Continuous Noninvasive Measurement of Pulsus Paradoxus Complements Medical Decision Making in Assessment of Acute Asthma Severity: Discussion
The greater number of patients who had been unnecessarily admitted to the hospital may reflect the conservative approach that many physicians have in the management of asthma. The alternate disposition indicated by AT-PP supports its inclusion as an adjunct tool in patient assessment. Relapsing patients who had been discharged from the hospital are comparatively less common. As this study progresses, we anticipate observing additional relapsing asthmatic patients who were inappropriately discharged from the hospital, which would add to the cost of care for patients with an AT-PP of > 20 mm Hg, resulting in a cost-of-care curve (Fig 2, top, A) that looks more U-shaped. We further posit that these latter patients, who are discharged from the hospital with an AT-PP of > 15 mm Hg, could be managed differently if a bedside PP monitor suggested that either additional ED treatment or hospitalization was needed. Similarly, the cost of asthma care among patients admitted to the hospital could be decreased by a PP measure, which objectively confirms a physiologic response to therapy. The hypothetical mean cost per patient associated with dispositioning that is based on AT-PP measurement prior to treatment were comparatively higher at all thresholds. This was to be expected based on the poorer ability of AT-PP to disposition patients prior to treatment compared to after treatment, since there would have been more errors overall, and errors are costlier than correct dispositions. in detail
Any agreement between physicians performing objective asthma scoring was lacking. For both the pretreatment and posttreatment periods, their scores had low intraclass correlations (Table 3) and little similarity in absolute objective asthma severity scores. However, while absolute scores varied, physicians did show similar trends in the ratings of some of the physical examination findings across the standardized treatment period (Table 4). Most notably, OD and, possibly, prolonged expiratory phase followed similar trends and appeared to be examination findings that physicians monitor, though they rate absolute magnitude differently. Ratings in OD also correlated with those in AT-PP. These results are indicative of the lack of consensus among treating physicians in appreciating asthma severity and also support previous observations that physicians underappreciate asthma-related symptoms. The results from this study are also supported by investigations that showed that PP is a suitable surrogate for work of breathing and predicted the need for hospital admission in pediatric patients. However, this conclusion was reached with the manual measurement of PP, which is imprecise in adult patients and therefore likely to be inaccurate in pediatric patients, who have a higher respiratory rate.