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Background: Self-reported prior morbidity levels and medication use among survivors of a near-fatal asthma attack (NFA) were studied., Aims: To identify deficiencies in asthma management and opportunities for intervention., Methods: A hundred and twenty-seven consecutive patients aged 15 years or more presenting with a NFA to accident and emergency departments of teaching hospitals were interviewed., Results: High levels of morbidity due to asthma were reported. Most cases (79%) reported symptoms occurring at least weekly in the three months before their NFA. A mean of 20.8 days was reportedly lost from work, school or other usual daily activity in the 12 months before these events. Regular use of beta agonist as nebuliser solution was reported by 27% of cases, increasing to 34.5% in response to increased symptoms, while 41% reported use of nebulised beta agonist in response to the NFA event. Less than half of all cases (46%) reported using an inhaled corticosteroid on a regular basis. Oral corticosteroids were used by 33% of cases at times of increased symptoms in the preceding 12 months. However, only 7% of cases reported initiating or increasing oral corticosteroids at the time of the NFA., Conclusions: Despite high levels of prior asthma morbidity, regular preventive inhaled corticosteroid use was not widespread in this series of NFA asthmatics. By comparison, over-reliance on regular beta agonist medication was common. Oral corticosteroids were rarely commenced in response to the NFA.

As part of the South Australian asthma mortality survey, we examined 30 cases of near-fatal asthma attacks in children under 15 years of age who were seen over a 3-year period from May 1988 to June 1991. Subjects presented with asthma and either respiratory arrest, PaCO2 above 50 mm Hg, and/or an altered state of consciousness or inability to speak on presentation at a metropolitan Adelaide teaching hospital. A standardized interview and questionnaire was completed with subjects/parents and medical practitioners. Data were reviewed by the assessment panel which made collective judgments based on predetermined criteria. Seventeen patients (57%) were male, 20% were less than 7 years of age, and the majority (53%) were aged between 12 and 15 years. The majority (83%) had severe asthma and only one case (3.3%) had mild asthma. Half of the subjects were waking every night due to asthma and 79% had significant exercise limitation. A quarter of the subjects had a previous ICU admission and 70% had a hospital admission in the last 12 months. Primary care was carried out by a general practitioner in 57% of cases, and 70% of subjects had a crisis plan. Only 46% of those older than 7 years of age had ever used a peak-flow meter. Eighty percent of subjects or their families had high denial scores, and in 73% of cases psychosocial factors were considered to be significant. Eighty percent of cases experienced acute progressive respiratory distress, and 63% of cases delayed seeking medical care.(ABSTRACT TRUNCATED AT 250 WORDS)

Background: The associations between psychiatric caseness, denial, and self reported measures of handicap and morbidity due to asthma in patients suffering a near fatal attack of asthma have not been fully explored., Methods: Seventy seven consecutive subjects who presented to Adelaide teaching hospitals with a near fatal attack of asthma were assessed with a validated semi-structured interview following discharge from hospital., Results: 43% of the patients scored > or = 5 on the GHQ-28 questionnaire. There was a positive correlation between GHQ-28 score and limitation to daily activities due to asthma, and between GHQ-28 score and days lost from work, school or usual daily activities, both of which were retained after adjusting for age and sex. Asthma severity did not show a clear association with GHQ-28 score. The asthmatic patients reported high levels of denial, 57% scoring more than 3 out of 5 on the denial scale of the Illness Behaviour Questionnaire. Presentation with a history of progressive respiratory distress was negatively associated with denial score. This persisted after adjustment for age and sex--that is, those with high denial scores were more likely to report presentation as sudden collapse than progressive respiratory distress., Conclusions: Psychiatric caseness (GHQ score > or = 5) is associated with high levels of morbidity in asthmatic patients who survive a near fatal attack of asthma. High levels of denial in asthmatic subjects may be life threatening. The link between morbidity associated with asthma and psychiatric features, along with other psychosocial issues, warrants further investigation. A broader paradigm than the traditional medical model should be considered when assessing patients with asthma.

Aim: This study, carried out in 1989, set out to assess general practitioners' knowledge of asthma management and their reported management practices., Method: Of 153 randomly selected South Australian general practitioners 127 (83%) completed a questionnaire designed to explore issues relating to the management of asthma., Results: The survey revealed substantial differences between general practitioners in their knowledge and management practices including the assessment of the severity of asthma, the need for objective monitoring, that is by the use of spirometry and peak flow meters, and the use of medication. Overall, the sampled general practitioners believed that patient-related factors were the main barriers to effective treatment of asthma., Conclusion: The findings of this study suggest that ideal asthma management was not being attained. More research is required to ascertain why such variability among practitioners exists and how best to remedy these differences.

