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CPAP and NIPPV are no better than O₂ in acute pulmonary edema

Clinical question Does noninvasive ventilation improve outcomes in patients with acute cardiogenic pulmonary edema?

Bottom line In patients with acute cardiogenic pulmonary edema, continuous positive airway pressure (CPAP) and noninvasive positive pressure support (NIPPV) do not reduce mortality or the risk of requiring intubation more than standard oxygen (O₂) therapy. They may provide a small benefit in terms of greater relief of dyspnea. (Level of evidence = 1b)

Synopsis The optimal approach to noninvasive ventilation for patients with acute cardiogenic pulmonary edema remains unclear, with only a few small randomized controlled trials. CPAP provides the same level of positive airway pressure throughout the respiratory cycle, whereas NIPPV increases pressure more during inspiration than during expiration. There are theoretical reasons to think that NIPPV may be better, but it has also been associated with a greater risk of acute MI. In this study, 1,069 adults with acute cardiogenic pulmonary edema at 26 United Kingdom emergency departments were randomized to receive O₂ therapy, CPAP, or NIPPV. All patients had pulmonary edema on chest radiograph, a pH of less than 7.35, and a respiratory rate greater than 20 breaths per minute. Their mean age was 78 years and 57% were women. All patients received the assigned treatment for at least 2 hours, with the duration of further treatment determined by the treating physician. Groups were balanced at the start of the study and analysis was by intention to treat. Overall adherence to the assigned treatment was good, although patients initially assigned to O₂ were more likely to change therapy because of respiratory distress (8.4% vs 1.4% for CPAP and 3.4% for NIPPV; P < .001), whereas those assigned to NIPPV were more likely to change therapy because of patient discomfort (8.4% vs 5.2% for CPAP and 0.3% for O₂; P < .001). After 7 days, there was no significant difference between groups regarding rates of mortality or need for intubation, or regarding mortality at 30 days. Patients receiving CPAP or NIPPV had a greater improvement on a 10-point dyspnea score than those receiving O₂ alone (4.6 vs 3.9 points), but this difference is of questionable clinical significance. There were also greater improvements in arterial pCO₂ and pH, but again the clinical significance is uncertain.

Gray A, Goodacre S, Newby DE, et al; 3CPO Trialists. Noninvasive ventilation in acute cardiogenic pulmonary edema. N Engl J Med. 2008;359(2):142-151.

USPSTF recommends screening for diabetes in hypertensive patients

Clinical question Who should be screened for the presence of type 2 diabetes?

Bottom line Patients with BP greater than 135/80 mm Hg should be screened no more frequently than every 3 years for the presence of type 2 diabetes. In patients with both hypertension and type 2 diabetes, coronary heart disease prevention should be intensified, because strict control of blood glucose offers only a small benefit in comparison. (Level of evidence = 5)

Synopsis This guideline from the United States Preventive Services Task Force (USPSTF) is based on a systematic review evaluating the current evidence of benefit for screening for type 2 diabetes (Ann Intern Med. 2008; 148[11]:855-868). There is no direct evidence of benefit of screening for diabetes compared with treating patients when the diagnosis is made. Even then, intensive control of blood glucose has not been shown to reduce macrovascular and other patient- oriented outcomes. However, there may be benefit to intensifying coronary heart disease strategies—aspirin, BP control, lipid lowering—in patients identified with type 2 diabetes. The USPSTF recommends screening for type 2 diabetes in patients with treated or untreated BP greater than 135/80 mm Hg (grade B recommendation: moderate to high certainty of a moderate to high benefit). They do not recommend screening of asymptomatic individuals without this slight elevation in BP.

U.S. Preventive Services Task Force. Screening for Type 2 diabetes mellitus in adults: U.S. Preventive Services Task Force Recommendation Statement. Ann Intern Med. 2008;148(11):846-854.

Nesiritide provides no additional benefit in ED treatment of heart failure

Clinical question In patients presenting to an emergency department with acutely decompensated heart failure, does the addition of nesiritide to standard treatment decrease return visits or hospitalization?

Bottom line Nesiritide (Natrecor), when added to standard therapy for heart failure in the emergency department, does not reduce return visits or hospitalizations over the subsequent 30 days compared with standard therapy alone. (Level of evidence = 1b)

Synopsis Nesiritide is a B-type natriuretic peptide that decreases afterload through vasodilation and natriuresis. The researchers conducting this study enrolled 101 patients using concealed allocation. All patients had heart failure ranging from New York Heart Association class II (dyspnea on exertion) to class IV (dyspnea at rest or with minimal exertion). More than half of the patients were men. All patients were treated with a standard protocol of oxygen as needed, diuretic, and the patient’s previous therapy. Patients also received normal saline placebo or nesiritide, 2 mcg/kg bolus followed by 0.01 mcg/kg per minute for up to 8 hours. Re-admission to the emergency department or hospital over the next 30 days was similar in both groups, occurring in 41.5% of patients receiving nesiritide and 39.6% of patients receiving placebo (P = NS).

Miller AH, Nazeer S, Pepe P, et al. Acutely decompensated heart failure in a county emergency department: a double-blind randomized controlled comparison of nesiritide versus placebo treatment. Ann Emerg Med. 2008;51(5):571-578.

Antidepressants are helpful in chronic rheumatic and other pain disorders

Clinical question Are antidepressants helpful in managing pain in patients with chronic rheumatic disorders?

