Semester Investigation PICO Search Strategy Sample Paper
Introduction
Severe acute asthma is a clinical emergency that can easily be managed by various clinical therapies. However, if poorly managed, it can invariably lead to death by cardiorespiratory collapse. Typically, therapeutic management of severe asthma targets to increase air passage through bronchodilators dilation and oxygen supplementation. Ultimately, these therapies should stabilize the patient.
The available treatment options for children with severe acute asthma refractory to SAMA/LAMA combination are limited because the remaining ones are either not safe or are expensive. Nonetheless, the patients must the treated and therefore alternatives such as IV steroids with or without heliox are often used as the most feasible options. Against this backdrop, there are various pieces of research evidence that have confirmed the role of IV methylprednisolone as well as that of heliox in improving severe asthma. However, evidence on the latter is a bit controversial due to its side effects and availability. Study seeks to unravel the available evidence on the use of IV methylprednisolone or a combination of IV methylprednisolone and heliox in the treatment of severe acute asthma in children between the age of 5-15 years old.
The study takes the form of an annotated bibliography; evaluating the quality of evidence in 8 peer reviewed journal articles. The review will summarize the content of each journal article in terms of its purpose, findings and implications of those findings to the management of severe acute asthma. It is worth noting that all the journal articles have been published within the past five years. Meanwhile, after the annotated bibliography, this study will synthesize the results of all the 8 journal articles to develop a concrete conclusion out of the review.
Article 1
Henderson et al (2017) argue that asthma is one of the most common chronic respiratory condition in children affecting millions of children and continues to be a common cause of Intensive Care Unit (ICU) admission. Bearing this in mind, the authors conducted a study on asthma therapy in paediatric ICU, describing asthma management, evaluating practice evaluation, and describing the resource use during asthma management at the paediatric ICU.
Being a retrospective study single-centre cohort study, it involved 262 children of age 2 to 18 years in paediatric ICU treated with asthma from 2008 to 201;1 with data collected through intermountain Healthcare Enterprise Data Warehouse. Majority of the participants only received only the first tier of recommended therapy (inhaled short-acting b-agonists, pre-hopsitalization inhaled ipratropium bromide, systemic corticosteroids and oxygen), while 70% of them did not receive any further respiratory support beyond non-breather mask or nasal cannula mask including inhaled nitric oxide, IV b-agonists, intravenous (IV) magnesium sulfate, inhaled heliox. While heliox were rarely used before or after pediatric ICU, no adverse event was reported on its use.
The study results indicated that most of the patients with severe asthma were treated with only the minimum interventions (i.e. first-tier medication, none-breather or nasal canular mask). These treatments minimized the paediatric ICU length of stay and thus reduced expenses involved in asthma care. these findings confirm that heliox can be used as a treatment therapy for asthma in paediatric ICU with no side effects. Its methodology was effective, and the resultant evidence can be useful in comparing the use of heliox versus the use of a combination of heliox and IV methylprednisolone.
However, the fact that this study was a single-hospital cohort study limits the generalization of its findings. Furthermore, the generalization of the study finding is also limited by the fact that it did not consider specific factors such as patient ethnicity, which was not a representative of the US population.
Article 2
The study by Doymaz et al (2020) was inspired by the statistics that asthma is a chronic
childhood illness that affects at least 6 million children and by 2017, it was responsible for 863 per every 100,000 deaths in the United States. Furthermore, the authors were motivated by the fact that whereas various intravenous IV corticosteroids are available of the treatment of acute severe asthma, the choice of IV corticosteroids largely depends on physician’s preferences or institution. Against this background, the researchers conducted a study to compare the efficacy of IV methylprednisolone, dexamethasone and hydrocortisone during paediatric ICU admission.
The study took the form of a randomized clinical trial that entoled patients of 1-12 years old requiring continuous beta-2 agonist treatment.
The randomization was done in three groups: IV Dexamethasone group, IV Hydrocortisone and IV Methylprednisolone. The researchers measured primary outcomes based on durations of beta-2 agonist continuous nebulization treatment. On the other hand, the secondary outcomes were measured by paediatric asthma severity score, maximum dose of beta-2 agonist treatment, need for mechanic ventilation and paediatric ICU and hospital length of stay.
The study findings indicated no difference in efficacy of dexamethasone, hydrocortisone and IV methylprednisolone when used in appropriate doses to treat pediatric asthma. This was demonstrated by a no difference in the various outcome measurements such as B2 agonist maximum dose, paediatric asthma severity score, pidreatic ICU length of stay and need for mechanic ventilation. While the generalization of these study findings is affected by the small sample cohort, it produces useful evidence to support the use of IV methylprednisolone in the management of pediatric severe asthma.