Studies seeking to identify factors predictive of asthma mortality have relied on information obtained from relatives, other close acquaintances, and doctors who cared for the deceased. We wanted to determine whether asthmatics who have suffered a near-fatal asthma attack (NFA) are similar to asthmatics who have died of asthma with respect to important features, because studies of NFA asthmatics may provide a better insight into causes of asthma death. Such studies would avoid the difficulties associated with seeking information secondhand from proxy informants. Two groups were studied: asthmatics who had suffered a near-fatal asthma attack resulting in a visit to the accident and emergency departments of teaching hospitals (n = 154), and asthmatics certified as dying of asthma who, following panel review, were confirmed to have died from this disease (n = 80). For each case in the two groups, an interview questionnaire was administered to a close acquaintance (household or family member) and to the general practitioner. Both groups shared many important characteristics. Similarities related to: frequency of symptoms; frequency of hospital and intensive care unit admissions for asthma; use of asthma crisis plans; compliance with prescribed medications; quality of personal asthma management; and asthma severity. The two groups also showed similar psychiatric profiles, and similar use of asthma medications on a regular basis and with increased symptoms. However, NFA cases tended to be younger, were more likely to be male, and less likely to have concurrent medical conditions.(ABSTRACT TRUNCATED AT 250 WORDS)

Background: The reliability of information collected from close acquaintances of the deceased in studies on mortality from asthma has not been assessed. As part of a South Australian asthma mortality study, levels of agreement for information obtained directly from cases--that is, cases who had experienced near fatal asthma attacks--were compared with corresponding information concerning these cases obtained independently from close acquaintances., Methods: The first 51 subjects presenting from the outset of the main study to hospital accident and emergency departments with near fatal asthma attacks were included to gain an early assessment of the reliability of responses. The level of agreement between self reported information and that obtained from close acquaintances was compared by means of a kappa statistic or intraclass correlation coefficient, depending on the measurement scale. Both score one for complete agreement and zero when there is no agreement., Results: High levels of agreement were found for questions relating to use of hospital services, with agreement levels ranging from 0.92 for visits in the past month to accident and emergency departments, to 0.86 for prior hospital admissions and 0.78 for prior need for assisted ventilation. Levels of agreement for drug treatment ranged from 1.00 for use of beta agonists to 0.64 for corticosteroid use, and to a low 0.24 for use of sodium cromoglycate. There was moderate agreement for histories of regular use of over the counter medications without a medical consultation (0.57). Psychiatric characteristics showed moderate levels of agreement, with values of 0.44 for personal history of psychiatric consultations and 0.50 for denial score. Agreement scores were 0.66 for doctor visits in the past month, 0.66 for limitations in daily activities, 0.76 for loss of work days in the past month, 0.59 for severity of asthma, and 0.55 for frequency of asthma attacks in the past month. Poorer agreement scores were found for trends in asthma symptoms (0.21) and frequency of symptoms during the past three years (0.12). Sleep disturbance was also associated with a low agreement score (0.25)., Conclusions: The more visible the asthma manifestation, and the more recent the period to which it applies, the more reliable is the information provided by close acquaintances. These factors need to be taken into account when using information from close acquaintances in asthma mortality studies.

Objective: To assess the accuracy of asthma statistics from death certificates in South Australia., Design: Comparison of death certificate coding with expert panel assessments of causes of death after interviews with certifying doctors, regular medical practitioners and close acquaintances of the deceased., Subjects: 261 subjects for whom the term "asthma", "asthmatic" or "asthmaticus" was recorded in Part I or Part II of death certificates lodged in the 24-month period from May 1988., Main Outcome Measures: Sensitivity, specificity and predictive value of death certificate coding, with expert panel assessments as the reference standard., Results: About 95% of deaths assessed as definitely due to asthma were so coded from death certificates, but only 69% of deaths assessed by the panel as not due to asthma were coded to a "non-asthmatic" cause. Of the 129 deaths coded to asthma, the percentage assessed as definitely or likely to be due to asthma was 56%. For ages under 65 years, this figure was 84% compared with only 38% for older subjects., Conclusion: The accuracy of death certificate data on asthma for the age group 65 years and over would be too low at present for most epidemiological purposes.