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.

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.

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.

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.

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.

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.

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.

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.

[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.

[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.

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.

Interobserver variability in the radiographic diagnosis of adult outpatient pneumonia.

Acute chest radiographs were obtained from 319 adult patients with acute respiratory infections. Where a lower respiratory infection was diagnosed, follow-up chest radiographs were obtained in most patients. A radiologic panel diagnosed pneumonia in 21 patients. The agreements between the panel and 3 independent interpreters, 2 residents in radiology, and one senior chest physician, were assessed. Also the reports given by the specialist in radiology at the Department of Radiology were compared with the panel's evaluation. While the kappa-agreements between the panel's interpretations and those by the Department of Radiology and the consultant in chest medicine was 0.71 and 0.72, respectively, the corresponding kappa-values between the residents and the panel was only 0.50. The proportion of agreement when pneumonia was diagnosed was 0.56 between the panel and the Department of Radiology, and 0.59 between the panel and the chest consultant, compared to 0.36 between the panel and the residents. The study demonstrates the difficulty of diagnosing outpatient pneumonia and the importance of experience.

[A personal physician, wishes and realities in Northern Norway. A patient study in Northern Norway in 1987]. / Fast lege, ønsker og realiteter i Nord-Norge. Pasientundersøkelsen i Nord-Norge 1987.

Among patients consulting general practitioners in northern Norway, 57% had a stable relationship with one doctor, according to answers to a questionnaire. Rather than having a free choice between several doctors, 85% preferred to have a personal doctor. About half the patients wanted the same doctor for the whole family. Even if they had to wait longer for the consultation, 63% would prefer to meet their own doctor. A personal doctor was much less common in northern Norway than in the rest of the country, which could be put down to lower stability in the practices.

[C-reactive protein, SR and white blood cell count in acute lower respiratory tract diseases. The usefulness of blood tests in diagnosis of pneumonia]. / C-reaktivt protein, SR og hvite blodlegemer ved akutte nedre luftveislidelser. Nytten av blodprøver i diagnostisering av pneumoni.

C-reactive protein (CRP) analysis, erythrocyte sedimentation rate and white blood cell count were evaluated as tests in the diagnosis of pneumonia in 84 patients with acute lower respiratory disease. Marked elevated values of CRP were frequently found in pneumonia patients, whereas in most patients with acute asthma, acute exacerbation of chronic obstructive bronchitis and acute bronchitis the values were within the normal range. The combined sensitivities and specificities of the tests were best for CRP, followed by erythrocyte sedimentation rate and white blood cell count.

Does near-to-patient testing contribute to the diagnosis of streptococcal pharyngitis in adults?

OBJECTIVE: To asses the efficacy of near-to-patient laboratory testing in diagnosing group A beta haemolytic streptococci throat infection in adults, alone and in conjunction with the doctor's clinical judgement. SETTING AND SUBJECTS: 174 primary care patients with a sore throat, of which 59 (34%) were identified as having group A streptococci. MAIN OUTCOME MEASURES: The erythrocyte sedimentation rate, leucocyte count, and C-reactive protein, and a specific streptococcal immunological assay were evaluated separately and in conjunction with the doctor's clinical diagnosis. The presence of GAS throat infection, the reference standard, was defined as those patients presenting with a chief complaint of sore throat and having a positive GAS culture or a four-fold or more increase or fall of AST or ADNase B serum levels during a four-week observation period. RESULTS: The discriminatory ability of the sedimentation rate was not satisfactory and added little useful clinical information. Leucocytes and C-reactive protein both yielded clinically significant information and had similar test characteristics. The immunological test had the best characteristics of the tests evaluated. CONCLUSION: Near-to-patient testing, except the erythrocyte sedimentation rate, may, in addition to the clinical evaluation, contribute to the differential diagnosis of streptococcal pharyngitis in adults.

The spectrum of patients strongly influences the usefulness of diagnostic tests for pneumonia.

