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The Evidence Base to Treatment in the Guide For The Treatment Of Respiratory Diseases At District Level 1 Report prepared for WHO by Health Reviews Ltd

THE EVIDENCE BASE TO TREATMENT IN THE GUIDE FOR THE TREATMENT OF RESPIRATORY DISEASES AT DISTRICT LEVEL

Report1 prepared by Dr Tom Jefferson, Health Reviews Ltd and UK Cochrane Centre for Dr Robert Scherpbier on behalf of Strategy Development and Monitoring for Endemic Bacterial and Viral Diseases, Communicable Disease Control Prevention and Eradication, World Health Organization, Geneva

1 The report is based on the August 1999 version of the guideline The Evidence Base to Treatment in the Guide For The Treatment Of Respiratory Diseases At District Level 2 Report prepared for WHO by Health Reviews Ltd

Introduction A recent assessment of WHO treatment guidelines2 identified 71 primary treatment guidelines and 12 secondary treatment guidelines. Not all of these guidelines contained linked references, and only one documented the guideline development process, consistent with good practice on evidence- based treatment guideline development. The development process of the Adult Health Initiative practice guidelines is well described3. State-of-the- art-papers synthesising the available evidence preceded guideline development, but were not based on systematic reviews using standard procedures and methods. A systematic evidence assessment of the Adult Lung Health Initiative (ALHI) practice guidelines has now become important in order to enable WHO to comply with modern practice guideline standards, and to assist countries to adapt the generic ALHI guidelines in an evidence- based manner.

Objective To validate each intervention or group of interventions in the ALHI guidelines on the basis of available evidence, graded by quality of evidence and decision-making context (healthcare level and country setting).

This report assesses the evidence base of the Guide for the Treatment of Respiratory Diseases at District Level.

Methods

• We listed the interventions included in the guideline by relevant clinical problem. • We identified evidence of effectiveness and, where possible, safety by searching Cochrane Reviews and non-Cochrane systematic reviews in the following sources: Cochrane Database of Systematic Reviews (CDSR), Database of Abstracts of Reviews of Effectiveness (DARE). • We assessed the evidence of effect on the basis of the evidence from identified systematic reviews. • We graded the strength of evidence of effect using the following symbols:

A = Presence evidence of effect superior to either placebo, control or specified comparator X = Presence of evidence of effect not superior to either placebo, control or specified comparator H = Presence of evidence of harmful effect

I = Insufficient evidence from systematic reviews

2 Review of WHO treatment guidelines (work in progress), by Ms E. Jambert, Dr R. Gray, Dr H. Hogerzeil, Department of Essential Drugs and Medicines Policy, WHO Geneva 3 Report Adult Lung Health Initiative. WHO/TB/98.257. Dr Robert Scherpbier, Ms Christy Hanson, Dr Mario Raviglione (eds.) The Evidence Base to Treatment in the Guide For The Treatment Of Respiratory Diseases At District Level 3 Report prepared for WHO by Health Reviews Ltd

• We classified the source of evidence of effect using the following symbols:

CR = Cochrane review NCR = Non-Cochrane review • We classified the setting of the reviews as: Primary care (PC - in bold) Secondary care (SC – in bold) Tertiary care (TC – in bold) Community care (CC – in bold) Mixed setting (MS - in bold)

• Whenever possible we further classified the setting of the review as: mostly (MD) or completely in developed (CD) or developing country (MD+, CD+) or countries. • We made recommendations by intervention categories (e.g. ).

When no reviews were available, a non-exhaustive review of the Cochrane Controlled Trails Register (CCTR) was carried out and good-quality single trial evidence is presented.

Findings and recommendations Evidence of effect graded by source and setting is presented in tabular format in Annex A. As some interventions, such as inhaled through a MDI for , were repeated several times in the guideline we only report the assessment of effect once to avoid lengthy repetitions. A similar approach was taken for intervention listed in Annex 2 (A2) to the Guideline. For some interventions, such as morphine for pain relief and some types of antibiotics, the evidence was thin, a probable reflection of their long- established nature. Care must be taken not to confuse absence of evidence with evidence of absence (of effect). The majority of interventions have been assessed in a mostly developed country setting. It is the opinion of the reviewers that this does not invalidate their use in developing country settings within the framework of the guidelines. Assuming the primum non nocere principle, all interventions listed (with the exception of local decongestants for relieving upper in children and long-acting theophylline) are recommended for use. We recommend the adding of single dose Dexamethasone as adjuvant therapy for severe acute (reference 30).

