Introduction
The PICO is a process, a mnemonic, or technique used by nurses in evidence-based practice to address, answer or frame health care or related clinical questions. Researchers use the framework of PICO to develop and formulate literature search strategies like solution-based reviews. The acronyms used in this word have a specific meaning, especially in medical fields. For instance, “P” used means problem, patient, or population; “I” is used to illustrate the mode of intervention. The “C” used can define Control, comparator, or Comparison when addressing the question. Finally, the “O” is used to emphasize the outcome not limited to disease of interest, fatigue, pain, infections, nausea, or death.
Most nurses use it as a mnemonic device to remember all the elements or components of their well-focused clinical problem questions. It is the method used during the initial stages of Evidence-Based Practice (EBP) to ask and assess when researching to create a searchable clinical question to develop critical terms used. The clinical question has well-built and organized parts; it can serve as a mnemonic. One can quickly formulate a search strategy when identifying the essential concepts that need to be in the article used to answer and address the solution to the clinical question.
The Source of the Question
The question I am addressing is critical in the current clinical world. After analyzing different cases of exacerbated COPD patients, I felt there is a need to change the mode of prescribing therapies. For instance, the triple therapy method seems to be the best way to reduce COPD patients’ exacerbations. Therefore, monotherapy and dual therapy with prolonged-acting bronchodilators and triple treatment seem to be the best therapy to reduce exacerbations of patients with COPD.
Although, sometimes, it is not guaranteed to work a hundred per cent since it might lead to increased risks of being infected with pneumonia. Nevertheless, according to the current meta-analysis, ICS/LAMA/LABA combined therapy is the most effective compared with the combination of LAMA/LABA therapy and bronchodilator therapies when lowering the rate of exacerbations among the COPD victims. In addition, it improves the function of the lungs and reduces the potential risks of being infected with AECOPD.
Nevertheless, this will work best mainly in those patients with severe chronic obstructive pulmonary diseases, especially with triple therapy comprising long-acting β2-agonists, LAMAS, and corticosteroids. Those with moderate illness should receive this triple ICS/LAMA/LABA therapy. The prescription should be in concordance with the recommended treatments; it should be stipulated to those victims with COPD only.
Background of the Clinical Problem
The question is worthy of investigation because the issue of distinguishing which is the best therapy to reduce the rate of exacerbations among COPD victims has been a problem over the past years. The combination of LAMA/ICS/LABA is very effective. It has tremendous positive impacts when treating patients with AECOPD than combining LAMA/LABA with bronchodilator therapy which is single long-acting (Nici et al., 2020). It improves the functions of the lungs and reduces the severity of AECOPD, which serves as a protective effect of LABA/ICS/LAMA. The best results are witnessed when prescribed to victims with higher counts of blood eosinophil.
Patients with increased blood eosinophil add up to 280 cells·µL−1 the NNT for LAMA/LABA compared to the compound of ICS/LAMA/LABA to prevent patients of COPD will reduce from one patient to another. In addition, there are higher chances of those with a higher blood count of eosinophil recovering from COPD (Leung & Sin, 2018). However, in most cases, no significant differences are detected when determining the risks of infecting patients with pneumonia. This has been a challenge when choosing the best therapy to prescribe to any patient between comparators and triple combination therapy.
Such finding seems to correspond with current guidelines and recommendations by the Global Initiatives for all Obstructive lung diseases. Therefore, the GOLD, which controls any obstructive lung disease, seems to recommend triple therapy as the best therapy to all patients with severe exacerbations of COPD; also, it improves the functions of the lungs. However, GOLD does not address the escalated risk of pneumonia when the victims are prescribed Triple therapy.
Nevertheless, it is also essential to highlight the causes of COPD and the symptoms associated with the disease. In most cases, COPD is caused by excessive smoking since the hazardous chemicals found in smoke usually damage the lining of the airways and lungs. Therefore, if the smoking rate is reduced, the exacerbations of COPD can reduce by a higher percentage. In addition, chronic bronchitis and emphysema are common diseases that destroy the lung’s air sacs and cause inflammation, narrowing the bronchus tube.
PICO Question
Is triple therapy (ICS/LABA/LAMA) more successful in COPD exacerbations than dual therapy (LAMA/LABA)?
