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Doğan NÖ, Varol Y, Köktürk N, Aksay E, Alpaydın AÖ, Çorbacıoğlu ŞK, Aksel G, Baha A, Akoğlu H, Karahan S, Şen E, Ergan B, Bayram B, Yılmaz S, Gürgün A, Polatlı M. 2021 Guideline for the Management of COPD Exacerbations: Emergency Medicine Association of Turkey (EMAT) / Turkish Thoracic Society (TTS) Clinical Practice Guideline Task Force. Turk J Emerg Med 2021; 21:137-176. [PMID: 34849428 PMCID: PMC8593424 DOI: 10.4103/2452-2473.329630] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Revised: 10/08/2021] [Accepted: 10/09/2021] [Indexed: 01/18/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is an important public health problem that manifests with exacerbations and causes serious mortality and morbidity in both developed and developing countries. COPD exacerbations usually present to emergency departments, where these patients are diagnosed and treated. Therefore, the Emergency Medicine Association of Turkey and the Turkish Thoracic Society jointly wanted to implement a guideline that evaluates the management of COPD exacerbations according to the current literature and provides evidence-based recommendations. In the management of COPD exacerbations, we aim to support the decision-making process of clinicians dealing with these patients in the emergency setting.
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Affiliation(s)
- Nurettin Özgür Doğan
- Department of Emergency Medicine, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Yelda Varol
- Department of Pulmonology, Dr. Suat Seren Chest Diseases and Chest Surgery Training and Research Hospital, University of Health Sciences, İzmir, Turkey
| | - Nurdan Köktürk
- Department of Pulmonology, Faculty of Medicine, Gazi University, Ankara, Turkey
| | - Ersin Aksay
- Department of Emergency Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Aylin Özgen Alpaydın
- Department of Pulmonology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Şeref Kerem Çorbacıoğlu
- Department of Emergency Medicine, Keçiören Training and Research Hospital, University of Health Sciences, Ankara, Turkey
| | - Gökhan Aksel
- Department of Emergency Medicine, Ümraniye Training and Research Hospital, University of Health Sciences, İstanbul, Turkey
| | - Ayşe Baha
- Department of Pulmonology, Near East University, Nicosia, TRNC
| | - Haldun Akoğlu
- Department of Emergency Medicine, Faculty of Medicine, Marmara University, İstanbul, Turkey
| | - Sevilay Karahan
- Department of Biostatistics, Faculty of Medicine, Hacettepe University, Ankara, Turkey
| | - Elif Şen
- Department of Pulmonology, Faculty of Medicine, Ankara University, Ankara, Turkey
| | - Begüm Ergan
- Department of Pulmonology, Faculty of Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Başak Bayram
- Department of Emergency Medicine, Dokuz Eylül University, İzmir, Turkey
| | - Serkan Yılmaz
- Department of Emergency Medicine, Faculty of Medicine, Kocaeli University, Kocaeli, Turkey
| | - Alev Gürgün
- Department of Pulmonology, Faculty of Medicine, Ege University, İzmir, Turkey
| | - Mehmet Polatlı
- Department of Pulmonology, Faculty of Medicine, Aydın Adnan Menderes University, Aydın, Turkey
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Cheetham AL, Navanandan N, Leonard J, Spaur K, Markowitz G, Adelgais KM. Impact of prehospital pediatric asthma management protocol adherence on clinical outcomes. J Asthma 2021; 59:937-945. [PMID: 33504232 DOI: 10.1080/02770903.2021.1881969] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
OBJECTIVE To evaluate the frequency of EMS protocol non-adherence during pediatric asthma encounters and its association with emergency department (ED) length of stay (LOS) and hospital admission. METHODS This is a retrospective review of asthma encounters aged 2-17 years transported by EMS to a pediatric ED from 2012 to 2017. Our primary outcome was hospital admission based on prehospital protocol adherence defined as: (1) bronchodilator administration, (2) treatment of hypoxia with oxygen, or (3) administration of intramuscular (IM) epinephrine in encounters with high severity of distress. Multivariable logistic regression estimated the association between protocol non-adherence and hospital admission. RESULTS During the study period, 290 EMS encounters met inclusion criteria. Median age was 9 years (IQR 5-12), 63% were male, 40% had moderate to severe exacerbations, and 24% were admitted. Protocol non-adherence occurred in 32% of encounters with failure to administer bronchodilators in 27% and failure to administer IM epinephrine when indicated in 83%. Prehospital steroids were administered in 8% of encounters. After adjusting for covariates, protocol non-adherence was not statistically associated with likelihood of inpatient admission (OR 1.3; 95% CI: 0.6-2.6). CONCLUSIONS Among prehospital pediatric asthma encounters, EMS protocol non-adherence is common but not associated with a higher frequency of hospital admission. Hospital admission was associated with acute exacerbation severity suggesting further research is needed to develop a valid prehospital asthma severity assessment scoring tool. Supplemental data for this article can be accessed at publisher's website.
