TB disease, and extra pulmonary TB was as prevalent as pulmonary TB. CXR, US and sputum Xpert were the optimum tests for rapid diagnosis of TB. South African national TB/HIV guidelines should incorporate these specific tests to diagnose TB in patients with HIV and severe anaemia.

Teaching a Hypothesis-driven Physical Diagnosis Curriculum to Pulmonary Fellows Improves Performance of First-Year Medical Students

RATIONALE

Hypothesis-driven physical examination emphasizes the role of bedside examination in the refinement of differential diagnoses and improves diagnostic acumen. This approach has not yet been investigated as a tool to improve the ability of higher-level trainees to teach medical students.

OBJECTIVES

To assess the effect of teaching hypothesis-driven physical diagnosis to pulmonary fellows on their ability to improve the pulmonary examination skills of first-year medical students.

METHODS

Fellows and students were assessed on teaching and diagnostic skills by self-rating on a Likert scale. One group of fellows received the hypothesis-driven teaching curriculum (the "intervention" group) and another received instruction on head-to-toe examination. Both groups subsequently taught physical diagnosis to a group of first-year medical students. An oral examination was administered to all students after completion of the course.

MEASUREMENTS AND MAIN RESULTS

Fellows were comfortable teaching physical diagnosis to students. Students in both groups reported a lack of comfort with the pulmonary examination at the beginning of the course and improvement in their comfort by the end. Students trained by intervention group fellows outperformed students trained by control group fellows in the interpretation of physical findings (P < 0.05).

CONCLUSIONS

Teaching hypothesis-driven physical examination to higher-level trainees who teach medical students improves the ability of students to interpret physical findings. This benefit should be confirmed using validated testing tools.

Wheezes, crackles and rhonchi: simplifying description of lung sounds increases the agreement on their classification: a study of 12 physicians' classification of lung sounds from video recordings

Background

The European Respiratory Society (ERS) lung sounds repository contains 20 audiovisual recordings of children and adults. The present study aimed at determining the interobserver variation in the classification of sounds into detailed and broader categories of crackles and wheezes.

Methods

Recordings from 10 children and 10 adults were classified into 10 predefined sounds by 12 observers, 6 paediatricians and 6 doctors for adult patients. Multirater kappa (Fleiss' κ) was calculated for each of the 10 adventitious sounds and for combined categories of sounds.

Results

The majority of observers agreed on the presence of at least one adventitious sound in 17 cases. Poor to fair agreement (κ<0.40) was usually found for the detailed descriptions of the adventitious sounds, whereas moderate to good agreement was reached for the combined categories of crackles (κ=0.62) and wheezes (κ=0.59). The paediatricians did not reach better agreement on the child cases than the family physicians and specialists in adult medicine.

Conclusions

Descriptions of auscultation findings in broader terms were more reliably shared between observers compared to more detailed descriptions.

The validity and reliability of the clinical assessment of increased work of breathing in acutely ill patients

BACKGROUND

Mechanical ventilation is frequently indicated to reduce the work of breathing. Because it cannot be measured easily at the bedside, physicians rely on surrogate measurements such as patient appearance of distress and increased breathing effort.

OBJECTIVE

We determined the validity and reliability of subjectively rating the appearance of respiratory distress and the reliability of 11 signs of increased breathing effort.

SUBJECTS

The study included consecutive, acutely ill patients requiring various levels of respiratory support.

METHODS

Blinded to each other's observations, a fellow and a critical care consultant rated the severity of distress (absent, slight, moderate, severe) after observing subjects for 10 seconds and then determined the presence of the signs of increased breathing effort.

RESULTS

A total of 149 paired examinations occurred 6±6 minutes apart. The rating of respiratory distress correlated with oxygenation, respiratory rate, and 9 signs of increased work of breathing. It had the highest intraclass correlation coefficient (0.69; 95% confidence interval, 0.59-0.78). Rating distress as moderate to severe had a sensitivity of 70%, specificity of 92%, and positive likelihood ratio of 8 for the presence of 3 or more of hypoxia, tachypnea, and any sign of increased breathing effort. Agreement was moderate (κ = 0.53-0.47) for rating of distress, nasal flaring, scalene contraction, gasping, and abdominal muscle contraction, and fair (κ = 0.36-0.23) for sternomastoid contraction, tracheal tug, and thoracoabdominal paradox.

CONCLUSION

Assessing the increased work of breathing by rating the severity of respiratory distress based on subject appearance is a valid and moderately reliable sign that predicts the presence of serious respiratory dysfunction. The reliability of the individual signs of increased breathing effort is moderate at best.