Bottom line In general, antidepressants are modestly effective in managing chronic pain and weakly effective in managing rheumatic conditions. Tricyclic antidepressants (TCAs) are the most widely studied antidepressants and are more effective than selective serotonin reuptake inhibitors (SSRIs). Finally, antidepressants are effective in alleviating the sleep disturbances and fatigue associated with these conditions. (Level of evidence = 2a)

Synopsis This team of researchers searched several databases and the bibliographies of relevant papers (including published guidelines and other systematic reviews). Two reviewers independently assessed the study quality and assigned a quality score. To be included, a paper had to have a quality score of 2 or higher (maximum Jadad score = 5). The team used pain as the primary outcome and calculated analgesic effect sizes (the difference between the analgesic effect of the antidepressant and the analgesic effect of the placebo). Although antidepressants were effective in reducing pain, the authors found no consistent data demonstrating a dose response to antidepressants in treating chronic pain. They also found that the analgesic effect begins before seeing the antidepressant response. In treating chronic nonmalignant pain, the analgesic effect size was greater for TCAs than for other classes, and SSRIs were generally ineffective. In treating fibromyalgia, the authors found a significant placebo effect and found the effects of antidepressants modest and of short duration. TCAs appear to be more effective than SSRIs in treating fibromyalgia, but a few studies have demonstrated the combination of a TCA and an SSRI has synergistic effects. In addition to pain, antidepressants alleviate fatigue, sleep disturbances, and functional impairment in patients with fibromyalgia. In treating low back pain, TCAs have been the most studied antidepressants and appear to be effective; however, the overall quality of the studies is poor. Only 2 studies have assessed SSRIs. The authors found 15 randomized controlled trials of antidepressants in patients with rheumatoid arthritis and ankylosing spondylitis, but only eight met the quality threshold. TCAs have weak analgesic effect in rheumatoid arthritis. The authors found no studies of antidepressants in degenerative joint disease.

Perrot S, Javier RM, Marty M, et al; CEDR (Cercle d’Etude de la Douleur en Rhumatologie France), French Rheumatological Society, Pain Study Section. Is there any evidence to support the use of anti-depressants in painful rheumatological conditions? Systematic review of pharmacological and clinical studies. Rheumatology (Oxford). 2008;47(8):1117-1123.

ADAPT finds NSAIDs do not improve cognitive function in older adults

Clinical question Do NSAIDs prevent cognitive decline in older adults?

Bottom line In this randomized trial, NSAIDs were no better than placebo in preventing cognitive decline in the elderly. (Level of evidence = 2b)

Synopsis In order to be eligible for the Alzheimer’s Disease Anti-inflammatory Prevention Trial (ADAPT), patients had to be older than 70 years and have at least one relative with Alzheimer’s disease, but not have any cognitive impairment on standardized test batteries. Patients regularly using NSAIDs were ineligible. Patients were randomly assigned to receive celecoxib (200 mg twice a day; n = 726), naproxen sodium (220 mg twice a day; n = 719), or placebo (n = 1,083). Patients underwent several tests of cognitive function at baseline and throughout the study, all evaluated by intention to treat. Although originally designed as a 7-year study, this study was terminated after 4 years because of safety concerns raised about celecoxib in another study. At the time of the termination of the study, cognitive function declined at the same rate in all three groups. This study was powerful enough to detect a 30% reduction in the incidence of Alzheimer’s disease.

ADAPT Research Group, Martin BK, Szekely C, Brandt J, et al. Cognitive function over time in the Alzheimer’s Disease Anti-inflammatory Prevention Trial (ADAPT): results of a randomized, controlled trial of naproxen and celecoxib. Arch Neurol. 2008; 65(7):896-905.

Saline irrigation is more effective than spray for nasal symptoms

Clinical question Is nasal washing more effective than saline spray at decreasing symptoms in patients with chronic nasal or sinus symptoms?

Bottom line Nasal irrigation, nasal washing using a stream of normal saline, is more effective in decreasing general nasal or sinus symptoms than saline spray. The saline can be made at home, purchased as a kit, or administered using a neti pot. Direct your patients to an online source of video (eg, www.youtube.com) to see how it is administered. (Level of evidence = 1b)

Synopsis These US researchers evaluated 121 adults with chronic nasal and sinus symptoms using community advertisements. The patients were men and women (average age, 46 years) who reported symptoms of stuffiness, congestion, or thick or discolored nasal discharge. Most reported symptoms “often” or “always” for more than 6 months. Patients were excluded if they had recent sinus surgery or respiratory infection. The patients were randomized, using concealed allocation, to be treated with isotonic nasal saline as a spray or as a large volume nasal irrigation flowed into a nostril and drained out of the mouth. The patients were asked to use the treatment twice daily for 2 months along with their usual treatments. Symptoms were evaluated using a previously validated instrument —I’m not making this up—the SNOT-20 measure of symptom severity, including the physical problems, functional limitations, and emotional consequences of sinusitis. From an initial average score of 35.5 to 37.6 of a possible 100 at baseline, SNOT scores dropped approximately twice as much, on average, in the irrigation group. The changes were significantly different at 4 weeks (–7.4 vs 16.2; P = .002) and at 8 weeks (8.5 vs 15.0; P = .04) of treatment. A decrease of 16 points is considered to be clinically relevant. By the end of 8 weeks, 61% of patients using the spray reported that symptoms were present “often” or “always” as compared with 40% in the irrigation group (P = .02). Hypertonic saline irrigation also has been shown to be effective for sinusitis (J Fam Pract. 2002;51:1049-1055).

Pynnonen MA, Mukerji SS, Kim HM, et al. Nasal saline for chronic sinonasal symptoms. Arch Otolaryngol Head Neck Surg. 2007; 133(11):1115-1120.