Controlled investigation of deaths from asthma in hospitals in the North East Thames region

Acute severe asthma

Acute severe asthma remains a major economic and health burden. The natural history of acute decompensations is one of resolution and only about 0.4% of patients succumb overall. Mortality in medical intensive care units is higher but is less than 3% of hospital admissions. "Near-fatal" episodes may be more frequent, but precise figures are lacking. However, about 30% of medical intensive care unit admissions require intubation and mechanical ventilation with mortality of 8%. Morbidity and mortality increase with socioeconomic deprivation and ethnicity. Seventy to 80% of patients in emergency departments clear within 2 hours with standardized care. The relapse rate varies between 7 and 15%, depending on how aggressively the patient is treated. The airway obstruction in the 20-30% of people resistant to adrenergic agonists in the emergency department slowly reverses over 36-48 hours but requires intense treatment to do so. Current therapeutic options for this group consist of ipratropium and corticosteroids in combination with beta2 selective drugs. Even so, such regimens are not optimal and better approaches are needed. The long-term prognosis after a near-fatal episode is poor and mortality may approach 10%.

Clinical practice guidelines: medical follow-up of patients with asthma--adults and adolescents

The follow-up of patients with asthma should focus on asthma control (disease course over a number of weeks).

The pathobiology of acute asthma

Acute bronchial asthma is a common problem with immense medical and economic impacts. It is estimated that this disease affects 12 to 14 million people in the United States with costs in excess of $6 billion per year. Most of the morbidity and all of the mortality of asthma tends to be associated with acute exacerbations, and treatment of these events accounts for the majority of expenditures in money and health care resources. Unfortunately, the factors that contribute to the destabilization of asthma are rarely studied and much of the pathogenesis and pathobiology of acute asthma remains unknown. This article examines these issues and suggests treatment for acute asthma.

Acute adult asthma--assessment of severity and management and comparison with British Thoracic Society Guidelines

To investigate the accuracy of clinical severity assessment of asthmatics and to compare emergency and subsequent ward management with British Thoracic Society (BTS) Guidelines, the records of all patients admitted for severe asthma (46) over a 5-month period to a District General Hospital were inspected. Variations from recommended management were revealed. Appropriate oxygen administration was often not provided in casually and patients frequently left hospital before their discharge criteria were attained: recommended diurnal variations in peak flow were exceeded in 26%. Eleven per cent of discharges were against medical advice, making provision of adequate management logistically difficult. Adherence to BTS guidelines on the need for arterial blood gas (ABG) analysis would have led to a failure to detect significant hypoxaemia in 25% of cases. This study identified substantial variations from BTS management guidelines. It is suggested that oximetry is necessary on arrival to guide selection for arterial blood gas analysis.

Asthma mortality and antipsychotic or sedative use. What is the link?

Evidence in the medical literature suggests that patients with asthma who use antipsychotics or sedatives are at increased risk for serious complications of asthma. A number of mechanisms are potentially responsible for this observed association. The principle noncausal reasons for the increased risk of complications in this patient population include patient characteristics (such as the indication for antipsychotic use, noncompliance with asthma therapy, risk taking behaviour and family dysfunction) and treatment issues (including differential prescribing and the quality of medical care). The main causal mechanism involves depression of the CNS and impaired respiratory drive due to sedation during acute asthma attacks. Although it appears that most of the excess risk is a consequence of the noncausal mechanisms mentioned, physicians treating patients with asthma who have a history of antipsychotic use need to recognise the challenges inherent in managing such patients. Further research into the increased risk associated with sedative use is also warranted.

