Does Patient Weight, Age, or Gender Correlate With the Ability to Visualize the Distal Aorta on Bedside Aortic Ultrasounds in the Emergency Department?

INTRODUCTION: Abdominal aortic aneurysms (AAA) have a varied presentation, which often makes the diagnosis difficult. The most common location for an AAA is in the infra-renal or distal aorta, which can be difficult to visualize using bedside ultrasound.  Objective: This study was designed to identify if a patient's weight, gender, or age influenced our ability to visualize the distal aorta on bedside abdominal aortic ultrasound scans.  Methods: All aortic scans completed in the Emergency Department (ED) from September 2010 to September 2013 were retrospectively evaluated. Patients 21 years and older were included. Scans missing age, gender, or self-reported weight were excluded.  Results: 500 aortic scans were included. The distal aorta was visualized in 393 scans (78.6%). The mid aorta was visualized in 417 scans (83.4%). The proximal aorta was visualized in 454 scans (90.8%). For the distal aorta, the average weight for visualized versus not visualized was 75.7 kg versus 79.7 kg. For the proximal aorta, the average weight for visualized versus not visualized was 75.8 kg versus 84.0 kg. Weight significantly predicted the ability to visualize the proximal aorta (unadjusted p=0.0098, adjusted p=0.0095) and marginally predicted the ability to visualize the distal aorta (unadjusted p=0.071, adjusted p=0.019). Neither age (unadjusted p=0.13, adjusted p=0.052) nor gender (unadjusted p=0.74, adjusted p=0.40) was significantly associated with visualization. CONCLUSION: There is no clinically significant difference in the ability to visualize a patient's distal aorta with bedside ultrasound based on a patient's body weight, gender, or age.

Impact of Bedside Ultrasound on Emergency Department Length of Stay and Admission in Patients With a Suspected Peritonsillar Abscess.

Introduction Patients presenting to the Emergency Department (ED) with a suspected peritonsillar abscess (PTA) often pose a diagnostic dilemma, as clinical impression is often unreliable and traditional diagnostic methods have multiple downsides. Bedside ultrasonography has been cited as a modality to improve the diagnosis and management of PTA. We aimed to determine the impact bedside ultrasound (US) could have in suspected PTA on ED length of stay (LOS) and hospital admission rates. Methods We performed a retrospective chart review on patients who presented to the ED with suspected ''peritonsillar abscess''. Results From a sample of 58 charts, seven had documented bedside US performed. The average ED length of stay for these seven cases was 160 minutes (range: 52 to 270 minutes). The ED length of stay for all other cases utilizing other diagnostic methods during the same time period was 293 minutes (range: 34 to 780 minutes). None of the patients who were diagnosed with US were admitted to the hospital, whereas 36.4% of patients where US was not used were admitted. Conclusion The use of bedside US in seven cases of suspected PTA had reduced LOS in the ED and none required hospital admission.

Feasibility of Health Literacy Tools for Older Patients in the Emergency Department.

INTRODUCTION: This study evaluates the feasibility of using a volunteer research associate (RA) to administer two separate health literacy assessment tools in the emergency department (ED), specifically in an older population of patients. The outcomes measured were administration time and interruptions. METHODS: Using a prospective, cross-sectional study with a convenience sample, adult patients over the age of 55 presenting between June-August 2018 to one urban, academic ED were evaluated by a volunteer RA using either the Newest Vital Sign (NVS) or the Short Assessment of Health Literacy (SAHL). All patients 55 years of age or older who consented to participate were included. We excluded from this study the following: patients with dementia or other disability involving reading, speech, or cognitive function, as noted in their medical record or by their attending physician; prisoners; and those subjectively deemed in extremis or too ill to participate by their attending physician. RESULTS: Health literacy was assessed in 202 patients using either the NVS or SAHL. Mean time of administration was 214.0 seconds for the NVS, and 206.8 for the SAHL. The maximum time of administration for the NVS was 563 seconds, compared to 607 seconds for the SAHL. We found that 95.2% of NVS and 93.9% of SAHL tests incurred no interruptions during administration. CONCLUSION: No significant difference was found between the length of time needed to administer the NVS or SAHL to older patients in the ED. Both tools averaged an administration time of around three to four minutes, and neither incurred regular interruptions to its administration by a volunteer RA. Further study is needed to assess validity of these tools in an ED setting.

