NURS5106 : Critical Evaluation of Treatment Modalities

Instruction

The systematic review should adhere to the protocol submitted earlier in this unit. It is allowed to use the background from the protocol but now, in this final paper, there must be evidence of advanced use of the text. You cannot just copy, without any amendment or elaboration of the content. The background should communicate the existing knowledge of the researched topic and include a justification as to why there is a need for this systematic review. The method section should: 1) describe how the search work was undertaken to search for all relevant articles and how these were appraised before inclusion and analysis. The review should include a summary of included articles by including the PRISMA flowchart. All included articles need to be presented in a MATRIX table for results to be presented in a narrative form. The discussion section should show ability for critical and analytical thinking by conveying ideas and arguments.

The paper should finally summarise the new findings in a conclusion and suggest clinical applications of the findings.

You are expected to submit a sound academic presentation of the systematic review in written form that is submission of a journal academic journal.

The PRISMA and MATRIX templates will be provided in Learnline.

Suggested Report Headings:

• Background

• Method

• Results

• Discussion

• Recommendations

• Conclusion 

Asthma is a chronic condition that significantly affects children worldwide and is a leading cause of childhood illness.

• Prevalence in Australia: Around 1 in 10 children live with asthma, and many are hospitalised every year (AIHW, 2023).

• Vulnerable groups: Aboriginal and Torres Strait Islander children, and those in rural or low-income areas, face additional challenges due to restricted access to timely healthcare.

• Preventable hospitalisations: In 2022–2023, over 31,000 people were hospitalised for asthma, with more than 90% considered preventable through optimal management and primary care (Asthma Australia, 2024).

This demonstrates asthma as both a community health and public health priority.

Current Treatment Options

Inhaled Corticosteroids (ICS)

• First-line treatment recommended for children with persistent asthma (Australian Asthma Handbook, 2022).

• Benefits: Reduce airway swelling, improve lung function, reduce exacerbations, and lower hospitalisation rates (NACA, 2022).

Leukotriene Receptor Antagonists (LTRAs)

• Example: Montelukast.

• Advantages: Oral tablets, easier for children and families compared to inhalers.

• Mechanism: Block leukotrienes responsible for airway narrowing, mucous production, and swelling.

• Evidence: Less effective than ICS for symptom control and flare-up prevention (Chauhan et al., 2017).

Safety and Prescribing Considerations

• Montelukast Guidelines:

  • Can be considered in children ≥6 years who cannot use inhalers or when parents are reluctant about ICS (Therapeutic Guidelines Limited, 2025).

• Safety Warnings:

  • TGA (2022) highlights risks such as sleep disturbance, anxiety, depression, and suicidal thoughts.

  • FDA and TGA reviews acknowledge risks but note they are uncommon (FDA, 2020; TGA, 2020).

International Use

• South Korea: Montelukast prescribed more often than ICS due to parental concerns about steroids, cultural preferences for tablets, and ease of administration (Seo et al., 2022).

• Rural Australia: Tablets are sometimes preferred because educating families on inhaler use is difficult. Dispensing data (2018) shows LTRAs prescribed in ~20% of paediatric preventer therapies despite ICS-first guidelines (Seo et al., 2022).

Rationale

The differences between clinical guidelines and real-world prescribing patterns highlight the need for this review. Comparing ICS and LTRAs will provide clearer evidence to support practical, culturally sensitive, and accessible asthma management in Australian children.

Objectives

The review aims to examine whether ICS are more effective and safer than LTRAs in managing persistent asthma in children aged 5–12 years.

Review Questions

1. Do ICS reduce asthma exacerbations more effectively than LTRAs in children aged 5–12 years?

2. Do ICS improve lung function more than LTRAs?

3. How do ICS and LTRAs compare in improving quality of life and symptom-free days?

4. What side effects are reported with ICS and LTRAs, particularly behaviour-related effects?

5. How do factors like delivery method (inhaled vs tablet), convenience, and cultural acceptability affect adherence and treatment success?

Criteria for Considering Studies

Types of Studies

• RCTs, cohort studies, and comparative studies.

• Reviews, editorials, and case studies may be included if they meet eligibility criteria.

Participants

• Children aged 5–12 years with confirmed asthma diagnosis.

• Studies with wider age ranges included only if subgroup data (5–12 years) is available.

Interventions

• ICS alone (e.g., fluticasone, budesonide, beclomethasone).

Comparators

• LTRAs alone (primarily Montelukast).

• Combination therapies excluded unless monotherapy results are separately reported.

Outcomes

• Primary Outcome:

  • Number of exacerbations requiring steroids, ED visits, or hospitalisations.

• Secondary Outcomes:

  • Lung function (spirometry).

  • Symptom-free days.

  • Quality of life scores.

  • Side effects (particularly neuropsychiatric).

  • Adherence and treatment satisfaction.

Search Strategy

Initial Search

• MEDLINE and CINAHL to identify keywords and indexing terms.

Comprehensive Search

• Databases: MEDLINE (via PubMed), CINAHL, Embase, Scopus, Cochrane CENTRAL, Web of Science.

• Grey Literature: OpenGrey, ProQuest, ANZCTR, ClinicalTrials.gov.

