Combined inhaled beta-agonist and anticholinergic agents for emergency management in adults with asthma.

BACKGROUND: Inhaled short-acting anticholinergics (SAAC) and short-acting beta2-agonists (SABA) are effective therapies for adult patients with acute asthma who present to the emergency department (ED). It is unclear, however, whether the combination of SAAC and SABA treatment is more effective in reducing hospitalisations compared to treatment with SABA alone. OBJECTIVES: To conduct an up-to-date systematic search and meta-analysis on the effectiveness of combined inhaled therapy (SAAC + SABA agents) vs. SABA alone to reduce hospitalisations in adult patients presenting to the ED with an exacerbation of asthma. SEARCH METHODS: We searched MEDLINE, Embase, CINAHL, SCOPUS, LILACS, ProQuest Dissertations & Theses Global and evidence-based medicine (EBM) databases using controlled vocabulary, natural language terms, and a variety of specific and general terms for inhaled SAAC and SABA drugs. The search spanned from 1946 to July 2015. The Cochrane Airways Group provided search results from the Cochrane Airways Group Register of Trials which was most recently conducted in July 2016. An extensive search of the grey literature was completed to identify any other potentially relevant studies. SELECTION CRITERIA: Included studies were randomised or controlled clinical trials comparing the effectiveness of combined inhaled therapy (SAAC and SABA) to SABA treatment alone to prevent hospitalisations in adults with acute asthma in the emergency department. Two independent review authors assessed studies for inclusion using pre-determined criteria. DATA COLLECTION AND ANALYSIS: For dichotomous outcomes, we calculated individual and pooled statistics as risk ratios (RR) or odds ratios (OR) with 95% confidence intervals (CI) using a random-effects model and reporting heterogeneity (I²). For continuous outcomes, we reported individual trial results using mean differences (MD) and pooled results as weighted mean differences (WMD) or standardised mean differences (SMD) with 95% CIs using a random-effects model. MAIN RESULTS: We included 23 studies that involved a total of 2724 enrolled participants. Most studies were rated at unclear or high risk of bias.Overall, participants receiving combination inhaled therapy were less likely to be hospitalised (RR 0.72, 95% CI 0.59 to 0.87; participants = 2120; studies = 16; I² = 12%; moderate quality of evidence). An estimated 65 fewer patients per 1000 would require hospitalisation after receiving combination therapy (95% 30 to 95), compared to 231 per 1000 patients receiving SABA alone. Although combination inhaled therapy was more effective than SABA treatment alone in reducing hospitalisation in participants with severe asthma exacerbations, this was not found for participants with mild or moderate exacerbations (test for difference between subgroups P = 0.02).Participants receiving combination therapy were more likely to experience improved forced expiratory volume in one second (FEV1) (MD 0.25 L, 95% CI 0.02 to 0.48; participants = 687; studies = 6; I² = 70%; low quality of evidence), peak expiratory flow (PEF) (MD 36.58 L/min, 95% CI 23.07 to 50.09; participants = 1056; studies = 12; I² = 25%; very low quality of evidence), increased percent change in PEF from baseline (MD 24.88, 95% CI 14.83 to 34.93; participants = 551; studies = 7; I² = 23%; moderate quality of evidence), and were less likely to return to the ED for additional care (RR 0.80, 95% CI 0.66 to 0.98; participants = 1180; studies = 5; I² = 0%; moderate quality of evidence) than participants receiving SABA alone.Participants receiving combination inhaled therapy were more likely to experience adverse events than those treated with SABA agents alone (OR 2.03, 95% CI 1.28 to 3.20; participants = 1392; studies = 11; I² = 14%; moderate quality of evidence). Among patients receiving combination therapy, 103 per 1000 were likely to report adverse events (95% 31 to 195 more) compared to 131 per 1000 patients receiving SABA alone. AUTHORS' CONCLUSIONS: Overall, combination inhaled therapy with SAAC and SABA reduced hospitalisation and improved pulmonary function in adults presenting to the ED with acute asthma. In particular, combination inhaled therapy was more effective in preventing hospitalisation in adults with severe asthma exacerbations who are at increased risk of hospitalisation, compared to those with mild-moderate exacerbations, who were at a lower risk to be hospitalised. A single dose of combination therapy and multiple doses both showed reductions in the risk of hospitalisation among adults with acute asthma. However, adults receiving combination therapy were more likely to experience adverse events, such as tremor, agitation, and palpitations, compared to patients receiving SABA alone.

