Background
Non‐invasive ventilation (NIV) with bi‐level positive airway pressure (BiPAP) is commonly used to treat patients admitted to hospital with acute hypercapnic respiratory failure (AHRF) ...secondary to an acute exacerbation of chronic obstructive pulmonary disease (AECOPD).
Objectives
To compare the efficacy of NIV applied in conjunction with usual care versus usual care involving no mechanical ventilation alone in adults with AHRF due to AECOPD. The aim of this review is to update the evidence base with the goals of supporting clinical practice and providing recommendations for future evaluation and research.
Search methods
We identified trials from the Cochrane Airways Group Specialised Register of trials (CAGR), which is derived from systematic searches of bibliographic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), the Allied and Complementary Medicine Database (AMED), and PsycINFO, and through handsearching of respiratory journals and meeting s. This update to the original review incorporates the results of database searches up to January 2017.
Selection criteria
All randomised controlled trials that compared usual care plus NIV (BiPAP) versus usual care alone in an acute hospital setting for patients with AECOPD due to AHRF were eligible for inclusion. AHRF was defined by a mean admission pH < 7.35 and mean partial pressure of carbon dioxide (PaCO2) > 45 mmHg (6 kPa). Primary review outcomes were mortality during hospital admission and need for endotracheal intubation. Secondary outcomes included hospital length of stay, treatment intolerance, complications, changes in symptoms, and changes in arterial blood gases.
Data collection and analysis
Two review authors independently applied the selection criteria to determine study eligibility, performed data extraction, and determined risk of bias in accordance with Cochrane guidelines. Review authors undertook meta‐analysis for data that were both clinically and statistically homogenous, and analysed data as both one overall pooled sample and according to two predefined subgroups related to exacerbation severity (admission pH between 7.35 and 7.30 vs below 7.30) and NIV treatment setting (intensive care unit‐based vs ward‐based). We reported results for mortality, need for endotracheal intubation, and hospital length of stay in a 'Summary of findings' table and rated their quality in accordance with GRADE criteria.
Main results
We included in the review 17 randomised controlled trials involving 1264 participants. Available data indicate that mean age at recruitment was 66.8 years (range 57.7 to 70.5 years) and that most participants (65%) were male. Most studies (12/17) were at risk of performance bias, and for most (14/17), the risk of detection bias was uncertain. These risks may have affected subjective patient‐reported outcome measures (e.g. dyspnoea) and secondary review outcomes, respectively.
Use of NIV decreased the risk of mortality by 46% (risk ratio (RR) 0.54, 95% confidence interval (CI) 0.38 to 0.76; N = 12 studies; number needed to treat for an additional beneficial outcome (NNTB) 12, 95% CI 9 to 23) and decreased the risk of needing endotracheal intubation by 65% (RR 0.36, 95% CI 0.28 to 0.46; N = 17 studies; NNTB 5, 95% CI 5 to 6). We graded both outcomes as 'moderate' quality owing to uncertainty regarding risk of bias for several studies. Inspection of the funnel plot related to need for endotracheal intubation raised the possibility of some publication bias pertaining to this outcome. NIV use was also associated with reduced length of hospital stay (mean difference (MD) ‐3.39 days, 95% CI ‐5.93 to ‐0.85; N = 10 studies), reduced incidence of complications (unrelated to NIV) (RR 0.26, 95% CI 0.13 to 0.53; N = 2 studies), and improvement in pH (MD 0.05, 95% CI 0.02 to 0.07; N = 8 studies) and in partial pressure of oxygen (PaO2) (MD 7.47 mmHg, 95% CI 0.78 to 14.16 mmHg; N = 8 studies) at one hour. A trend towards improvement in PaCO2 was observed, but this finding was not statistically significant (MD ‐4.62 mmHg, 95% CI ‐11.05 to 1.80 mmHg; N = 8 studies). Post hoc analysis revealed that this lack of benefit was due to the fact that data from two studies at high risk of bias showed baseline imbalance for this outcome (worse in the NIV group than in the usual care group). Sensitivity analysis revealed that exclusion of these two studies resulted in a statistically significant positive effect of NIV on PaCO2. Treatment intolerance was significantly greater in the NIV group than in the usual care group (risk difference (RD) 0.11, 95% CI 0.04 to 0.17; N = 6 studies). Results of analysis showed a non‐significant trend towards reduction in dyspnoea with NIV compared with usual care (standardised mean difference (SMD) ‐0.16, 95% CI ‐0.34 to 0.02; N = 4 studies). Subgroup analyses revealed no significant between‐group differences.
