The use of spectrograms improves the classification of wheezes and crackles in an educational setting.

Chest auscultation is a widely used method in the diagnosis of lung diseases. However, the interpretation of lung sounds is a subjective task and disagreements arise. New technological developments like the use of visSual representation of sounds through spectrograms could improve the agreement when classifying lung sounds, but this is not yet known. In this study, we tested if the use of spectrograms improves the agreement when classifying wheezes and crackles. To do this, we asked twenty-three medical students at UiT the Arctic University of Norway to classify 30 lung sounds recordings for the presence of wheezes and crackles. The sample contained 15 normal recordings and 15 with wheezes or crackles. The students classified the recordings in a random order twice. First sound only, then sound with spectrograms. We calculated kappa values for the agreement between each student and the expert classification with and without display of spectrograms and tested for significant improvement between these two coefficients. We also calculated Fleiss kappa for the 23 observers with and without the spectrogram. In an individual analysis comparing each student to an expert annotated reference standard we found that 13 out of 23 students had a positive change in kappa when classifying wheezes with the help of spectrograms. When classifying crackles 16 out of 23 showed improvement when spectrograms were used. In a group analysis we observed that Fleiss kappa values were k = 0.51 and k = 0.56 (p = 0.63) for classifying wheezes without and with spectrograms. For crackles, these values were k = 0.22 and k = 0.40 (p = <0.01) in the same order. Thus, we conclude that the use of spectrograms had a positive impact on the inter-rater agreement and the agreement with experts. We observed a higher improvement in the classification of crackles compared to wheezes.

Prevalence and clinical associations of wheezes and crackles in the general population: the Tromsø study.

BACKGROUND: Wheezes and crackles are well-known signs of lung diseases, but can also be heard in apparently healthy adults. However, their prevalence in a general population has been sparsely described. The objective of this study was to determine the prevalence of wheezes and crackles in a large general adult population and explore associations with self-reported disease, smoking status and lung function. METHODS: We recorded lung sounds in 4033 individuals 40 years or older and collected information on self-reported disease. Pulse oximetry and spirometry were carried out. We estimated age-standardized prevalence of wheezes and crackles and associations between wheezes and crackles and variables of interest were analyzed with univariable and multivariable logistic regressions. RESULTS: Twenty-eight percent of individuals had wheezes or crackles. The age-standardized prevalence of wheezes was 18.6% in women and 15.3% in men, and of crackles, 10.8 and 9.4%, respectively. Wheezes were mostly found during expiration and crackles during inspiration. Significant predictors of expiratory wheezes in multivariable analyses were age (10 years increase - OR 1.18, 95%CI 1.09-1.30), female gender (1.45, 1.2-1.8), self-reported asthma (1.36, 1.00-1.83), and current smoking (1.70, 1.28-2.23). The most important predictors of inspiratory crackles were age (1.76, 1.57-1.99), current smoking, (1.94, 1.40-2.69), mMRC ≥2 (1.79, 1.18-2.65), SpO2 (0.88, 0.81-0.96), and FEV1 Z-score (0.86, 0.77-0.95). CONCLUSIONS: Nearly over a quarter of adults present adventitious lung sounds on auscultation. Age was the most important predictor of adventitious sounds, particularly crackles. The adventitious sounds were also associated with self-reported disease, current smoking and measures of lung function. The presence of findings in two or more auscultation sites was associated with a higher risk of decreased lung function than solitary findings.

The complexity of managing COPD exacerbations: a grounded theory study of European general practice.