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Affiliation(s)
- Alexandra L Cheetham
- Pediatric Residency Program, University of Colorado School of Medicine, Aurora, CO, USA
| | - Nidhya Navanandan
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Jan Leonard
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
| | - Kelsey Spaur
- University of Colorado School of Medicine, Aurora, CO, USA
| | | | - Kathleen M Adelgais
- Section of Pediatric Emergency Medicine, Department of Pediatrics, University of Colorado School of Medicine, Aurora, CO, USA
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Hodroge SS, Glenn M, Breyre A, Lee B, Aldridge NR, Sporer KA, Koenig KL, Gausche-Hill M, Salvucci AA, Rudnick EM, Brown JF, Gilbert GH. Adult Patients with Respiratory Distress: Current Evidence-based Recommendations for Prehospital Care. West J Emerg Med 2020; 21:849-857. [PMID: 32726255 PMCID: PMC7390576 DOI: 10.5811/westjem.2020.2.43896] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2019] [Accepted: 02/21/2020] [Indexed: 01/18/2023] Open
Abstract
INTRODUCTION We developed evidence-based recommendations for prehospital evaluation and treatment of adult patients with respiratory distress. These recommendations are compared with current protocols used by the 33 local emergency medical services agencies (LEMSA) in California. METHODS We performed a review of the evidence in the prehospital treatment of adult patients with respiratory distress. The quality of evidence was rated and used to form guidelines. We then compared the respiratory distress protocols of each of the 33 LEMSAs for consistency with these recommendations. RESULTS PICO (population/problem, intervention, control group, outcome) questions investigated were treatment with oxygen, albuterol, ipratropium, steroids, nitroglycerin, furosemide, and non-invasive ventilation. Literature review revealed that oxygen titration to no more than 94-96% for most acutely ill medical patients and to 88-92% in patients with acute chronic obstructive pulmonary disease (COPD) exacerbation is associated with decreased mortality. In patients with bronchospastic disease, the data shows improved symptoms and peak flow rates after the administration of albuterol. There is limited data regarding prehospital use of ipratropium, and the benefit is less clear. The literature supports the use of systemic steroids in those with asthma and COPD to improve symptoms and decrease hospital admissions. There is weak evidence to support the use of nitrates in critically ill, hypertensive patients with acute pulmonary edema (APE) and moderate evidence that furosemide may be harmful if administered prehospital to patients with suspected APE. Non-invasive positive pressure ventilation (NIPPV) is shown in the literature to be safe and effective in the treatment of respiratory distress due to acute pulmonary edema, bronchospasm, and other conditions. It decreases both mortality and the need for intubation. Albuterol, nitroglycerin, and NIPPV were found in the protocols of every LEMSA. Ipratropium, furosemide, and oxygen titration were found in a proportion of the protocols, and steroids were not prescribed in any LEMSA protocol. CONCLUSION Prehospital treatment of adult patients with respiratory distress varies widely across California. We present evidence-based recommendations for the prehospital treatment of undifferentiated adult patients with respiratory distress that will assist with standardizing management and may be useful for EMS medical directors when creating and revising protocols.
