Plymouth Health Community NICE Guidance Implementation Group Asthma inhalers for routine treatment...
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Transcript of Plymouth Health Community NICE Guidance Implementation Group Asthma inhalers for routine treatment...
Plymouth Health CommunityNICE Guidance Implementation Group
Asthma inhalers for routine treatment of chronic asthma in older children (aged 5 - 15 years)
Miss Faye DorisUniversity of Plymouth
The National Institute of Clinical ExcellenceClinical Guidelines
View arrived at after careful consideration of the available evidence
Health professionals are expected to consider these when making a clinical judgement
The National Institute of Clinical ExcellenceClinical Guidelines
do not ‘override the individual responsibility of health professionals, to make appropriate decisions in the circumstances of the individual patient, in consultation with the patient and or their guardian or carer’.
Previous Guidance: management of asthma in adults and children
British Thoracic Society (BTS) guideline issued in 1997 was the most commonly used in the UK
Not explicitly evidenced based
largely considered the management of asthma in adults and older children
Previous Guidance: British Thoracic Society Guidance Contd.
Principles for selection of devices stated
Recommendations about specific devices not made
The Appraisal Process
Examination of the evidence on the clinical effectiveness and cost effectiveness of inhaler devices
Stakeholder consultations
The Appraisal Process: Systematic Reviews
A review of research-based evidence on a topic in which the evidence has been systematically identified, appraised and summarised according to pre determined criteria.
Randomised Controlled Trials
A trial in which subjects are randomly assigned to either a group receiving an intervention that is being tested or control group receiving an alternative or no intervention. The results compare the results of different groups.
Clinical effectiveness: Systematic Review
The specificity of device and drug effect meant one drug in one device could not be compared to other drugs
Limited evidence found in relation to quantity and quality
Clinical effectiveness: Systematic Review
Studies claiming to demonstrate equivalence were unable to do so and some studies used inappropriate dose comparators
Available evidence therefore limited and poor
Delivery of bronchodilators- the evidence
23 studies examined Some used inappropriate
dosing schedules, which may have biased their findings
Some included a high proportion of adults
Some were small or included few children
Delivery of anti-flammatory drugs- the evidence
A number of studies were examined
The quality of the studies was variable either in relation to number of children or the use of the design
Well designed studies did not report on differences in effectiveness between devices
CFC- free devices - the evidence
No evidence of difference in CFC containing or CFC free devices
Although some reports of higher deposition of cortico steroids in HFA inhalers
Other influences on effectiveness
31 studies on ease of use, preference or compliance
quality generally poor, small numbers, some included adults
Only 11 were RCTs
Other influences on effectiveness: Key finding
Good individual (verbal) instruction was the key to good inhaler technique
Two studies found that above age 5 or 6 years this was so regardless of device
Cost effectiveness
No robust cost effectiveness or utility studies examining the use of inhalers in children aged 5 - 15 years were identified in the systematic review
Consideration and Conclusions
‘The available evidence failed to distinguish adequately between devices to suggest advantage in clinical effectiveness for one single delivery system’
Consideration and Conclusions
Limited evidence supports the use of press and breathe pMDIs with large volume spacers compared to press and breathe devices alone in the delivery of bronchodilators.
Consideration and Conclusions
Economic analysis suggests that no device should be excluded on grounds of cost effectiveness
Further research and implementation
In view of the lack of robust evidence the need for further good quality research is identified
Good practice guidance is however provided to enable use of the limited evidence available.