I hope to learn from this PICO question to determine which the best therapy is to lower the rate of exacerbations among the patients infected with COPD between dual therapy and triple therapy. At the end of this PICO question, there is a need to give a shred of conclusive evidence on which treatment is best by determining disease-associated morbidity, healthcare costs, resource burden, and mortality. This is because the cost of acute exacerbation care among COPD patients has been increasing due to the severity of the disease. Furthermore, there is a need to determine the best therapy because even after the exacerbation is resolved, the patient’s physical, respiratory, social, physical, and emotional impairment may persist for a long time.
There is a need to find the best way to reduce the severity of COPD and its frequent exacerbations among the patients to reduce the acceleration of mortality and disease progression and see how to minimize malfunction or failure of lungs among the COPD patients. At the end of the PICO question, one will understand the best therapy to apply to such patients to reduce the severity and incidence of exacerbations. It will also help one know how to advance the long-term health status of the victims and lower both medical costs and resources. It will also help one control changes associated with a patient’s baseline sputum or dyspnea.
Search Terms
LABA/LAMA is fixed-dose combined to treat COPD, improve lung hyperinflation, quality of life, and lung function to reduce COPD progressions.
Three Articles and Levels of Evidence Used
In 2018, Zheng et al. wrote an article about the prescription of triple therapy when managing and controlling the exacerbations among COPD patients. The researchers provided a meta-analysis and systematic method of reducing exacerbations among COPD patients (Zheng et al., 2018). According to the research, the patients who had severe exacerbations of COPD were relieved from the condition after being administered triple therapy. The exacerbations were moderated quickly, and their lungs started functioning normally. In the study, the level of evidence can be termed as 3A. Due to the application of meta-analysis and systematic review, the researchers confirmed by several trials in which there was a comparison between dual and triple therapy in patients mostly with COPD. There was also the availability of safety and efficiency outcomes.
Their health-related quality of life improved with time, unlike those administered with monotherapy or dual therapy.
The evidence is solid since the data used to conduct the research was collected independently. To calculate the hazard ratios, rate ratios, mean difference, and risk ratios, the researchers used meta-analyses with 96% confidence intervals. The researchers used the Grade methodology to summarize the quality of evidence comprised of grading recommendations, development, evaluation, and assessment. There were 20 human subjects subjected to trials; ten of them were prescribed triple therapy consisting of ICS, LABA, and LAMA. In comparison, the other ten patients were subjected to dual therapy. Assuming that LAMA (rate ratio 0.72, 96% confidence interval 0.57 to 0.83), LABA and LAMA (0.77, 0.69 to 0.87), and LABA( 0.78, 0.65 to 0.90).Of the patients subjected to triple therapy, nine patients showed a reduced rate of exacerbations compared to those subjected to dual therapy. Only 2 showed a reduced rate of exacerbations. Despite patients showing good life quality with triple therapy, the chances of being infected with pneumonia were higher than in dual therapy.
In 2018, Cazzola et al. (2018) wrote an article; the researchers compared dual therapy with Triple therapy in COPD. The researchers utilized the meta-analysis and a systematic review when conducting the research (Cazzola et al., 2018). The evidence is solid since the data used to conduct the study was collected independently. The researchers conducted a meta-analysis to contrast the effects of dual therapy with those of triple therapy among COPD patients. The level of evidence in the research is 3A; hence, there was a meta-analysis and systematic review. Researchers applied meta-analysis in which its purpose was to determine ICS/LABA/LAMA effects on primary end-points compared with LAMA/LABA in combination therapy. The results showed that the patients with high acidophils blood counts had a higher protective effect when administered triple therapy than those prescribed dual therapy. Therefore, the researchers concluded that triple therapy was the best therapy to counter and reduce exacerbations of COPD patients.
In 2020, Janson wrote an article discussing COPD treatment with inhaled corticosteroids. He combined all three classes of drugs, namely, triple therapy and dual therapy separated. A group of COPD patients was subjected to trials to determine the best treatment, which shows a reduced rate of exacerbations among the patients (Janson, 2020). The results showed that patients subjected to triple therapy had reduced exacerbations compared to those subjected to dual treatment. The patients showed a quality of life. However, those patients subjected to triple therapy had a higher chance of being infected with pneumonia, unlike the COPD patients subjected to dual treatments. The level of evidence was 3A because he conducted a meta-analysis and a systematic review to ensure the evidence was solid and collected data independently. He used the Grade methodology to summarize the quality of evidence, which comprised the grading of recommendations, development, evaluation, and assessment. He calculated the hazard ratios, rate ratios, mean difference, and risk ratios using meta-analyses with 96% confidence intervals. The level of evidence used in both articles was 3A since there was a systematic review and meta-analysis with homogeneity and case-control studies in each piece. The researchers used case reports, observational studies, and a series of cases to randomize the clinical trials.