References

1. Edwards JE, Oldman A, Smith L, Collins SL, Carroll D, Wiffen PJ, McQuay HJ, Moore RA. Single dose oral aspirin for acute pain (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

2. Moore A, Collins S, Carroll D, McQuay H, Edwards J. Single dose (acetaminophen), with and without codeine, for postoperative pain (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

The Evidence Base to Treatment in the Guide For The Treatment Of Respiratory Diseases At District Level 4 Report prepared for WHO by Health Reviews Ltd

3. Gove S, Campbell H. and Cold Remedies in the Treatment of Acute Respiratory Infections in Young Children. WHO, Geneva 2000. Unpublished

4. Smith MBH, Feldman W. Over-the counter cold medications. A critical review of trials between 1950 and 1991. JAMA 1993;269:2258-63.

5. Turner M O, Patel A, Ginsburg S, FitzGerald J M. Bronchodilator delivery in acute airflow obstruction. Archives of Internal Medicine 1997, 157:1736-1744.

6. Crockett AJ, Cranston JM, Moss JR, Alpers JH. Domicilary oxygen for COPD. (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

7. Rowe BH, Spooner CH, Ducharme FM, Bretzlaff JA , Bota GW. Corticosteroids for preventing relapse following acute exacerbations of asthma (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

8. Manser R, Reid D, Abramson M. Corticosteroids for in hospitalised patients (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

9. Smucny J, Fahey T, Becker L, Glazier R, McIsaac W. Antibiotics for acute (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

10. de Ferranti S D, Ioannidis J P, Lau J, Anninger W V, Barza M. Are amoxycillin and folate inhibitors as effective as other antibiotics for acute ? A meta-analysis. BMJ 1998, 317, pp.632-637.

11. Balgos AA, Rodriguez-Gomez G, Nasnas R, Mahasur AA, Margono BP, Tinoco- Favila JC, Sansores-Martinez RH, Hassan M, Beppo O, Wongsa A, Cukier A, Vargas F. Efficacy of twice-daily amoxycillin/clavulanate in lower respiratory tract infections. International Journal of Clinical Practice 1999; 53 (5): 325-30.

12. Roggla M, Wagner A, Brunner C, Roggla G. The management of with the thoracic vent versus conventional intercostal tube drainage. Wiener Klinische Vochenschrift 1996; 108(11): 330-3.

13. Pakistan Co-trimoxazole Study Group. Straus WL; Qazi SA; Kundi Z; Nomani NK; Schwartz B. and clinical effectiveness of co-trimoxazole versus amoxycillin for among children in Pakistan: randomised controlled trial. Lancet 1998; 352 (9124):270-4.

14. Gelband H. Regimens of less than six months for treating tuberculosis (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

15. Smieja MJ, Marchetti CA, Cook DJ, Smaill FM. Isoniazid for preventing tuberculosis in non-HIV infected persons (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

16. Bilaceroglu S, Perim K, Buyuksirin M, Celikten E. Prednisolone: a beneficial and safe adjunct to antituberculosis treatment? A randomized controlled trial. International Journal of Tuberculosis & Lung Disease 1999; 3(1 ): 47-54.

17. Lee CH, Wang WJ, Lan RS, Tsai YH, Chiang YC. Corticosteroids in the treatment of tuberculous . A double-blind, placebo-controlled, randomized study. Chest 1988; 94 (6): 1256-9.

18. Acuin J, Smith A, Mackenzie I. Interventions for chronic suppurative (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

The Evidence Base to Treatment in the Guide For The Treatment Of Respiratory Diseases At District Level 5 Report prepared for WHO by Health Reviews Ltd

19. McCormick DP; John SD; Swischuk LE; Uchida T. A double-blind, placebo-controlled trial of decongestant-antihistamine for the treatment of sinusitis in children. Clinical Pediatrics 1996; 35(9):457-60.

20. Del Mar CB, Glasziou PP, Spinks AB. Antibiotics for (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

21. Kneen R; Pham NG; Solomon T; Tran TM; Nguyen TT; Tran BL; Wain J; Day NP; Tran TH; Parry CM. Penicillin vs. erythromycin in the treatment of diphtheria. Clinical Infectious Diseases 1998; 27(4 ): 845-50.

22. Rose G; Hamilton PJ A randomised controlled trial of the effect on middle-aged men of advice to stop smoking. Journal of Epidemiology & Community Health; 1978; 32(4): 275-81.

23. Poole PJ, Black PN. Mucolytic agents for chronic bronchitis (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

24. Wood-Baker R, Walters E.H, Gibson P. Corticosteroids for acute exacerbations of COPD (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

25. Kolbe J, Wells A, Ram FSF. Inhaled steroids for (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

26. Saint S, Bent S, Vittinghaoff E, Grady D. Antibiotics in chronic obtrusive pulmonary disease exacerbations: a meta-analysis. JAMA. 1995, 273(12), pp.957-960.