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Affiliation(s)
- Sammy S Hodroge
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Melody Glenn
- University of Arizona, Department of Emergency Medicine, Tucson, Arizona
| | - Amelia Breyre
- Alameda Health System, Highland Hospital, Department of Emergency Medicine, Oakland, California
| | - Bennett Lee
- Hawaii Emergency Physicians Associated, Kailua, Hawaii
| | - Nick R Aldridge
- Kaiser Permanente San Diego, Department of Emergency Medicine, San Diego, California
| | - Karl A Sporer
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Kristi L Koenig
- County of San Diego Health & Human Services Agency, EMS, University of California, Irvine, Department of Emergency Medicine, Orange, California
| | - Marianne Gausche-Hill
- Harbor-UCLA Medical Center, Department of Emergency Medicine, Los Angeles County EMS Agency, Santa Fe Springs, California
| | | | | | - John F Brown
- University of California, San Francisco, Department of Emergency Medicine, San Francisco, California
| | - Gregory H Gilbert
- Stanford University, Department of Emergency Medicine, Palo Alto, California
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Travers AH, Milan SJ, Jones AP, Camargo CA, Rowe BH. Addition of intravenous beta(2)-agonists to inhaled beta(2)-agonists for acute asthma. Cochrane Database Syst Rev 2012; 12:CD010179. [PMID: 23235685 PMCID: PMC11289706 DOI: 10.1002/14651858.cd010179] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Inhaled beta-agonist therapy is central to the management of acute asthma. This review evaluates the benefit of an additional use of intravenous beta(2)-agonist agents. OBJECTIVES To determine the benefit of adding intravenous (IV) beta(2)-agonists to inhaled beta(2)-agonist therapy for acute asthma treated in the emergency department. SEARCH METHODS Randomised controlled trials (RCTs) were identified using the Cochrane Airways Group Register which is a compilation of systematic searches of MEDLINE, EMBASE, CINAHL, and CENTRAL as well as handsearching of 20 respiratory journals. Bibliographies from included studies and known reviews were also searched. Primary authors and content experts were contacted to identify eligible studies. The search was performed in September 2012. SELECTION CRITERIA Only RCTs were considered for inclusion. Studies were included if patients presented to the emergency department with acute asthma and were treated with IV beta(2)-agonists with inhaled beta(2)-agonist therapy and existing standard treatments versus inhaled beta(2)-agonists and existing standard treatments. DATA COLLECTION AND ANALYSIS Two review authors independently extracted data and confirmed their findings with corresponding authors of trials. We obtained missing data from authors or calculated from data present in the papers. We used fixed-effect model for odds ratios (OR) and for mean differences (MD) we used both fixed-effect and random-effects models and reported 95% confidence intervals (CI). MAIN RESULTS From 109 potentially relevant studies only three (104 patients) met our inclusion criteria: Bogie 2007 (46 children), Browne 1997 (29 children) and Nowak 2010 (29 adults). Bogie 2007 investigated the addition of intravenous terbutaline to high dose nebulised albuterol in children with acute severe asthma, requiring intensive care unit (ICU) admission. Browne 1997 investigated the benefit of adding intravenous salbutamol to inhaled salbutamol in children with acute severe asthma in the emergency department. Nowak 2010 investigated addition of IV bedoradrine to standard care (nebulised albuterol, ipratropium and oral corticosteroids) among adults, and was reported as a conference abstract only.There was no significant advantage (OR 0.29; 95%CI 0.06 to 1.38, one trial, 29 adults) for adding IV bedoradrine to standard care (nebulised albuterol, ipratropium and oral corticosteroids) with regard to hospitalisation rates.Various outcome indicators for the length of stay were reported among the trials. Browne 1997 reported a significantly shorter recovery time (in terms of cessation of 30 minute salbutamol) for children in the IV salbutamol with inhaled salbutamol group (four hours) versus the 11.1 hours for the inhaled salbutamol group (P = 0.03). Time to cessation of hourly nebuliser was also significantly shorter (P = 0.02) for the IV plus inhaled salbutamol group (11.5 hours versus 21.2 hours), and they were ready for emergency patient discharge on average 9.7 hours earlier than the inhaled salbutamol group (P < 0.05). In a paediatric ICU study Bogie 2007 reported no significant advantage in length of paediatric ICU admission (hours) for adding IV terbutaline to nebulised albuterol (MD -12.95, 95% CI: -38.74, 12.84).Browne 1997 reported there were only six out of 14 children with a pulmonary index score above six in the IV plus inhaled salbutamol group at two hours compared with 14 of the 15 in the inhaled salbutamol group (P = 0.02)In Browne 1997 there was a higher proportion of tremor in the IV plus inhaled salbutamol group than in the inhaled salbutamol group (P < 0.02). Nowak 2010 did not report any statistically significant adverse effects associated with adding IV bedoradrine to standard care (nebulised albuterol, ipratropium and oral corticosteroids). Troponin levels were elevated in three children in the IV terbutaline + nebulised albuterol group at 12 and 24 hours in Bogie 2007 AUTHORS' CONCLUSIONS There is very limited evidence from one study (Browne 1997) to support the use of IV beta(2)-agonists in children with severe acute asthma with respect to shorter recovery time, and similarly there is limited evidence (again from one study Browne 1997) suggesting benefit with regard to pulmonary index scores; however this advantage needs to be considered carefully in relation to the increased side effects associated with IV beta(2)-agonists. We identified no significant benefits for adults with severe acute asthma. Until more, adequately powered, high quality clinical trials in this area are conducted it is not possible to form a robust evaluation of the addition of IV beta(2)-agonists in children or adults with severe acute asthma.
