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In addition to time pressures that we encounter when searching for evidence to support care decisions for individual patients, it may be difficult for clinicians to apply the evidence that we find. The rate limiting step may not be doing the search, but the steps needed in “setting evidence-based medicine (EBM) in motion.”
We present an example of a search for evidence by a Physician Assistant (PA) student that highlights this challenge. PAs receive accelerated training in the medical model and work in teams under physician supervision. Approximately 40 000 PAs currently work in the US in a wide range of settings and specialties. Practising EBM has become an important component of training for PAs.
During an internal medicine rotation, a PA student encountered a common clinical practice unsupported by current evidence—administration of nebulised albuterol in patients with community acquired pneumonia (CAP). While this practice may be justified in patients with underlying chronic obstructive pulmonary disease (COPD) who also present with CAP, this student questioned the grounds for its use in patients with CAP who do not have COPD.
Clinical scenario
A 68 year old man presented to the emergency department with fever, chills, and a non-productive cough of 1 week’s duration. He had fatigue, headache, rhinorrhoea, and mild nausea, but denied dyspnoea. He had no history of smoking or COPD. He had atrial fibrillation and was taking warfarin for stroke prevention.
On admission, his temperature was 38.4 °C, heart rate was 108 beats/minute, respiratory rate was 24 breaths/minute, blood pressure was 156/88 mm Hg, and oxygen saturation was 86% by pulse oximetry on room air. Rales were heard in both lung bases and in the right middle lobe. Chest radiography showed a diffuse infiltrate in the right middle and lower lobes. Complete blood count showed a white blood cell count of 22 000 cells/ml with a left shift, and arterial blood gases showed mild respiratory acidosis.
One dose of ceftriaxone was administered parenterally, and a course of azithromycin was started. Albuterol, 5% solution, delivered by nebuliser 3 times daily was also ordered, in addition to a combination of inhaled ipratropium and albuterol, delivered by metered dose inhaler every 4 hours as needed. During the hospital stay, his pneumonia resolved, but his heart rate increased to 150 beats/minute and his blood pressure rose from 156/88 to 200/110 mm Hg.
Clinical question
Although there was no institutional protocol for use of nebulised albuterol for treatment of CAP, the house staff often ordered it. The PA student queried: In a 68 year old man with CAP and no underlying COPD, does use of nebulised β 2 agonists improve symptoms? What is the risk of harm in this patient?
Search strategy
Firstly, a treatment guideline was sought to clarify recommendations regarding use of nebulised albuterol for treatment of CAP. The American Thoracic Society guidelines for management of CAP1 were rapidly retrieved through PubMed, UpToDate, and MD Consult. The British Thoracic Society (BTS) guidelines for the management of CAP in adults2 were also found in PubMed. Both sets of guidelines were relevant to our patient, but neither guideline discussed the use of nebulised albuterol in the treatment of CAP. The BTS guidelines had a section on general management, which discussed the use of adjunctive therapies for CAP, but nebulised albuterol was not mentioned. Evidence from controlled clinical trials was mentioned in the guideline for “bottle blowing,”3 but not for physiotherapy.
Having not fully answered our question with a review of relevant guidelines (and having not attracted the attention of anyone who could change the patient’s treatment plan), we searched PubMed again, this time specifically for studies on the use of albuterol in patients with CAP. No relevant trials were found on the use of nebulisers for CAP.
To identify evidence about harm with the use of albuterol, PubMed was searched using the terms nebulised albuterol, cardiac arrhythmias, and randomised or controlled clinical trials. No trials were found. When just the content terms were searched, 9 articles, not directly relevant to our patient, were found. One prospective, open label study on the effect of nebulised albuterol (for treatment of asthma) on cardiac rhythm was found.4 10 patients were studied, and although no adverse effect on cardiac rhythm or blood pressure was found, the study did not convince the team that no potential for harm existed in this, or other patients, especially when there was no clear indication for use of albuterol.
Recognising that searching and appraising the literature are not the only important aspects of practicing EBM, we consulted an experienced pulmonologist, who practises and teaches using the EBM model. In addition to reviewing treatment plans for multiple cases of CAP requiring hospital admission with the Nurse Practitioner/Physician Assistant service, he recommended review of the Centre for Evidence-Based Medicine website at Mount Sinai Hospital in Toronto, Ontario, Canada (www.cebm.utoronto.ca/), which suggested bubble blowing as a method for helping clear secretions.2–3 This served as an excellent, rapid approach to finding good information on treatment of CAP, and confirmed the evidence previously found in the literature search.
Application of the evidence to this, and future patients
The treatment plan for this patient was not altered by the student’s rapid search for evidence. Changes in usual care for a common illness required a comprehensive search and discussion among all clinicians in our institution caring for patients with CAP. The clinical team reviewed the results of the search and because no evidence was found to support use of albuterol in patients like ours, changes were made to future practice. As a result of this process, which took a few hours and evolved over several weeks, orders for bronchodilators for patients with CAP are now made on an individual basis, depending on the presence of patient comorbid illnesses, such as COPD.
Conclusion
The need for a rapid search for evidence is sometimes, but not always, important to the care of an individual patient. In this case, the speed of the search did not affect the ability of the PA student to apply the evidence to the patient. Setting the evidence in motion may require communication of search results to other members of the clinical team and may affect the care of future patients. Although the catalyst for setting EBM in motion was a student, the evidence, including the results of further research, along with the judgment of the experienced pulmonologist, convinced the clinical team to make changes to usual care and to base future treatment of this common condition on the best available evidence.
Acknowledgments
We would like to thank Dermot Killian, MD, Mercy Pulmonary Associates, for his precepting and teaching of PA students through the University of New England, Portland, Maine, USA, and his help in preparing this manuscript. He served his residency in Respirology at St. Joseph’s Hospital, Division of McMaster University.
Thanks also, to Bob McNellis, MPH, PA-C, of the American Academy of Physician Assistants, Alexandria, Virginia, USA, for his review of the manuscript.