Authors' conclusions
Data from good quality randomised controlled trials show that NIV is beneficial as a first‐line intervention in conjunction with usual care for reducing the likelihood of mortality and endotracheal intubation in patients admitted with acute hypercapnic respiratory failure secondary to an acute exacerbation of chronic obstructive pulmonary disease (COPD). The magnitude of benefit for these outcomes appears similar for patients with acidosis of a mild (pH 7.30 to 7.35) versus a more severe nature (pH < 7.30), and when NIV is applied within the intensive care unit (ICU) or ward setting.
Background
Studies report that up to 80% of individuals with chronic obstructive pulmonary disease (COPD) may struggle with symptoms of depression. However, this major comorbidity in COPD is rarely ...managed effectively. A number of recent studies indicate that left untreated, COPD‐related depression is associated with worse quality of life, worse compliance with COPD treatment plan, increased exacerbations, hospital admissions, and healthcare costs when compared to individuals with COPD without depression. Regrettably, COPD practice guidelines do not provide conclusive treatment recommendations for the use of antidepressants in patients with COPD, and base their guidelines on findings from trials in the general population. This may be problematic, as there is an elevated risk of respiratory issues associated with antidepressant treatment and COPD. Evaluating effectiveness and safety of pharmacological interventions specifically for patients with COPD and depression was therefore paramount.
Objectives
To assess the effectiveness and safety of pharmacological interventions for the treatment of depression in patients with COPD.
Search methods
The last search was performed on 26 November 2018. We initially searched the following databases via the Specialised Trials Registers of the Cochrane Airways and Common Mental Disorders Groups (to June 2016): MEDLINE, Embase, PsycINFO, CINAHL, AMED, and the Cochrane Library trials register (CENTRAL). Searches from June 2016 to November 2018 were performed directly on Ovid MEDLINE, Embase, PsycINFO and the Cochrane Library (Issue 11, 2018). We searched ClinicalTrials.gov, the ISRCTN registry, and the World Health Organization International Clinical Trials Registry Platform to 26 November 2018. We searched the grey literature databases to identify studies not indexed in major databases and the reference lists of studies initially identified for full‐text screening.
Selection criteria
All published and unpublished randomised controlled trials (RCTs) comparing the efficacy of pharmacological interventions with no intervention, placebo or co‐intervention in adults with diagnosed COPD and depression were eligible for inclusion.
Data collection and analysis
Two review authors independently assessed articles identified by the search for eligibility. Our primary outcomes were change in depressive symptoms and adverse events. The secondary outcomes were: change in quality of life, change in dyspnoea, change in forced expiratory volume in one second (FEV1), change in exercise tolerance, change in hospital utilisation (length of stay and readmission rates), and cost‐effectiveness. For continuous outcomes, we calculated the pooled mean difference (MD) or standardised mean difference (SMD) with 95% confidence interval (CI) as appropriate. For dichotomous outcomes, we calculated the pooled odds ratio (OR) and corresponding 95% CI using a random‐effects model. We assessed the quality of evidence using the GRADE framework.
Main results
Of the 1125 records screened for eligibility, four RCTs (N = 201 participants), and one on‐going study, met the inclusion criteria. Two classes of antidepressants were investigated in two separate comparisons with placebo: a tricyclic antidepressant (TCA) and selective serotonin reuptake inhibitors (SSRIs).
