Respiratory Distress


COCHRANE SYSTEMATIC REVIEW: Inhaled corticosteroids for stable chronic obstructive pulmonary disease
Implications for practice: Unclear implications for EMS.
Review Overview: Pooling of the data from the 55 trials with 16,154 people showed that there was no consistent long-term benefit in the rate of decline in breathing capacity. Death rates were unchanged. Inhaled steroids were beneficial in slowing down the rate of decline in quality of life and reducing the frequency of exacerbations. Inhaled steroids increased the risk of side effects including thrush (candida) infection in the mouth and hoarseness, and the rate of pneumonia. In deciding whether to use this treatment, consumers and health professionals should weigh up the benefits (reduced rate of exacerbations, reduced decline in quality of life and possible reduction in the rate of decline of breathing capacity) against the side effects (mouth thrush, hoarseness and increased risk of developing pneumonia).
LINK to Cochrane Library: Issue 7, 2012 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002991.pub3/abstract


COCHRANE SYSTEMATIC REVIEW: Non-invasive positive pressure ventilation for treatment of respiratory failure due to severe acute exacerbations of asthma
Implications for practice: More research needed.
Review Overview: Non-invasive positive pressure ventilation (NPPV) enhances breathing in acute respiratory conditions by resting tired breathing muscles. It has the advantage that it can be used intermittently for short periods, which may be sufficient to reverse the breathing problems experienced by patients during severe acute asthma. We undertook this review to determine the effectiveness of NPPV in patients with severe acute asthma. Six randomized controlled trials were included in the review. Compared to usual medical care alone, NPPV reduced hospitalizations, increased the number of patients discharged from the emergency department, and improved respiratory rate and lung function measurements. The application of NPPV in patients with asthma, despite some promising preliminary results, still remains controversial. Further studies are needed to determine the role of NPPV in the management of severe acute asthma and especially in status asthmaticus.
LINK to Cochrane Library: Issue 12, 2012 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004360.pub4/abstract;jsessionid=49B4A12A21CBB6CD6022F88DE63B641B.d01t04


COCHRANE SYSTEMATIC REVIEW: Inhaled magnesium sulfate in the treatment of acute asthma
Implications for practice: There is some evidence to suggest that MgSO4, when used in conjunction with Beta-agonists can improve severe asthma exacerbations.
Review Overview: There is currently no good evidence that inhaled MgSO4 can be used as a substitute for inhaled β2-agonists. When used in addition to inhaled β2-agonists (with or without inhaled ipratropium), there is currently no overall clear evidence of improved pulmonary function or reduced hospital admissions. However, individual study results from three trials suggest possible improved pulmonary function in those with severe asthma exacerbations (FEV1 less than 50% predicted). Heterogeneity among trials included in this review precludes a more definitive conclusion. Further studies should focus on inhaled MgSO4 in addition to the current guideline treatment for acute asthma (inhaled β2 -agonist and ipratropium bromide). As the evidence suggests that the most effective role of nebulized MgSO4 may be in those with severe acute features and this is where future research should be focused. A set of core outcomes needs to be agreed upon both in adult and paediatric studies to allow improved study comparison in future.
LINK to Cochrane Library: Issue 12, 2012 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003898.pub5/abstract;jsessionid=CC20045A5AF2BB7315026FAEE7E19D50.d01t01


COCHRANE SYSTEMATIC REVIEW: Intermittent versus daily inhaled corticosteroids for persistent asthma in children and adults
Implications for practice: Unknown
Review Overview: In children and adults with persistent asthma and in preschool children suspected of persistent asthma, there was low quality evidence that intermittent and daily ICS strategies were similarly effective in the use of rescue oral corticosteroids and the rate of severe adverse health events. The strength of the evidence means that we cannot currently assume equivalence between the two options.. Daily ICS was superior to intermittent ICS in several indicators of lung function, airway inflammation, asthma control and reliever use. Both treatments appeared safe, but a modest growth suppression was associated with daily, compared to intermittent, inhaled budesonide and beclomethasone. Clinicians should carefully weigh the potential benefits and harm of each treatment option, taking into account the unknown long-term (> one year) impact of intermittent therapy on lung growth and lung function decline.
LINK to Cochrane Library: Issue 2, 2013 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD009611.pub3/abstract


