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It is surprising to say the least that, although the two inquiries into asthma deaths published recently inThorax 1 2 made the point that most asthma deaths occurred outside hospital (the Welsh study commented on the “relative rarity” of deaths in hospital), neither addressed the question as to whether more prompt admission to a hospital with respiratory intensive care facilities could have prevented some, or even many, of the domestic deaths.
The Respiratory Unit at the Northern General Hospital in Edinburgh first addressed that question as long ago as 19683 when it inaugurated a self-admission scheme for patients known by the unit to be subject to life threatening attacks of asthma, whereby the often long delays inherent in conventional admission procedures were bypassed with the willing cooperation of their general practitioners. The scheme was more fully described in 19754 and reports on 10 year and 15 year reviews of its progress were published in 19795 and 1987.6 These showed that the death rate in patients admitted under the scheme was only 0.3%, substantially lower than that recorded in asthmatic patients admitted to other Edinburgh hospitals which relied on conventional admission procedures.
The asthma self-admission scheme was widely welcomed as a measure which could save lives and was copied in many other countries, including Australia. Yet in neither of the studies reported in the November 1999 issue of Thorax was this important initiative even mentioned. May I ask the authors why?
authors' reply Dr Grant's comments are welcome and highlight the impossibility of including all the information obtained in a study such as SCIAD1-1 in a paper of suitable length for publication. The sudden deterioration of previously well patients, so called “brittle asthma”, was not a major feature of the deaths studied, raising the possibility that there may be relatively fewer such patients or that patients who die suddenly in the community, even with a history of asthma, are certified with other causes of death. It is noteworthy that the routine management of patients studied, including the use of inhaled steroids, was appropriate in the majority of cases, so it may be that, with a general improvement in standards of asthma care, there are fewer patients with brittle disease than there were previously. Review of the cases where delays were cited as a factor showed no case where delay in reaching hospital was the only factor in patients in whom a sudden onset of symptoms was reported; poor compliance was also commented on in these few patients. A review of the cases where death occurred in A&E likewise revealed no case of sudden deterioration (within hours) definitely due to sudden onset of severe asthma; in most cases a number of other factors including aspiration of vomit and the use of non-prescribed drugs was a factor. There is therefore no evidence of deaths which would have been prevented by fast track admission and, with the more widespread administration of oxygen and nebulised bronchodilators by paramedical ambulance crews, there are other reasons for emphasising the use of normal referral services, as well as promoting patient self-management to minimise the occurrence of such episodes.
authors' reply We are aware of the work to which Dr Grant refers, and agree that self-admission schemes can prevent asthma deaths by avoiding the delays that sometimes occur with conventional admission procedures. Different versions of self-admission schemes operate throughout Wales, but there is no uniform practice and it is possible that a few deaths in our series might have been prevented had such a scheme operated everywhere. However, in most cases it is unlikely that the outcome would have been different, particularly when patients failed to take their illness seriously, were not under the care of a respiratory physician, or had no prior history of severe attacks.
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