Rehab Aly Rayan

EBM Final Assignment

(64)

What is Inside… !!!

Examine

Clinical Question

Evidence

Summery

Conclusion ---To the Patient …

•Scenario

•Background… more

•PICO

•Pre-appraised

•Un-appraised

Evidence

•PubMed

•Trip-database

•SUMSearch

•Cochrane Library

•Up-to-Date

•Best-Practice

•Clinical-Evidence

•National Guideline Clearinghouse

•Essential-Evidence-Plus

•DynaMed

AppraisedMeta search

Engine

Un-appraised

Examine

Scenario

12-y girl/ED

12-hr troublesome cough /wheezing /increasing breathlessness

/unresponsive to inhaled albuterol

troublesome asthma since age 18 months

fluticasone/salmeterol via a pressurized metered-dose inhaler and

large-volume spacer, and an albuterol inhaler, needed/ properly

compliant with her preventive medication

More About the Case ...

•Acute Asthma Attack

Diagnosis

•Acute Severe Asthma

•Acute asthma Exacerbation

•Status Asthmaticus

Disease Synonyms •Disease Synonyms

•Fluticasone

•Child* Or pediatr* Or

Audolescen*

•Recurrence/Relapse

Key words/Search Terms

The clinical question

• In a 12-year-old girl presents to the emergency department with Acute Asthma Attack, Dose the use of the current Medication Regimen including Inhaled Fluticasone (375 µg/d) compared to other medications, will prevent attacks recurrence or relapse?

• PICO Therapy/Prevention

Patient12-year-old girl with Acute Asthma Exacerbation

InterventionCurrent treatment regimen including Inhaled Fluticasone (375µg/d)