Self-reported modifying effects of resilience factors on perceptions of workload, patient outcomes, and burnout in physician-attendees of an international emergency medicine conference.

Emergency medicine has one of the highest rates of burnout of all medical specialties. Recent research has identified putative sources of burnout in emergency medicine, including stress of overnight shifts, psychological demands of handling emergency patients, and perceived poor departmental support systems. This burnout is detrimental to the quality of patient care, and thus represents an important target to simultaneously improve both physician wellness and patient outcomes. We lack consensus on the best way to combat the impacts of physician burnout in part, because we do not know the protective factors that best enable individuals to manage their burnout and be resilient to its impacts on their patient care. The goal of this study was to identify the resilience factors that have the greatest influence on the relationship between physician burnout symptoms and perceptions of workload impact on patient outcomes. We conducted a cross-sectional web-based anonymous survey of full-time attending emergency medicine physicians and measured self-reported responses about perceived impacts of workload on patient care and symptoms of burnout. Additionally, we measured resilience factor-related items (such as shift length/type, spirituality, home life, etc.), stratified the responses by level of agreement with the statements, and assessed how each impacted the relationship between burnout domains and perceived workload/patient outcomes. The level of agreement with five resilience factor statements influenced the magnitude of correlation between workload's effects on patient outcomes and burnout. These factors included personal spirituality, utility of mindfulness techniques, sleep quality, perceptions of home life, and the presence of institutional debriefing procedures. This work identified five resilience factors that may enable emergency medicine physicians to mitigate the impact of their burnout on their work and patient care. Promoting these resilience factors represent targets for institutional-level interventions to improve both physician wellness and patient outcomes.

Impact of physician workload on burnout in the emergency department.

Emergency medicine is one of the medical fields with the highest rates of physician burnout. Research demonstrates hospitalists believe increasing workloads contribute to decreases in patient safety and satisfaction, and increases in morbidity and mortality. Our objective was to identify if emergency physicians who believe workload impacts patient care also experience worse rates of burnout symptoms. This two-phase study used an online survey with cross-sectional design distributed to emergency medicine physicians following the New Jersey American College of Emergency Physicians (NJ ACEP) Scientific Assembly in May 2016 and members of the ACEP Well-Being Committee and Wellness Section in December 2016. Respondents felt the greatest workload burdens by being '…unable to fully discuss treatment options or answer questions of a patient or family member' or leading to 'Delay in admitting or discharging patients.' Excessive workload also contributed to respondents having to 'Admit to hospital instead of discharge' and resulted in 'Worsened patient satisfaction.' The 'Emotional Exhaustion' domain of the Maslach Burnout Inventory was the most highly affected by the perceived effects of workload on patient outcomes and 'Personal Accomplishment' was least affected. This research highlights the perception that workload contributing to patient harm may be associated with emergency medicine burnout.

Procedure rates performed by emergency medicine residents: a retrospective review.

BACKGROUND: The purpose of our study is to investigate rates of individual procedures performed by residents in our emergency medicine (EM) residency program. Different programs expose residents to different training environments. Our hypothesis is that ultrasound examinations are the most commonly performed procedure in our residency. METHODS: The study took place in an academic level I trauma center with multiple residency and fellowship programs including surgery, surgical critical care, trauma, medicine, pulmonary/critical care, anesthesiology and others. Also, the hospital provides a large emergency medical services program providing basic and advanced life support and critical care transport, which is capable of performing rapid sequence intubation. Each EM residency class, except for the first 2 months of the inaugural class, used New Innovations to log procedures. New Innovations is an online database for tracking residency requirements, such as procedures and hours. For the first 3 months, procedures were logged by hand on a log sheet. In addition, our department has a wireless electronic system (Qpath) for recording and logging ultrasound images. These logs were reviewed retrospectively without any patient identifiers. Actual procedures and simulation procedures were combined for analysis as they were only logged separately halfway through the study period. Procedures were summed and the average procedure rate per resident per year was calculated. RESULTS: In total, 66 full resident years were analyzed. Overall, ultrasound was the most commonly performed procedure, with each resident performing 125 ultrasounds per year. Removing "resuscitations," the second most common was endotracheal intubation, performed 28.91 times per year, and third most was laceration repair, which was performed 17.39 times per year. Our lowest performed procedure was thoracentesis, which was performed on average 0.11 times per resident per year. CONCLUSIONS: Residents performed a variety of procedures each year. Ultrasound examinations were the most frequent procedure performed. The number of ultrasound procedures performed may reflect the changing training landscape and influence future Accreditation Council of Graduate Medical Education requirements.