The Best Therapy and Generalizability of the Problem
Generally, triple therapy is the best therapy compared with dual therapy, as shown from the articles discussed above. Triple therapy (LABA/LAMA/ICSS) usually reduces the severity of exacerbations and improves the functionalities of the lungs, unlike dual therapy (LAMA /LABA). Triple therapy will help the physician identify the people with exacerbations risks and manage them effectively to counter such threats. Although numerous methods have been recommended to treat and reduce frequent exacerbations associated with COPD patients, it differs from their phenotype (Zheng et al., 2018). Triple therapy helps maximize bronchodilation, which is the first step of reducing risks associated with exacerbations. With the aid of triple therapy and an initial bronchodilator, the health caregivers will successfully mitigate the effects of exacerbations and reduce the chances of being infected with pneumonia. The physician should also not consider the patient’s phenotype when treating COPD patients when the Triple therapy fails.
According to current data provided by GOLD, adding ICS to the LABA/LABA will automatically overlap syndrome or high blood counts of eosinophil when exacerbating COPD patients. Roflumilast, high-dose mucolytic agents and high phosphodiesterase (PDE)-4 inhibitor should always be considered before treating a patient with chronic bronchitis (Leung, & Sin, 2018). Patients with bronchiectasis or bacterial exacerbations, macrolide antibiotics, or additional mucolytic agents should also be considered.
Nevertheless, it is also essential to advise patients about the causes of COPD and the symptoms associated with the disease. For example, patients should be advised that excessive smoking will accelerate the effects of exacerbations since the hazardous chemicals found in smoke usually damage the lining of the airways and lungs. Therefore, if they stop smoking, the rate of risks associated with exacerbations of COPD can reduce by a higher percentage. In addition, chronic bronchitis and emphysema are common diseases that destroy the lung’s air sacs and cause inflammation, narrowing the bronchus tube, and patients should be aware of this.
Treatment and Prevention
Triple therapy has contributed to lung function and symptoms, which has improved on them, hence reducing exacerbation risks and disease progression. Triple treatment can be used to some of assuring impacts as per as LABA/ICS is concerned to survival benefits. In addition, researchers should conduct further investigations for easy identification of patients with COPD characteristics. Clinical assessments and responses should be based on therapy treatment while managing timely ICS if there are any symptoms. Preventive measures should be considered to minimize pharmacological treatment side effects.
References
Cazzola, M., Rogliani, P., Calzetta, L., & Matera, M. G. (2018). Triple therapy versus single and dual long-acting bronchodilator therapy in COPD: a systematic review and meta-analysis. European Respiratory Journal (Vol. 52, Issues 6, p. 1801586).
Janson, C. (2020). Treatment with inhaled corticosteroids in chronic obstructive pulmonary disease. Journal of thoracic disease, 12(4), 1561.
Leung, J. M., & Sin, D. D. (2018). Inhaled corticosteroids in COPD: the final verdict is…. In European Respiratory Journal (Vol. 52, Issues 6, p. 1801940).
Nici, L., Mammen, M. J., Charbel, E., Alexander, P. E., Au, D. H., Boyd, C. M., Criner, G. J., Donaldson, G. C., Dreher, M., Fan, V. S., Gershon, A. S., Han, M. K., Krishnan, J. A., Martinez, F. J., Meek, P. M., Morgan, M., Polkey, M. I., Puhan, M. A., Sadatsafavi, M., Sin, D. D., Washko, G. R., Wedzicha, J. A., & Aaron, S. D. (2020). Pharmacologic Management of Chronic Obstructive Pulmonary Disease. An Official American Thoracic Society Clinical Practice Guideline. In American Journal of Respiratory and Critical Care Medicine (Vol. 201, Issues 9).
Zheng, Y., Zhu, J., Liu, Y., Lai, W., Lin, C., Qiu, K., Wu, J., Yao, W., & Kim, P. (2018). Triple therapy in the management of chronic obstructive pulmonary disease: Systematic review and meta-analysis. BMJ.