COCHRANE SYSTEMATIC REVIEW: Early use of inhaled corticosteroids in the emergency department treatment of acute asthma
Implications for practice: orticosteroids may be beneficial in asthma attacks in conjunction with beta agonists.
Review Overview: Standard treatment for asthma attacks is to administer beta2-agonists (to open up the airways) and systemic corticosteroids (to reduce the inflammation). The purpose of this review was to determine if the use of inhaled corticosteroid (ICS) agents is beneficial in emergency department treatment settings. A total of 90 studies were identified for this review; 20 were deemed relevant and selected for inclusion (13 paediatric, 7 adult), with a total number of 1403 patients. This review found that inhaled corticosteroids used alone or in combination with systemic corticosteroids helped to relieve asthma attacks, were well tolerated and had few side effects. However, the most effective drug and dosage are unclear. The studies in the review included a variety of ICSmedications: beclomethasone (Beclovent/Becloforte/QVAR), budesonide (Pulmicort), dexamethasone sodium phosphate, fluticasone propionate (Flovent or Flixotide), Flunisolide (Aerobid) and triamcinolone (Azmacort). The review also found that ICS administered in this setting resulted in fewer hospital admissions. There was a reduction from 32 to 17 hospital admissions per hundred patients treated with ICS agents compared with placebo. At this time there is insufficient evidence to support using ICS agents alone as a replacement for systemic corticosteroid therapy in acute asthma attacks
LINK to Cochrane Library: Issue 12, 2012 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD002308.pub2/abstract;jsessionid=701A365D38D167AF966CC52C9C65376C.d01t03


COCHRANE SYSTEMATIC REVIEW: Addition of intravenous beta2-agonists to inhaled beta2-agonists for acute asthma
Implications for practice: There may be shorter recovery time in pediatrics but there are more side effects compared to inhaled.
Review Overview: There is very limited evidence from one study (Browne 1997) to support the use of IV beta2-agonists in children with severe acute asthma with respect to shorter recovery time, and similarly there is limited evidence (again from one study Browne 1997) suggesting benefit with regard to pulmonary index scores; however this advantage needs to be considered carefully in relation to the increased side effects associated with IV beta2-agonists. We identified no significant benefits for adults with severe acute asthma. Until more, adequately powered, high quality clinical trials in this area are conducted it is not possible to form a robust evaluation of the addition of IV beta2-agonists in children or adults with severe acute asthma.
LINK to Cochrane Library: Issue 12, 2012 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010179/abstract;jsessionid=2D7AD05AAC7442559308143EE4A089A9.d01t03


COCHRANE SYSTEMATIC REVIEW: High-frequency ventilation versus conventional ventilation for treatment of acute lung injury and acute respiratory distress syndrome
Implications for practice: More research needed.
Review Overview: We included eight randomized controlled trials enrolling 419 patients. HFO as an initial ventilation strategy reduced the risk of death in hospital by 23% in six trials enrolling 365 patients, and reduced the risk of treatment failure by 33% in five trials enrolling 337 patients. The ability of the lungs to oxygenate blood, measured at 24 to 72 hours of ventilation after randomization, was 16% to 24% better in patients receiving HFO. HFO had no effect on the duration of mechanical ventilation. The risk of adverse events, including low blood pressure or further injury to the lung due to high airway pressure, was not increased. We found substantial inconsistency for physiological outcomes such as oxygenation and carbon dioxide removal from the blood but not clinical outcomes. The quality of evidence is moderate at best for outcomes that would be most important to patients due to small numbers of trials, patients, and events. This indicates that randomized trials that are currently ongoing may change or impact these findings.
LINK to Cochrane Library: Issue 2, 2013 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004085.pub3/abstract