Recognizing thyrotoxic hypokalemic periodic paralysis.

Thyrotoxic hypokalemic periodic paralysis (THPP) is a rare but potentially serious complication of thyrotoxicosis. The resulting muscle weakness is profound, associated with more severe hypokalemia, yet reversible. However, clinicians must be cautious because patients can develop life-threatening hyperkalemia during treatment. Underlying causes should be investigated as repeated episodes of THPP may occur.

How Does Emergency Department Crowding Affect Medical Student Test Scores and Clerkship Evaluations?

INTRODUCTION: The effect of emergency department (ED) crowding has been recognized as a concern for more than 20 years; its effect on productivity, medical errors, and patient satisfaction has been studied extensively. Little research has reviewed the effect of ED crowding on medical education. Prior studies that have considered this effect have shown no correlation between ED crowding and resident perception of quality of medical education. OBJECTIVE: To determine whether ED crowding, as measured by the National ED Overcrowding Scale (NEDOCS) score, has a quantifiable effect on medical student objective and subjective experiences during emergency medicine (EM) clerkship rotations. METHODS: We collected end-of-rotation examinations and medical student evaluations for 21 EM rotation blocks between July 2010 and May 2012, with a total of 211 students. NEDOCS scores were calculated for each corresponding period. Weighted regression analyses examined the correlation between components of the medical student evaluation, student test scores, and the NEDOCS score for each period. RESULTS: When all 21 rotations are included in the analysis, NEDOCS scores showed a negative correlation with medical student tests scores (regression coefficient= -0.16, p=0.04) and three elements of the rotation evaluation (attending teaching, communication, and systems-based practice; p<0.05). We excluded an outlying NEDOCS score from the analysis and obtained similar results. When the data were controlled for effect of month of the year, only student test score remained significantly correlated with NEDOCS score (p=0.011). No part of the medical student rotation evaluation attained significant correlation with the NEDOCS score (p≥0.34 in all cases). CONCLUSION: ED overcrowding does demonstrate a small but negative association with medical student performance on end-of-rotation examinations. Additional studies are recommended to further evaluate this effect.

Reduced Hospital Duration of Stay Associated with Revised Emergency Department-Intensive Care Unit Admission Policy: A before and after Study.

BACKGROUND: Emergency department (ED) and hospital crowding adversely impacts patient care. Although reduction methods for duration of stay in the ED have been explored, few focus on medical intensive care unit (MICU) patients. OBJECTIVE: To quantify duration of stay or mortality changes associated with a policy intervention that changed the role of an MICU resident to "screen" and write MICU admission orders in the ED to instead meet the patient and write orders in the MICU if there was an available bed. The intervention moved "screening" bed management-appropriateness discussions to the MICU attending or fellow level. METHODS: We performed a retrospective before and after study at an urban, level 1 trauma center of adults admitted to the MICU from the ED during the first 6 months in 2009 before, and the corresponding 6 months in 2010, after the intervention. We collected demographics, ED, MICU, and hospital duration of stay, duration of mechanical ventilation, Acute Physiology and Chronic Health Evaluation (APACHE) scores, and mortality from electronic medical records. Linear models compared duration of stay differences; logistic regression compared in-hospital mortality. T-tests assessed APACHE score changes before and after the policy change. Analyses were adjusted for age and sex. RESULTS: We included 498 patients, average age 66 years (±18), 52% male. Hospital duration of stay decreased 18% from 6.8 to 5.6 days (unadjusted p = 0.029). MICU duration of stay decreased from 3.5 to 3.3 days (unadjusted p = 0.34) and ED duration of stay from arrival to physical transfer decreased 40 min (375 to 324 min; unadjusted p = 0.006). Mortality and APACHE scores were unchanged. CONCLUSIONS: A streamlined admission intervention from the ED to the MICU was associated with decreased ED and hospital duration of stay without altering mortality.

Use of an Intravascular Heat Exchange Catheter and Intravenous Lipid Emulsion for Hypothermic Cardiac Arrest After Cyclobenzaprine Overdose.

