The appraisal of evidence from different sources is a necessary part of the evidence-based healthcare delivery process. It improves the reliability and trustworthiness of the sources and serves as a valuable tool in the process of improvement of clinical practice. The following case study aims at gathering, appraising, and ranking the evidence of the effectiveness of air ventilation for reducing the rate or shortness of breath among the patients with advanced disease.
PICO Question
Does air stimulation of the facial area as a non-pharmacological intervention reduce the scale of shortness of breath in mobile patients with advanced disease?
Search for Evidence
In order to ensure the reliability of the results, multiple sources were consulted in the process of search for evidence. The preference was given to the reputable, peer-reviewed academic journals. The findings derived from the research evidence were given higher priority. The search results were refined by eliminating outdated entries and choosing the most recent findings. As a result of the search, five reliable sources were detected. All sources were relevant to the formulated question and satisfied the described quality criteria.
Evidence Appraisal
The study by Galbraith, Fagan, Perkins, Lynch, and Booth (2010) investigated the possibility of reducing the effect of shortness of breath in moving patients by facial cooling through the use of handheld fan. The study was an experimental evidence appraisal in the form of a clinical trial. The sample size was 50 individuals, which is an adequate size for an RCT. The participants were randomized, and the control group was introduced to improve the reliability of the results.
The article contains a detailed description of the experiment procedures. No inequalities in the treatment of groups are detectable in the design. The study showed a significant reduction of shortness of breath in patients who used a handheld fan to cool the facial area. The effect was not observed in the control group, where the fan was directed at the leg (Galbraith et al., 2010). The results were presented in a clear manner and extensively discussed. Notably, the limitations of the study were not highlighted.
A study by Bausewein, Booth, Gysels, Kühnbach, and Higginson (2010) compared the effectiveness of a handheld fan to the wristband. The study used an adequate sample of 109 patients. The sample was randomized. The design included the control group. There is no indication that the groups were treated unequally treated outside the chosen intervention. The data collection and analysis were described in detail.
The study did not locate a statistically significant difference between the outcomes of the groups. However, half of the participants continued using handheld fans two months after the intervention, while only 20% decided to use wristbands (Bausewein et al., 2010). This effect was discussed in detail in the respective section of the paper. The authors also identified three limiting factors to the trial and discussed their impact on the validity of the results.
The study by Abernethy et al. (2010) evaluated the effect of administering medical oxygen to the patients with shortness of breath in comparison to the effect of the similarly administered room air. The study used a much bigger sample of 239 individuals who were randomized. The design included a control group and thoroughly documented the equal treatment of both groups. The data collection methods were described in a clear manner.
The results suggested no significant difference between the effect of medical gas and the room air, with 46% of the participants reporting the improvement caused by oxygen versus 42% of favorable outcomes for those who were administered room air. The results were presented in detail and thoroughly discussed. The authors provided clear conclusions and implications for the finding and acknowledged the limitations of the study.
The study by Booth, Galbraith, Ryan, Parker, and Johnson (2016) aimed at determining the washout period after the use of the hand-held fan by the patients suffering from shortness of breath. The study was neither randomized nor controlled since it was intended to assist the design of the future RCT. The sample consisted of 31 patients, which is sufficient for the purpose of the study but may not be an adequate size for the current case study.
The procedure was sufficiently detailed in the paper. The results indicated a 27% improvement in breathlessness relative to the mean baseline, with approximately half of the participants experiencing a moderate-size improvement (Booth et al., 2016). The results were accompanied by the interpretation and a summary of implications. The limitations of the study were properly acknowledged.
A study by Puspawati, Sitorus, and Herawati (2017) aimed at identifying the effects of air stimulation initiated by a handheld fan on the shortness of breath among the patients with lung cancer. The researchers used a sample of 21 participants, which is inadequate for generating reliable results. The sample was randomized and divided into a control and intervention group. All aspects of the data collection were described in detail. The results suggested that both the respiratory rate and the scale of the dyspnea scale were positively influenced by airflow stimulation. The results were clearly presented both in a textual and visual format and consistent with the conclusions made by the authors. The limitations were not acknowledged.