27. Adams NP, Bestall JB, Jones PW. Inhaled beclomethasone versus placebo for chronic asthma (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

28. Wilson AJ, Gibson PG, Coughlan J. Long acting beta-agonists versus theophylline for maintenance treatment of asthma (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

29. Yilmaz T, Unal OF, Figen G, Akyol MU, Ayas K. A comparison of procaine penicillin with sulbactam-ampicillin in the treatment of peritonsillar abscesses. European Archives of Oto-Rhino-Laryngology 1998; 255(3): 163-165.

30. O'Brien JF, Meade JL, Falk JL. Dexamethasone as adjuvant therapy for severe acute pharyngitis. Annals of Emergency Medicine 1993; 22(2):212-5.

31. De Simone C, Trinchieri V, Tzantzoglou S, Famularo G, Moretti S, Delia S. AIDS patients with bacterial lower respiratory tract infections: treatment with ofloxacin versus sulbactam-ampicillin. Journal of Chemotherapy 1992; 4(6):376-80.

32. Cotrimo-CI Study Group: Anglaret X, Chene G, Attia A, Toure S, Lafont S, Combe P, Manlan K, N'Dri-Yoman T, Salamon R. Early chemoprophylaxis with trimethoprim- sulphamethoxazole for HIV-1-infected adults in Abidjan, Cote d'Ivoire: a randomised trial. Lancet 1999; 353(9163):1463-8.

33. Wiktor SZ, Sassan-Morokro M, Grant AD, Abouya L, Karon JM, Maurice C, Djomand G, Ackah A, Domoua K, Kadio A, Yapi A, Combe P, Tossou O, Roels TH, Lackritz EM, Coulibaly D, De Cock KM, Coulibaly IM, Greenberg AE. Efficacy of trimethoprim- sulphamethoxazole prophylaxis to decrease morbidity and mortality in HIV-1-infected patients with tuberculosis in Abidjan, Cote d'Ivoire: a randomised controlled trial [published erratum appears in Lancet 1999 Jun 12;353(9169):2078]. Lancet 1999; 353 (9163):1469-75.

34. Haller L, Sossouhounto R, Coulibaly IM, Dosso M, Kone M, Adom H, Meyer UA, Betschart B, Wenk M, Haefeli WE, Lobognon LR, Porquet M, Kabore G, Sorenson F, Reber- Liske R, Sturchler D. Isoniazid plus sulphadoxine-pyrimethamine can reduce morbidity of HIV- The Evidence Base to Treatment in the Guide For The Treatment Of Respiratory Diseases At District Level 6 Report prepared for WHO by Health Reviews Ltd positive patients treated for tuberculosis in Africa: a controlled clinical trial. Chemotherapy 1999; 45(6):452-65.

35. Collins SL, Moore RA, McQuay HJ, Wiffen PJ, Edwards JE. Single dose oral ibuprofen and diclofenac for postoperative pain (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

35a. Stambaugh JE Jr, Drew J. The combination of ibuprofen and oxycodone / acetaminophen in the management of chronic cancer pain. Clinical Pharmacology & Therapeutics 1988; 44(6):665-9.

36. Edwards JE, McQuay HJ, Moore RA. Single dose dihydrocodeine for acute postoperative pain (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

37. Mimoz O, Karim A, Mercat A, Cosseron M, Falissard B, Parker F, Richard C, Samii K, Nordmann P. Chlorhexidine compared with povidone-iodine as skin preparation before blood culture. A randomized, controlled trial. Annals of Internal Medicine 1999; 131(11):834-7.

38. Briggs M, Nelson EA. Topical agents or dressings for pain in venous leg ulcers (Cochrane Review). In: The Cochrane Library, Issue 4, 2000. Oxford: Update Software.

39. Bhatt AD, Vaidya AB, Sane SP, Sahani S, Koya R, Rajaseharan A, Perumal SV, Chauhan CK, Pathak KJ, Sainath BR et al. Comparative effect of dimethindene maleate and chlorpheniramine maleate on histamine-induced weal and flare. Journal of International Medical Research 1991; 19(6)479-83.

Note on availability of evidence on the effects of ipatropium bromide. Wait for: Appleton S, Pilotto L, Smith B, Muhammad J. Anti-cholinergic bronchodilators vs. beta2-adrenoceptor agonists for stable COPD. Review expected to be published in: Issue 1, 2001.