In this case report, a 22-year-old male developed severe hypothermia after an accidental overdose of cyclobenzaprine. During transport, the patient developed cardiac arrest. He received active rewarming measures, including pleural lavage, gastric lavage, an intravascular heat exchange catheter, and cardiopulmonary bypass. Intravenous lipid emulsion (ILE) was also administered. A discussion of cyclobenzaprine toxicity, hypothermia, ILE, and accidental hypothermic cardiac arrest follows.

Diagnosis and Treatment of Acute Gout at a University Hospital Emergency Department.

BACKGROUND: Acute gout attacks account for a substantial number of visits to the emergency department (ED). Our aim was to evaluate acute gout diagnosis and treatment at a University Hospital ED. METHODS: Our study was a retrospective chart review of consecutive patients with a diagnosis of acute gout seen in the ED 1/01/2004 - 12/31/2010. We documented: demographics, clinical characteristics, medications given, diagnostic tests, consultations and whether patients were hospitalized. Descriptive and summary statistics were performed on all variables. RESULTS: We found 541 unique ED visit records of patients whose discharge diagnosis was acute gout over a 7 year period. 0.13% of ED visits were due to acute gout. The mean patient age was 54; 79% were men. For 118 (22%) this was their first attack. Attack duration was ≤ 3 days in 75%. Lower extremity joints were most commonly affected. Arthrocentesis was performed in 42 (8%) of acute gout ED visits. During 355 (66%) of ED visits, medications were given in the ED and/or prescribed. An anti-inflammatory drug was given during the ED visit during 239 (44%) visits. Medications given during the ED visit included: NSAIDs: 198 (56%): opiates 190 (54%); colchicine 32 (9%) and prednisone 32 (9%). During 154 (28%) visits an anti-inflammatory drug was prescribed. Thirty two (6%) were given no medications during the ED visit nor did they receive a prescription. Acute gout rarely (5%) led to hospitalizations. CONCLUSION: The diagnosis of acute gout in the ED is commonly clinical and not crystal proven. Anti-inflammatory drugs are the mainstay of treatment in acute gout; yet, during more than 50% of ED visits, anti-inflammatory drugs were not given during the visit. Thus, improvement in the diagnosis and treatment of acute gout in the ED may be required.

Decreasing length of stay in the emergency department with a split emergency severity index 3 patient flow model.

OBJECTIVES: There has been a steady increase in emergency department (ED) patient volume and wait times. The desire to maintain or decrease costs while improving throughput requires novel approaches to patient flow. The break-out session "Interventions to Improve the Timeliness of Emergency Care" at the June 2011 Academic Emergency Medicine consensus conference "Interventions to Assure Quality in the Crowded Emergency Department" posed the challenge for more research of the split Emergency Severity Index (ESI) 3 patient flow model. A split ESI 3 patient flow model divides high-variability ESI 3 patients from low-variability ESI 3 patients. The study objective was to determine the effect of implementing a split ESI 3 flow model has on patient length of stay (LOS) for discharged patients. METHODS: This was a retrospective chart review at an urban academic ED seeing over 70,000 adult patients a year. Cases consisted of adults who presented from 9 a.m. to 11 p.m. from June 1, 2011, to December 31, 2011, and were discharged. Controls were patients who presented on the same times and days, but in 2010. Visit descriptors included age, race, sex, ESI score, and first diagnosis. The first diagnosis was coded based on methods used by the Agency for Healthcare Research and Quality to codify International Classification of Diseases, ninth version, into disease groups. Linear models compared log-transformed LOS for cases and controls. A front-end ED redesign involved creating guidelines to split ESI 3 patients into low and high variability, a hybrid sort/triage registered nurse, an intake area consisting of an internal results waiting room, and a treatment area for patients after initial assessment. The previous low-acuity area (ESI 4s and 5s) began to see low-variability ESI 3 patients as well. This was done without additional beds. The intake area was staffed with an attending emergency physician (EP), a physician assistant (PA), three nurses, two medical technicians, and a scribe. RESULTS: There was a 5.9% decrease, from 2.58 to 2.43 hours, in the geometric mean of LOS for discharged patients from 2010 to 2011 (95% confidence interval CI = 4.5% to 7.2%; 2010, n = 20,215; 2011, n = 20,653). Abdominal pain was the most common diagnostic grouping (2010, n = 2,484; 2011, n = 2,464) with a reduction in LOS of 12.9%, from 4.37 to 3.8 hours (95% CI = 10.3% to 15.3%). CONCLUSIONS: A split ESI 3 patient flow model improves door-to-discharge LOS in the ED.