OBJECTIVES: To understand the concerns and challenges faced by general practitioners (GPs) and respiratory physicians about primary care management of acute exacerbations in patients with chronic obstructive pulmonary disease (COPD). DESIGN: 21 focus group discussions (FGDs) were performed in seven countries with a Grounded Theory approach. Each country performed three rounds of FGDs. SETTING: Primary and secondary care in Norway, Germany, Wales, Poland, Russia, The Netherlands, China (Hong Kong). PARTICIPANTS: 142 GPs and respiratory physicians were chosen to include urban and rural GPs as well as hospital-based and out patient-clinic respiratory physicians. RESULTS: Management of acute COPD exacerbations is dealt with within a scope of concerns. These concerns range from 'dealing with comorbidity' through 'having difficult patients' to 'confronting a hopeless disease'. The first concern displays medical uncertainty regarding diagnosis, medication and hospitalisation. These clinical processes become blurred by comorbidity and the social context of the patient. The second concern shows how patients receive the label 'difficult' exactly because they need complex attention, but even more because they are time consuming, do not take responsibility and are non-compliant. The third concern relates to the emotional reactions by the physicians when confronted with 'a hopeless disease' due to the fact that most of the patients do not improve and the treatment slows down the process at best. GPs and respiratory physicians balance these concerns with medical knowledge and practical, situational knowledge, trying to encompass the complexity of a medical condition. CONCLUSIONS: Knowing the patient is essential when dealing with comorbidities as well as with difficult relations in the consultations on exacerbations. This study suggests that it is crucial to improve the collaboration between primary and secondary care, in terms of, for example, shared consultations and defined work tasks, which may enhance shared knowledge of patients, medical decision-making and improved management planning.

Antibiotic prescribing for discoloured sputum in acute cough/lower respiratory tract infection.

We investigated whether discoloured sputum and feeling unwell were associated with antibiotic prescription and benefit from antibiotic treatment for acute cough/lower respiratory tract infection (LTRI) in a prospective study of 3,402 adults in 13 countries. A two-level model investigated the association between producing discoloured sputum or feeling generally unwell and an antibiotic prescription. A three-level model investigated the association between an antibiotic prescription and symptom resolution. Patients producing discoloured sputum were prescribed antibiotics more frequently than those not producing sputum (OR 3.2, 95% CI 2.1-5.0), unlike those producing clear/white sputum (OR 0.95, 95% CI 0.61-1.48). Antibiotic prescription was not associated with a greater rate or magnitude of symptom score resolution (as measured by a 13-item questionnaire completed by patients each day) among those who: produced yellow (coefficient 0.00; p = 0.68) or green (coefficient -0.01; p = 0.11) sputum; reported any of three categories of feeling unwell; or produced discoloured sputum and felt generally unwell (coefficient -0.01; p = 0.19). Adults with acute cough/LRTI presenting in primary care settings with discoloured sputum were prescribed antibiotics more often compared to those not producing sputum. Sputum colour, alone or together with feeling generally unwell, was not associated with recovery or benefit from antibiotic treatment.

Variation in antibiotic prescribing and its impact on recovery in patients with acute cough in primary care: prospective study in 13 countries.

OBJECTIVE: To describe variation in antibiotic prescribing for acute cough in contrasting European settings and the impact on recovery. DESIGN: Cross sectional observational study with clinicians from 14 primary care research networks in 13 European countries who recorded symptoms on presentation and management. Patients followed up for 28 days with patient diaries. SETTING: Primary care. PARTICIPANTS: Adults with a new or worsening cough or clinical presentation suggestive of lower respiratory tract infection. MAIN OUTCOME MEASURES: Prescribing of antibiotics by clinicians and total symptom severity scores over time. RESULTS: 3402 patients were recruited (clinicians completed a case report form for 99% (3368) of participants and 80% (2714) returned a symptom diary). Mean symptom severity scores at presentation ranged from 19 (scale range 0 to 100) in networks based in Spain and Italy to 38 in the network based in Sweden. Antibiotic prescribing by networks ranged from 20% to nearly 90% (53% overall), with wide variation in classes of antibiotics prescribed. Amoxicillin was overall the most common antibiotic prescribed, but this ranged from 3% of antibiotics prescribed in the Norwegian network to 83% in the English network. While fluoroquinolones were not prescribed at all in three networks, they were prescribed for 18% in the Milan network. After adjustment for clinical presentation and demographics, considerable differences remained in antibiotic prescribing, ranging from Norway (odds ratio 0.18, 95% confidence interval 0.11 to 0.30) to Slovakia (11.2, 6.20 to 20.27) compared with the overall mean (proportion prescribed: 0.53). The rate of recovery was similar for patients who were and were not prescribed antibiotics (coefficient -0.01, P<0.01) once clinical presentation was taken into account. CONCLUSIONS: Variation in clinical presentation does not explain the considerable variation in antibiotic prescribing for acute cough in Europe. Variation in antibiotic prescribing is not associated with clinically important differences in recovery. TRIAL REGISTRATION: Clinicaltrials.gov NCT00353951.

