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#260 Are there tools to help assess dyspnea virtually?


CLINICAL QUESTION
QUESTION CLINIQUE
Are there any techniques (like the Roth Score) to augment a typical history when assessing dyspnea/pneumonia over the phone or by video?


BOTTOM LINE
RÉSULTAT FINAL
Unfortunately, no specific technique, including the Roth Score, is reliable in assuring dyspneic patients are not at risk and safe to stay home. Furthermore, no studies have evaluated dyspnea assessment in COVID-19 patients. Clinicians are encouraged to use available tools (https://www.bmj.com/content/368/bmj.m1182/infographic) and have patients assessed in-person if there are any concerns.   



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EVIDENCE
DONNÉES PROBANTES
1) Roth Score for virtual (phone/videoassessment of dyspnea.1 Patients count upward from “1” as quickly as possible after a single deep breath. Can repeat after 3 deep breaths. Measure highest number attained and time (seconds) to highest numberOnly one study: 
  • 103 healthy people (mean age 56)In one breath: 
    • 100% counted to 15.   
    • 94% counted to 20.
  • 93 patients with dyspnea (mean age 76) admitted to internal medicine or cardiac intensive care (conditions like heart failure and pneumonia). Roth Score compared to pulse oximetry on room air:    
    • Area-under-the-curve (assesses overall test utility):  
      • Predicted <95% O2 pulse oximetry: 0.83 (pretty good). 
      • Predicting <90% O2 pulse oximetry: 0.84 (pretty good). 
    • Sensitivity and specificity appear to be presented incorrectly. It is impossible to determine predictive cut-offs for helping make or exclude diagnosis. 
      • [We emailed the authors twice without response.]    
2) Clinical features of pneumonia: Systematic review of 13 diagnostic studies (outpatient or emergency departments) with 11,144 patients:2  
  • Small-moderate help making the diagnosis of pneumonia (Likelihood Ratio ~3.5): 
    • Respiratory rate 20/minute or fever ≥38°C.  
  • No individual clinical features helpful in excluding pneumonia. 
3) Patient self-rating of dyspnea on numerical rating scale (0-10, higher=worse).   
  • 253 emergency patients (mean age 61) with complaint of dyspnea.3 
    • Correlated quite well with respiratory rate (r=0.77) and okay with oxygen saturation (r=0.43). 
  • In 188 chronic COPD patientsdid not correlate with oxygen saturation.4 
Context: 
  • Dyspnea encompasses more than oxygen saturation and has no gold standard for assessment.5 
  • None of these studies assessed patients with COVID-19 which may have distinct clinical characteristics.  
  • BMJ provides a helpful resource for assessment of COVID-19 patients virtually [https://www.bmj.com/content/368/bmj.m1182/infographic].6   


Gilbert Bretecher June 15, 2023

difficult to assess severity of dyspnea without physical exam


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Author(s)
Auteur(s)
  • G. Michael Allan MD CCFP
  • James McCormack BSc(Pharm) PharmD

1. Chorin E, Padegimas A, Havakuk O, et al. Clin Cardiol. 2016;39:636-9.

2. Htun TP, Sun Y, Chua HL, Pang J. Sci Rep. 2019;9(1):7600.

3. Saracino A, Weiland T, Dent A, et al. Emerg Med Australas. 2008; 20:475–81.

4. Gift AG, Narsavage G. Am J Crit Care. 1998;7:200-4.

5. Bausewein C, Booth S, Higginson IJ. Curr Opin Support Palliat Care. 2008;2:95-9.

6. Greenhalgh T, Koh GCH, Car J. BMJ. 2020 Mar 25;368:m1182. doi: 10.1136/bmj.m1182. https://www.bmj.com/content/368/bmj.m1182

Authors do not have any conflicts of interest to declare.

Les auteurs n’ont aucun conflit d’intérêts à déclarer.