COCHRANE SYSTEMATIC REVIEW: Partial liquid ventilation for the prevention of mortality and morbidity in paediatric acute lung injury and acute respiratory distress syndrome
Implications for practice: Unknown current implications for EMS care.
Review Overview: There is no evidence from RCTs to support or refute the use of partial liquid ventilation in children with acute lung injury or acute respiratory distress syndrome. Adequately powered, high quality RCTs are still needed to assess its efficacy. Clinically relevant outcome measures should be assessed (mortality at discharge and later, duration of both respiratory support and hospital stay, and long-term neurodevelopmental outcomes). The studies should be published in full.
LINK to Cochrane Library: Issue 2, 2013 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003845.pub3/abstract


COCHRANE SYSTEMATIC REVIEW: Lung protective ventilation strategy for the acute respiratory distress syndrome
Implications for practice: There is limited evidence but lower tidal volumes are considered best practice at this point.
Review Overview: Critically ill people affected by severe, acute respiratory failure need air to be pumped into their lungs (mechanical ventilation) to survive. Mechanical support buys time for the lungs to heal. Nevertheless, 35% to 65% still die. Several studies have suggested that mechanical breathing can also cause lung damage and bleeding. A new lung protective way of mechanical ventilation was tested in large studies. In this third update of the Cochrane review we searched the databases until September 2012 but we did not find any new study which was eligible for inclusion. The total number of studies remained unchanged, six trials involving 1297 people. This systematic review shows that a gentler form of mechanical breathing (so-called protective ventilation) can decrease deaths in the short term, by 26% on average, but the effects in the long term are uncertain or unknown.
LINK to Cochrane Library: Issue 2, 2013 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003844.pub4/abstract


COCHRANE SYSTEMATIC REVIEW: Holding chambers (spacers) versus nebulizers for beta-agonist treatment of acute asthma
Implications for practice: Spacers may have some advantages compared to nebulizers for children with acute asthma.
Review Overview: Taking beta-agonists through either a spacer or a nebulizer in the emergency department did not make a difference to the number of adults being admitted to hospital, whilst in children we can be fairly confident that nebulizers are not better than spacers at preventing admissions. In children, the length of stay in the emergency department was significantly shorter when the spacer was used instead of a nebulizer. The average stay in the emergency department for children given nebulized treatment was 103 minutes. Children given treatment via spacers spent an average of 33 minutes less. In adults, the length of stay in the emergency department was similar for the two delivery methods. However the adult studies were conducted slightly differently which may have made it more difficult to show a difference in the length of stay in the emergency department. Because all the adult studies used a so-called "double-dummy" design, the adults received a spacer AND a nebulizer (either beta-agonist in a spacer and a dummy nebulizer or vice versa) which meant both groups of people were in the emergency department for as long as it took to take both treatments.
LINK to Cochrane Library: Issue 9, 2013 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000052.pub3/abstract


COCHRANE SYSTEMATIC REVIEW: Combined inhaled anticholinergics and short-acting beta2-agonists for initial treatment of acute asthma in children
Implications for practice: Children with an asthma exacerbation experience a lower risk of admission to hospital if they are treated with the combination of inhaled SABAs plus anticholinergic versus SABA alone.
Review Overview: We found that children with a moderate or severe asthma attack who were given both drugs in the emergency department were less likely to be admitted to the hospital than those who only had SABAs. In the group receiving only SABAs, on average 23 out of 100 children with acute asthma were admitted to hospital compared with an average of 17 (95% CI 15 to 20) out of 100 children treated with SABAs plus anticholinergics. Taking both drugs was also better at improving lung function. Taking both drugs did not seem to reduce the possibility of another asthma attack. Fewer children treated with anticholinergics reported nausea and tremor, but no significant group difference was observed for vomiting.
LINK to Cochrane Library: Issue 8, 2013 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD000060.pub2/abstract