TCA versus placebo
Only one RCT (N = 30 participants) provided results for this comparison.
Primary outcomes
The TCA (nortriptyline) reduced depressive symptoms post‐treatment compared to placebo (MD ‐10.20, 95% CI ‐16.75 to ‐3.65; P = 0.007; very low‐quality evidence), as measured by the Hamilton Depression Rating Scale (HAM‐D). Three participants withdrew from the trial due to adverse events related to the tested antidepressant (dry mouth, sedation, orthostatic hypotension).
Secondary outcomes
The overall results post‐treatment indicated that nortriptyline was not effective in improving the quality of life of individuals with COPD, as measured by the Sickness Impact Profile (MD ‐2.80, 95% CI ‐11.02 to 5.42; P = 0.50; very low‐quality evidence).
The results for the change in dyspnoea for the domains examined (e.g. dyspnoea scores for 'most day‐to‐day activities') post‐treatment showed no improvement in the intervention group (MD 9.80, 95% CI ‐6.20 to 25.80; P = 0.23; very low‐quality evidence).
No data were reported for change in FEV1, change in exercise tolerance, change in hospital utilisation, or cost‐effectiveness. The TCA study provided short‐term results, with the last follow‐up data collection at 12 weeks.
The quality of the evidence for all the outcomes evaluated was very low due to a small sample size, imprecision, attrition, and selection and reporting bias.
SSRIs versus placebo
Three RCTs (N = 171 participants) provided results for this comparison.
Primary outcomes
The pooled results for two studies showed no difference for the change in depressive symptoms post‐intervention (SMD 0.75, 95% CI ‐1.14 to 2.64; 148 participants; 2 studies; P = 0.44; very low‐quality evidence). High heterogeneity was observed (I² = 95%), limiting the reliability of these findings.
While it was not possible to meta‐analyse the total adverse events rates across the studies, it was possible to combine the results for two medication‐specific adverse effects: nausea and dizziness. There were no significant post‐treatment group differences for nausea (OR 2.32, 95% CI 0.66 to 8.12; 171 participants; 3 studies; P = 0.19; very low‐quality evidence) or dizziness (OR 0.61, 95% CI 0.09 to 4.06; 143 participants; 2 studies; P = 0.61; very low‐quality evidence).
Secondary outcomes
The pooled analysis of two trials reporting data for the change in quality of life did not show improvement post‐treatment in the intervention group compared to placebo (SMD 1.17, 95% CI ‐0.80 to 3.15; 148 participants; 2 studies; P = 0.25; very low‐quality evidence).
There was no difference between groups in change in FEV1 post‐treatment (MD 0.01, 95% CI ‐0.03 to 0.05; 148 participants; 2 studies; P = 0.60; low‐quality evidence). However, two trials reported improvement in exercise tolerance in the SSRI group versus the placebo group (MD 13.88, 95% CI 11.73 to 16.03; 148 participants; 2 studies; P < 0.001; very low‐quality evidence).
The trials included in this comparison did not report data related to the change in dyspnoea, hospital utilisation rates, or cost‐effectiveness.
Authors' conclusions
There is insufficient evidence to make definitive statements about the efficacy or safety of antidepressants for treating COPD‐related depression. New RCTs are needed; with better methodological quality and more accurate reporting of the methods used. Moreover, longer‐term follow‐up data collection is needed, including outcomes such as adverse events, hospital utilisation and cost‐effectiveness.
