Noninvasive assessment of asthma severity using pulse oximeter plethysmograph estimate of pulsus paradoxus physiology

Donald H Arnold, Cathy A Jenkins, Tina V Hartert, Donald H Arnold, Cathy A Jenkins, Tina V Hartert

Abstract

Background: Pulsus paradoxus estimated by dynamic change in area under the oximeter plethysmograph waveform (PEP) might provide a measure of acute asthma severity. Our primary objective was to determine how well PEP correlates with forced expiratory volume in 1-second (%FEV1) (criterion validity) and change of %FEV1 (responsiveness) during treatment in pediatric patients with acute asthma exacerbations.

Methods: We prospectively studied subjects 5 to 17 years of age with asthma exacerbations. PEP, %FEV1, airway resistance and accessory muscle use were recorded at baseline and at 2 and 4 hours after initiation of corticosteroid and bronchodilator treatments. Statistical associations were tested with Pearson or Spearman rank correlations, logistic regression using generalized estimating equations, or Wilcoxon rank sum tests.

Results: We studied 219 subjects (median age 9 years; male 62%; African-American 56%). Correlation of PEP with %FEV1 demonstrated criterion validity (r = - 0.44, 95% confidence interval [CI], - 0.56 to - 0.30) and responsiveness at 2 hours (r = - 0.31, 95% CI, - 0.50 to - 0.09) and 4 hours (r = - 0.38, 95% CI, - 0.62 to - 0.07). PEP also correlated with airway resistance at baseline (r = 0.28 for ages 5 to 10; r = 0.45 for ages 10 to 17), but not with change over time. PEP was associated with accessory muscle use (OR 1.16, 95% CI, 1.11 to 1.21, P < 0.0001).

Conclusions: PEP demonstrates criterion validity and responsiveness in correlations with %FEV1. PEP correlates with airway resistance at baseline and is associated with accessory muscle use at baseline and at 2 and 4 hours after initiation of treatment. Incorporation of this technology into contemporary pulse oximeters may provide clinicians improved parameters with which to make clinical assessments of asthma severity and response to treatment, particularly in patients who cannot perform spirometry because of young age or severity of illness. It might also allow for earlier recognition and improved management of other disorders leading to elevated pulsus paradoxus.

Figures

Figure 1
Figure 1
Plethysmograph Estimate of Pulsus Paradoxus Calculation. 1) AUC is calculated for each cardiac cycle from plethysmograph waveform. 2) ΔAUC is calculated for each successive 3-sec interval. 3) PEP is 180-sec moving average of ΔAUC.
Figure 2
Figure 2
Identification Study Subjects.
Figure 3
Figure 3
Correlation of Plethysmograph Estimate of Pulsus Paradoxus with %FEV1 and Airway Resistance at baseline. Horizontal axes in each panel are plethysmograph estimates of pulsus paradoxus (PEP) expressed as %. Vertical axes are percent predicted values for FEV1 and airway resistance (ages 5 to 10 years) and absolute value (kPa/L/s) for airway resistance (ages 11 to 17 years).

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