COCHRANE SYSTEMATIC REVIEW: Nebulized hypertonic saline solution for acute bronchiolitis in infants
Implications for practice: Current evidence suggests nebulized 3% saline may significantly reduce the length of hospital stay among infants hospitalized with non-severe acute viral bronchiolitis and improve the clinical severity score in both outpatient and inpatient populations.
Review Overview: This study included 11 randomized trials involving 1090 infants with mild to moderate bronchiolitis. All but one of the 11 trials are considered as high-quality studies with low risk of error (i.e. bias) in their conclusions. Meta-analysis suggests that nebulized hypertonic saline could lead to a reduction of 1.2 days in the mean length of hospital stay among infants hospitalized for non-severe acute bronchiolitis and improve the clinical severity score in both outpatient and inpatient populations. No significant short-term effects (at 30 to 120 minutes) of one to three doses of nebulized hypertonic saline were observed among emergency department patients. However, more trials are needed to address this question. There were no significant adverse effects noted with the use of nebulized hypertonic saline when administered along with bronchodilators.
LINK to Cochrane Library: Issue 7, 2013 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006458.pub3/abstract


COCHRANE SYSTEMATIC REVIEW: Safety of regular formoterol or salmeterol in adults with asthma: an overview of Cochrane reviews
Implications for practice: An increase in non-fatal serious adverse events of any cause was found with salmeterol monotherapy, and the same increase cannot be ruled out when formoterol or salmeterol was used in combination with an inhaled corticosteroid, although possible increases are small in absolute terms.
Review Overview: The risk of fatal or non-fatal serious adverse events was lower overall in trials with adults taking randomly assigned inhaled corticosteroids, but we found no significant difference between monotherapy and combination therapy in the impact of treatment on risk of death or serious adverse events. We saw no differences between formoterol and salmeterol monotherapy in risk of death or serious adverse events from any cause or in risk of death or serious adverse events related to asthma. We saw no differences between formoterol and salmeterol combination therapy in the number of deaths or serious adverse events from any cause or in the risk of death related to asthma. We found no clear differences between the safety of monotherapy and that of combination therapy with long-acting beta2-agonists, or between the safety of formoterol and that of salmeterol. The lower estimates of risk on combination therapy support current guidelines, which advise that long-acting beta2-agonists should be used only in combination with inhaled steroids for adults with asthma. This review suggests that combination therapy is probably safer than use of long-acting beta2-agonists alone, but we do not know exactly how much safer. It is important to continue to collect information on the safety of long-acting beta2-agonists. Three large ongoing trials may provide more information.
LINK to Cochrane Library: Issue 1, 2014 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010314.pub2/abstract


COCHRANE SYSTEMATIC REVIEW: Conservative versus interventional management for primary spontaneous pneumothorax in adults
Implications for practice: The current guidelines are based on expert consensus rather than evidence, and a systematic review may help in identifying evidence for this practice.
Review Overview: The authors of this review searched for studies that compared interventional management with observational management but found no completed studies, although there is one study in progress. This means that there is a lack of high-quality evidence about the best way to manage a primary spontaneous pneumothorax in adults aged over 18 without previous lung disease; further studies are needed. The evidence is current to 26th June 2014.
LINK to Cochrane Library: Issue 12, 2014 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010565.pub2/abstract


COCHRANE SYSTEMATIC REVIEW: Continuous positive airway pressure (CPAP) for acute bronchiolitis in children
Implications for practice: Unknown at present time
Review Overview: Data were available for the following outcomes, but the results of the analyses were not precise enough to draw conclusions about them: need for mechanical ventilation, respiratory rate, change in arterial oxygen saturation and change in partial pressure of carbon dioxide (pCO2). Duration of hospital stay appeared to be similar whether CPAP was used or not. There were no cases of pneumothorax or death in either study. The studies did not measure the following outcomes: time to recovery, change in partial pressure of oxygen (pO2), hospital admission rate (from emergency department to hospital), duration of emergency department stay, need for intensive care unit admission, local nasal effects and shock.
LINK to Cochrane Library: Issue 1, 2015 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010473.pub2/abstract