Daily reduction in C-reactive protein values, symptoms, signs and temperature in group-A streptococcal pharyngitis treated with antibiotics.

C-reactive protein (CRP) value is usually elevated in patients with group A streptococcal (GAS) pharyngitis. The aim of this study was to describe the daily changes in CRP value after start of antibiotic treatment and to compare these changes with commonly used outcome measures in GAS pharyngitis. Eleven adult patients with sore throat and confirmed GAS infection were examined daily by specially trained medical students who registered symptoms and signs, performed a CRP test (NycoCard) and measured body temperature. At baseline, the mean CRP value was 100.3 mg/L (SD 80.9). The mean reduction after one day was 34.1% (SD 15.3), after two days 60.1% (SD 14.1) and after three days 75.3% (SD 12.5). Corresponding reductions were found for sign and symptom scores and temperature, but the standard deviations for these measures were much larger. The CRP value was significantly associated with both the symptom score and the number of days after start of treatment (p < 0.01), but not with the sign score and body temperature, as shown by multiple regression analysis for repeated measurements. The CRP test seems to be a valid test for monitoring the clinical course in GAS pharyngitis.

Sulphur dioxide exposure and lung function in a Norwegian and Russian population living close to a nickel smelter.

The Norwegian-Russian border area is polluted by sulphur dioxide (SO2) emitted from a Russian nickel smelter in the city of Nikel. We studied the effects of daily variations in SO2 on the lung function levels of people on both sides of the border. A cross-sectional population-based study was performed among adults in Sør-Varanger, Norway (n = 3438) and Nikel, Russia (n = 1613). All subjects were assigned 24 h mean SO2 concentrations for their day of screening and the day before on basis of residency. The SO2-concentrations were compared with the daily recordings of forced expiratory volume in one second expressed as percentage of the predicted value (FEV1% predicted). In Sør-Varanger, no significant associations between SO2 and FEV1% predicted were found. In Nikel, FEV1% predicted was exceeded non-systematically in some of the exposure categories (10-50, 50-90, or > 90 micrograms/m3) compared to the reference exposure group (0-10 micrograms/m3). In conclusion, neither of the study populations suffered from a measurable reduction in lung function when SO2 increased above the reference level.

[Auscultation of the lungs--still a useful examination?]. / Lungeauskultasjonen--fortsatt en nyttig undersøkelse?

Auscultation of the lungs has been a central element in clinical examination since the early part of the nineteenth century. However, the role of the stethoscope in our diagnostic work-up has more and more been challenged by newer diagnostic equipment. Research carried out over the last 30 years has given us new knowledge about the physical basis of lung sounds and the meaning of the sounds. Electronic stethoscopes and computer-based analysis of digital lung sounds are now available. Lungs auscultation findings should be interpreted with caution and be related to the case history and other clinical findings.

Prognosis for chronic obstructive pulmonary disease patients who receive long-term oxygen therapy.

OBJECTIVE: To investigate the survival of patients with chronic obstructive pulmonary disease (COPD) receiving long-term oxygen therapy (LTOT). DESIGN: Retrospective study of 124 patients (76 males and 48 females, mean age 68 years) using LTOT from 1990 to 1996, studied with lifetable analyses. Seventy-six patients with PaO2 < or = 7.3 kPa, and 48 patients with PaO2 > or = 7.4 kPa were allocated to Groups I and II, respectively. RESULTS: The groups had similar FEV1 and FVC levels. The 2- and 5-year survival rates were 73% and 50%, respectively, in Group I, and 78% and 40% in Group II. PaCO2 and FVC were predictors of survival in Group II. Women lived significantly longer than men (Group I: P < 0.01, relative risk [RR] 0.341) but had better FEV1 (P < 0.01). Survival was significantly poorer for patients in the general hospital (P < 0.05, RR 2.096) compared with those at a university hospital. CONCLUSION: Survival during LTOT was similar in patients with and without severe hypoxaemia at the same level of loss of lung function. Survival was poorer when LTOT was not prescribed and followed in a department of respiratory medicine.