Background
Chronic obstructive pulmonary disease (COPD) has been recognised as a global health concern, and one of the leading causes of morbidity and mortality worldwide. Projections of the World ...Health Organization (WHO) indicate that prevalence rates of COPD continue to increase, and by 2030, it will become the world's third leading cause of death. Depression is a major comorbidity amongst patients with COPD, with an estimate prevalence of up to 80% in severe stages of COPD. Prevalence studies show that patients who have COPD are four times as likely to develop depression compared to those without COPD. Regrettably, they rarely receive appropriate treatment for COPD‐related depression. Available findings from trials indicate that untreated depression is associated with worse compliance with medical treatment, poor quality of life, increased mortality rates, increased hospital admissions and readmissions, prolonged length of hospital stay, and subsequently, increased costs to the healthcare system. Given the burden and high prevalence of untreated depression, it is important to evaluate and update existing experimental evidence using rigorous methodology, and to identify effective psychological therapies for patients with COPD‐related depression.
Objectives
To assess the effectiveness of psychological therapies for the treatment of depression in patients with chronic obstructive pulmonary disease.
Search methods
We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (2018, Issue 11), and Ovid MEDLINE, Embase and PsycINFO from June 2016 to 26 November 2018. Previously these databases were searched via the Cochrane Airways and Common Mental Disorders Groups' Specialised Trials Registers (all years to June 2016). We searched ClinicalTrials.gov, the ISRCTN registry, and the World Health Organization International Clinical Trials Registry Platform (ICTRP) to 26 November 2018 to identify unpublished or ongoing trials. Additionally, the grey literature databases and the reference lists of studies initially identified for full‐text screening were also searched.
Selection criteria
Eligible for inclusion were randomised controlled trials that compared the use of psychological therapies with either no intervention, education, or combined with a co‐intervention and compared with the same co‐intervention in a population of patients with COPD whose depressive symptoms were measured before or at baseline assessment.
Data collection and analysis
Two review authors independently assessed the titles and s identified by the search to determine which studies satisfied the inclusion criteria. We assessed two primary outcomes: depressive symptoms and adverse events; and the following secondary outcomes: quality of life, dyspnoea, forced expiratory volume in one second (FEV1), exercise tolerance, hospital length of stay or readmission rate, and cost‐effectiveness. Potentially eligible full‐text articles were also independently assessed by two review authors. A PRISMA flow diagram was prepared to demonstrate the decision process in detail. We used the Cochrane 'Risk of bias' evaluation tool to examine the risk of bias, and assessed the quality of evidence using the GRADE framework. All outcomes were continuous, therefore, we calculated the pooled standardised mean difference (SMD) or mean difference (MD) with a corresponding 95% confidence interval (CI). We used a random‐effects model to calculate treatment effects.
Main results
The findings are based on 13 randomised controlled trials (RCTs), with a total of 1500 participants. In some of the included studies, the investigators did not recruit participants with clinically confirmed depression but applied screening criteria after randomisation. Hence, across the studies, baseline scores for depressive symptoms varied from no symptoms to severe depression. The severity of COPD across the studies was moderate to severe.
Primary outcomes
There was a small effect showing the effectiveness of psychological therapies in improving depressive symptoms when compared to no intervention (SMD 0.19, 95% CI 0.05 to 0.33; P = 0.009; 6 studies, 764 participants), or to education (SMD 0.23, 95% CI 0.06 to 0.41; P = 0.010; 3 studies, 507 participants).
Two studies compared psychological therapies plus a co‐intervention versus the co‐intervention alone (i.e. pulmonary rehabilitation (PR)). The results suggest that a psychological therapy combined with a PR programme can reduce depressive symptoms more than a PR programme alone (SMD 0.37, 95% CI ‐0.00 to 0.74; P = 0.05; 2 studies, 112 participants).
We rated the quality of evidence as very low. Owing to the nature of psychological therapies, blinding of participants, personnel, and outcome assessment was a concern.
None of the included studies measured adverse events.
Secondary outcomes
Quality of life was measured in four studies in the comparison with no intervention, and in three studies in the comparison with education. We found inconclusive results for improving quality of life. However, when we pooled data from two studies using the same measure, the result suggested that psychological therapy improved quality of life better than no intervention. One study measured hospital admission rates and cost‐effectiveness and showed significant reductions in the intervention group compared to the education group. We rated the quality of evidence as very low for the secondary outcomes.