Diagnosis of asthma: clinical assessment

BACKGROUND

Asthma is a common condition that presents with varied symptomatology and exam findings. The diagnosis of asthma is made through a combination of clinical assessment and diagnostic testing.

METHODS

A literature review was conducted through PubMed, focusing on systematic reviews and practice parameters. The highest-quality studies and those including the highest number of patients were included. References were reviewed for additional relevant articles.

RESULTS

Patients with asthma present with the symptoms of cough, dyspnea, and wheezing. The physical exam can demonstrate hyperinflation, wheezing, and increased work of breathing, but most patients will present with a normal pulmonary exam because they are between episodes. The symptoms and examination of patients with asthma varies greatly from patient to patient and within the same patient over time. The diagnosis of asthma in the pediatric population may be more difficult because the classic symptoms may not be present in many of those patients.

CONCLUSION

The diagnosis of asthma is made in the setting of clinical history, physical exam, and diagnostic testing. The astute physician will rely on all 3 of these factors when making the diagnosis.

Imaging Congestion With a Pocket Ultrasound Device: Prognostic Implications in Patients With Chronic Heart Failure

BACKGROUND

Venous congestion is common in patients with chronic heart failure (HF). We used a pocket-sized ultrasound imaging device (PID) to assess the patients' congestive status and related our findings to prognosis.

METHODS AND RESULTS

One hundred four consecutive outpatients from an HF outpatient clinic were studied. Interstitial lung water (ILW), pleural effusion (PE), and the diameter of the inferior vena cava (VCI) were assessed with the use of a PID. ILW was assessed by demonstration of B-lines (comet tail artifact (CTA). Out of the 104 patients, 28 had CTA and 8 had PE. Median VCI diameter was 18 mm (interquartile range 14-22 mm). Each of these parameters correlated weakly (r = 0.26-0.37; P < .05) with the HF biomarker N-terminal pro-B-type natriuretic peptide (NT-proBNP). During the median follow-up time of 530 days, 18 hospitalizations and 14 deaths were registered. Findings of CTA, PE, or both increased the risk of death or hospitalization (hazard ratio 3-4; P < .05). After adjustment for age, cardiac systolic function, and NT-proBNP, this difference remained significant for CTA alone and CTA + PE combined, but not for PE alone.

CONCLUSIONS

With the use of a handheld ultrasound device, signs of pulmonary congestion could be demonstrated. When found, these had a significant prognostic impact in clinically stable HF.

Comparison of thoracic auscultation, clinical score, and ultrasonography as indicators of bovine respiratory disease in preweaned dairy calves

Background

The diagnostic tools for bovine respiratory disease diagnosis include clinical inspection, thoracic auscultation, and ultrasonography.

Hypothesis

Thoracic auscultation and clinical examination have limitations in the detection of lung consolidation in dairy calves.

Animals

Prospective cohort of 106 preweaned calves from 13 different dairy herds (10 with a history of active bovine respiratory disease (BRD) in calves and 3 without suspected BRD problems).

Methods

Each preweaned calf was clinically inspected using the Wisconsin calf respiratory scoring chart (CRSC) and treatment history was noted. Systematic thoracic auscultation and ultrasonography then were performed, the latter focusing on lung consolidation. Mortality was recorded over a 30‐day period.

Results

A total of 56 of 106 calves had ultrasonographic evidence of lung consolidation. The sensitivity of thoracic auscultation to detect consolidation was 5.9% (range, 0–16.7%). Only 41.1% (23/33) of calves with consolidated lungs had been treated previously by the producers. When adding CRSC and previous BRD treatment by the producer, sensitivity of detection increased to 71.4% (40/56). The area under the receiver operating characteristics curve was 0.809 (95% CI, 0.721–0.879) for the number of areas within the lungs with consolidation and 0.743 (95% CI, 0.648–0.823) for the maximal depth of consolidation as predictors of death within 1 month after examination. These were not significantly different (P = .06).

Conclusions and Clinical Importance

This study shows that thoracic auscultation is of limited value in diagnosing lung consolidation in calves. Ultrasonographic assessment of the thorax could be a useful tool to assess BRD detection efficiency on dairy farms.

The reliability of the physical examination to guide fluid therapy in adults with severe falciparum malaria: an observational study

Background

Adults with severe malaria frequently require intravenous fluid therapy to restore their circulating volume. However, fluid must be delivered judiciously as both under- and over-hydration increase the risk of complications and, potentially, death. As most patients will be cared for in a resource-poor setting, management guidelines necessarily recommend that physical examination should guide fluid resuscitation. However, the reliability of this strategy is uncertain.

Methods

To determine the ability of physical examination to identify hypovolaemia, volume responsiveness, and pulmonary oedema, clinical signs and invasive measures of volume status were collected independently during an observational study of 28 adults with severe malaria.