Article 3
Systemic corticosteroids have always been administered to children with asthma admitted in the emergency department with the aim of reducing their length of stay. However, as per Fishe et al (2019), there is a paucity of research examining the improvement effect of corticosteroids on patient outcomes. In response, the researchers conducted a state-wide study to investigate the emergency department outcomes upon the use of corticosteroids on paediatric asthma.
The retrospective observational cohort study relied on patients whose records remained in Florida’s EMS Tracking and Reporting System with information on emergency department’s outcome of patients between 2011 – 2016. The inclusion criteria were children of age 2-18 admitted in the emergency department with respiratory distress, whose acute asthma exacerbation was indicated by their receipt of albuterol. The study found that the administration of IV methylprednisolone was associated with decreased odds of emergency department discharge. Fishe et al (ddd) attributed these results to a few reasons. For instance, IV methylprednisolone was only reserved for patients with more severe asthma.
The findings of this study are especially useful in understanding not only the effects of IV methylprednisolone as an emergency department intervention for severe asthma in children, but also the role of severity as a factor to consider when using IV methylprednisolone on pediatric asthma. Nonetheless, this study had several methodological limitations that must be pointed out. For instance, the study only focused on one state and this affects its generalizability to other areas of the United States. Furthermore, only on third of the patients had identifiable emergency department outcomes. More importantly, the researchers did not have any prior knowledge of any medications the patients had taken before their arrival at the emergency departments, affecting validity of the study.
Article 4
Fishe et al (2019) argued that at least ten percent of all pediatric emergency department patients use emergency medical services for transport and prehospital management. While studies show that the most frequently used medication was albuterol, there is a paucity of research evidence on pediatric emergency medical services experiences with respiratory distress or asthma. Therefore, the researchers set out to investigate the relevant clinical, geographic, demographic and characteristics of pediatric asthma treated in the emergency medical services in a state with the fourth-largest pediatric population to examine the current emergency medical services treatment practices.
The retrospective observational cohort study relied on patients whose records remained in Florida’s EMS Tracking and Reporting System with information on emergency department’s outcome of patients between 2011 – 2016. The inclusion criteria were children of age 2-18 admitted in the emergency department with respiratory distress, whose acute asthma exacerbation was indicated by their receipt of albuterol. The study found that in practice, IV methylprednisolone is reserved for the small percent of patients with generally more severe asthma. However, they are more liberally administered in the emergency department because they are of benefit to those with moderate and severe asthma exacerbations.
These findings are important to the study of IV methylprednisolone as a treatment therapy for pidreatic asthma in the emergency department because it explores the general practice and how IV methylprednisolone is used. However, it has several methodological limitations that limits its generalizability. For instance, the study only focused on one state and this affects its generalizability to other areas of the United States. Furthermore, the EMS Tracking and Reporting System does not distinguish ground versus air transport, and therefore some emergency medical service users might have been omitted.
Article 5
Leung (2020) considers asthmas one of the most common chronic illnesses in children and a major contributor of child death globally. As such, the researcher conducted a review of literature to investigate the various medications used in treating acute asthma exacerbations and their efficacy. The review presented the evidence in the context of a stepwise management of acute asthma exacerbations and provided several recommendations for practice based on his findings.
The study found that in children, IV methylprednisolone is a recommended oral medication that may however be safe due to concerns associated with vomiting. Furthermore, Leung (2020) observed that there is a paucity of data supporting that IV methylprednisolone can provide additional efficacy benefits over other oral formulas. Furthermore, the study did not find any evidence of increased intramuscular corticosteroids have better benefits that oral corticosteroids.
The findings of this study are useful in having a better understanding of IV methylprednisolone as a corticosteroid used to treat acute asthma exacerbations. It compares IV methylprednisolone with other therapies to give a better comparison of evidence on the treatment of acute asthma exacerbations in children. However, because the study relied on secondary data, the generalizability of study is affected by the literature search and selection bias.
Article 6
Pediatric emergency departments encounter unique challenges with acute asthma exacerbations. Whereas most children respond well to treatments such as systemic corticosteroids, ipratropium, and inhaled β2-agonists, some children may require adjunct treatments. As such, Batabyal and O’Connell (2018) conducted a literature review study to investigate the various guidelines on the management of severe asthma exacerbations in pediatric emergency departments.
The review covers both the use of heliox as well as the use of Corticosteroids such as IV methylprednisolone. Reviewed evidence indicate that early use of IV methylprednisolone is important and even a slight delay can increase the chances of hospital admission. Another important finding of this review is that whereas one would want to administer more doses of IV methylprednisolone to mitigate inflammation, there is no evidence supporting greater doses of more than 2mg/kg even in the case of acute asthma; and therefore, higher doses is not recommended.