Authors' conclusions
The findings from this review indicate that psychological therapies (using a CBT‐based approach) may be effective for treating COPD‐related depression, but the evidence is limited. Depressive symptoms improved more in the intervention groups compared to: 1) no intervention (attention placebo or standard care), 2) educational interventions, and 3) a co‐intervention (pulmonary rehabilitation). However, the effect sizes were small and quality of the evidence very low due to clinical heterogeneity and risk of bias. This means that more experimental studies with larger numbers of participants are needed, to confirm the potential beneficial effects of therapies with a CBT approach for COPD‐related depression.
New trials should also address the gap in knowledge related to limited data on adverse effects, and the secondary outcomes of quality of life, dyspnoea, forced expiratory volume in one second (FEV1), exercise tolerance, hospital length of stay and frequency of readmissions, and cost‐effectiveness. Also, new research studies need to adhere to robust methodology to produce higher quality evidence.
Time to rethink tobacco dependence treatment in Australia Buchanan, Tanya; White, Sarah L.; Marshall, Henry ...
Australian and New Zealand journal of public health,
December 2021, 2021-Dec, 2021-12-00, 20211201, 2021-12-01, Letnik:
45, Številka:
6
Journal Article
Recenzirano
Odprti dostop
Despite, widespread success and reductions in smoking prevalence rates, tobacco use remains the leading modifiable risk factor for ill health in Australia accounting for 22% of the cancer burden, 12% ...of cardiovascular disease and 41% of respiratory illness.1 The forthcoming National Preventive Health Strategy identifies reducing tobacco use as a priority for all Australian Governments and cites “increased provision and access to evidence-based cessation services and support to help people who use tobacco to quit “as a key policy area.2 Australia, as a signatory to the Framework Convention on Tobacco Control (FCTC), has an obligation to provide evidence-based tobacco dependence treatment (TDT) as part of routine health care. Article 14 of the FCTC requires signatories to ensure cessation access and develop and implement a national cessation strategy, national treatment guidelines and a consistent approach to training health practitioners to provide brief advice, all of which must be free from conflicts of interest and integrated with comprehensive population level tobacco control measures.3 The recent TGA decision on liquid nicotine and the introduction of smoking cessation via telehealth together with the aspiration of increasing cessation in the new National Preventive Health Strategy provides an opportune moment for a commitment to improving the provision of TDT. In this commentary, we argue that TDT is an overlooked component of Australia’s comprehensive national tobacco strategy and must be implemented urgently to complement population level actions that prevent uptake and encourage cessation.
Issue addressed: Health professionals have described barriers to providing carer smoking cessation support in children's wards. This article reports the findings of a research translation process ...that explored opportunities and developed pathways for change.
Methods: A facilitated discussion workshop and scheduled stakeholder meetings were used to evaluate research evidence and translate it to an evidence-informed organisational change process, with actions for implementation. Workshop and meeting participants were senior health staff with either a pharmacist, personnel with expertise in alcohol and other drugs, medical or nursing backgrounds, and who held senior managerial roles who worked in a hospital in the Northern Territory. A qualitative approach was used. The data from the workshop were transcribed and analysed using thematic analysis. The first author took notes for meetings that were not recorded and analysed these alongside the transcripts.
Results: The process was able to initiate change to overcome barriers to providing carer smoking cessation support. All participants agreed to prioritise and make carer smoking cessation everybody's responsibility and supported a systematic approach, including provision of nicotine replacement therapy, new record-keeping systems, and training to address staff knowledge deficits and skills gaps. This movement to solution-focused change continued after the workshop.
Conclusions: With some preparation, a research translation workshop and meetings with selected leaders can initiate organisational change in similar settings and is consistent with theories of planned change.