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Affiliation(s)
- Andrew H Travers
- Department of Emergency Medicine and Community Health and Epidemiology, Emergency Health Services, Nova Scotia, Canada.
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Brulotte CA, Lang ES. Acute exacerbations of chronic obstructive pulmonary disease in the emergency department. Emerg Med Clin North Am 2012; 30:223-47, vii. [PMID: 22487106 DOI: 10.1016/j.emc.2011.10.005] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Chronic obstructive pulmonary disease (COPD) is a significant cause of morbidity and mortality worldwide. Acute exacerbations of COPD (AECOPDs) are a common presentation to emergency departments and are an important cause of respiratory failure. This article discusses the disease process and diagnosis of COPD and AECOPD. A further in-depth discussion is undertaken of evidence-based treatments, palliation, and disposition of patients who present to emergency departments with AECOPD.
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Affiliation(s)
- Cory A Brulotte
- Department of Emergency Medicine, Alberta Health Services: Calgary Zone, Foothills Medical Center, 1403 29th Street Northwest, Room C231, Calgary, Alberta, Canada T2N 2T9.
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Abstract
BACKGROUND After the safety issues raised by the Salmeterol Multicenter Asthma Research Trial, concerns persist about the safety of agents that cause prolonged β-adrenoceptor stimulation in asthmatic patients. We therefore decided to revisit and review the use of continuous subcutaneous infusions of terbutaline (CSIT)-a treatment often reserved for those with severe and refractory disease. RESULTS Original studies from the 1980s included 26 patients and showed that CSIT was well tolerated with predominately cutaneous side effects despite maintaining very high serum levels of terbutaline. CSIT led to improved outcomes in approximately 75% of patients which included rises in lowest daily peak expiratory flow rate (PEFR), diminution in diurnal variation, reduction in other medication requirements, and subjective opinion of symptoms. Almost all patients demonstrating an improvement had a wide variation in their pretreatment PEFRs. However, in a retrospective follow-up of 42 patients, the only outcome to be significantly improved by CSIT was that of mean hospital admissions (p = .031). CSIT is theorized to stimulate a discrete set of β-receptors not accessible by the inhaled route as further increases in Forced expiratory volume in one second (FEV(1)) occur with concurrent nebulized therapy. CONCLUSION Although some findings are encouraging, they are drawn from small observational studies done at a time when the standard management of asthma was quite different from today. No randomized controlled trials exist for the use of CSIT, which remains off-license for the treatment of asthma in the United Kingdom. Clearly, prospective well-powered studies are required to fully ascertain its potential benefits and safety profile-something that is unlikely to occur given that the use of CSIT remains low and appears to be declining.
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Affiliation(s)
- Gareth H Jones
- Respiratory Department, Countess of Chester Hospital, Chester, UK.
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O’Donnell DE, Aaron S, Bourbeau J, Hernandez P, Marciniuk DD, Balter M, Ford G, Gervais A, Goldstein R, Hodder R, Kaplan A, Keenan S, Lacasse Y, Maltais F, Road J, Rocker G, Sin D, Sinuff T, Voduc N. Canadian Thoracic Society recommendations for management of chronic obstructive pulmonary disease - 2007 update. Can Respir J 2007; 14 Suppl B:5B-32B. [PMID: 17885691 PMCID: PMC2806792 DOI: 10.1155/2007/830570] [Citation(s) in RCA: 273] [Impact Index Per Article: 16.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Chronic obstructive pulmonary disease (COPD) is a major respiratory illness in Canada that is both preventable and treatable. Our understanding of the pathophysiology of this complex condition continues to grow and our ability to offer effective treatment to those who suffer from it has improved considerably. The purpose of the present educational initiative of the Canadian Thoracic Society (CTS) is to provide up to date information on new developments in the field so that patients with this condition will receive optimal care that is firmly based on scientific evidence. Since the previous CTS management recommendations were published in 2003, a wealth of new scientific information has become available. The implications of this new knowledge with respect to optimal clinical care have been carefully considered by the CTS Panel and the conclusions are presented in the current document. Highlights of this update include new epidemiological information on mortality and prevalence of COPD, which charts its emergence as a major health problem for women; a new section on common comorbidities in COPD; an increased emphasis on the meaningful benefits of combined pharmacological and nonpharmacological therapies; and a new discussion on the prevention of acute exacerbations. A revised stratification system for severity of airway obstruction is proposed, together with other suggestions on how best to clinically evaluate individual patients with this complex disease. The results of the largest randomized clinical trial ever undertaken in COPD have recently been published, enabling the Panel to make evidence-based recommendations on the role of modern pharmacotherapy. The Panel hopes that these new practice guidelines, which reflect a rigorous analysis of the recent literature, will assist caregivers in the diagnosis and management of this common condition.