ComparisonOther Medications

OutcomePrevent Recurrence/Relapse of Asthma Attacks

Evidence

•PubMed

•Trip-database

•SUMSearch

•Cochrane

Library•

Up-to-Date

•Best-Practice

•Clinical-Evidence

•National Guideline Clearinghouse

•Essential-Evidence-Plus

•DynaMed

AppraisedMeta search

Engine

Un-appraised

Evidence

•PubMed

•Trip-database

•SUMSearch

•Cochrane Library

•Up-to-Date

•Best-Practice

•Clinical-Evidence

•National Guideline Clearinghouse

•Essential-Evidence-Plus

•DynaMed Appraised

Meta search

Engine

Un-appraised

Evidence

•PubMed

•Trip-database

•SUMSearch

•Cochrane Library

•Up-to-Date

•Best-Practice

•Clinical-Evidence

•National Guideline Clearinghouse

•Essential-Evidence-Plus

•DynaMed

AppraisedMeta search

Engine

Un-appraised

Evidence

•PubMed

•Trip-database

•SUMSearch

•Cochrane Library

•Up-to-Date

•Best-Practice

•Clinical-Evidence

•National Guideline Clearinghouse

•Essential-Evidence-Plus

•DynaMed

AppraisedMeta search

Engine

Un-appraised

Evidence

•PubMed

•Trip-database

•SUMSearch

•National Guideline

Clearinghouse•

Essential-Evidence-Plus

•DynaMed

AppraisedMeta search

Engine

Un-appraised

Evidence

•PubMed

•Trip-database

•SUMSearch

•National Guideline

Clearinghouse

•Essential-Evidence-Plus

•DynaMed

AppraisedMeta search

Engine

Un-appraised

Evidence

•PubMed

•Trip-database

•SUMSearch

•National Guideline

Clearinghouse•

Essential-Evidence-Plus

•DynaMed

AppraisedMeta search

Engine

Un-appraised

Evidence

•PubMed

•Trip-database

•SUMSearch

•Cochrane Library

•Up-to-Date

•Best-Practice

•Clinical-Evidence

•National Guideline Clearinghouse

•Essential-Evidence-Plus

•DynaMed

AppraisedMeta search

Engine

Un-appraised

Evidence

•PubMed

•Trip-database

•SUMSearch

•Cochrane Library

•Up-to-Date

•Best-Practice

•Clinical-Evidence

•National Guideline Clearinghouse

•Essential-Evidence-Plus

•DynaMed

AppraisedMeta search

Engine

Un-appraised

Evidence

•PubMed

•Trip-database

•SUMSearch

•Cochrane Library

•Up-to-Date

•Best-Practice

•Clinical-Evidence

•National Guideline Clearinghouse

•Essential-Evidence-Plus

•DynaMed

AppraisedMeta search

Engine

Un-appraised

Summery• Inhaled bronchodilators and oral corticosteroids are

the first-line treatment for acute asthma. (7)

• Inhaled short-acting beta 2-agonists plus Systemic glucocorticoids added according to increased severity. (4)

• Doubling dose of inhaled steroid not recommended for home management of exacerbations. While high-dose inhaled, steroid or oral steroids may be effective. (12)

• A high-dose Inhaled Corticosteroids therapy alone may be of a similar effectiveness as oral corticosteroid therapy when used after Emergency Department discharge. (3, 7, 16, 17)

• Systematic corticosteroids may be better than high-dose inhaled corticosteroids in reducing relapse and preventing hospitalization in severe attacks. (2, 5, 6, 11, 13-16)

• Oral prednisone is more preferable over any other inhaled corticosteroid including fluticasone. (1)

To the Patient…

• The patient can continue the usual treatment with an increased dose (800 µg /day) of Inhaled Corticosteroids after Emergency Department discharge along with a prescribed short course of oral corticosteroids (3-10 d). (2, 3, 8-10)

Refrences• Schuh S , Reisman J , Alshehri M , Dupuis A , Corey M , Arseneault R ,

Alothman G , Tennis O and Canny G. A comparison of inhaled fluticasone and oral prednisone for children with severe acute asthma .The New England journal of medicine, 2000, 343(10), 689.

• National Guideline Clearinghouse 2012 Oct 22. Systemic corticosteroids for acute asthma in adults and adolescents. DynaMed [database on the Internet]. 2013 [cited 2013 Dec 27]. Available from: http://web.ebscohost.com/dynamed/detail?sid=e5ed58d4-1dcb-4a1c-9314-b0746cccae77%40sessionmgr113&vid=5&hid=120&bdata=JnNpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d#db=dme&AN=361024 .

• Edmonds ML, Milan SJ, Brenner BE, Camargo Jr CA, Rowe BH. Inhaled steroids for acute asthma following emergency department discharge. Cochrane Database of Systematic Reviews 2012, Issue 12. Art. No.: CD002316. DOI:10.1002/14651858.CD002316.pub2.

• Richard J Scarfone, Md, Faap. Acute asthma exacerbations in children: Outpatient management. Uptodate [database on the Internet]. 2013 [cited 2013 Dec 27]. Available from: http://www.uptodate.com.search.sti.sci.eg:2048/contents/acute-asthma-exacerbations-in-children-outpatient-management?source=search_result&search=acute+asthma+exacerbation+children&selectedTitle=2~150#H45 .

• Quon BS, FitzGerald JM, Lemiere C, et al. Increased versus stable doses of inhaled corticosteroids for exacerbations of chronic asthma in adults and children. Cochrane Database Syst Rev. 2010 ;( 10):CD007524.

Refrences• Bestpractice. Acute asthma exacerbation in children. BestPractice

[database on the Internet]. 2013 [cited 2013 Dec 27]. Available from: http://bestpractice.bmj.com/best-practice/monograph/1098/treatment/evidence.html .

• Augusta Okpapi, Amanda J Friend, and Stephen W Turner. Asthma and other recurrent wheezing disorders in children (acute). ClinicalEvidence [database on the Internet]. 2010 [cited 2013 Dec 27]. Available from: http://clinicalevidence.bmj.com/x/systematic-review/0300/key-points.html .

