Kolbe J, Vamos M, Fergusson W, Elkind G
Department of Respiratory Medicine, Green Lane Hospital, Auckland, New Zealand.
Thorax. 1998 Jan;53(1):14-20. doi: 10.1136/thx.53.1.14.
It is hypothesised that, despite recent initiatives to improve asthma self-management including asthma education, detailed investigation of the sequence of events culminating in hospital admission will lead to the identification of important management errors and thus the likelihood that the majority of severe asthma attacks are preventable by currently available strategies, and that psychological, health care and socioeconomic factors are risk factors for such management errors.
A cross sectional study was undertaken of 138 patients aged 15-50 years admitted to hospital (general ward or intensive care unit) with acute severe asthma who were assessed within 24-72 hours of admission using a number of previously validated instruments. A detailed history of events of the attack was assessed against predetermined criteria for non or delayed use of oral corticosteroids and non or delayed use of emergency ambulance services.
Subjects had evidence of severe chronic asthma and had acute severe asthma at presentation (n = 90, pH = 7.3 (0.2), PaCO2 = 7.2 (5.0) kPa) but duration of hospital stay was short (3.7 (2.6) days). Serious management errors occurred very frequently and most were deemed to have been made by the patient. Forward stepwise regression revealed that delayed or non-use of oral corticosteroids was predicted independently by lack of paying job (p = 0.02), high total use of inhaled beta agonists in the 24 hours before index admission (p = 0.04), loss of a job in the last year (p = 0.04), low frequency of use of oral corticosteroids in the last year (p = 0.06), concerns during the index attack about medical expenses (p = 0.07), and delay in the use of ambulance services (p = 0.05)--the model being responsible for 23% of the variance. Delayed or non-summoning of emergency ambulance services was predicted independently by total life events (p = 0.03), having something stolen in the last year (p = 0.003), panic during the index attack (p = 0.01), and concerns during the index attack about taking time off work (p = 0.07)--the model being responsible for 21% of the variance.
The results of this study show that, despite recent educational advances, serious management errors are common in those admitted to hospital with acute severe asthma and that most management errors relate to patient self-management behaviour. Serious management errors are predicted by a variety of socio-economic and psychological factors. While the results of this study are consistent with the widely held view that most acute severe attacks are theoretically preventable, the challenge for the future is to change patients' behaviour in the face of considerable adverse socioeconomic and psychological factors.
据推测，尽管近期采取了包括哮喘教育在内的多项举措来改善哮喘自我管理，但对导致住院的一系列事件进行详细调查，将有助于识别重要的管理失误，从而发现大多数严重哮喘发作可通过现有策略预防，且心理、医疗保健和社会经济因素是此类管理失误的风险因素。
对138名年龄在15至50岁之间因急性重度哮喘入院（普通病房或重症监护病房）的患者进行了横断面研究，这些患者在入院后24至72小时内使用多种先前验证过的工具进行评估。根据预先确定的标准，针对口服糖皮质激素未使用或延迟使用以及紧急救护服务未使用或延迟使用的情况，评估发作事件的详细病史。
受试者有严重慢性哮喘的证据，入院时患有急性重度哮喘（n = 90，pH = 7.3（0.2），动脉血二氧化碳分压[PaCO2] = 7.2（5.0）kPa），但住院时间较短（3.7（2.6）天）。严重管理失误非常常见，且大多数被认为是患者造成的。向前逐步回归显示，口服糖皮质激素延迟使用或未使用可独立由以下因素预测：无带薪工作（p = 0.02）、入院前24小时内吸入β受体激动剂的总使用量高（p = 0.04）、去年失业（p = 0.04）、去年口服糖皮质激素使用频率低（p = 0.06）、本次发作期间对医疗费用的担忧（p = 0.07）以及救护服务使用延迟（p = 0.05）——该模型解释了23%的变异。紧急救护服务延迟召唤或未召唤可独立由以下因素预测：生活事件总量（p = 0.03）、去年有物品被盗（p = 0.003）、本次发作期间恐慌（p = 0.01）以及本次发作期间对请假的担忧（p = 0.07）——该模型解释了21%的变异。
本研究结果表明，尽管近期在教育方面取得了进展，但在因急性重度哮喘入院的患者中，严重管理失误很常见，且大多数管理失误与患者自我管理行为有关。多种社会经济和心理因素可预测严重管理失误。虽然本研究结果与广泛持有的观点一致，即大多数急性重度发作在理论上是可预防的，但未来的挑战是在存在相当多不利的社会经济和心理因素的情况下改变患者的行为。