Summary of Evidence
Overall, the evidence from all sources points to the fact that air stimulation of the facial area decreases the rate and severity of shortness of breath. It should be noted that the sources of the air stimulation differed across the studies and included the use of handheld fans as well as the involvement of gas administering equipment.
All of the reviewed sources of evidence fall into category of research. Of the five sources in question, three can be considered evidence of high quality. These include the sources by Bausewein et al. (2010), Abernethy et al. (2010), and Booth et al. (2016). In all of the mentioned studies, the sample sizes were adequate, the study design was reliable and well-documented, and the findings were exhaustively explained and supplied with a proper conclusion. In two other cases – those by Galbraith et al. (2010) and Puspawati et al. (2017) the studies had some inconsistencies – specifically, the sample was only marginally sufficient, and the study description lacked one important component (the acknowledgment of limitations of the study). Nevertheless, the design was reliable, and which allows categorizing the results as good.
Strength of Evidence
All of the reviewed sources of evidence can be categorized as level I in regard to their strength. All five articles describe a randomized controlled trial that uses primary data and follows a standard protocol. It should be acknowledged that on one occasion the study was intended as a method of ensuring the soundness of design of a future RCT, but its results are applicable to the current case study.
Recommendations
Considering the information above, it is reasonable to describe air stimulation as a valid non-pharmacological intervention for reduction in scale of shortness of breath. These results have several implications for clinical management of the patients suffering from the conditions. First, non-pharmacological interventions, in this case, are considerably safer than their alternatives. Therefore, their introduction into the clinical setting can present several logistical benefits to the patients as well as healthcare providers. Next, the most common device for facial air ventilation – a hand-held fan – is incredibly cheap, simple to use, and intuitive for first-time users.
Thus, it provides additional financial advantages since it decreases the dependence on sophisticated equipment. Finally, the fact that approximately half of the patients choose to continue using it suggests that handheld fans are beneficial for patient satisfaction, which has a positive indirect effect on the clinical outcome. Therefore, it is recommended to explore the possibilities of integrating the non-pharmacological interventions such as handheld fans into the clinical practice. Since the presented evidence is credible and reliable, the focus should be shifted towards the administrative domain, with the eventual assistance of the managerial department.
Conclusion
The analysis and evaluation of evidence are the important components of the health care delivery. The strength and quality of evidence in the case study above comprise a valid reason for adoption of the identified non-pharmacological intervention into clinical practice and provide us with the relevant tools for estimation of the results. It also ensures the predictability of the patient outcomes and minimizes ambiguity. The evidence appraisal and rating are, therefore, necessary as important parts of the evidence-based clinical practice.
References
Abernethy, A. P., McDonald, C. F., Frith, P. A., Clark, K., Herndon, J. E., Marcello, J.,… Wheeler, J. L. (2010). Effect of palliative oxygen versus room air in relief of breathlessness in patients with refractory dyspnoea: A double-blind, randomised controlled trial. The Lancet, 376(9743), 784-793.
Bausewein, C., Booth, S., Gysels, M., Kühnbach, R., & Higginson, I. J. (2010). Effectiveness of a hand-held fan for breathlessness: A randomised phase II trial. BMC Palliative Care, 9(1), 22-30.
Booth, S., Galbraith, S., Ryan, R., Parker, R. A., & Johnson, M. (2016). The importance of the feasibility study: Lessons from a study of the hand-held fan used to relieve dyspnea in people who are breathless at rest. Palliative Medicine, 30(5), 504.
Galbraith, S., Fagan, P., Perkins, P., Lynch, A., & Booth, S. (2010). Does the use of a handheld fan improve chronic dyspnea? A randomized, controlled, crossover trial. Journal of Pain and Symptom Management, 39(5), 831-838.
Puspawati, N. L. P. D., Sitorus, R., & Herawati, T. (2017). Hand-held fan airflow stimulation relieves dyspnea in lung cancer patients. Asia-Pacific Journal of Oncology Nursing, 4(2), 162-167.