Improving pulmonary auscultation as a tool in the diagnosis of bronchial obstruction--results of an educational intervention.

OBJECTIVE: To study the effect of an educational intervention on general practitioners' (GPs') ability to diagnose bronchial obstruction after clinical examination. DESIGN: Based on physical chest examination 11 GPs assessed the degree of bronchial obstruction by estimating the patient's predicted forced expiratory volume in one second (FEV1%). Half way in the study the GPs were taught new knowledge on associations between lung sounds and bronchial airflow. The agreements between estimated and measured FEV1% predicted before and after this educational intervention were compared. SETTING: 11 GPs in five health centres in northern Norway took part. PATIENTS: 351 adult patients were included in phase 1, and 341 in phase 2. MAIN OUTCOME MEASURES: Estimated and measured FEV1% predicted were compared in subgroups of patients according to clinical findings in phase 1 and 2. The effect of the intervention on the doctors' weighting of various chest signs could thus be evaluated. Kappa agreement and correlation between estimated and measured FEV1% predicted in both phases were determined. RESULTS: The agreement between estimated and measured FEV1% predicted increased from Kw (weighted Kappa) = 0.33 in phase 1 to Kw = 0.43 in phase 2 (95% confidence interval 0.35-0.52). The GPs laid more relevant emphasis on rhonchi in their estimates after the educational intervention, while too much weight was laid on uncertain chest findings in phase 2. CONCLUSION: The study shows a potential for better use of physical chest examination in the diagnosis of bronchial obstruction.

Is the general practitioner hospital a potential "patient trap"? A panel study of emergency cases transferred to higher level hospitals.

OBJECTIVES: 1. To find out whether a stay in local general practitioner hospitals (GP hospitals) prior to an emergency admission to higher level hospitals aggravated or prolonged the course of the disease, or contributed to permanent health loss for some patients. 2. To detect cases where a transitory stay in a GP hospital might have been favourable. DESIGN: A retrospective expert panel study based on records from GP hospitals and general hospitals. The included patients had participated in a previous prospective study of consecutive admissions to GP hospitals during 8 weeks. SETTING: Fifteen out of 16 GP hospitals in Finnmark county, Norway. SUBJECTS: Seventy-three patients transferred to higher level hospitals from a total of 395 admitted to GP hospitals. MAIN OUTCOME MEASURES: Three outcome categories were considered for each patient: "possible permanent health loss", "possible significantly prolonged or aggravated disease course", and "possible favourable effect on the disease course". RESULTS: There was agreement about the possibility of negative effects in two patients (2.7%), while a possible favourable influence was ascribed to six cases (8.2%). CONCLUSION: Negative health effects due to transitory stays in GP hospitals are uncommon and moderate, and balanced by benefits, particularly with regard to early access to life saving treatment for critically ill patients.

[The usefulness of clinical pulmonary examination in the diagnosis of bronchial obstruction]. / Nytten av klinisk lunge-undersøkelse i diagnostikk av bronkial obstruksjon.

In order to evaluate the usefulness of physical examination of the chest in diagnosing bronchial obstruction, 11 doctors recorded their findings in 692 adult chest patients. Spirometry was carried out after the physical examination. Two categories of patients were selected; patients with known or suspected pulmonary disease (n = 209) and patients who had consulted their doctors for other reasons (n = 483). Bronchial obstruction defined as either FEV1 < 70% predicted or FEV1 < 70% of FVC, was found in 74 of the "pulmonary patients" and 55 of the "non-pulmonary" patients. In the group of patients with bronchial obstruction, a pathological or less certain sign of chest disorder was found in 91% of the "pulmonary" patients, and in 42% of the "non-pulmonary" patients (p < 0.000001). Strenuous respiration was registered in 41% of the "pulmonary" patients with bronchial obstruction, whereas sensitivity was only 2% in the other group. Where there were two or more pathological chest findings, the risk of bronchial obstruction occurring was 66% among the "pulmonary" patients, as opposed to 37% in the "non-pulmonary" group. Physical examination of the chest appeared to be very useful in the detection of bronchial obstruction in patients with pulmonary symptoms, but of limited value in screening for bronchial obstruction.