Change in the use of and attitude to peak flow measurement among general practitioners in Northern Ireland between 1989 and 1994

In 1994 we repeated a study first performed in 1989 to assess the change in general practitioners' use of and attitudes to peak flow measurement. Of 232 general practitioners surveyed, 199 (86%) and 192 (83%) responded in 1989 and 1994 respectively. The percentage who reported having patients using domiciliary peak flow monitoring rose form 58.3 (95% confidence limits 51.4 to 65.2)% to 97.9 (95.9 to 99.9)%. The percentage who reported 'usually' using peak flow measurements for the diagnosis and management of asthma rose from 81.9 (76.5 to 87.3)% to 93.2 (89.6 to 96.8)% and from 83.3 (78.1 to 88.5)% to 95.8 (92.9 to 98.7)% respectively. An unchanged proportion took peak flow meters on house calls. General practitioners have become more aware of the potential of peak flow measurements but are still unlikely to have a meter available to assess patients seen at home. They are therefore likely to be ill-equipped to manage acute exacerbations of asthma in this setting.

Reaudit of acute asthma admissions using a severity marker stamp and determinants of an outcome measure

Subsequent to the implementation of a severity marker stamp in case notes, an audit was performed in 86 admissions with acute asthma to a specialist centre over a 12 month period. Compared to previous audit the documentation of severity markers was significantly better (PEFR: 52% vs 83% p = 0.001, Respiratory rate: 44% vs 81% p = 0.001, ABG: 72% vs 80% p = 0.04, air entry: 58% vs 86% p = 0.001, speech: 27% vs 86% p = 0.001, exhaustion: 4% vs 86% p = 0.001). In contrast to the previous audit where no patient received FiO2 > 0.35, 66% of the cases in the repeat audit received FiO2 0.60 (p = 0.001). The mean duration of admission was five days and showed highest partial correlation (r = 0.6) to the time in hours for the pulse to fall to 80/min. Multiple linear regression showed that this was the only variable best predicting the duration of admission (R2 = 0.3). Admission pulse rate (p = 0.04) and serum K+ (p = 0.04) best discriminated between patients admitted for over and under five days. Logistic regression identified only the admission pulse as significant in calculating the odds of the patient staying in the hospital for > 5 days.

A repeat audit of hospital discharge letters in patients admitted with acute asthma

Subsequent to the implementation of recommendations from a previous audit of acute asthma admission discharge letters from our specialist respiratory unit, a repeat audit of typed discharge letters of 86 patients (33 male, mean age 29 SD 9 years) admitted with acute asthma to the same unit over a 12 month period was performed. There was significant improvement in the discharge letter documentation of precipitating factors (p < 0.001), previous admissions with acute asthma (p < 0.01), admission arterial blood gas analysis (p < 0.001), admission peak flow rates (p < 0.05), discharge peak flow rates (p < 0.001), corticosteroid (p < 0.01) and inhaled beta 2 agonist (p < 0.01) prescription on discharge and on the specification of inhaler delivery device on discharge (p < 0.001). No significant differences in discharge letters were found in the documentation of acute therapy or post discharge follow up plan. The improvement in discharge letter quality was attributed to closing the feed back loop from the previous audit though continuing deficiencies in discharge letter contents have been identified again. These deficiencies need to be rectified and the results reaudited.

Definitions of severity and outcome measures

Outcome measurement is still a difficult area in general, and in asthma in particular, with further research needed. (Attributable) outcomes of health care are the only sort of outcome measure which are of direct use as a contracting tool. However, less well-researched and understood outcomes are useful as quality improvement tools, and within more open-ended discussions involving purchasers and providers. In terms of hospital care of acute asthma, there is no well-defined outcome measure which reflects the quality of hospital care; re-admission rates show promise as an outcome measure which relate to the quality of discharge planning and merit further study. In terms of ambulatory care, there is an urgent need to develop and evaluate a symptom-based outcome measure which would be usable in routine practice and could be recommended for widespread use. As a physiological outcome measure, percentage of best function is one which corrects for the degree of irreversible air flow obstruction and is independent of treatment step. It is valuable for individual patients by providing a realistic gold standard and if best function is assessed in a standard manner, it also allows results of groups of patients to be compared in a meaningful manner. Severity scores, which might allow categorization of patients on the basis of characteristics other than current symptoms or therapy, are currently being evaluated.

