Rubian, Roeylene Joyce G,

BSN 3-B

Evidence Based Nursing Care Process

I. Clinical Question

Does long-term use of popular inhalers increase the risk for pneumonia in COPD?

II. Citation

Long-Term Use of Popular Inhalers May Increase Risk for Pneumonia in COPD
(http://cme.medscape.com/viewarticle/588143)

III. Study Characteristics

1. Patients included

The reviewers assessed various endpoints including any pneumonia, serious pneumonia,
pneumonia-related mortality rate, and overall mortality rate. After a detailed screening of 97
articles, the reviewers included 18 randomized controlled trials, which enrolled a total of 16,996
patients followed up for 24 to 156 weeks.

2. Interventions compared
The trials ranged in duration from 24 weeks to 3 years, and sample size ranged from 186 to 6184.
6 randomized controlled trials compared inhaled corticosteroids vs placebo, and 7 trials
compared inhaled corticosteroid and long-acting beta-agonist combinations vs long-acting beta-
agonists alone.10 trials assessed fluticasone propionate 500 g twice daily, 6 assessed fluticasone
propionate at 250 g twice daily, and 2 assessed budesonide at 400 g twice daily.
3. Outcomes Monitored

Outcomes associated with inhaled corticosteroids were a significantly increased risk for any
pneumonia. However, the risk for pneumonia-related mortality was not significantly increased,
nor was the risk for overall mortality.

4. Does the study focus on a significant problem in clinical practice?

Yes, the study focuses on a significant problem which is the long term use of inhalers leading to
the development of an increase risk in developing pneumonia in COPD.

IV. Methodology/ Design

1. Methodology Used
The study was conducted by selecting people with and without COPD. The purpose of selecting
unaffected individuals is to compare the results. The selection was done by inclusion criteria.
This study has been replicated many times but each studies has some differences and unique in
some manner. Those who are selected as samples for the study were not harmed. They actually
gain some benefits upon participating in that study.

2. Design

Systematic review of randomized clinical trials

3. Setting
North Carolina, USA

4. Data Sources

Using no date restrictions, the reviewers conducted systematic searches with MEDLINE, EMBASE,
the Cochrane Database of Systematic Reviews, regulatory documents, and trial registries through
June 30, 2008.

5. Subject Selection

Inclusion criteria were randomized controlled trials comparing any inhaled corticosteroid vs a
control treatment of COPD, follow-up 24 weeks or longer, and reporting of pneumonia as an
adverse event. The reviewers assessed various endpoints including any pneumonia, serious
pneumonia, pneumonia-related mortality rate, and overall mortality rate.

6. Has the original study been replicated?

No, the study has not been replicated.

7. What were the risks and benefits of the nursing action / intervention tested in the study?

Subjects under the study will benefit from it since they will be able to know and identify the
associated risks with regards to long term use of inhalers.

V. Results of the Study

1. Discuss briefly the results of the study.

Among patients with COPD, inhaled corticosteroid use for at least 24 weeks is associated with a
significantly increased risk of serious pneumonia, without a significantly increased risk of death,"
the review authors write. "The magnitude of this risk of serious pneumonia associated with
inhaled corticosteroid use in patients with COPD is substantial (RRs, approximately 70% increased
risk) and may pose a substantial public health burden.

Limitations of this meta-analysis include the quality of reported data (the trials did not
consistently use an objective definition of pneumonia or require a chest radiographic
examination, most of the trials were inadequately powered, and 9 trials were at unclear risk for
bias). Other limitations include inability to determine the onset of pneumonia, dose-response
relationships, or the effect of age, body mass index, and concomitant use of systemic
corticosteroids, influenza, and pneumococcal vaccination status on the risk for pneumonia linked
to inhaled corticosteroid use.

Outcomes associated with inhaled corticosteroids were a significantly increased risk for any
pneumonia. However, the risk for pneumonia-related mortality was not significantly increased,
nor was the risk for overall mortality. Compared with placebo, inhaled corticosteroids were
associated with a significantly increased risk for serious pneumonia. Compared with long-acting
beta-agonists alone, the combination of inhaled corticosteroids and long-acting beta-agonists
was also associated with a significantly increased risk for serious pneumonia.

VI. Authors Conclusions/ Recommendations

1. What overall contribution to client health status and nursing knowledge do the nursing
action / intervention make?
Clinicians should remain vigilant for the development of pneumonia with inhaled corticosteroid
use because the signs and symptoms of pneumonia may closely mimic those of COPD
exacerbations," the review authors conclude. "Clinicians should reevaluate the benefit-harm
profile of long-term inhaled corticosteroid use among patients with COPD.

VII. Applicability

1. Does the study provide a direct enough answer to our clinical question in terms of type of
patients, intervention and outcome?

The study provides enough information and direct answers to the clinical question in terms of
type of patients, intervention and outcome.

2. Is it feasible to carry out nursing action in the real world?

Yes, The study is feasible to carry out the nursing actions. The resources needed like the subjects,
money, facilities and manpower are enough and available. The availability of the subjects has
never been a question since individuals with this infection are not too hard to find. Money as
well as facilities and equipment have never been a problem.

VIII. Reviewers Conclusion/ Commentary

We therefore conclude that all medical practitioners should be vigilant for the development of
any complications to our patients. It is our responsibility to give a quality care to them. We
should be careful especially in giving medications. We should check first the contraindications
and the adverse reaction of the drugs that we are going to administer. The 10 rights in giving the
medications should also be observed. Finally, all preventions must be done in order to avoid
complications and hospital-acquired infections such as pneumonia.

Learning Insights

In this case, medical practitioners should watch very carefully about any possibilities of
complications that might happen to our patients since it is our duty to give them the
quality care that they deserve.We should be very cautious when giving medication. we
should always check and be aware about the the contraindications and adverse reaction
of the drugs that we will be giving to our patients. We have to consider the 10 rights in
giving medications. Therefore, in order to avoid complications and hospital-acquired
infections, all preventions must be take into account.