OBJECTIVE: To study the influence of the spectrum of patients on the usefulness of five clinical cues, "very annoying dyspnoea", "strong lateral chest pain", crackles, C-reactive protein analysis, and erythrocyte sedimentation rate in the diagnosis of pneumonia. DESIGN: Evaluating the diagnostic properties of the cues against radiographic pneumonia at four steps in the diagnostic process, associated with increasing prevalence of pneumonia: 1. in all the 581 patients included, 2. in 402 of these patients who underwent physical chest examination, 3. in 188 patients classified by the doctors as having a lower respiratory tract infection, and 4. in 79 patients referred for radiography by the doctors. SETTING: The municipal emergency clinic in Tromsø, Norway. PARTICIPANTS: 581 adult patients with respiratory tract infection. OUTCOME MEASURES: Sensitivity, specificity, Likelihood Ratio, and Positive predictive value. RESULTS: A tendency of decreasing specificity and Likelihood Ratio with increasing prevalence of pneumonia was demonstrated for all test, except for C-reactive protein analysis. This tendency may be explained either by the emphasis laid on the tests by the doctors when selecting patients for the diagnostic steps, or by an association between the evaluated tests and those emphasized by the doctors. CONCLUSION: As the diagnostic value of symptoms and signs are strongly influenced by selection, caution should be shown when transferring diagnostic values from one clinical setting to another.

Laboratory tests for pneumonia in general practice: the diagnostic values depend on the duration of illness.

The usefulness in the diagnosis of pneumonia of temperature and the laboratory tests: erythrocyte sedimentation rate (ESR), leucocyte count, and C-reactive protein (CRP) was evaluated against a radiographic reference standard in 402 adult patients with respiratory tract infection in general practice. Radiographic pneumonia was diagnosed in 20 patients. CRP and ESR were the most useful tests. CRP greater than 50 mg/l had lower sensitivity and likelihood ratio (LR), 0.50 and 4.8, respectively, compared with previous studies of selected patient populations. Among patients whose duration of illness exceeded six days the corresponding LR was 11.3, due to a higher specificity in this subgroup of patients. ESR and oral temperature were also more useful in this subgroup than in patients with a shorter duration of illness. A highly significant diagnostic contribution of adding ESR and CRP to history and physical examination, particularly when the illness had lasted one week or more, was demonstrated by logistic regression.

[Relation between erythrocyte sedimentation and C-reactive protein in serum of adults with lower respiratory tract infections. Significance of microbiological agents]. / Sammenheng mellom senkningsreaksjonen og C-reaktivt protein i serum hos voksne med nedre luftveisinfeksjon. Betydning av mikrobiologisk agens.

Correlation between erythrocyte sedimentation rate and C-reactive protein was determined in 239 adult patients in general practice who were suspected of having an infection of the lower respiratory tract. A correlation coefficient of 0.62 (95% CI 0.54-0.69) was found, but there was no association between the results of the two tests when the illness had lasted less than four days. With such a short duration of illness a test for C-reactive protein is to be preferred before erythrocyte sedimentation rate when evaluating lower respiratory tract infections.

["Hello, doctor's office? May I talk to the doctor?" An analysis of telephone accessibility in offices of general practitioners. A survey of patients in northern Norway 1987]. / "Hallo, er det legekontoret--kan jeg få snakke med legen?" En analyse av telefontilgjengelighet ved allmennpraktikerkontorer. Pasientundersøkelsen i Nord-Norge 1987.

In a survey among 3,739 patients belonging to 36 general practices in northern Norway, 33% reported difficult access to their local surgery by telephone. 43% reported difficulty in obtaining access to the doctor once they had obtained contact with the reception. The proportion of patients reporting problems of accessibility by telephone varied greatly, from 5 to 75%. Patients belonging to practices located in towns, with long waiting lists and many doctors, were most dissatisfied with the telephone service. Stable doctor/patient-relationships made direct contact with the doctor easier, while a scheduled time when patients could call the office made direct contact more difficult. We discuss ways to improve accessibility by telephone.