Accuracy of recording of deaths from asthma in the UK: the false negative rate

BACKGROUND

A study was carried out to determine the extent to which asthma deaths are wrongly attributed to another cause on UK death certificates.

METHODS

Deaths from all causes occurring anywhere in the UK were identified amongst 2382 subjects aged 16-64 years within three years of discharge following hospital treatment for asthma (ICD9 493) in hospitals in the South East Thames region. The deaths were reviewed by an expert panel to assess the proportion of asthma deaths identified by the panel which were attributed to another cause of death on the death certificate (false negatives).

RESULTS

Eighty five deaths from all causes were identified in a mean follow up period of two years and three months. In 61 cases (72%) there was sufficient information for the expert panel to be confident about the cause of death. The panel identified 22 deaths from asthma, four of which were certified as non-asthma deaths (two as deaths from chronic obstructive pulmonary disease (COPD) and two as deaths from cardiovascular disease). The proportion of false negative death certificates was four of 22 (18%, 95% confidence interval (CI) 5 to 40).

CONCLUSIONS

There is evidence that asthma deaths in the UK are wrongly certified as deaths from both chronic obstructive pulmonary disease and diseases of the cardiovascular system.

Death from asthma: rare but real

Asthma mortality has been increasing over the past 15 years. Since the incidence of fatal asthma is rare, death is perceived as an unexpected outcome. This paper reviews the nature of asthma, and the circumstances and characteristics of patients with fatal asthma attacks. In light of these features, the emergency care of acute asthma is discussed. Recommendations for improvement of prehospital and hospital care are made. Despite optimum therapy and management, death is sometimes unavoidable.

Proposta de indicadores e padrões para a avaliação de qualidade da atenção hospitalar: o caso da asma brônquica

Este artigo tem por objetivos propor indicadores para a avaliação de qualidade da assistência hospitalar a pacientes com asma brônquica, através de critérios explícitos baseados em revisão bibliográfica. O problema central da atenção apontado pela bibliografia foi a existência de falhas na avaliação da gravidade da crise de asma, tanto por parte dos pacientes e familiares, como pelos profissionais de saúde de todos os níveis da atenção, resultando em sérias conseqüências não só para o paciente, como também para a sociedade em geral. No Brasil, de 1980 a 1990, ocorreram em média 2.000 óbitos por asma/ano, sendo cerca de 70% deles intra-hospitalares. O diagnóstico de asma foi a quarta causa de internação no Estado do Rio de Janeiro em 1993. Somente 12% dos 81 casos que foram a óbito fizeram uso de UTI. Essas informações justificam uma avaliação mais apurada da assistência hospitalar a essa doença, e, como contribuição para o processo de avaliação, propomos a realização de revisão da internação de todos os casos que resultaram em óbito e revisão esporádica de uma amostra das internações. Os critérios propostos são: avaliação da gravidade da crise, avaliação da terapia medicamentosa prescrita, educação do paciente e/ou familiares e agendamento de consulta pós-alta hospitalar.

Oxygen saturation in adults with acute asthma

Avoidable deaths from asthma continue. Some of these result from the difficulty in determining the severity of an acute asthma attack at the initial assessment. This study evaluated the relation of pulse oximetry with other markers of severity in 46 patients attending an accident and emergency (A&E) department with acute asthma. Neither oxygen saturation nor peak flow correlated with length of admission or with other "retrospective" markers of severity. Attempts to collect follow up data (for example, peak flow charts) from patients discharged from the A&E department failed. It proved impossible to determine whether pulse oximetry predicts which adults can be discharged.

Physician-targeted program on inhaled therapy for childhood asthma

BACKGROUND

Inhaled medications are the mainstay of asthma therapy, but significant deficiencies exist in the knowledge and skills of physicians regarding use of metered-dose inhalers (MDI) and spacer devices.

OBJECTIVE

We developed, implemented, and evaluated the effects of a physician-targeted educational program on inhaled therapy in a group of pediatric residents in our institution.