COCHRANE SYSTEMATIC REVIEW: Different durations of corticosteroid therapy for exacerbations of chronic obstructive pulmonary disease
Implications for practice: : We wanted to assess whether a shorter course (seven or fewer days) of this treatment was as good as a course of usual length (longer than seven days) and caused fewer side effects
Review Overview: We found eight studies that included 582 people with COPD who experienced a flare-up that required extra treatment in hospital. These studies compared oral or injected corticosteroid treatment given for seven or fewer days versus treatment for longer than seven days. No differences were observed between shorter and longer courses of treatment. People treated for seven or fewer days did not have a higher rate of treatment failure or longer time to their next exacerbation; the number of people who avoided treatment failure ranged from 51 fewer to 34 more per 1000 treated (average 22 fewer people per 1000). Time in hospital and lung function (blowing tests) at the end of treatment were not different. No differences in side effects or death were noted between treatments. Information on quality of life, which is an important outcome for people with COPD, is limited, as only one study measured it.
LINK to Cochrane Library: Issue 12, 2014 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006897.pub3/abstract


COCHRANE SYSTEMATIC REVIEW: Mucolytic agents for chronic bronchitis or chronic obstructive pulmonary disease
Implications for practice: Mucolytics have a small effect on acute COPD exacerbations.
Review Overview: Mucolytics are a group of medications used in the treatment of people with chronic obstructive pulmonary disease (COPD) or chronic bronchitis. This review assessed how effective they were in these patients. Mucolytic medications are intended to break up or loosen sputum (or both) and make it easier to cough up. The review authors looked at 30 studies with a total of 7436 patients. The results showed that if the medication was taken on a regular basis there could be a small reduction in the number of exacerbations (worsening of disease/symptoms) experienced by the patient. The number was approximately one less patient exacerbating for every seven treated with a mucolytic over 10 months. However, the studies included in the review were a mix of small older ones and large newer ones with the newer ones not showing as much benefit. This fact reduces our confidence in the results found. The medicines appear to be safe and well-tolerated but they do not slow the worsening of lung function in people with COPD.
LINK to Cochrane Library: Issue 8, 2012 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001287.pub4/abstract;jsessionid=5134679730D452ACE7857817E3656087.d01t02


COCHRANE SYSTEMATIC REVIEW: Intravenous beta2-agonists versus intravenous aminophylline for acute asthma
Implications for practice: Conclusions unclear.
Review Overview: They found 11 studies involving 350 patients (157 children and 193 adults) with acute asthma. No consistent evidence favouring either IV beta2-agonists or IV aminophylline was found from randomised trials of patients with acute asthma. It is recommended that these results should be viewed carefully alongside the conclusions from separate Cochrane reviews comparing IV beta2-agonists plus inhaled beta2-agonists versus inhaled beta2-agonists alone and IV aminophylline plus inhaled beta2-agonists versus inhaled beta2-agonists alone.
LINK to Cochrane Library: Issue 12, 2012 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD010256/abstract;jsessionid=AC2D492F51268B37596507F21E98A162.d01t04


COCHRANE SYSTEMATIC REVIEW: Hospital at home for acute exacerbations of chronic obstructive pulmonary disease
Implications for practice: Home care for COPD can be effective
Review Overview: These results show that fewer people are readmitted to hospital if they receive their care at home. These results are only applicable to a subgroup of patients who could be treated at home, but for a majority of the patients with acute COPD exacerbations, “ hospital at home” schemes are probably not a suitable option.
LINK to Cochrane Library: Issue 5 2012 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003573.pub2/pdf/abstract