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | - Alan Kaplan
- Family Physician Airways Group of Canada, Richmond Hill, Ontario
| | - Sean Keenan
- University of British Columbia, Vancouver, British Columbia
| | | | | | - Jeremy Road
- University of British Columbia, Vancouver, British Columbia
| | | | - Don Sin
- University of British Columbia, Vancouver, British Columbia
| | | | - Nha Voduc
- University of Ottawa, Ottawa, Ontario
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Affiliation(s)
- Michael R Sayre
- Department of Emergency Medicine, Good Samaritan Hospital, Cincinnati, OH 45220, USA.
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McCrory DC, Brown C, Gelfand SE, Bach PB. Management of acute exacerbations of COPD: a summary and appraisal of published evidence. Chest 2001; 119:1190-209. [PMID: 11296189 DOI: 10.1378/chest.119.4.1190] [Citation(s) in RCA: 134] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022] Open
Abstract
STUDY OBJECTIVES To critically review the available data on the diagnostic evaluation, risk stratification, and therapeutic management of patients with acute exacerbations of COPD. DESIGN, SETTING, AND PARTICIPANTS English-language articles were identified from the following databases: MEDLINE (from 1966 to week 5, 2000), EMBASE (from 1974 to week 18, 2000), HealthStar (from 1975 to June 2000), and the Cochrane Controlled Trials Register (2000, issue 1). The best available evidence on each subtopic then was selected for analysis. Randomized trials, sometimes buttressed by cohort studies, were used to evaluate therapeutic interventions. Cohort studies were used to evaluate diagnostic tests and risk stratification. Study design and results were summarized in evidence tables. Individual studies were rated as to their internal validity, external validity, and quality of study design. Statistical analyses of combined data were not performed. MEASUREMENT AND RESULTS Limited data exist regarding the utility of most diagnostic tests. However, chest radiography and arterial blood gas sampling appear to be useful, while short-term spirometry measurements do not. In terms of the risk of relapse and the risk of death after hospitalization for an acute exacerbation, there are identifiable clinical variables that are associated with these outcomes. Therapies for which there is evidence of efficacy include bronchodilators, corticosteroids, and noninvasive positive-pressure ventilation. There is also support for the use of antibiotics in patients with more severe exacerbations. Based on limited data, mucolytics and chest physiotherapy do not appear to be of benefit, and oxygen supplementation appears to increase the risk of respiratory failure in an identifiable subgroup of patients. CONCLUSIONS Although suggestions for appropriate management can be made based on available evidence, the supporting literature is spotty. Further high-quality research is needed and will require an improved, generally acceptable, and transportable definition of the syndrome "acute exacerbation of COPD" and improved methods for observing and measuring outcomes.