METHODS

Patient-directed instruction sheets on aerosol therapy were developed on the basis of literature review and expert guidelines. These served to establish a consistent foundation for the educational curriculum. The program was delivered through one-on-two teaching sessions (45 minutes). Residents were provided with a summary of theoretical and practical information and with devices for practice (a placebo MDI, InspirEase and AeroChamber holding chambers, and the AeroChamber device with mask). Each session included review of an educational monograph, demonstration of proper technique, and practice with the different devices. The program was evaluated by a randomized-control design. Assessment of practical skills included number of correct steps for the use of MDI (maximum score, 7), InspirEase (maximum, 7) and AeroChamber (maximum, 6). Theoretical knowledge was assessed with 25 multiple-choice questions.

RESULTS

Pretest scores in the experimental group (n = 24) were 3.7 of 7, 1.9 of 7, and 0.3 of 6 steps correct for MDI, InspirEase, and AeroChamber devices, respectively, and 13 of 25 for the theoretical knowledge assessment. The control group (n = 26) had similar pretest scores. After the program the experimental group significantly improved in all parameters: 6.3 of 7, 5.9 of 7, and 4.5 of 6 steps correct for MDI, InspirEase, and AeroChamber devices, respectively, and 18 of 25 questions correct (p < 0.01 for all parameters).

CONCLUSIONS

Implementation of a simple educational program among pediatric residents can significantly increase their skills in the use of inhalational therapy.

National audit of acute severe asthma in adults admitted to hospital. Standards of Care Committee, British Thoracic Society

OBJECTIVE

To ascertain the standard of care for hospital management of acute severe asthma in adults.

DESIGN

Questionnaire based retrospective multicentre survey of case records.

SETTING

36 hospitals (12 teaching and 24 district general hospitals) across England, Wales, and Scotland.

PATIENTS

All patients admitted with acute severe asthma between 1 August and 30 September 1990 immediately before publication of national guidelines for asthma management.

MAIN MEASURES

Main recommendations of guidelines for hospital management of acute severe asthma as performed by respiratory and non-respiratory physicians.

RESULTS

766 patients (median age 41 (range 16-94) years) were studied; 465 (63%) were female and 448 (61%) had had previous admissions for asthma. Deficiencies were evident for each aspect of care studied, and respiratory physicians performed better than non-respiratory physicians. 429 (56%) patients had had their treatment increased in the two weeks preceding the admission but only 237 (31%) were prescribed oral steroids. Initially 661/766 (86%) patients had peak expiratory flow measured and recorded but only 534 (70%) ever had arterial blood gas tensions assessed. 65 (8%) patients received no steroid treatment in the first 24 hours after admission. Variability of peak expiratory flow was measured before discharge in 597/759 (78%) patients, of whom 334 (56%) achieved good control (variability < 25%). 47 (6%) patients were discharged without oral or inhaled steroids; 182/743 (24%) had no planned outpatient follow up and 114 failed to attend, leaving 447 (60%) seen in clinic within two months. Only 57/629 (8%) patients were recorded as having a written management plan.

CONCLUSIONS

The hospital management of a significant minority of patients deviates from recommended national standards and some deviations are potentially serious. Overall, respiratory physicians provide significantly better care than non-respiratory physicians.

Care of asthmatics on discharge from hospital: a hospital audit

The objective of this study was to audit the care of patients after discharge from hospital, following admission for acute severe asthma, using the British Thoracic Society guidelines (1) as a standard. Discharge prescriptions and questionnaires sent to patients at home were analyzed for 51 patients who had been admitted to a teaching hospital with acute severe asthma. Main outcome measures were Peak flow measurements, written instructions, prescription of steroids, and outpatient follow-up. Of the 34 patients responding to the questionnaires, 15 (44%) had no peak flow meter, 23 (68%) had no written instructions, 13 (38%) had no supply of oral steroids at home, and 32 (94%) were prescribed a beta-agonist regularly of whom 12 (35%) were not on an inhaled steroid. Four (9%) patients were not followed up as outpatients; appointments ranged from 2 to 56 days following discharge. In over 60% of asthmatic patients discharged from hospital the guidelines recommended by the British Thoracic Society were not followed. The method used is an inexpensive, efficient way of auditing hospital practice.