COCHRANE SYSTEMATIC REVIEW: Angiotensin receptor blockers for heart failure
Implications for practice: Effectivness unclear
Review Overview: In patients with symptomatic heart failure and systolic dysfunction or preserved ejection fraction, Angiotensin receptor blockers compared to placebo or Angiotensin converting enzyme inhibitors do not reduce total mortality or morbidity. Adding an ARB in combination with an ACEI does not reduce total mortality or total hospital admission but increases withdrawals due to adverse effects with ACEI alone.
LINK to Cochrane Library: Issue 4 2012 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003040.pub2/pdf/abstract


COCHRANE SYSTEMATIC REVIEW: Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary oedema
Implications for practice: NPPV is an effective treatment in conjunction with standard treatment of pulmonary edema.
Review Overview: NPPV in addition to standard medical care is an effective and safe intervention for the treatment of adult patients with acute cardiogenic pulmonary oedema. The evidence to date on the potential benefit of NPPV in reducing mortality is entirely derived from small-trials and further large-scale trials are needed.
LINK to Cochrane Library: Issue 5, 2013 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD005351.pub3/abstract


COCHRANE SYSTEMATIC REVIEW: Oxygen therapy for pneumonia in adults
Implications for practice: It is unknown which oxygen delivery method is ideal
Review Overview: At present, oxygen therapy for individuals with pneumonia is commonly prescribed. However, inconsistent results on the effects of oxygen therapy on pneumonia have been reported and no systematic review has been conducted in patients with pneumonia to determine which delivery system of oxygen therapy leads to the best clinical outcome.
LINK to Cochrane Library: Issue 3, 2012 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006607.pub4/pdf/abstract


COCHRANE SYSTEMATIC REVIEW: Positive end expiratory pressure for preterm infants requiring conventional mechanical ventilation for respiratory distress syndrome or bronchopulmonary dysplasia
Implications for practice: It is not clear what level of PEEP results in the greatest benefit.
Review Overview: Positive end expiratory pressure for preterm infants requiring conventional mechanical ventilation for respiratory distress syndrome or bronchopulmonary dysplasia
LINK to Cochrane Library: Issue 1, 2012 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004500.pub2/pdf/abstract


COCHRANE SYSTEMATIC REVIEW: Home-based educational interventions for children with asthma
Implications for practice: Education about asthma is important to families
Review Overview: We found inconsistent evidence for home-based asthma education interventions compared to the standard care, education delivered outside of the home or a less intensive educational intervention delivered at home. Although, education remains a key component of managing asthma in children, advocating in numerous guidelines.
LINK to Cochrane Library: Issue 10, 2011 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD008469.pub2/pdf/abstract


COCHRANE SYSTEMATIC REVIEW: Epinephrine for Bronchiolitis
Implications for practice: Epinephrine may be effective for treatment of bronchiolitis
Review Overview: This review demonstrates the superiority of epinephrine compared to placebo for the short-term outcomes for outpatients, particularly in the first 24 hours of care. Exploratory evidence from a single study suggests benefits of epinephrine and steroid combination for later time points. More research is required to confirm the benefits of combined epinephrine and steroids among outpatients. There is no evidence of effectiveness for repeated does or prolonged use of epinephrine or epinephrine and dexamethasone combined among patients.
LINK to Cochrane Library: Issue 6, 2011 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD003123.pub3/pdf/abstract


COCHRANE SYSTEMATIC REVIEW: Symptomatic oxygen for non-hypoxaemic chronic obstructive pulmonary disease
Implications for practice: Oxygen can relive dyspnea in mildly and non-hypoxamic people with
Review Overview: Oxygen can relive dyspnea in mildly and non-hypoxamic people with COPD who would not otherwise qualify for home oxygen therapy. Given the significant heterogeneity among he included studies, clinicians should continue to evaluate patients on an individual basis until supporting data from ongoing, large randomized controlled trials are available.
LINK to Cochrane Library: Issue 6 2011 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD006429.pub2/pdf/abstract