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Affiliation(s)
- D C McCrory
- Center for Clinical Health Policy Research, Duke Evidence-Based Practice Center and Duke University Medical Center, Durham, NC, USA
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Brown CD, McCrory DC, White J. Inhaled short-acting beta2-agonists versus ipratropium for acute exacerbations of chronic obstructive pulmonary disease. Cochrane Database Syst Rev 2001; 2001:CD002984. [PMID: 11406052 PMCID: PMC8475645 DOI: 10.1002/14651858.cd002984] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
BACKGROUND Inhaled short acting beta2 adrenergic agonists and ipratropium bromide are both used in the treatment of acute exacerbations of chronic obstructive pulmonary disease. OBJECTIVES In patients with acute exacerbations of COPD to: 1. To assess the efficacy of short-acting beta-2 agonists against placebo; 2. Compare the efficacy of short-acting beta-2 agonists and ipratropium. SEARCH STRATEGY A comprehensive search of the literature was carried out of EMBASE, MEDLINE, CINAHL and the Cochrane COPD trials register was carried out using the terms: bronchodilator* OR albuterol OR metaproterenol OR terbutaline OR isoetharine OR pirbuterol OR salbutamol OR beta-2 agonist. SELECTION CRITERIA All trials that appeared to be relevant were assessed by two reviewers who independently selected trials for inclusion. Differences were resolved by consensus. DATA COLLECTION AND ANALYSIS All trials that appeared to be relevant were assessed by two reviewers who independently selected trials for inclusion. Differences were resolved by consensus. References listed in each included trial were searched for additional trial reports. Trials were combined using Review Manager using a fixed effects model. The size of the treatment effects were tested for heterogeneity. MAIN RESULTS We identified no placebo-controlled comparisons of beta-2 agonists. Three studies permitted comparison of ipratropium to an inhaled beta-2 agonist. These studies included a total of 103 patients. The beta2-agonists used were: fenoterol and metaproterenol. One study was a parallel group trial of regular therapy for seven days. The other two were cross over studies of single dose treatments, with efficacy measured 90 min post dose. There was no washout period between treatments. Both treatments produced an improvement in forced expiratory volume (FEV1) after 90 min in the range 150-250 ml. The was no difference between treatments, mean difference in FEV1 10 ml; 95% CI -220, 230 ml. In one small crossover study (n=10) there was a significant improvement in arterial PaO2 after 30 minutes with ipratropium (+5.8 mm Hg +/- 3.0 (SEM)) compared to metaproterenol (-6.2 +/- 1.2 mm Hg), but this was not significant at 90 min. There were no data concerning respiratory symptoms. The crossover studies showed no evidence of an additive effect of the two treatments, although they were not designed specifically to test this. REVIEWER'S CONCLUSIONS There are few controlled trial data concerning the use of inhaled beta2-agonist agents in acute exacerbations of COPD and none that have compared these agents directly with placebo. None of the studies used the more modern beta2-agonists used most widely in this setting (salbutamol and terbutaline). Beta2-agonists and ipratropium both produce small improvements in FEV1, but beta2-agonists may worsen PaO2 for a period. We could not draw conclusions concerning possible additive effects.
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Affiliation(s)
- Cynthia D Brown
- Brody School of MedicineSection of Pulmonary & Critical Care MedicineRoom E‐149B, Brody Medical Science Building600 Moye BlvdGreenvilleNorth CarolinaUSA27858
| | - Douglas C McCrory
- Duke UniversityCenter for Clinical Health Policy Research2200 W. Main Street, Suite 220DurhamNCUSA27705
| | - John White
- York District HospitalRespiratory MedicineWigginton RdYorkNorth YorksUKYO31 8HE
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Pollock MJ, Brown LH, Dunn KA. The perceived importance of paramedic skills and the emphasis they receive during EMS education programs. PREHOSP EMERG CARE 1997; 1:263-8. [PMID: 9709368 DOI: 10.1080/10903129708958821] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
OBJECTIVE The National Standard Curriculum for paramedics is currently being revised. There is little scientific evidence of what does and what does not work in prehospital care, and of whether the National Standard Curriculum prepares paramedics for the field. To provide some basis for the current revisions to the National Standard Curriculum, the authors determined which prehospital skills are perceived by paramedics to be the most important, and whether the emphasis placed on those skills during initial and continuing education programs corresponds with the perceived importance. METHODS Surveys listing 21 paramedic skills were mailed to the directors of 41 EMS agencies who agreed to participate in the study. The directors distributed the surveys to 1,364 paramedics affiliated with their organizations. The participants were asked to rate the importance of each skill, and the emphasis placed on each skill during their initial and continuing education. Skills were ranked on a scale of 0 to 4, with 0 representing no importance or emphasis, and 4 representing the most possible importance or emphasis. RESULTS Six-hundred of the 1,364 (44%) surveys were returned. Respondents had a mean of 9.9 +/- 5.6 years of EMS experience, and 5.4 +/- 4.0 years of experience as paramedics. The three skills ranked highest in importance were: 1) endotracheal intubation; 2) defibrillation; and 3) assessment. Importance in prehospital care was ranked equal to or higher than emphasis in both initial and continuing education for all skills except splinting and urinary catheterization, which received higher rankings for emphasis in initial education. Emphasis in initial education equaled or exceeded the emphasis in continuing education for all skills except intraosseous infusion. CONCLUSION The perceived importance of most prehospital skills is very high, and exceeds the emphasis placed on those skills during both initial and continuing education programs. These findings have implications for medical directors, EMS instructors, and persons involved with the revision of the National Standard Curriculum.
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Affiliation(s)
- M J Pollock
- Department of Emergency Medicine, East Carolina University School of Medicine, Greenville, North Carolina 27858, USA
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