Added salmeterol versus higher-dose corticosteroid in asthma patients with symptoms on existing inhaled corticosteroid. Allen & Hanburys Limited UK Study Group

Guidelines on asthma management recommend that in patients who still have symptoms on treatment with low-dose inhaled corticosteroids the first step should be an increase in inhaled corticosteroid dose. The addition of long-acting inhaled beta 2-adrenoceptor agonists is another option. We have compared these two strategies in a randomised, double-blind, parallel-group trial. We studied 429 adult asthmatic patients who still had symptoms despite maintenance treatment with 200 micrograms twice daily inhaled beclomethasone dipropionate (BDP). 3 did not provide verifiable data. Of the others, 220 were assigned salmeterol xinafoate (50 micrograms twice daily) plus BDP and 206 were assigned higher-dose BDP (500 micrograms twice daily) for 6 months. The mean morning peak expiratory flow increased from baseline in both groups, but the increase was greater in the salmeterol/BDP group than in the higher-dose BDP group at all time points (differences 16-21 L/min, p < 0.05). Mean evening PEF also increased with salmeterol/BDP but not with higher-dose BDP. There were significant differences in favour of salmeterol/BDP in diurnal variation of PEF (all time points) and in use of rescue bronchodilator (salbutamol) and daytime and night-time symptoms (some time points). There was no significant difference between the groups in adverse effects or exacerbations of asthma, indicating that in this group of patients regular beta 2-agonist therapy was not associated with any risk of deteriorating asthma control over 6 months. This study suggests a need for a flexible approach to asthma management.

Adult Asthma Assessment in an Accident & Emergency Department

Poor initial assessment contributes to morbidity and mortality in acute severe asthma. We have audited this aspect of management in an A & E department over a single 6-month senior house officer employment cycle. The use of a cheap and simple stamp highlighting important clinical features of asthma was associated with a significant improvement in early assessment.

Uses and limitations of mortality and health care utilization statistics in asthma research

Mortality and health care utilization (HCU) statistics for asthma reflect both the acute and chronic aspects of this condition. We present a conceptual model that incorporates this dichotomy and also distinguishes between measures of disease occurrence (e.g., incidence and prevalence) and measures of disease management. We also discuss the use of mortality and HCU statistics in the literature, review their limitations and advantages, and make a number of general recommendations for their use.

Comparison of asthmatic patients admitted to hospital from health districts experiencing high and low asthma mortality rates

Geographical variation in asthma mortality rates within the United Kingdom could be a reflection of variability in effectiveness of medical care services, or epidemiological variation. In order to ascertain whether differing hospital admission processes could contribute to this variation, asthmatic patients admitted from two districts, experiencing above and below average mortality rates were compared. The present study was part of a cohort study of 1,200 consecutive acute adult admissions in 1987/88. In the main study, social data and information on referral were collected by interview for all patients. The admitting doctors' perception of the patient's severity was assessed on the basis of the severity of symptoms, and likelihood of morbidity or mortality if the patient was not admitted. Further information on asthmatic patients (treatment and physiological measurements) was retrieved from the notes. Sixty-six asthmatic patients resident in Wandsworth (a district with high asthma mortality rates) were admitted to St George's Hospital or St James' Hospital (WW) and 31 patients resident in East Surrey (ES) (a district with low asthma mortality rates) were admitted to the East Surrey Hospital (ESH). Notes were obtained on 55 (83%) and 27 (87%) of patients in the two districts, respectively. WW received significantly more patients by self-referral: 68% of patients called an ambulance or came directly to casualty compared with 30% in ES (chi-squared = 13.7, d.f. = 2, P = < 0.001). There was a tendency for more admissions to ESH to be taking oral steroids (chi-squared = 3.2, d.f. = 1, P = 0.07). Patients admitted in WW tended to have more severe disease: 39 (85%) of patients admitted to WW had peak expiratory flow less than 200 1/minute on admission compared to 14 (58%) in ES (chi-squared = 6, d.f. = 1, P = 0.01). In WW the mean first recorded peak expiratory flow on admission was 154 1/minute compared to 172 1/minute in ES; their mean peak flow on discharge was 318 1/minute compared with 377 1/minute in ES. Twenty-one (38%) of admissions in WW were considered to be very urgent by the admitting hospital doctor compared to four (15%) in ESH (chi-squared = 4.67, d.f. = 1, P = 0.03). This opportunistic study found that, in an area experiencing high mortality rates, more patients with severe disease were admitted to hospital compared to a low mortality area. This does not appear to be due to differing hospital practices but rather to increased levels of morbidity in the community. As patients with more severe asthma are at a greater risk of dying, these finding reinforce the need to standardize asthma treatment in the community.