On heliox, the study revealed variable efficacy of heliox as a therapy for acute severe asthma exacerbations among the Pediatric population. However, the reviewed evidence also shows that some guidelines (e.g. NAEPP) recommend the administration of inhaled beta agonists with heliox in patients whose asthma exacerbations is life threatening. Similarly, as per Batabyal and O’Connell (2018), the GINA guidelines recommend heliox for acute severe asthma for patients who do not respond to conventional treatment.
Practice guidelines are integral part of evidence-based practice because they reveal the generally accepted practices backed by evidence. As such, the study by Batabyal and O’Connell (2018) is useful in studying the use of IV methylprednisolone and or heliox in the management of acute severe asthma in children because it compares various guidelines on the same. However, the study is limited by the fact that it relies on secondary material, which is susceptible to selection and inclusion bias.
Article 7
Indinnimeo et al (2018) opined that it is important to deliver appropriate care to children with asthma considering its life-threatening risk and its high prevalence on children. In the spirit of evidence-based practice, they conducted a study to guide the management of asthma attack in children. The study relied on Grading of Recommendations, Assessment, Development, and Evaluation (GRADE) methodology. They also conducted a literature search on Cochrane library to retrieve Italian journal articles on children of age 2 years and above.
One of the most relevant recommendation given by Indinnimeo et al (2018) is that heloix can be given to children with life-threatening asthma attack, especially for those not responding to alternative treatment. The study further explained that heloix can improve ventilation and reduce respiratory failure in patients experiencing airway obstruction. This study gives important insights that are useful in answering some of the background questions of the study such as those concerning the therapeutic options of severe asthma.
Article 8
The study by Seliem & Sultan (2018) sought to study how heliox delivered trhough high flow nasal canula can improve oxygenation in children with respiratory syncytial virus acute bronchitis/asthma. It took the design of a randomized control trial that included 48 patients. The treatment group received heliox (70:30) while the control group received air-oxygen mixture through high flow nasal cannula at 8 L per minute continuously for 24 hours. After two hours of treatment with heliox, the treatment group registered a more significant improvement compared to the control group of 98.3% versus 92.9% respectively.
Seliem & Sultan (2017) concluded that transient improvement of oxygenation can be achieved in children with respiratory syncytial virus acute bronchitis if heliox is used so that other therapeutic agents can find more time to work on the disease and resolve it naturally. However, this study has a few limitations. First, the randomization was not blinded due to an existing discrepancy between the delivery systems of both gases. Furthermore, the small sample size hindered discrimination between clinical phenotypes based on chest radiology.
References
- Batabyal, R. A., & O’Connell, K. (2018). Improving Management of Severe Asthma: BiPAP and Beyond. Clinical Pediatric Emergency Medicine, 19(1), 69-75. https://doi.org/10.1016/j.cpem.2018.02.007
- Doymaz, S., Ahmed, Y. E., Francois, D., Pinto, R., Gist, R., Steinberg, M., & Giambruno, C. (2020). Methylprednisolone, dexamethasone or hydrocortisone for acute severe pediatric asthma: does it matter?. Journal of Asthma, 1-10. https://doi.org/10.1080/02770903.2020.1870130
- Fishe, J. N., Gautam, S., Hendry, P., Blake, K. V., & Hendeles, L. (2019). Emergency medical services administration of systemic corticosteroids for pediatric asthma: A statewide study of emergency department outcomes. Academic Emergency Medicine, 26(5), 549-551. https://doi.org/10.1111/acem.13660
- Fishe, J. N., Palmer, E., Finlay, E., Smotherman, C., Gautam, S., Hendry, P., & Hendeles, L. (2019). A statewide study of the epidemiology of emergency medical services’ management of pediatric asthma. Pediatric emergency care. doi: 10.1097/PEC.0000000000001743
- Henderson, M. B., Schunk, J. E., Henderson, J. L., Larsen, G. Y., Wilkes, J., & Bratton, S. L. (2018). An assessment of asthma therapy in the pediatric ICU. Hospital pediatrics, 8(6), 361-367. DOI: https://doi.org/10.1542/hpeds.2017-0003
- Indinnimeo, L., Chiappini, E., & Del Giudice, M. M. (2018). Guideline on management of the acute asthma attack in children by Italian Society of Pediatrics. Italian Journal of Pediatrics, 44(1), 1-10. https://doi.org/10.1186/s13052-018-0481-1
- Leung, J. S. (2021). Paediatrics: how to manage acute asthma exacerbations. Drugs in Context, 10. doi: 10.7573/dic.2020-12-7
- Seliem, W., & Sultan, A. M. (2018). Heliox delivered by high flow nasal cannula improves oxygenation in infants with respiratory syncytial virus acute bronchiolitis☆. Jornal de pediatria, 94, 56-61. https://doi.org/10.1016/j.jped.2017.04.004