Discordance between microcirculatory alterations and arterial pressure in patients with hemodynamic instability.

PURPOSE: Recent studies reported that microcirculatory blood flow alterations occur in patients with circulatory shock independent of arterial pressure but typically lack baseline microcirculatory data before the insult and after recovery. We selected cardiopulmonary bypass (CPB) patients with expected and rapidly reversible hemodynamic instability to test the hypothesis that microcirculatory alterations can occur independent of mean arterial pressure (MAP). METHODS: Prospective observational study using sidestream darkfield videomicroscopy to measure sublingual microcirculatory flow preoperative (PRE), postoperatively after CPB (POST), and after recovery (REC). We determined the microcirculatory flow index (MFI) at each time point, blinded to all clinical data and compared change in MFI and MAP across time points using analysis of variance adjusted for multiple comparisons. RESULTS: We enrolled 20 subjects, 17 of 20 required inotrope/vasopressor agents at CPB discontinuation, 7 of 20 were on inotrope/vasopressor agents at the time of imaging, 20 of 20 were receiving continuous nitroglycerin. We observed an increase in post-CPB MFI (PRE, 2.16 ± 0.29; POST, 2.45 ± 0.62; REC, 2.26 ± 0.25; P < .01) without a concomitant increase in MAP. CONCLUSION: In this cohort of patients with hemodynamic instability, we observed discordance between microcirculatory blood flow and arterial pressure. These data support the concept that microcirculatory blood flow indices can yield physiologic information distinct from macrocirculatory hemodynamic parameters.

Electrocardiographic manifestations of cardiac infectious-inflammatory disorders.

Inflammatory disorders of the heart, although uncommon in the general population, often present initially to the emergency department. Symptoms and clinical manifestations are shared with other more common cardiopulmonary diseases, particularly acute coronary syndrome and congestive heart failure, making prompt diagnosis challenging. This review will highlight some of the clinical and electrocardiographic features that will help early diagnosis and differentiation of inflammatory cardiac disorders from other more common conditions.

Continuous cardiac index monitoring: A prospective observational study of agreement between a pulmonary artery catheter and a calibrated minimally invasive technique.

INTRODUCTION: Continuous cardiac index (CCI) monitoring can provide information to assist in hemodynamic support. However, pulmonary artery catheters (PAC) pose logistic challenges in acute care settings. We hypothesized that CCI measured with a calibrated minimally invasive technique (LiDCO/PulseCO, UK) would have good agreement with the PAC. METHODS: We performed a prospective observational study in post-operative cardiac surgery patients. All patients had a PAC with CCI monitoring capability. We connected the LiDCO apparatus to a radial artery line and performed a one-time calibration with a lithium dilution indicator. In order to test the least invasive method possible, we used a peripheral intravenous (IV) line for indicator delivery rather than the conventional central line technique. We recorded paired PAC/LiDCO-PulseCO CCI measurements every minute for 3h. We blinded investigators and clinicians to minimally invasive data with an opaque shield over the monitor. We assessed agreement with Bland-Altman analysis. RESULTS: We obtained 1485 paired measurements in 8 subjects. The mean CI was 2.9L/min/m(2). By Bland-Altman plot, PAC and LiDCO measurements showed minimal bias (-0.01), but the 95% limits of agreement (+/-2SD) of+/-1.3L/min/m(2) were relatively wide with respect to the mean. CONCLUSIONS: This calibrated minimally invasive (i.e. radial arterial line and peripheral IV) technique demonstrated low bias compared with CCI measured by PAC. However, the relatively wide confidence limits indicate that differences in the two measurements could still be clinically significant.

Early increases in microcirculatory perfusion during protocol-directed resuscitation are associated with reduced multi-organ failure at 24 h in patients with sepsis.