Pre-hospital management of anaphylaxis in one Canadian Urban Centre.

STUDY AIM: Anaphylaxis requires prompt recognition and management to improve patient outcomes. This study examined the diagnosis and treatment of anaphylactic reactions by the Emergency Medical Services (EMS) in a Canadian urban centre. METHODS: Electronic patient care records (ePCRs), identifying allergy-related calls in the Edmonton-Zone for the year 2011, were retrospectively reviewed to confirm anaphylaxis diagnosis and record treatments. Data were abstracted and entered into the REDCap electronic platform. Descriptive and multivariable analyses were performed. Pre-hospital management included any care provided by paramedic personnel and/or first-aid treatment received prior to EMS arrival. RESULTS: From 481 identified allergy-related case records, 136 (28%) met guideline criteria for anaphylaxis. Seventy-six (56%) of these confirmed cases were deemed high acuity by medical dispatchers. Self-medication and bystander first-aid was recorded in 60 (44%) anaphylactic events; 34 (25%) received epinephrine. Paramedics administered epinephrine in an additional 49 cases (36%); only 7% received all three primary pre-hospital anaphylaxis treatments: epinephrine, corticosteroids, and antihistamines. Factors associated with pre-hospital epinephrine administration included: previous episode of anaphylaxis (adjusted odds ratio [aOR]=4.9, 95% confidence interval [CI]: 1.30, 19.21); administration of corticosteroids by bystanders or EMS personnel (aOR=3.8, 95% CI: 1.36, 10.65); and transport severity (aOR=3.2, 95% CI: 1.21, 8.36). CONCLUSION: Paramedics in this region demonstrated higher use of epinephrine than reported elsewhere; however, almost half of all patients meeting anaphylaxis criteria did not receive pre-hospital epinephrine. Instead, more patients received antihistamines. Efforts to improve adherence to anaphylaxis protocols and guidelines appear warranted.

Enhancing screening, brief intervention, and referral to treatment among socioeconomically disadvantaged patients: study protocol for a knowledge exchange intervention involving patients and physicians.

BACKGROUND: Screening, Brief Intervention, and Referral for Treatment (SBIRT) is an effective approach for managing alcohol and other drug misuse in primary care; however, uptake into routine care has been limited. Uptake of SBIRT by healthcare providers may be particularly problematic for disadvantaged populations exhibiting alcohol and other drug problems, and requires creative approaches to enhance patient engagement. This knowledge translation project developed and evaluated a group of patient and health care provider resources designed to enhance the capacity of health care providers to use SBIRT and improve patient engagement with health care. METHODS/DESIGN: A nonrandomized, two-group, pre-post, quasi-experimental intervention design was used, with baseline, 6-, and 12-month follow-ups. Low income patients using alcohol and other drugs and who sought care in family medicine and emergency medicine settings in Edmonton, Canada, along with physicians providing care in these settings, were recruited. Patients and physicians were allocated to the intervention or control condition by geographic location of care. Intervention patients received a health care navigation booklet developed by inner city community members and also had access to an experienced community member for consultation on health service navigation. Intervention physicians had access to online educational modules, accompanying presentations, point of care resources, addiction medicine champions, and orientations to the inner city. Resource development was informed by a literature review, needs assessment, and iterative consultation with an advisory board and other content experts. Participants completed baseline and follow-up questionnaires (6 months for patients, 6 and 12 months for physicians) and administrative health service data were also retrieved for consenting patients. Control participants were provided access to all resources after follow-up data collection was completed. The primary outcome measure was patient satisfaction with care; secondary outcome measures included alcohol and drug use, health care and addiction treatment use, uptake of SBIRT strategies, and physician attitudes about addiction. DISCUSSION: Effective knowledge translation requires careful consideration of the intended knowledge recipient's context and needs. Knowledge translation in disadvantaged settings may be optimized by using a community-based participatory approach to resource development that takes into account relevant patient engagement issues. TRIAL REGISTRATION: Northern Alberta Clinical Trials and Research Centre #30094.