So what?: This article describes the use of a process to support health promotion through new policies and practices following research which identified barriers in a hospital ward.
ABSTRACT
The TSANZ develops position statements where insufficient data exist to write formal clinical guidelines. In 2018, the TSANZ addressed the question of potential benefits and health impacts ...of electronic cigarettes (EC). The working party included groups focused on health impacts, smoking cessation, youth issues and priority populations. The 2018 report on the Public Health Consequences of E‐Cigarettes from the United States NASEM was accepted as reflective of evidence to mid‐2017. A search for papers subsequently published in peer‐reviewed journals was conducted in August 2018. A small number of robust and important papers published until March 2019 were also identified and included. Groups identified studies that extended, modified or contradicted the NASEM report. A total of 3793 papers were identified and reviewed, with summaries and draft position statements developed and presented to TSANZ membership in April 2019. After feedback from members and external reviewers, a collection of position statements was finalized in December 2019. EC have adverse lung effects and harmful effects of long‐term use are unknown. EC are unsuitable consumer products for recreational use, part‐substitution for smoking or long‐term exclusive use by former smokers. Smokers who require support to quit smoking should be directed towards approved medication in conjunction with behavioural support as having the strongest evidence for efficacy and safety. No specific EC product can be recommended as effective and safe for smoking cessation. Smoking cessation claims in relation to EC should be assessed by established regulators.
Background
The vicious cycle hypothesis for bronchiectasis predicts that bacterial colonisation of the respiratory tract perpetuates inflammatory change. This damages the mucociliary escalator, ...preventing bacterial clearance and allowing persistence of pro‐inflammatory mediators. Conventional treatment with physiotherapy and intermittent antibiotics is believed to improve the condition of people with bronchiectasis, although no conclusive data show that these interventions influence the natural history of the condition. Various strategies have been tried to interrupt this cycle of infection and inflammation, including prolonging antibiotic treatment with the goal of allowing the airway mucosa to heal.
Objectives
To determine the benefits of prolonged antibiotic therapy in the treatment of patients with bronchiectasis.
Search methods
We searched the Cochrane Airways Group Trials Register and reference lists of identified articles. Searches were current as of February 2014.
Selection criteria
Randomised trials examining the use of prolonged antibiotic therapy (for four or more weeks) in the treatment of bronchiectasis compared with placebo or usual care.
Data collection and analysis
Two review authors independently assessed trial quality and extracted data. We contacted study authors to ask for missing information.
Main results
Eighteen trials met the inclusion criteria, randomly assigning a total of 1157 participants. Antibiotics were given for between four weeks and 83 weeks. Limited meta‐analysis was possible because of the diversity of outcomes reported in these trials. Based on the number of participants with at least one exacerbation, the meta‐analysis showed significant effects in favour of the intervention (odds ratio (OR) 0.31, 95% confidence interval (CI) 0.19 to 0.52; P value < 0.00001), with events occurring in 271 per 1000 people in the intervention arm (95% CI 126 to 385) and in 546 per 1000 in the control population, based on evidence of moderate quality. A non‐statistically significant reduction in hospitalisation favoured the use of prolonged antibiotics with a moderate quality grade of supporting evidence (37 per 1000 in the intervention arm (95% CI 13 to 96) and 87 per 1000 in control (OR 0.40, 95% CI 0.14 to 1.11; P value = 0.08). Drug resistance developed in 36 of 220 participants taking antibiotics compared with 10 of 211 participants given placebo or standard therapy (OR 3.48, 95% CI 1.20 to 10.07; P value = 0.02), translating to natural frequencies of 155 per 1000 in the intervention arm (95% CI 59 to 346) and 50 per 1000 in the control arm. The intervention was well tolerated with no overall significant difference in withdrawal between treatment and placebo groups (OR 0.91, 95% CI 0.56 to 1.49). Diarrhoea was commonly reported as an adverse event, particularly with an oral intervention.