OBJECTIVE: Sepsis mortality is closely linked to multi-organ failure, and impaired microcirculatory blood flow is thought to be pivotal in the pathogenesis of sepsis-induced organ failure. We hypothesized that changes in microcirculatory flow during resuscitation are associated with changes in organ failure over the first 24 h of sepsis therapy. DESIGN: Prospective observational study. SETTING: Emergency Department and Intensive Care Unit. PARTICIPANTS: Septic patients with systolic blood pressure <90 mmHg despite intravenous fluids or lactate >or=4.0 mM/L treated with early goal-directed therapy (EGDT). MEASUREMENTS AND RESULTS: We performed Sidestream Dark Field (SDF) videomicroscopy of the sublingual microcirculation <3 h from EGDT initiation and again within a 3-6 h time window after initial. We imaged five sites and determined the mean microcirculatory flow index (MFI) (0 no flow to 3 normal) blinded to all clinical data. We calculated the Sequential Organ Failure Assessment (SOFA) score at 0 and 24 h, and defined improved SOFA a priori as a decrease >or=2 points. Of 33 subjects; 48% improved SOFA over 0-24 h. Age, APACHE II, and global hemodynamics did not differ significantly between organ failure groups. Among SOFA improvers, 88% increased MFI during EGDT, compared to 47% for non-improvers (P = 0.03). Median change in MFI was 0.23 for SOFA improvers versus -0.05 for non-improvers (P = 0.04). CONCLUSIONS: Increased microcirculatory flow during resuscitation was associated with reduced organ failure at 24 h without substantial differences in global hemodynamics. These data support the hypothesis that targeting the microcirculation distinct from the macrocirculation could potentially improve organ failure in sepsis.

Corticosteroid use after hospital discharge among high-risk adults with asthma.

Despite the efficacy of corticosteroid therapy, patients hospitalized for asthma exacerbations are at high risk for re-exacerbation and death after discharge. The objective of this prospective cohort study was to evaluate adherence to inhaled corticosteroids (ICS) and oral corticosteroids (OCS) after discharge in adults hospitalized for asthma exacerbations. ICS and OCS were equipped with electronic medication monitors and were provided at discharge. Adherence (use/prescribed use x 100%) was measured by self-report and canister weight (ICS), pill count (OCS), and electronic medication monitors (both ICS and OCS) 2 weeks after discharge. Poor adherence was defined as adherence of less than 50%. The Asthma Control Questionnaire was used to assess symptom control. Sixty patients were enrolled (age 42.2 years, 98.3% African American, 65.0% female, 46.7% with history of near-fatal asthma). Electronically measured adherence to both corticosteroids dropped to approximately 50% within 7 days of discharge. Poor adherence to both corticosteroids predicted significantly worse symptom control (p = 0.04). Self-report, canister weight, and pill count all had low sensitivity (29.2%, 65.0%, and 7.7%, respectively) for detecting poor adherence. We conclude that adherence to ICS and OCS deteriorates within days of hospital discharge but may not be recognized in a substantial proportion of patients.

Nebulized beta2-agonist use in high-risk inner-city adults with asthma.

Nebulizer use has been linked to worse asthma outcomes, but the precise reason(s) for this relationship is not known. We assessed the frequency of nebulized beta2-agonist use in high-risk inner-city adults with asthma and compared asthma self-management practices according to nebulizer use in this population. This was a cross-sectional study conducted over 6 weeks from July to August 2000. A convenience sample (N=50) was recruited from an inner-city emergency department (ED). Adults (age > or = 18 years) were eligible if they had a physician diagnosis of acute asthma exacerbation. Data regarding asthma symptoms, acute care utilization, use of nebulized beta2-agonist for symptom relief, and indicators of asthma self-management (physician for asthma care, use of controller medications, current cigarette smoking, and substance use) were collected by an interviewer-administered survey. Nebulized beta2-agonist use was reported by 54.0% of patients during the 30 days before their ED visit. Nebulizer users reported more severe asthma symptoms (96.3% vs. 73.9% with moderate or severe persistent asthma, p=0.02) than nonusers. Nebulizer users were more likely to have a physician for asthma care (85.2% vs. 56.5%, p=0.02), have more frequent care from their physicians in the past 12 months (e.g., >3 visits: 59.3% vs. 30.4%, p=0.02), and notify their physician during their asthma exacerbation (39.1% vs. 7.7%, p=0.04). Compared with nonusers, nebulizer users reported better care across other indicators of care, though differences between groups were not significant. After accounting for symptom severity, results were largely unchanged. If these findings are confirmed in other studies with larger numbers of patients, we conclude that the relationship between nebulizer use and higher asthma morbidity largely represents preferential use of nebulizers by patients with more symptomatic disease.