The Cochrane Abstract below is a su...

The Cochrane Abstract below is a summary of a review from the Cochrane Library. It is accompanied by means of an interpretation that will help clinicians deposit evidence into practice. John Epling, MD and Min Ho Chang not past nor future a clinical scenario and question based onward the Cochrane Abstract, along with the evidence-based answer and a satiated critique of the abstract.

Clinical Scenario

A 15-year-old lad with an acute asthma exacerbation is brought to the turn of events department.

Clinical Question

Is a metered-dose inhaler (MDI) with a holding chamber more effective than a nebulizer for delivering [beta.sub.2] agonists to treat acute asthma exacerbations?

Evidence-Based Answer

In the juncture room, MDIs with holding chambers are as effective as nebulizers for delivering [beta.sub.2] agonists to treat acute asthma in adults and children older than age brace There might be slightly les [beta.sub.2] agonist-induced tachycardia in children when MDIs with holding chambers are used.

Cochrane Critique

Did the authors address a focused clinical question? Yes

Were the criteria used to excellent articles for inclusion appropriate? Ye However, solitary one community-based study was found; the peace were emergency-department studies.

Is it likely that important relevant articles were missed? No. Funnel-plot testing did not reveal any publication bias.

Was the validity of the individual articles appraised? Yes

Were the assessments of studies reproducible? Ye The kappa values for the Jadad quality-rating questions ranged from 08 to 10 (strong agreement), with the exception of the "method of blinding" question, which had a kappa value of 05 (moderate agreement).

Were the ensues similar from study to study? Ye However, studies of adults and children were separated for the analysis to improve homogeneity.

by what means precise were the results? All deductions fell within reasonably narrow confidence intervals.

Can the springs be applied to patient care? Yes

Do the conclusions make biologic and clinical sense? Yes

Are the benefits worth the harms and cost? Probably, if it were not that a formal cost analysis is needed

Practice Pointers

In 1999 more than 10 million persons reported an asthma episode that occurr during the previous year, almost 2 million race visited an emergency department for an asthma episode, and almost 478000 patients were hospitalized. (3) take away froms of treatment and indirect tenors are estimated to total $127 billion annually. (4) Standard therapy for acute asthma includes [beta.sub.2] agonists, oxygen and corticosteroid therapy.

Nebulization generally has been the preferr orderly disposition of [beta.sub.2]-agonist delivery because of its ease of use, yet since the introduction of holding chambers, this practice has been re-evaluated. MDIs with holding chambers generally are a less-expensive arrangement of [beta.sub.2]-agonist delivery in pinch departments and are certainly les expensive in outpatient settings, where air-compressor machinery is urgencyed for nebulization. The National Heart, Lung and relations Institute guidelines on asthma diagnosis and management state that MDIs with holding chambers can effect bronchodilation equivalent to that achieved with nebulizers. However, they note that the effectiveness can be limited by dint of the patient's age and agitation flush and by the severity of the exacerbation. In addition, more research is necessary to determine whether MDIs with holding chambers occasion similar results in outpatient settings where there is not a respiratory therapist to supervise the administration of the medication.

This review point out tos that in adult patients who used nebulizers or MDIs with holding chambers, there were no significant differences in hospital admission rate, peak follow or forced expiratory volume. The findings in children were similar to those in adults. In children, MDIs with holding chambers have the added advantages of decreasing the time worn out in the emergency department and limiting the [beta.sub.2] agonist-induced rise in pulsation rate. The data in this review are from studies of patients who were treated in hospital difficulty departments and who were not in imminent respiratory failure; individual study done in a community setting was of poor quality and was not used in the analysis.

MDIs with holding chambers are an effective alternative to nebulizers for treating asthma exacerbations in exigency departments when respiratory failure is not imminent. Further formal cost-effectiveness analysis, taking into account equipment take away froms and infection-control issues, is necessary to determine whether MDIs with holding chambers should be routinely recommended

REFERENCES

(1) Cates CJ Rowe B Bara A. Holding chambers versus nebulizers for beta-agonist treatment of acute asthma (Cochrane Review). Cochrane Database Syst Rev 2002;2:CD000052

(2) Statistical rules available in Review Manager and CDSR In: Cochrane reviewers' handbook 415 Accessed November 2002 from www.cochrane.org/software/Documentation/Handbook/ handbook.pdf.