Authors' conclusions
Available evidence shows benefit associated with use of prolonged antibiotics in the treatment of patients with bronchiectasis, at least halving the odds of exacerbation (with 275 fewer exacerbations per every 1000 people treated in the antibiotic arm compared with the control arm) and hospitalisation (50 fewer hospitalisations per 1000 people in the antibiotic arm compared with the control arm). However, the risk of emerging drug resistance is increased more than threefold. This review is limited by diversity of trials and by evidence of moderate to low quality. Further randomised controlled trials with adequate power and standardised end points are required.
Background
Asthma and gastro‐oesophageal reflux disease (GORD) are common medical conditions that frequently co‐exist. GORD has been postulated as a trigger for asthma; however, evidence remains ...conflicting. Proposed mechanisms by which GORD causes asthma include direct airway irritation from micro‐aspiration and vagally mediated oesophagobronchial reflux. Furthermore, asthma might precipitate GORD. Thus a temporal association between the two does not establish that GORD triggers asthma.
Objectives
To evaluate the effectiveness of GORD treatment in adults and children with asthma, in terms of its benefits for asthma.
Search methods
The Cochrane Airways Group Specialised Register, CENTRAL, MEDLINE, Embase, reference lists of articles, and online clinical trial databases were searched. The most recent search was conducted on 23 June 2020.
Selection criteria
We included randomised controlled trials comparing treatment of GORD in adults and children with a diagnosis of both asthma and GORD versus no treatment or placebo.
Data collection and analysis
A combination of two independent review authors extracted study data and assessed trial quality. The primary outcome of interest for this review was acute asthma exacerbation as reported by trialists.
Main results
The systematic search yielded a total of 3354 citations; 23 studies (n = 2872 participants) were suitable for inclusion. Included studies reported data from participants in 25 different countries across Europe, North and South America, Asia, Australia, and the Middle East. Participants included in this review had moderate to severe asthma and a diagnosis of GORD and were predominantly adults presenting to a clinic for treatment. Only two studies assessed effects of intervention on children, and two assessed the impact of surgical intervention. The remainder were concerned with medical intervention using a variety of dosing protocols.
There was an uncertain reduction in the number of participants experiencing one or more moderate/severe asthma exacerbations with medical treatment for GORD (odds ratio 0.53, 95% confidence interval (CI) 0.17 to 1.63; 1168 participants, 2 studies; low‐certainty evidence). None of the included studies reported data related to the other primary outcomes for this review: hospital admissions, emergency department visits, and unscheduled doctor visits.
Medical treatment for GORD probably improved forced expiratory volume in one second (FEV₁) by a small amount (mean difference (MD) 0.10 L, 95% CI 0.05 to 0.15; 1333 participants, 7 studies; moderate‐certainty evidence) as well as use of rescue medications (MD ‐0.71 puffs per day, 95% CI ‐1.20 to ‐0.22; 239 participants, 2 studies; moderate‐certainty evidence). However, the benefit of GORD treatment for morning peak expiratory flow rate was uncertain (MD 6.02 L/min, 95% CI 0.56 to 11.47; 1262 participants, 5 studies). It is important to note that these mean improvements did not reach clinical importance. The benefit of GORD treatment for outcomes synthesised narratively including benefits of treatment for asthma symptoms, quality of life, and treatment preference was likewise uncertain. Data related to adverse events with intervention were generally underreported by the included studies, and those that were available indicated similar rates regardless of allocation to treatment or placebo.
Authors' conclusions
Effects of GORD treatment on the primary outcomes of number of people experiencing one or more exacerbations and hospital utilisation remain uncertain. Medical treatment for GORD in people with asthma may provide small benefit for a number of secondary outcomes related to asthma management. This review determined with moderate certainty that with treatment, lung function measures improved slightly, and use of rescue medications for asthma control was reduced. Further, evidence is insufficient to assess results in children, or to compare surgery versus medical therapy.
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