Kuo E, Kesten S
Asthma Centre, Toronto Hospital, Canada.
Chest. 1993 Jun;103(6):1655-61. doi: 10.1378/chest.103.6.1655.
Recent controversies examining the management of acute asthma prompted us to investigate whether there had been any significant changes in our management practices. We therefore audited the charts of all patients admitted to a large tertiary-care university-affiliated hospital with a primary diagnosis of acute asthma during the years of 1984 and 1989. A total of 67 patients' charts were reviewed (39 in 1984 and 28 in 1989). The mean age and initial flow rates (FEV1 or peak expiratory flow rate [PEFR]) were similar. In the emergency room, chest radiographs and arterial blood gas analyses were done more frequently than objective measures of flow. Fifty-one percent (20/39) of the patients had no measurement of flow in the emergency room in 1984 and 39 percent (11/28) in 1989 (p > 0.05). In both years, approximately 20 percent of the patients had no record of flow rates during their hospitalization (21 percent [8/39] in 1984 and 18 percent [5/28] in 1989). More studies of the blood were ordered in 1989, including hepatic enzyme and electrolyte measurements for no clear reasons. The clinical utility of chest radiographs was negligible. While the vast majority of patients received systemic corticosteroids in both years (85 percent [33/39] in 1984 and 96 percent [27/28] in 1989), 23 percent (9/39) and 18 percent (5/28) were discharged without oral steroid therapy in 1984 and 1989, respectively (p > 0.05). There was a significant decline in the use of aminophylline (95 percent [37/39] to 54 percent [15/28]; p < 0.05) and an increase in the use of ipratropium bromide (15 percent [6/39] to 75 percent [21/28]; p < 0.05) in 1989. Theophylline levels were less likely to be measured in 1989, and the majority of levels in both years were either subtherapeutic or toxic. No patients were discharged with peak flow meters or recorded action plans, although follow-up arrangements were recorded in 87 percent (34/39) and 96 percent (27/28) of the patients in 1984 and 1989. We conclude that while improvements in in-hospital management of asthma were noted in 1989, suboptimal management practices are still common.
近期有关急性哮喘治疗的争议促使我们调查我们的治疗方法是否发生了重大变化。因此，我们查阅了1984年至1989年间在一家大型三级医疗大学附属医院以急性哮喘为主要诊断入院的所有患者的病历。共查阅了67例患者的病历（1984年39例，1989年28例）。平均年龄和初始流速（第一秒用力呼气容积或呼气峰值流速[PEFR]）相似。在急诊室，胸部X光片和动脉血气分析比流速客观测量更频繁地进行。1984年，51%（20/39）的患者在急诊室未进行流速测量，1989年为39%（11/28）（p>0.05）。在这两年中，约20%的患者在住院期间没有流速记录（1984年为21%[8/39]，1989年为18%[5/28]）。1989年进行了更多的血液检查，包括肝功能酶和电解质测量，原因不明。胸部X光片的临床实用性可忽略不计。虽然这两年绝大多数患者都接受了全身用皮质类固醇治疗（1984年为85%[33/39]，1989年为96%[27/28]），但1984年和1989年分别有23%（9/39）和18%（5/28）的患者出院时未接受口服类固醇治疗（p>0.05）。1989年氨茶碱的使用显著减少（从95%[37/39]降至54%[15/28]；p<0.05），异丙托溴铵的使用增加（从15%[6/39]增至75%[21/28]；p<0.05）。1989年测量茶碱水平的可能性较小，两年中大多数水平要么低于治疗剂量要么有毒性。没有患者出院时携带峰值流量计或记录的行动计划，尽管1984年和1989年分别有87%（34/39）和96%（27/28）的患者记录了随访安排。我们得出结论，虽然1989年哮喘住院治疗有所改善，但仍普遍存在管理欠佳的情况。
