title: Continuous noninvasive measurement of pulsus paradoxus complements medical decision making in assessment of acute asthma severity.
abstract: BACKGROUND
  Pulsus paradoxus (PP) is a pathophysiologic parameter that is indicative of asthma severity. The ability of PP to categorize acutely asthmatic patients in accordance with the earlier National Asthma Education and Prevention Program (NAEPP) expert panel report 1 guidelines was determined.
  
  
  METHODS
  An arterial tonometric BP monitor, which was interfaced to an analog-digital converter, executed a periodic amplitude analysis algorithm, which computed PP in real time. The PP measurement was compared to the criterion standard of emergency physicians in determining the hospital admission vs hospital discharge disposition following the NAEPP standardized treatment. Receiver operating characteristics (ROCs) were calculated, and the PP threshold, which maximized sensitivity and specificity, was identified. In a separate laboratory investigation, PP was induced in a healthy volunteer by inspiration through a fixed resistance. Plethysmographic waveform changes, induced by PP, were measured by a second analog-to-digital converter that was connected to a pulse oximeter.
  
  
  RESULTS
  A total of 79 patients were enrolled in the study, of whom 63 met a priori inclusion criteria and had uninterrupted data acquisition. The mean PP for patients who were appropriately discharged from the hospital was 9.1 mm Hg (95% confidence interval [CI], 7.3 to 10.9 mm Hg) and differed from the PP of 17.6 mm Hg (95% CI, 13.5 to 21.8; p < 0.001) for patients admitted to the hospital/relapsed. The sensitivity and specificity for physician disposition were 0.83 and 0.89, respectively, and for PP values were 0.78 and 0.78, respectively. The Wilcoxon area under the ROC curve was 0.82 (95% CI, 0.64 to 0.99) following treatment. The risk ratio was 5.32 for hospital admission among patients with a PP of > 11.3 mm Hg. Changes in the photoplethysmography peak height were correlated to PP from the BP monitor by a regression line with a slope of 0.01 V/mm Hg.
  
  
  CONCLUSIONS
  Continuous PP can aid in determining disposition among emergency department (ED) patients with acute asthma. ED physicians equipped with a PP monitor would be able to objectify the work of breathing and would more closely adhere to NAEPP guidelines. The possibility that a PP detection algorithm could reside in a pulse oximeter warrants further investigation.
authors.affiliation: Department of Emergency Medicine, Brown Medical School, Providence, RI, USA.
authors.forename: James
authors.initials: J
authors.lastname: Rayner
authors.forename: Flor
authors.initials: F
authors.lastname: Trespalacios
authors.forename: Jason
authors.initials: J
authors.lastname: Machan
authors.forename: Vijaya
authors.initials: V
authors.lastname: Potluri
authors.forename: George
authors.initials: G
authors.lastname: Brown
authors.forename: Linda M
authors.initials: LM
authors.lastname: Quattrucci
authors.forename: Gregory D
authors.initials: GD
authors.lastname: Jay
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000403:Airway Resistance / Q000502:physiology; D000465:Algorithms; D001249:Asthma / Q000145:classification* / Q000503:physiopathology* / Q000628:therapy; D001794:Blood Pressure / Q000502:physiology; D003362:Cost-Benefit Analysis; D003658:Decision Making, Computer-Assisted; D005260:Female; D017408:Guidelines as Topic; D006801:Humans; D008297:Male; D008875:Middle Aged; D010991:Plethysmography / Q000191:economics / Q000379:methods; D012372:ROC Curve; D012680:Sensitivity and Specificity; D012720:Severity of Illness Index