Top POEMs of 2014: Respiratory Disease

Top 20 POEMs of 2014

Cold Symptoms Unaffected by Regular Analgesic Dosing or Use of Steam

Clinical question

Is advice to use an analgesic “only as needed,” regular dosing of an analgesic, steam inhalation, or any combination effective in treating cold symptoms?

Bottom line
Advice regarding the use of steam inhalation, ibuprofen alone or with acetaminophen compared with acetaminophen alone, and regular versus as-needed use of analgesics did not show any improved effectiveness in treating symptoms of acute respiratory tract infections. Ibuprofen may be beneficial in patients with chest symptoms and in children. However, ibuprofen advice was associated with a slight increase in the number of patients seeking a second visit for the same illness. (LOE = 1a)

Reference
Little P, Moore M, Kelly J, et al, for the PIPS Investigators. Ibuprofen, paracetamol, and steam for patients with respiratory tract infections in primary care: pragmatic randomised factorial trial. BMJ 2013;347:f6041.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (primary care)

Synopsis

These investigators enrolled 889 patients at least 3 years of age who presented to 1 of 25 primary care practices with a respiratory tract infection of any sort. The authors needed a lot of patients because they were assigned, using concealed allocation, to 1 of 12 groups. The patients were given advice to treat symptoms: Take acetaminophen (paracetamol), or ibuprofen, or alternate both analgesics; using regular dosing or as-needed dosing; plus steam (inhaled via a bathroom shower for 5 minutes 3 times a day) or no steam. This was an "advice study” -- the patients received advice and not the actual drugs (or a steamed-up bathroom, for that matter). As a result, the drug dosing was similar between the regular dosing and as-needed use, and was below the maximum doses of either medication (eg, fewer than 3 doses per day of acetaminophen and 2 doses of ibuprofen per day, on average). Steam was used, on average, only twice a day. Respiratory symptoms were rated by patients on a 7-point scale from "no problem" to "as bad as it could be" 2 days to 4 days after the visit. Neither advice on analgesic dosing nor on steam inhalation was significantly associated with changes in outcomes. The study had sufficient power to find a difference in these outcomes, if one existed. In specific subgroups, there was no difference between ibuprofen and acetaminophen in patients with otalgia or fever or severe symptoms. Ibuprofen seemed to be more effective in patients with chest infections and ibuprofen improved symptom scores in children. Patients receiving ibuprofen or the analgesic combination were slightly more likely to return to the office for unresolved symptoms.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

Delayed Strategies Decrease Antibiotic Use in Adults

Clinical question
Is a method of delayed prescriptions for respiratory tract infections effective for decreasing antibiotic use?

Bottom line
A delayed prescription approach in children and adults with acute respiratory tract infections, combined with explicit instructions for symptom control, is effective in decreasing antibiotic use, while not adversely affecting patient satisfaction or symptom duration or severity. Asking patients to call, pick up, or simply hold a prescription for a prescribed time resulted in less than 40% of patients receiving antibiotics. (LOE = 1b)

Reference
Little P, Moore M, Kelly J, et al, for the PIPS Investigators. Delayed antibiotic prescribing strategies for respiratory tract infections in primary care: pragmatic, randomised controlled trial. BMJ 2014;348:g1606.

Study design: Randomized controlled trial (nonblinded)

Funding source: Government

Allocation: Concealed

Setting: Outpatient (primary care)

Synopsis
Primary care clinicians in 25 practices in the United Kingdom participated in this study. They enrolled 566 children (at least 3 years of age) and adults with acute respiratory infection evaluated for respiratory tract symptoms deemed to not require antibiotic treatment (62.5% of eligible visits). The patients were randomly assigned, using concealed allocation, to 1 of 4 strategies: (1) no prescription, (2) recontact the office if symptoms persist, (3) a post-dated prescription was given, (4) a prescription was left at reception to be picked up if symptoms persisted, or (5) patients were given a prescription and asked not to fill it unless symptoms persisted. The advice for length of delay was tailored to the type of illness (eg, 3 days for ear infections, 10 days for acute cough). In addition, patients were also randomized to receive different advice for symptom control (type of analgesic or use of steam inhalation). Symptom severity on the second and fourth days following the visit were similar between the no prescription group and any of the delayed prescription groups, as well as between these groups and the patients immediately treated with antibiotics. Patient satisfaction with the visit was also similar among all groups. The actual percentage of patients in the no prescription or delayed prescription groups that eventually took antibiotics ranged from 26% to 39% (difference not significant). Follow-up visits and complications were similar across all groups.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

Respiratory Tract Symptoms in Children Last Longer Than Expected

Clinical question
For common respiratory tract infections in children, what is the best guidance we can give parents regarding the time to symptom resolution?

Bottom line
No one has come up with a quick-fix-acillin for children with respiratory tract infections, which last longer than we expect and certainly longer than we want. The time for half the children with earache to be pain free is 3 days, but the time for 9 of 10 children to be pain free is 7 to 8 days. Sore throat symptoms will linger for at least 3 days in one third of children and 72% will have fever for at least 2 days. Cough will resolve in 50% of children within 10 days, but for the rest it will be another 2 weeks. For half the children, general symptoms of a common cold will last for at least 10 days. (LOE = 1a-)

Reference
Thompson M, Vodicka TA, Blair PS, et al, for the TARGET Programme Team. Duration of symptoms of respiratory tract infections in children: systematic review. BMJ 2013;347:f2027.

Study design: Meta-analysis (other)

Funding source: Government

Setting: Outpatient (primary care)

Synopsis
To determine the duration of symptoms in children seeking treatment for earache, sore throat, cough, and common cold, these authors identified 23 randomized trials and 25 observational studies by searching 3 databases, including DARE. They only included studies published in English and conducted in high-income countries. They excluded studies of children with chronic infection or medical conditions associated with a high risk of serious infections. Two authors reviewed articles for inclusion and also assessed the quality of the included studies. Most studies had a low risk of bias, but the researchers were often unable to combine data because of differences in outcomes. Earache was reported to resolve in 50% of children within 3 days and in 90% by 7 to 8 days. Fever lasted an average of 3 days. For children with sore throat, approximately one third will still have pain at day 3 and 72% will have fever for at least 2 days. Cough resolved in 50% of children at 10 days, but it took 25 days for 90% of children to be cough free. Similarly, 50% of children with bronchiolitis will improve by day 13. For nonspecific respiratory tract infections (ie, the common cold), 50% of children will improve by 10 days.

Allen F. Shaughnessy, PharmD, MMedEd
Professor of Family Medicine
Tufts University
Boston, MA

POEMs are provided by Essential Evidence Plus, a point-of-care clinical decision support system published by Wiley-Blackwell. For more information, please see http://www.essentialevidenceplus.com(www.essentialevidenceplus.com).

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