COCHRANE SYSTEMATIC REVIEW: Thrombolytic therapy for pulmonary embolism
Implications for practice: Appears effective, but similar effectiveness to heparin
Review Overview: Thrombolytic drugs are used to dissolve blood clots in patients with clinically serious or massive pulmonary embolism (PE). The use of thrombolytic therapies was assessed since concern remains about their side effects. Based on the results of eight trials, thrombolytic agents were not any better than heparin at reducing death or the recurrence of pulmonary embolism. Limited information from only three of the trials showed that thromolytics were better at improving blood flow through the lungs. Major bleeding events were similar with both therapies.
LINK to Cochrane Library: Issue 2 2008 http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004437/frame.html


COCHRANE SYSTEMATIC REVIEW: Simple aspiration versus intercostal tube drainage for primary spontaneous pneumothorax in adults
Implications for practice: Effectiveness unknown due to insufficient data
Review Overview: Two approaches, simple aspiration or intercostal tube drainage, can be used to remove air from the pleural space in patients with spontaneous pneumothorax. In reviewing the research comparing these two methods, only one small trial of 60 patients met the inclusion criteria. The results showed that simple aspiration reduced the likelihood of the patient being hospitalized and did not differ from the effects intercostal tube drainage on the other outcomes measured.
LINK to Cochrane Library: Issue 1 2007 http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD004479/frame.html


COCHRANE SYSTEMATIC REVIEW: Lung protective ventilation strategy for the acute respiratory distress syndrome
Implications for practice: : Appears effective in the short term
Review Overview: Critically ill patients affected by severe acute respiratory failure need air to be pumped into their lungs (mechanical ventilation) to survive. Ventilation with lower tidal volume was tested in large trials. This update adds one more trial, but clinical heterogeneity still makes the interpretation of combined results difficult. Mortality is significantly reduced at day 28 and at the end of hospital stay with lung-protective ventilation, but the effects on long-term mortality are unknown.
LINK to Cochrane Library: Issue 3 – 2007 Updated review http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD003844/frame.html


COCHRANE SYSTEMATIC REVIEW: Non-invasive positive pressure ventilation (CPAP or bilevel NPPV) for cardiogenic pulmonary edema
Implications for practice: Effectiveness demonstrated, especially CPAP
Review Overview: Acute heart failure may cause the abnormal build up of fluid in the lungs, or pulmonary edema. This review found that using non-invasive positive pressure ventilation (continuous positive airway pressure (CPAP) or bilevel NPPV) plus standard medical care, improved patient outcomes over standard care alone in adults with acute cardiogenic pulmonary edema. Mortality, endotracheal intubation rate and intensive care unit length of stay was decreased without increasing the risk of heart attack during or after treatment.
LINK to Cochrane Library: Issue 3 2008 http://www.mrw.interscience.wiley.com/cochrane/clsysrev/articles/CD005351/frame.html


COCHRANE SYSTEMATIC REVIEW: Systemic corticosteroids for acute exacerbations of chronic obstructive pulmonary disease
Implications for practice: To assess the effects of corticosteroids administered orally or parenterally for treatment of acute exacerbations of COPD, and to compare the efficacy of parenteral versus oral administration.
Review Overview: There is high-quality evidence to support treatment of exacerbations of COPD with systemic corticosteroid by the oral or parenteral route in reducing the likelihood of treatment failure and relapse by one month, shortening length of stay in hospital inpatients not requiring assisted ventilation in ICU and giving earlier improvement in lung function and symptoms. There is no evidence of benefit for parenteral treatment compared with oral treatment with corticosteroid on treatment failure, relapse or mortality. There is an increase in adverse drug effects with corticosteroid treatment, which is greater with parenteral administration compared with oral treatment
LINK to Cochrane Library: Issue 9, 2014 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001288.pub4/abstract