Do general practitioner hospitals reduce the utilisation of general hospital beds? Evidence from Finnmark county in north Norway.

STUDY OBJECTIVE: To assess whether populations with access to general practitioner hospitals (GP hospitals) utilise general hospitals less than populations without such access. DESIGN: Observational study comparing the total rates of admissions and of occupied bed days in general hospitals between populations with and without access to GP hospitals. Comparisons were also made separately for diagnoses commonly encountered in GP hospitals. SETTING: Two general hospitals serving the population of Finnmark county in north Norway. PATIENTS: 35,435 admissions based on five years' routine recordings from the two hospitals. MAIN RESULTS: The total rate of admission to general hospitals was lower in peripheral municipalities with a GP hospital than in central municipalities without this kind of institution, 26% and 28% lower for men and women respectively. The corresponding differences were 38% and 52%, when analysed for occupied bed days. The differences were most pronounced for patients with respiratory diseases, cardiac failure, and cancer who are primarily or intermediately treated or cared for in GP hospitals, and for patients with stroke and fractures, who are regularly transferred from general hospitals to GP hospitals for longer term follow up care. CONCLUSION: GP hospitals seem to reduce the utilisation of general hospitals with respect to admissions as well as occupied bed days.

[Diabetic care in Norwegian general practice. A report of current status from Salten and some regions in Rogaland]. / Diabetesomsorg i norsk allmennpraksis. En tilstandsrapport fra Salten og deler av Rogaland.

Few published data are available on the quality of diabetic care in Norway. This applies both to general practice and to hospital clinics. We reviewed the notes of 1,876 diabetic patients who were registered with general practitioners in Salten and Rogaland to assess the quality of care with reference to the Norwegian College of General Practitioners' guidelines for diabetic care. 89% of patients were classified as having type-2 diabetes. Hospital clinics were responsible for the care of 93 patients. Analysis of the results showed that during the last 12 months Hb A1c and blood pressure had been measured in 84 and in 86% of those patients under the care of their general practitioner. Some inspection of the foot had been carried out in 45% of the patients, and 37% of the patients had been referred to an ophthalmologist. Guideline targets for glycaemic control had been achieved in 46% of patients younger than 70 years of age (Hb A1c < 7.5%), and in 82% of patients older than 69 years of age (Hb A1c < 9%). Diabetic patients on insulin therapy had the worst glycaemic control. The study shows that the quality of diabetic care is not optimal, examination of the foot, referral for eye examination and glycaemic control of diabetic patients on insulin therapy are examples of areas where improvement is needed.

Bronchial airflow limitation and chest findings in adults with respiratory infection.

OBJECTIVE: To study the predictive value of clinical chest findings for bronchial airflow limitation in patients with respiratory tract infection. DESIGN: Associations were analysed between FEV1 (forced expiratory volume in one second) in % of predicted and physical chest findings. SETTING: The Municipal Emergency Clinic in Tromsø, Norway. PARTICIPANTS: 398 adult patients with respiratory tract infection and 40 general practitioners. OUTCOME MEASURES: Mean FEV1% predicted and frequency of FEV1 < 80% predicted according to chest findings. Regression coefficients of the findings with FEV % predicted as outcome variable. RESULTS: Mean FEV1% predicted was 87 (range 25-129). Pathological chest findings were recorded in 127 patients (32%) and in 22 of the 24 patients (92%) with FEV1% predicted less than 60. The 78 patients with wheezes had a mean FEV1% predicted of 74 (range 29-120), significantly lower than those without wheezes (p < 0.0001), and 63% had FEV1% predicted less than 80. Prolonged expiration or strenuous respiration was recorded in 49 patients. The 29 patients with wheezes in this subgroup had a significantly lower mean FEV1% predicted, 65, than the 20 patients without wheezes (p < 0.005). By multiple regression wheezes and strenuous respiration were the most significant predictors of FEV1% predicted, together with patients' statement of very annoying dyspnoea. CONCLUSION: When predicting the degree of bronchial obstruction in a patient with respiratory infection, the doctor may take into account wheezes heard by auscultation, an impression of strenuous respiration, and the patient's statement about severe dyspnoea.