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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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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 ?)

slide5

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

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

slide18
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 ?

slide25

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.

slide26

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.
slide32
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。

slide33

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)
slide35

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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