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情境題目

?. ?. ?. 一位 1 歲的寶寶由父母親帶來我小兒科求診 , 此次因下呼吸道感染由主治醫師收住院治療 , 過去該兒童曾在中部的醫學中心因肺炎住過院 , 父母親對於此次住院時開立的蒸氣吸入治療 (0.9% Sodium Chloride) 與醫學中心 (3% Sodium Chloride) 的製劑濃度不同 , 故想知道這兩種霧化吸入溶液治療效果的差別。. 情境題目. Foreground questions (Treatment).

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情境題目

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  1. ? ? ? 一位1歲的寶寶由父母親帶來我小兒科求診,此次因下呼吸道感染由主治醫師收住院治療,過去該兒童曾在中部的醫學中心因肺炎住過院,父母親對於此次住院時開立的蒸氣吸入治療 (0.9% Sodium Chloride) 與醫學中心 (3% Sodium Chloride) 的製劑濃度不同,故想知道這兩種霧化吸入溶液治療效果的差別。 情境題目

  2. Foreground questions (Treatment) • In children with lower respiratory tract infection, is inhalation 3% sodium chloride better than 0.9% sodium chloride in shortening hospital stay ? (兒童下呼吸道感染霧化吸入治療中, 關於縮短住院天數, 3%食鹽水是不是比0.9%食鹽水好 ?)

  3. ASKING ~ PICO

  4. Key Words & MeSH

  5. EBM 子曰：我非生而知之者，好古，敏以求之也

  6. ACQUIRING ~ Databases • Unfiltered / Primary Database - - • Prefiltered / Secondary Database - - - - - -

  7. Clinical queries:Nebuliz* hypertonic saline + therapy (category) + narrow, specific search (scope)  26篇 • Limit: Humans, Randomized Controlled Trial, Review, All Child: 0-18 years  12篇 PubMed Search ACQUIRING ~ Databases

  8. Cochrane Library 搜尋策略 : Advance search  • 1 (respi* infection OR bronchiolitis OR bronchitis OR pneumonia AND inhalation)in Title, Abstract or Keywords  6315 篇 • 2 (hypertonic saline AND therap* NOT cystic fibrosis)in Title, Abstract or Keywords  252篇  #1 and #2

  9. Cochrane Library

  10. ACP Journal Club • 搜尋策略 keywords: • hypertonic saline inhal* AND child* AND infection No matches. • hypertonic saline (inhal* OR nebuli*) 1篇

  11. National Guideline Clearinghouse • 搜尋策略  Key ward: hypertonic saline solution inhal* 1 related guideline.

  12. DynaMed • 搜尋策略  Key ward: hypertonic saline solution inhal* AND child* AND infection7 Documents

  13. Studies Extraction ACP Journal Club PubMed Cochrane DynaMed 1 12 + 1 link 9:CT 1:Review 7 Duplication 5 Excluded articles from title and abstract 13 6 Excluded articles from full text 1 Excluded articles from study quality Review study: 1 RCT study: 4 Guideline: 1

  14. Cochrane Database of Systematic Reviews 2008, Issue 4 Level of evidence : 1a

  15. Oxford Centre for Evidence-based Medicine Levels of Evidence

  16. 文獻評讀 Critical appraisal topic

  17. APPRAISING ~ Critical Appraisal Skills Programme (CASP) Systemic Review ~ Screening Questions • Is the study valid ? What are the results ? Will the results help locally ?  Validity, Importance, Practice. Q1: Didthe review ask aclearly-focused question ? • Yes, PICO P: Children with viral bronchiolitis. I: Inhalation 3% sodium chloride. C: Inhalation 0.9% sodium chloride. O: Reduce the length of hospital stay and clinical severity score.

  18. Systemic Review ~ Screening Questions Q2: Did the review include the right type of study ? • Yes, 4 studies randomized, double-blind, parallel-group, controlled trials.

  19. Systemic Review ~ Detailed Questions Q3: Did the reviewers try to identify all relevant studies?  Yes, 261 citations  7 potenitally relevant  4 met all the criteria.

  20. Systemic Review ~ Detailed Questions Q4: Did the reviewers assess the quality of the included studies ?  Yes, 2 assessors, Jadad scoring system.

  21. Systemic Review ~ Detailed Questions Q5: If the results of the studies have been combined, was it reasonable to do so?  Yes

  22. The 3% saline group also had a significantly lower post-inhalation clinical score than the 0.9% saline group in the first three days of treatment. The effect of nebulized hypertonic saline in improving clinical score was greater among outpatients than inpatients. Systemic Review ~ Detailed Questions Q6: How are the results presented and what is the main result ?

  23. Clinical bottom line Nebulized hypertonic saline(3%) appears more effective than nebulized normal saline in reducing symptoms and shortening hospital stay in children with viral bronchiolitis.

  24. J Pediatr 2007;151:266-70 Chest 2003;123;481-487

  25. Systemic Review ~ Detailed Questions Q7: How precise are these results ? Nebulized 3% saline had a significantly shorter mean length of hospital stay compared with nebulized 0.9% saline mean difference -0.94 days, 95% CI -1.48 ~ -0.40, P = 0.0006.

  26. Systemic Review ~ Detailed Questions Q8: Can the results be applied to the local population ? • Yes • 主診斷或次診斷為 Acute bronchiolitis (ICD-9: 46619),近三年來占兩歲以下總案例數的百分比:

  27. Systemic Review ~ Detailed Questions Q9: Were all important outcomes considered ? • Yes • Length of hospital stay • Clinical severity score

  28. Systemic Review ~ Detailed Questions Q10: Should policy or practice change as a result of the evidence contained in this review ? • Yes, nebulized hypertonic saline (3%): • Length of hospital stay: 但可否縮短 25.9% 的住院天數,需額外考量國情及醫療保險的制度. • Improving clinical score was greater among outpatients  OPD.

  29. 以去學術化術語的方式回答病人的問題 假如你(妳)的寶寶得到病毒性細支氣管炎,蒸氣治療使用3% sodium chloride,大約每治療14~20個人中就可以看到 縮短住院天數 這個差異。

  30. Cough suppressant and pharmacologic protussive therapy: ACCP evidence-based clinical practice guidelines. Chest 2006 Jan;129 (78 references)

  31. 影響 • 病人:縮短住院天數, 降低院內感染機率; 改善臨床嚴重度, 降低痛苦 • 病人家屬:減少請假天數 (勞基法: 基本時薪95元) • 醫院:增加家屬滿意度  縮短病情恢復時間 縮短等待床位時間, 增加病患週轉率 健保package給付  縮短住院天數, 從健保中獲得經濟利益增加 Cost  Benefit • Reduce length of hospital stay • Improving clinical severity score 8元 × 5天 40元 • 95/01~97/12,診斷Acute bronchiolitis平均住院天數: 5.26~6.01天 (健保給付ICD9-46619, 住院4天, 6M/O-2Y/O, 16807~18455元)

  32. 醫學倫理 • Beauchamp Childress 的四大原則 • 尊重自主原則 • 行善原則 • 不傷害原則 • 正義原則 病人安全 醫療經濟利益

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