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?. ?. ?. 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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5626746

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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

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 ?)


Asking pico

ASKING ~ PICO


Key words mesh

Key Words & MeSH


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EBM

子曰:我非生而知之者,好古,敏以求之也


Acquiring databases

ACQUIRING ~ Databases

  • Unfiltered / Primary Database

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  • Prefiltered / Secondary Database

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Acquiring databases1

  • 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


Cochrane library

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


Cochrane library1

Cochrane Library


Acp journal club

ACP Journal Club

  • 搜尋策略 keywords:

    • hypertonic saline inhal* AND child* AND infection No matches.

    • hypertonic saline (inhal* OR nebuli*) 1篇


National guideline clearinghouse

National Guideline Clearinghouse

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


Dynamed

DynaMed

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


Studies extraction

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


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Cochrane Database of Systematic Reviews 2008, Issue 4

Level of evidence : 1a


Oxford centre for evidence based medicine levels of evidence

Oxford Centre for Evidence-based Medicine Levels of Evidence


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文獻評讀

Critical appraisal topic


Appraising critical appraisal skills programme casp

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.


Systemic review screening questions

Systemic Review ~ Screening Questions

Q2: Did the review include the right type of study ?

  • Yes, 4 studies randomized, double-blind, parallel-group, controlled trials.


Systemic review detailed questions

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.


Systemic review detailed questions1

Systemic Review ~ Detailed Questions

Q4: Did the reviewers assess the quality of the included studies ?

 Yes, 2 assessors, Jadad scoring system.


Systemic review detailed questions2

Systemic Review ~ Detailed Questions

Q5: If the results of the studies have been combined, was it reasonable to do so?

 Yes


Systemic review detailed questions3

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 ?


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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.


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J Pediatr 2007;151:266-70

Chest 2003;123;481-487


Systemic review detailed questions4

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.


Systemic review detailed questions5

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:


Systemic review detailed questions6

Systemic Review ~ Detailed Questions

Q9: Were all important outcomes considered ?

  • Yes

    • Length of hospital stay

    • Clinical severity score


Systemic review detailed questions7

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.


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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。


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


Cost benefit

  • 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)


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  • 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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