• Scottish Intercollegiate Guidelines Network (SIGN), British Thoracic Society. British guideline on the management of asthma. A national clinical guideline. Edinburgh (Scotland): Scottish Intercollegiate Guidelines Network (SIGN); 2011 May. 141 p. (SIGN publication; no. 101).

• Sveum R, Bergstrom J, Brottman G, Hanson M, Heiman M, Johns K, Malkiewicz J, Manney S, Moyer L, Myers C, Myers N, O’Brien M, Rethwill M, Schaefer K, Uden D. Diagnosis and management of asthma. Bloomington (MN): Institute for Clinical Systems Improvement (ICSI); 2012 Jul. 86 p.

• This guideline updates a previous version: Michigan Quality Improvement Consortium. Management of asthma  in youth 12 years and older and adults. Southfield (MI): Michigan Quality Improvement Consortium; 2010 Jul. 1 p.

• Deborah A. Humphrey, Do, Facp. Asthma (acute exacerbation). EssentialEvidencePlus [database on the Internet]. 2011 [cited 2013 Dec 27]. Available from: http://www.essentialevidenceplus.com/content/eee/662 .

• Cochrane Database Syst Rev 2012 Dec 12. Inhaled corticosteroids for acute asthma in children. DynaMed [database on the Internet]. 2013 [cited 2013 Dec 27]. Available from: http://web.ebscohost.com/dynamed/detail?sid=e5ed58d4-1dcb-4a1c-9314-b0746cccae77%40sessionmgr113&vid=4&expand=NHLBIgeneral&hid=120&bdata=JnNpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d#db=dme&AN=361098&anchor=NHLBIgeneral .

Refrences• British Thoracic Society and Scottish Intercollegiate Guidelines Network

(sign) National Clinical Guideline on Management of Asthma. Systemic corticosteroids for acute asthma in children. DynaMed [database on the Internet]. 2012 [cited 2013 Dec 27]. Available from: http://web.ebscohost.com/dynamed/detail?sid=e5ed58d4-1dcb-4a1c-9314-b0746cccae77%40sessionmgr113&vid=4&expand=NHLBI-Discharge&hid=120&bdata=JnNpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d#db=dme&AN=361064&anchor=Asthma-exacerbation-in-children-2-years-old .

• Obstet Gynecol 2013 Feb. Asthma exacerbation in adults and adolescents. DynaMed [database on the Internet]. 2013 [cited 2013 Dec 27]. Available from: http://web.ebscohost.com/dynamed/detail?vid=4&sid=e5ed58d4-1dcb-4a1c-9314-b0746cccae77%40sessionmgr113&hid=120&bdata=JnNpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d#db=dme&AN=114076 .

• Cochrane Database Syst Rev 2012 Dec 12. Inhaled corticosteroids for acute asthma in adults and adolescents. DynaMed [database on the Internet]. 2013 [cited 2013 Dec 27]. Available from: http://web.ebscohost.com/dynamed/detail?vid=4&sid=e5ed58d4-1dcb-4a1c-9314 b0746cccae77%40sessionmgr113&hid=120&bdata=JnNpdGU9ZHluYW1lZC1saXZlJnNjb3BlPXNpdGU%3d#db=dme&AN=361022 .

• DUNCAN KEELEY, MICHAEL MCKEAN. Asthma and Other Wheezing Disorders in Children. Am Fam Physician. 2006 Dec 1; 74(11):1901-1905.

• Marcia L. Edmonds, Md, Msc; Carlos A. Camargo, Jr., Md, Drph, Fccp; Barry E. Brenner, Md, Phd, Fccp; Brian H. Rowe, Md, Msc. Replacement of Oral Corticosteroids With Inhaled Corticosteroids in the Treatment of Acute Asthma Following Emergency Department Discharge*: A Meta-analysis. Chest. 2002; 121(6):1798-1805. doi:10.1378/chest.121.6.1798 [homepage on the Internet].[cited 2013 Dec 27]. Available from: http://journal.publications.chestnet.org/article.aspx?articleid=1080705 .