COCHRANE SYSTEMATIC REVIEW: Long-acting muscarinic antagonists (LAMA) added to inhaled corticosteroids (ICS) versus addition of long-acting beta2-agonists (LABA) for adults with asthma
Implications for practice: Implications are currently unclear
Review Overview: People taking LAMA scored slightly worse on two scales measuring quality of life (Asthma Quality of Life Questionnaire; AQLQ) and asthma control (Asthma Control Questionnaire; ACQ); the evidence was rated high quality but the effects were small and unlikely to be clinically significant (AQLQ: mean difference (MD) -0.12, 95% CI -0.18 to -0.05; 1745 participants; 1745; 4 studies; ACQ: MD 0.06, 95% CI 0.00 to 0.13; 1483 participants; 3 studies). There was some evidence to support small benefits of LAMA over LABA on lung function, including on our pre-specified preferred measure trough forced expiratory volume in one second (FEV1) (MD 0.05 L, 95% CI 0.01 to 0.09; 1745 participants, 4 studies). However, the effects on other measures varied, and it is not clear whether the magnitude of the differences were clinically significant. More people had adverse events on LAMA but the difference with LABA was not statistically significant.
LINK to Cochrane Library: Issue 6, 2015 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD011438.pub2/abstract


COCHRANE SYSTEMATIC REVIEW: Thrombolytic therapy for pulmonary embolism
Implications for practice: Thrombolytics must be carefully considered and may not have a benefit in this group when considering the possible side effects.
Review Overview: Background A pulmonary embolism is a potentially fatal blood clot that lodges in the main artery of the lungs, straining the right side of the heart and affecting blood circulation. Patients are also at risk of new embolisms forming (recurrence). In the case of a massive pulmonary embolism, treatment to restore blood flow is urgently required. Heparin thins the blood, but newer drugs that actively break up the clots (thrombolytics) may act more quickly and be more effective. These newer drugs include streptokinase, urokinase and recombinant tissue-type plasminogen activator. The major complication of this treatment is bleeding. Key results The review authors searched the literature and included 18 studies in this update (evidence current to September 2014). The trials involved 2197 adult participants with pulmonary embolism, who were randomly assigned to a thrombolytic agent followed by heparin versus heparin alone or heparin plus placebo or surgical procedure. We were able to combine data from 17 clinical trials with a total of 2167 patients. Thrombolytics seemed to lower the likelihood of death or recurrence of blood clots over heparin. However, after excluding four very low quality studies, this benefit disappeared. On the other hand, thrombolytics caused more side effects, including major and minor bleeding events (haemorrhagic events) and stroke, than heparin alone. Limited information from five trials showed that thrombolytics were better at improving blood flow through the lungs; seven included studies showed they can improve heart function. Quality of the evidence The quality of the evidence is low because of several important design limitations, the potential influence of pharmaceutical companies and small sample sizes. We need more large, rigorous trials to understand if thrombolytic therapy is truly beneficial for pulmonary embolism.
LINK to Cochrane Library: Issue 9, 2015 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD004437.pub4/abstract


COCHRANE SYSTEMATIC REVIEW: Beta2-agonists for acute cough or a clinical diagnosis of acute bronchitis
Implications for practice: Little evidence available
Review Overview: : Study characteristics Our searches are current to May 2015. We found no new trials. In previous searches, we found seven randomised controlled trials that used beta2-agonist drugs for people with acute bronchitis. Two trials studied children aged one to 10 years (134 participants) and five were conducted in adults (418 participants). None of the studies reported receiving grants from drug-making companies to conduct the study, but people who work for a drug maker were listed as authors on reports from two trials and study drugs were supplied free of charge by the company in three trials. There is no evidence to support the use of beta2-agonists in children with acute cough who do not have evidence of airflow restriction. There is also little evidence that the routine use of beta2-agonists is helpful for adults with acute cough. These agents may reduce symptoms, including cough, in people with evidence of airflow restriction. However, this potential benefit is not well supported by the available data and must be weighed against the adverse effects associated with their use.
LINK to Cochrane Library: Issue 9, 2015 http://onlinelibrary.wiley.com/doi/10.1002/14651858.CD001726.pub5/abstract