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Bronchodilator administration

Question Type:
Intervention
Full Question:
Among adults and children in the prehospital setting who suffer from asthma and are experiencing difficulty in breathing  (P), does bronchodilator administration (I), compared with no brochodilator administration (C), change time to resolution of symptoms, time to resumption of usual activity, complications, harm to patient, therapeutic endpoints (eg oxygenation and ventilation), need for advanced medical care (O)?
Consensus on Science:
After application of inclusion and exclusion criteria, the search strategy yielded 8 double-blind RCTs,(Littner 1983, 309; Bentur 1992, 133; Karpel 1997, 348; Politiek 1999, 988; van der Woude 2004, 816; Berger 2006, 1217; Hermansen 2006, 1203; Amirav 2007, 1) 2 observational studies,(Emerman 1990, 512; Weiss 1994, 873) and 1 meta-analysis.(Osmond 1995, 651) It is important to note that all of these trials involved administration of the bronchodilators in a healthcare setting (prehospital EMS setting, emergency department, or in-hospital setting); because none involved administration by first aid providers in a typical first aid setting, all have been downgraded for indirectness.Regarding the critical outcome of time to resolution of symptoms, 2 RCTs were found. Very-low-quality evidence (downgraded for risk of bias, imprecision, and indirectness) from 1 RCT(Bentur 1992, 133) with 28 participants aged 3 months to 2 years showed benefit in reduction of respiratory rate (MD, 5.1; 95% CI, 0.45–9.75), wheezing score (MD, 0.8; 95% CI, 0.36–1.24), accessory muscle score (MD, 0.85; 95% CI, 0.45–1.23), and total clinical score (MD, 2.5; 95% CI, 1.06–3.94) when treatment (albuterol/salbutamol nebulization) was compared with placebo. Low-quality evidence (downgraded for imprecision and indirectness) from another RCT(van der Woude 2004, 816) with 17 participants aged 18 to 41 years showed benefit in reduction of time to subjective improvement in dyspnea in participants treated with fast-acting β2-adrenergic agonists (formoterol or salbutamol dry-powdered inhaler) compared with placebo dry-powdered inhaler or the slow-acting β2-agonist (salmeterol dry-powdered inhaler). This study also demonstrated a reduction in time to return to baseline symptoms in the fast-acting β2-adrenergic agonist group compared with the placebo or slow-acting β2-agonist groups (MD indeterminable). Regarding the critical outcome of time to resumption of usual activity, there were no human trials found. Regarding the important outcome of complications, very-low-quality evidence (downgraded for risk of bias, indirectness, and imprecision) from 1 RCT(Bentur 1992, 133) with 28 participants aged 3 months to 2 years failed to demonstrate a significant difference in mean HR between participants treated with nebulized albuterol/salbutamol and those treated with placebo (MD, 7; 95% CI, −9.6 to 23.6). Very-low-quality evidence (downgraded for risk of bias, imprecision, and indirectness) from a second RCT(Littner 1983, 309) comprising 11 participants aged between 9 and 16 years failed to demonstrate a difference in mean HR or mean blood pressure when albuterol/salbutamol metered-dose aerosol was compared with placebo. A total of 4 patients on the albuterol/salbutamol days reported tremors, compared with 6 on the placebo days. All tremors were “fine” in quality. Very-low-quality evidence (downgraded for risk of bias, imprecision, and indirectness) from a third RCT(Karpel 1997, 348) comprising 100 patients with an average age of 33 years failed to demonstrate a significant difference in potassium, SBP or DBP, tremor, headache, nervousness, weakness, palpitations, or dry mouth between the albuterol/salbutamol metered-dose aerosol given once group (T0), compared with every 30 minutes for 4 doses group (T30), compared with every 60 minutes for 2 doses group (T60). There was a statistically significant difference in mean HR change between the T30 compared with T0 groups, where the T30 group’s HR (beats per minute [BPM]) increased and the T0 group’s decreased (MD, 9.2; 95% CI, 3.51–14.93). Very-low-quality evidence (downgraded for risk of bias, imprecision, and indirectness) from an observational study(Emerman 1990, 512) comprising 52 participants with an average age of 33.6 years failed to demonstrate a significant difference in respiratory rate and HR between the treatment group (nebulized isoetharine) and the control group. One participant in the treatment group reported headache and 2 participants in the control group reported headache or nausea (MD undeterminable). Regarding the important outcome of harm to patient, there were no human trials found.Regarding the important outcome of therapeutic endpoints (eg, oxygenation and ventilation), 1 RCT(Littner 1983, 309-316) with very-low-quality evidence (downgraded for bias, imprecision, and indirectness) showed benefit in an improvement in percentage maximal achievable forced expiratory volume over 1 second (FEV1) and forced vital capacity (FVC) at 60 minutes when comparing inhaled albuterol/salbutamol metered-dose aerosol or isoproterenol metered-dose aerosol to placebo and at 360 minutes (MD undeterminable). A second RCT(Berger 2006, 1217) with very-low-quality evidence (downgraded for bias, imprecision, and indirectness) enrolled 134 participants with an average age of 8.3 years, which demonstrated a statistically significant improvement in FEV1 after initial treatment dose (day 0) for levalbuterol/salbutamol and albuterol/salbutamol compared with placebo (33.1%, 29.6% versus 17.8%; P
Treatment Recommendation:
When an individual with asthma is experiencing difficulty breathing, we suggest that trained first aid providers assist the individual with administration of a bronchodilator (weak recommendation, very-low-quality evidence).Values, Preferences, and Task Force InsightsIn making this recommendation, we place higher value in an intervention that may reduce mortality in a life-threatening situation over the risk of potential adverse effects. This review found evidence that use of a bronchodilator in asthmatics with acute difficulty breathing is effective for reducing wheezing, dyspnea, and respiratory rate, while improving measures of effectiveness such as FEV1 or PEFR, and with few reported side effects.As with the 2005 review and as noted above, no studies of bronchodilator administration in the first aid setting met the inclusion criteria; therefore, studies were used from the EMS and hospital settings. While these studies support the use of bronchodilators for asthmatics with difficulty in breathing, caution is required in extrapolating our findings to a first aid recommendation. The task force recognizes that first aid providers may be limited in their abilities to administer or assist with bronchodilator therapy due to clinical governance and local regulations. In addition, this recommendation must be appropriately operationalized by first aid organizations with due consideration to the setting and scope of practice in which the first aid is being applied.
CoSTR Attachments:
2014 07 11 FA534 bronchodilator inclusion_exclusion.docx    
2015 04 17 FA534 bronchodilator GRADE table.docx    
Osmond AMSTAR_final_n.docx    

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