Audit in acute severe asthma--who benefits?

This paper reviews published audit activity for a single common condition (asthma). Has this effort brought about better care for the patient? The result of this audit of audits reveals that specialists do follow the guidelines on the management of acute asthma with good results, but that general physicians, in whose care perforce many acute episodes are managed, do not seem to be aware of the published good practice guidelines.

Is the death rate from asthma exaggerated? Evidence from west Cumbria

Although the death rate from asthma in England and Wales is reported to be about 2000 a year, clinical experience suggests that it is much rarer. Doctors in West Cumbria health district could recall only seven cases in 14 years. Examination of case notes of patients officially recorded as dying of asthma showed that many were aged over 60 and cigarette smokers. An alternative cause of death was evident in over half the patients. If the picture is representative of that in the whole of Britain the reported mortality from asthma may be much too high.

An audit of antiasthmatic drug inhalation technique and understanding

Inhaled rather than oral antiasthmatic therapy is accepted as more advantageous but depends on patient technique and understanding. In 74 asthmatic outpatients, technique using metered-dose inhaler (MDI) was poor; in 56 patients inhaling beta-agonist, the mean peak expiratory flow rate (PEFR) increase was only 15 L/min (6%) greater than in 18 controls, p < 0.05, 95% confidence intervals 2-27 L/min or 2-11%. Tilting the head back and actuation "stopping" inspiration produced the least favorable PEFR responses; taken together, regression analysis yielded a statistically significant negative correlation with absolute or percentage PEFR change (R2 = 0.15; p < 0.02). Patients were unclear about which drugs to inhale as required or regularly. Among 19 patients reassessed inhaling beta-agonist, only 8 had baseline PEFR values within 10% of each other during both assessments. In the latter, the mean postinhalation PEFR increase was 36 L/min (or 13%) greater than the corresponding increase (or % change) at first assessment, p = 0.05 (0.08), 95% confidence intervals 0-73 L/min (-2 to 29%). Thus, MDI users should avoid tilting the head back, actuation stopping inhalation, and be more aware of prophylactic (steroid) versus symptomatic (beta-agonist) treatment.

Can fatal asthma be prevented?--a personal view

An increase in the mortality rate from asthma in several countries has been observed in recent years, notwithstanding the great improvement in pathophysiological findings and the introduction of new effective therapeutic agents. The phenomenon is difficult to explain but the causes of death and identification of high-risk patients have been widely studied. It is suggested that the most vital aim for physicians is the avoidance of those factors which may contribute to death from asthma. These are particularly: inadequate assessment of its severity by patients, general practitioners and hospital doctors, and inadequate and inappropriate treatment. From the diagnostic point of view, the measurement of airflow rates is necessary to establish the diagnosis in terms of reversibility, quantify the severity and assess the response to therapy. The different entity of reversibility of bronchial obstruction is due to the various mechanisms intervening in different patients. After adequate treatment, according to our observations, the reversibility is more complete in young people and when the duration of the disease is less than 2 years. Trigger factors must also be considered. From the therapeutic point of view, considering that the most important alteration in asthma is the inflammation of bronchial structures with intervention of several inflammatory cells and of numerous different chemical mediators, physicians have to apply treatment aimed at reducing inflammation rather than relying on symptomatic bronchodilator remedies. Treatment should be divided into three phases, according to symptoms: induction, consolidation and maintenance. Finally, on the basis of data here presented and of clinical experience, the essential measures for the prevention of asthma mortality are reported. If general practitioners take them into account, deaths from asthma will be reduced to a minimum.

