Chest
Volume 131, Issue 1, January 2007, Pages 164-171
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Original Research: Asthma
FEV1Performance Among Patients With Acute Asthma: Results From a Multicenter Clinical Trial

https://doi.org/10.1378/chest.06-0530Get rights and content

Abstract

Objective:To determine the ability of patients seen for acute asthma exacerbations in the emergency department (ED) to perform good-quality FEV1measurements.

Methods:Investigators from 20 EDs were trained to perform spirometry testing as part of a clinical trial that included standardized equipment with special software-directed prompts. Spirometry was done on ED arrival and 30 min, 1 h, 2 h, and 4 h later, and during follow-up outpatient visits.

Measurements:Study performance criteria differed from American Thoracic Society (ATS) guidelines because of the population acuity and severity of illness as follows: ability to obtain acceptable FEV1measures (defined as two or more efforts with forced expiratory times ≥ 2 s and time to peak flow < 120 ms or back-extrapolated volume < 5% of the FVC) and reproducibility criteria (two highest acceptable FEV1values within 10% of each other).

Results:Of the 620 patients (age range, 12 to 65 years), > 90% met study acceptability criteria on ED arrival and 74% met study reproducibility criteria. Mean initial FEV1was 38% of predicted. Spirometry quality improved over time; by 1 h, 90% of patients met study acceptability and reproducibility criteria. Patients with severe airway obstruction (FEV1< 25% of predicted) were initially less likely to meet quality goals, but this improved with time. The site was also an independent predictor of quality.

Conclusion:When staff are well trained and prompt feedback regarding adequacy of efforts is given, modified ATS performance goals for FEV1tests can be met from most acutely ill adolescent and adult asthmatics, even within the first hour of evaluation and treatment for an asthma exacerbation.

Section snippets

Materials and Methods

Inclusion and exclusion criteria for the trial have been described.10Briefly, patients were 12 to 65 years old and presented with an acute episode of asthma, with FEV1<70% of predicted at ED entry and after a single aerosol treatment with albuterol. Spirometry was performed on ED arrival (baseline, time 0) and after 30, 60, 120, and 240 min. Albuterol treatments were administered after each spirometry test. For patients not hospitalized, follow-up spirometry was scheduled at day 10 and day 28

Results

A total of 641 patients from 20 sites were enrolled in the clinical trial. Performance data from 620 of 641 patients (97%) with 3,782 time points and 13,615 spirometry maneuvers were available for analysis. The missing data included all performance data from 1 site (four patients), leaving 19 sites in the analysis. Spirometry was performed by 107 different investigators, two thirds of whom had no previous experience performing spirometry. The average patient age was 33 years, and almost half

Discussion

In contrast to most outpatient settings, the patients studied were acutely ill and severely obstructed and not expecting to perform spirometry during their ED visit. This study shows that with a strong emphasis on several quality measures, spirometry for the purpose of obtaining an FEV1can be performed in acutely ill ED asthmatics. Most patients (almost three quarters) were able to perform study-specific acceptable and reproducible tests on ED arrival. As FEV1improved with treatments, and

Appendix

The following were the principal investigators at the participating sites: Leonard Altman, MD, Harbor View Medical Center, Seattle, WA; Paula J. Anderson, MD, University of Arkansas for Medical Sciences, Little Rock, AR; Raymond E. Brady, MD, Vancouver, WA; Ronald A. Charles, MD, Parkland Hospital, UT Southwestern Medical Center, Dallas, TX; William Calhoun, MD, Presbyterian University Hospital, University of Pittsburgh, Pittsburgh, PA; Charles Emerman, MD, The Cleveland Clinic Foundation,

Acknowledgments

The authors thank AstraZeneca, Ltd, for providing the clinical trial database. The authors also thank Jean Fennimore, BS, RN, Mike Koeferl, PhD, and Scott Tutak, BS for trial management support; and Kathy Walsh, eResearch Technology, Inc., for assistance with spirometry data management.

References (15)

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None of the investigators have any financial interest in the company that manufactures the spirometer used in the study. Dr. Silverman has consulted for AstraZeneca, and Dr. Simonson is an employee of AstraZeneca. Ms. Flaster and Dr. Enright have no conflicts of interest to report.

Data analysis was supported in part by an unrestricted research grant from AstraZeneca Ltd.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestjournal.org/misc/reprints.shtml).

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