LEARN | Module 4

Practising Critical Appraisal

This week we will be doing things a little differently! To put in to practice everything you have learnt over the past three modules, read through the following scenario and then complete the attached worksheet. As always, please post any questions, comments or suggestions in the Disqus comment feed at the bottom of the module!

Scenario

You are the resident assessing a patient with an infective exacerbation of chronic obstructive pulmonary disease (COPD) in the emergency department.

Mrs DW is a 72-year old-woman with known COPD. She regularly attends the outpatient department, but has not previously required admission for COPD. Her past medical history includes hypertension and late onset diabetes (managed with dietary modifications alone). She stopped smoking 2 years ago having previously smoked approximately a packet of cigarettes per day for 40 years. Her usual medications include salbutamol 200mg MDI 2 puffs 6 hourly, Atrovent MDI 2 puffs 6 hourly and diltiazem slow release 240mg oral daily. She has no history of asthma and her previous lung function tests demonstrate severe fixed airflow obstruction with a baseline FEV1 of 0.9L.

She now presents with a week of increasing shortness of breath and productive cough. After taking a history and examining her, you conclude that she has an infective exacerbation of COPD. There is no evidence of pneumonia on her chest x-ray, but she is hypoxic and requires admission for oxygen therapy and treatment of airways disease. You commence treatment with regular nebulised bronchodilators, intranasal oxygen (2L/min), oral antibiotics and intravenous hydrocortisone 250mg IV QID.

Information gap

You are aware that systemic corticosteroids are usually used for the management of exacerbations of COPD, but you have heard colleagues cast doubt on the value of this treatment in the past. You decide to find out what evidence there is available to support the use of systemic corticosteroids for exacerbations of COPD and, in particular, whether this treatment should be offered to your patient.

Clinical question

How effective are systemic corticosteroids in the treatment for COPD in elderly patients with hypertension and diabetes?

You identify the following study:

Niewoehner DE, Erbland M, Deupree R, et al. Effect of systemic glucocorticoids on exacerbations of chronic obstructive pulmonary disease. New England Journal of Medicine 1999;340:1940-1947.

The article is available here or here.

Task

Critically appraise this article using this worksheet and submit it to friends4fiji@gmail.com