Improving management of asthma: closing the loop or progressing along the audit spiral?

OBJECTIVE

To assess whether the management of asthma has improved from three consecutive surveys.

DESIGN

Retrospective case note survey of acute asthma admissions in 1983 and 1989; case notes selected from 1985-6 survey of prospectively identified patients to include only patients with a final discharge code of asthma.

SETTING

A large city teaching hospital. Patients--101 patients with acute asthma as the primary diagnosis in 1983; 85 in 1985-6; and 133 in 1989, 14 of whom were subsequently transferred elsewhere.

MAIN MEASURES

Conformity with a checklist of important aspects of the process of asthma management including initial assessment, treatment, supervision, and discharge and review arrangements.

RESULTS

All patient groups were similar in age, smoking habit, and stay in hospital and, as an objective guide to severity of asthma, had similar initial pulse rates. Major improvements occurred in management: by 1989, 119(90%) patients were treated with oral corticosteroids (69(68%), 67(79%) in 1983, 1985-6 respectively) and 109(82%) with oxygen (62(61%), 51(60%)) (both p < 0.001). 114(86%) had regular recording of peak flow measurements (53(52%), 54(64%); p < 0.001), and 103/119(86%) were discharged taking oral corticosteroids (66(65%), 63(74%); p < 0.01). Significantly fewer patients, however, had their regular inhaled corticosteroid treatment increased on discharge (38/119(32%) v 53(52%), 39(46%); p < 0.01), but more were receiving high dose inhaled treatment on admission.

CONCLUSIONS

The management of asthma improved significantly, and the normal practice of doctors has changed in an area of practice with longstanding problems.

A criterion based audit of inpatient asthma care. Closing the feedback loop

We have assessed the care of patients admitted to a specialist respiratory medical ward acutely ill with asthma, using a criterion based audit derived from a standard management protocol already in use in our hospitals. The audit was first performed from 01.01.90 to 31.08.90; after implementing certain changes, the audit was repeated from 1.12.90 to 31.1.91. Special attention was paid in each audit review to pre-admission measures, inpatient management and pre-discharge and follow-up management. During both audit periods, of a total of 78 patients, 74 patients gave a reason for the worsening of their asthma; 59 had had PEF measured and 58 had received systemic steroids before admission; 77 patients had full objective assessment of severity on admission; 76 patients were discharged on oral steroids; 62 had PEF meters for home monitoring; and 65 of the 68 patients who lived in our district were seen again within six weeks as outpatients in the chest clinic. However, only 30/55 (54%) had PEF variability of 20% or less (our criterion for appropriateness of discharge, in the first audit period) and only 32/55 had a written check on their inhaler technique in the first audit period. By relaxing our PEF criterion for discharge (in line with national guidelines), by introducing a stamp for recording that inhaler technique had been checked, and with encouragement and exhortation from senior staff, we improved our performance of meeting the set standards to 17 of 23 (74%) patients for PEF variability and to 22 of 23 (96%) patients for written check on inhaler technique in the second audit period.(ABSTRACT TRUNCATED AT 250 WORDS)

Risk factors for death in patients admitted to hospital with asthma: a follow-up study