Hand Searching

• Reference lists of included studies and systematic reviews.

Sample Search Terms

• “Asthma OR persistent asthma AND children OR paediatric AND inhaled corticosteroids OR ICS OR fluticasone OR budesonide AND montelukast OR leukotriene receptor antagonist AND randomised controlled trial OR RCT.”

Screening

• Titles/abstracts screened for relevance.

• Full texts reviewed if inclusion criteria met.

Methods

Quality Assessment

• Joanna Briggs Institute (JBI) Critical Appraisal tools for RCTs and observational studies.

Data Extraction

• JBI data extraction form (Appendix B).

• Information: author, year, country, setting, participants, interventions, comparators, outcomes, results, follow-up, conflicts of interest.

Data Synthesis

• Narrative summary.

• Continuous outcomes → mean differences/standardised mean differences.

• Binary outcomes → risk ratios.

Heterogeneity Assessment

• I⊃2; statistic:

  • 0–25% = low.

  • 25–50% = moderate.

  • 50–75% = substantial.

  • 75% = considerable.

• Subgroup analyses for substantial heterogeneity.

Ethical Considerations

• Uses published data only → no ethics approval required.

• Protocol follows PRISMA 2020 reporting standards for transparency and reproducibility (Page et al., 2021).

• Any protocol changes will be documented.

Limitations

• Publication Bias: Positive results more likely published → grey literature inclusion will reduce risk.

• Heterogeneity: Different outcome measures and definitions may complicate synthesis.

• Language Restriction: Only English-language publications included.

• Generalisability: International findings may not fully apply to Australian healthcare.

Assessment Requirements

The assessment involves preparing a systematic review adhering to a previously submitted protocol. Key requirements include:

• Background: Present existing knowledge on asthma in children and justify the need for the review. Must go beyond the protocol with elaboration.

• Method: Describe the search strategy for relevant literature, screening process, quality appraisal, and data extraction. Include PRISMA flowchart.

• Results: Summarise findings using a MATRIX table, followed by narrative synthesis.

• Discussion: Provide critical and analytical interpretation of results, highlighting clinical relevance.

• Recommendations and Conclusion: Summarise key findings, propose clinical applications, and suggest future research directions.

• Ethical Considerations: Only published data used; follow PRISMA 2020 reporting standards.

• Learning outcomes: Demonstrate advanced academic writing, critical thinking, systematic review methodology, and application to clinical practice.

Assessment Approach

Step 1: Understanding the Requirements

• The mentor begins by explaining the purpose of a systematic review: to synthesise evidence on ICS vs LTRAs in children aged 5–12 years with persistent asthma.

• Students are encouraged to review their submitted protocol, identifying gaps or areas needing elaboration.

Step 2: Developing the Background

• The mentor guides the student to:

  • Expand on the prevalence and impact of asthma in Australian children.

  • Discuss vulnerable groups and preventable hospitalisations.

  • Compare current treatment options (ICS vs LTRAs) with reference to international and Australian prescribing patterns.

• Learning Objective: Develop ability to synthesise existing evidence and justify research needs.

Step 3: Designing the Method Section

• Mentor explains:

  • Search strategy: Databases (MEDLINE, CINAHL, Embase, etc.), grey literature, hand-searching.

  • Screening: Title/abstract review, full-text eligibility check.

  • Quality assessment: Using JBI tools for RCTs and observational studies.

  • Data extraction: Using a standardised JBI form capturing interventions, comparators, outcomes, and study characteristics.

• Learning Objective: Master systematic search, screening, and appraisal.

Step 4: Presenting Results

• Mentor shows how to:

  • Create a PRISMA flowchart for transparency of study selection.

  • Summarise data in a MATRIX table for clear comparison of interventions, outcomes, and adverse effects.

  • Perform a narrative synthesis highlighting key findings, trends, and patterns.

• Learning Objective: Translate complex data into clear, structured results.

Step 5: Discussion and Critical Analysis

• Mentor guides the student to:

  • Compare ICS and LTRAs effectiveness and safety.

  • Discuss adherence, cultural preferences, and real-world applicability.

  • Critically appraise study limitations, heterogeneity, and biases.

• Learning Objective: Enhance critical thinking and evidence-based interpretation skills.

Step 6: Recommendations and Conclusion

• Mentor advises to:

  • Suggest clinical applications for asthma management in Australian children.

  • Highlight knowledge gaps and areas for future research.

• Learning Objective: Connect evidence synthesis to practical clinical decision-making.

Step 7: Final Review

• Mentor supports the student in:

  • Editing for academic writing standards and journal-style presentation.

  • Ensuring PRISMA compliance and proper referencing.

  • Documenting any protocol amendments for transparency.

Outcome and Learning Objectives Achieved

• Outcome: A systematic review that compares ICS and LTRAs for children with persistent asthma, presented with PRISMA flowchart, MATRIX table, narrative synthesis, and critical discussion.

• Learning Objectives Covered:

  • Conduct a comprehensive literature search.

  • Critically appraise and synthesise scientific evidence.

  • Present findings in structured, journal-ready format.

  • Develop clinical reasoning and apply evidence to practice.

  • Enhance academic writing and reporting skills.

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