Results

The physical examination defined volume status poorly. Jugular venous pressure (JVP) did not correlate with intravascular volume as determined by global end diastolic volume index (GEDVI; r_s = 0.07, p = 0.19), neither did dry mucous membranes (p = 0.85), or dry axillae (p = 0.09). GEDVI was actually higher in patients with decreased tissue turgor (p < 0.001). Poor capillary return correlated with GEDVI, but was present infrequently (7% of observations) and, therefore, insensitive. Mean arterial pressure (MAP) correlated with GEDVI (r_s = 0.16, p = 0.002), but even before resuscitation patients with a low GEDVI had a preserved MAP. Anuria on admission was unrelated to GEDVI and although liberal fluid resuscitation led to a median hourly urine output of 100 ml in 19 patients who were not anuric on admission, four (21%) developed clinical pulmonary oedema subsequently. MAP was unrelated to volume responsiveness (p = 0.71), while a low JVP, dry mucous membranes, dry axillae, increased tissue turgor, prolonged capillary refill, and tachycardia all had a positive predictive value for volume responsiveness of ≤50%. Extravascular lung water ≥11 ml/kg indicating pulmonary oedema was present on 99 of the 353 times that it was assessed during the study, but was identified on less than half these occasions by tachypnoea, chest auscultation, or an elevated JVP. A clear chest on auscultation and a respiratory rate <30 breaths/minute could exclude pulmonary oedema on 82% and 72% of occasions respectively.

Conclusions

Findings on physical examination correlate poorly with true volume status in adults with severe malaria and must be used with caution to guide fluid therapy.

Trial registration

Clinicaltrials.gov identifier: NCT00692627

Should chest examination be reinstated in the early diagnosis of chronic obstructive pulmonary disease?

BACKGROUND

Although proven to be associated with bronchial obstruction, chest signs are not listed among cues that should prompt spirometry in the early diagnosis of chronic obstructive pulmonary disease (COPD) in established guidelines.

AIMS

We aimed to explore how chest findings add to respiratory symptoms and a history of smoking in the diagnosis of COPD.

METHODS

In a cross-sectional study, patients aged 40 years or older, previously diagnosed with either asthma or COPD in primary care, answered questionnaires and underwent physical chest examination and spirometry.

RESULTS

Among the 375 patients included, 39.7% had forced expiratory volume in 1 second/forced vital capacity <0.7. Hyperresonance to percussion was the strongest predictor of COPD, with a sensitivity of 20.8, a specificity of 97.8, and likelihood ratio of 9.5. In multivariate logistic regression, where pack-years, shortness of breath, and chest findings were among the explanatory variables, three physical chest findings were independent predictors of COPD. Hyperresonance to percussion yielded the highest odds ratio (OR = 6.7), followed by diminished breath sounds (OR = 5.0), and thirdly wheezes (OR = 2.3). These three chest signs also gave significant diagnostic information when added to shortness of breath and pack-years in receiver operating-characteristic curve analysis.

CONCLUSION

We found that chest signs may add to respiratory symptoms and a history of smoking in the diagnosis of COPD, and we conclude that chest signs should be reinstated as cues to early diagnosis of COPD in patients 40 years or older.

Variation in family physicians' recording of auscultation abnormalities in patients with acute cough is not explained by case mix. A study from 12 European networks

BACKGROUND

Conflicting data on the diagnostic and prognostic value of auscultation abnormalities may be partly explained by inconsistent use of terminology.

OBJECTIVES

To describe general practitioners use of chest auscultation abnormality terms for patients presenting with acute cough across Europe, and to explore the influence of geographic location and case mix on use of these terms.

METHODS

Clinicians recorded whether 'diminished vesicular breathing', 'wheezes', 'crackles' and 'rhonchi' were present in an observational study of adults with acute cough in 13 networks in 12 European countries. We describe the use of these terms overall and by network, and used multilevel logistic regression to explore variation by network, controlling for patients' gender, age, comorbidities, smoking status and symptoms.

RESULTS

2345 patients were included. Wheeze was the auscultation abnormality most frequently recorded (20.6% overall) with wide variation by network (range: 8.3-30.8%). There was similar variation for other auscultation abnormalities. After controlling for patient characteristics, network was a significant predictor of auscultation abnormalities with odds ratios for location effects ranging from 0.37 to 4.46 for any recorded auscultation abnormality, and from 0.25 to 3.14 for rhonchi.

CONCLUSION

There is important variation in recording chest auscultation abnormalities by general practitioners across Europe, which cannot be explained by differences in patient characteristics. There is a need and opportunity for standardization in the detection and classification of lung sounds.