Hospital records of patients with asthma admitted to teaching hospitals in Perth, Western Australia between 1976 and 1980 were examined retrospectively to identify characteristics of the illness which were associated with subsequent death. From 5722 admissions there were 195 deaths to December 1982, 186 of whom had records available (cases); 452 of the surviving subjects were used for comparison (controls). There was no difference in age of onset of asthma or cigarette smoking habits between the two groups, but ischaemic heart disease as an associated condition was significantly more frequent in cases. On admission to hospital an arterial PCO2 less than 45 mmHg was more frequent in those who died, but there were no differences in arterial PO2, lowest pH, highest or lowest FEV1 and FVC. Cases more frequently used home nebulisers and were more frequently prescribed corticosteroids, antibiotics and sedatives or tranquilizers prior to admission, corticosteroids and sedatives or tranquilisers during admission and sedatives or tranquilisers on discharge. These results suggest that cases had more severe asthma in that they were more often treated with home nebulisers, corticosteroids and antibiotics, but with the exception of PaCO2 the commonly used measurements of severity of asthma did not identify those at risk of death. The prescription of sedatives or tranquillisers appears to be associated with an increased risk of death in subjects with asthma.

Reassessment of asthma management in an accident and emergency department

To determine if shortcomings in asthma management in the Accident and Emergency (A & E) department identified in a previous (1983) study (Reed et al. Thorax 1985; 40: 897-902) had been corrected, we retrospectively reviewed the case records of patients attending with asthma between December 1987 and November 1988. There was an increase in the number of patients attending with asthma; 0.73 per 1000 in 1988 versus 0.57 per 1000 in 1983. Sixty-seven percent of patients were self-referred and 80% presented between 1600 h and 0800 h. There was inadequate recording of the asthma history and examination findings. Peak expiratory flow (PEF) was recorded in 86% before treatment (compared to 11% in 1983) and 70% after treatment. In addition, a prospective study of 40 patients responding to a questionnaire 2 weeks after discharge, revealed persistent symptoms of unstable asthma in 50%. Although there has been a marked improvement in the use of PEF measurements since the 1983 study, the standards of management of asthma patients may still be inadequate as evidence by the presence of unstable asthma symptoms in many of those discharged. A standardized management protocol which provides guidelines for treatment based on PEF has been introduced to the A & E department.

An attempt to determine the optimal duration of hospital stay following a severe attack of asthma

The optimal duration of hospital stay following admission for acute severe asthma is difficult to determine. An asthmatic is at particularly high risk of sudden death in the 6-12 weeks after admission, and too early hospital discharge may add to this risk. Thirty patients hospitalised for severe asthma recorded peak flows thrice daily for 8 weeks following discharge. Peak flow charts were reviewed at monthly intervals, and dips were divided into 'minor' (peak flow less than 75% of the patient's best), 'major' (less than 50%) and 'catastrophic' (less than 30%). Fourteen of the 30 patients had major dips (including 4 who had catastrophic dips as well). Four of these 14 patients were readmitted with acute severe asthma during the 8 weeks follow-up period; in contrast, none of the 16 patients without major dips required readmission. The only in-hospital factor that correlated with and was predictive of (p less than 0.001) multiple major dips post-discharge was the peak flow variability in the 24 hours before discharge, defined as [(highest-lowest peak flow)/highest] x 100. Thirteen of the 14 patients with major dips had pre-discharge peak flow variation greater than 20% compared with only 2 of the 16 without major dips. We believe it is unwise to discharge asthmatics from hospital until the diurnal variation in their peak flow is below 20%. Discharging them before this target is reached puts them at increased risk of further severe attacks of asthma requiring re-hospitalisation.

Aminophylline toxicity--how many hospital asthma deaths does it cause?

Aminophylline administration was compared in 43 patients who died from asthma and 43 matched controls who were admitted, suffering from acute asthma, to hospitals in the North East Thames Region. A computer program, which used information about individual characteristics, medical history and drug intake, was employed to calculate the serum theophylline levels which were likely to have resulted from the hospital treatment each patient received. Toxic theophylline levels were estimated to have occurred in 21% (9/43) of fatal cases and 7% (3/43) controls. Details of four patients who died when their serum theophylline levels were likely to have been very high are presented. Six fatal cases suffered gastro-intestinal bleeds during their final illness: four of these had theophylline levels which were calculated to have been toxic at the time of bleeding.