ANNEX A Page Intervention Problem Evidence Reference (strength and setting) 11 Furosemide IV pt Acute Pulmonary I oedema 11 Aspirin pt Pulmonary A, CR, 1,2 embolism PC/CC, MS 11 Morphine SC pt Myocardial I infarction 11 “Soothe the cough” pt Severe I 3,4 Haemorrhage 11 Aspirin/Paracetamol Chest injury A, CR, 1,2 PC/CC, MS 13 Salbutamol inh Mild Asthma A, NCR, 5 SC, CD 13 Salbutamol inh Moderate Asthma A, NCR, 5 SC, CD 13 O2 Moderate Asthma A, CR, CC 6 (Domicilary O2) 13 Prednisolone Moderate Asthma A, CR, SC, 7, 8 CD 13 Salbutamol SC Severe Asthma I 15 Amoxycillin COPD with A, CR, 9, 10 The Evidence Base to Treatment in the Guide For The Treatment Of Respiratory Diseases At District Level 7 Report prepared for WHO by Health Reviews Ltd

NCR, PC/CC, MD 15 Co-trimoxazole COPD with infection A, CR, 9, 10 NCR, PC/CC, MD 15 Amoxycillin+ COPD with infection A, single 11 Clavulanate trial, MS 15 Doxycicline COPD with infection A, CR, 9, 10 NCR, PC/CC, MD 15 Pleural drainage Pneumothorax A, single 12 trial, SC CD 18 Benzylpenicillin IM Severe pneumonia A, single 11, 13 +Gentamycin IM trials PC CD+ 18 Amoxycillin + Severe pneumonia A, single 11, 13 Gentamycin IM trials PC CD+ 18 Gentamycin IM Severe pneumonia A, single 11, 13 trials PC CD+ 18 Oxa/cloxacillin IM Pulmonary abscess I 18 Gentamycin IM Pulmonary abscess I 18 Oxa/cloxacillin IM Pyopneumothorax I Page Intervention Problem Evidence Reference (strength and setting) 18 Gentamycin IM Pyopneumothorax I 18 TB Treatment Miliary TB A, CR, 14, 15 NCR, PC, MD 18 Prednisolone Miliary TB A, single 16, 17 trials, SC, CD+ 18 TB Treatment TB pleurisy (clear A, CR, 14, 15 fluid) NCR, PC, MD 18 Prednisolone TB pleurisy (clear A, single 16, 17 fluid) trials, SC, CD+ 23 Disinfection of nose Head cold I, NCR 3 23 Nasal Decongestant Head Cold X, H*, NCR, 3, 4 PC/CC D 23 Aspirin/Paracetamol Head Cold A, CR, 1,2 PC/CC, MS 23 disinfection Red Throat I, NCR 3 23 Local Acute Otitis media A, CR, 18 borate/disinfection PC/CC, MD The Evidence Base to Treatment in the Guide For The Treatment Of Respiratory Diseases At District Level 8 Report prepared for WHO by Health Reviews Ltd

23 Aspirin/Paracetamol Acute Otitis media A, CR, 1,2 PC/CC, MS 23 Pharynx disinfection Acute laryingitis I, NCR 3 23 Aspirin/Paracetamol Acute laryingitis A, CR, 1,2 PC/CC, MS 23 Nasal Decongestant Suppurative I, single trial 19 sinusitis 23 Nostril disinfection Suppurative I sinusitis 23 Amoxycillin Suppurative A, CR, 5, 6 sinusitis PC/CC MD 23 Co-trimoxazole Suppurative I CR 5 sinusitis 23 Benzathine penicillin Steptococcal sore A, CR, 20 IM throat PC/CC CD 23 Benzylpenicillin Steptococcal sore A, CR, 20 throat PC/CC CD 23 Phenoxymethilpenicill Steptococcal sore A, CR, 20 in throat PC/CC CD 23 Erythromicin Ulcerated sore A, CR, 20 throat PC/CC CD 23 Anti-diphtheria serum Diphtheria I (serum) 21 +penicillin or A (penicillin) erythromicin The Evidence Base to Treatment in the Guide For The Treatment Of Respiratory Diseases At District Level 9 Report prepared for WHO by Health Reviews Ltd

Page Intervention Problem Evidence Reference (strength and setting) 23 Penicillin Spirochetal sore A, CR, 21 throat PC/CC CD 27 Nasal disinfection I 27 Codeine Influenza cough I, H*, NCR 3 27 Dextromethorphan Influenza cough I, NCR 3 27 Aspirin/Paracetamol Influenza A, CR, MS 1, 2 27 Chronic Bronchitis A, single 22 trial, CC, CD 27 Acetylcisteine Chronic Bronchitis A, CR, SC, 23 CD 27 Diazepam Hyperventilation I 27 Salbutamol Asthma A, NCR, 5 SC, CD 27 Salbutamol Dispnoeic episode A, NCR, 5 SC, CD 27 Prednisolone Dispnoeic episode A, CR, SC, 7, 8 CD 27 Salbutamol Dispnoeic episode A, NCR, 5 during SC, CD 27 Prednisolone Dispnoeic episode I 24 during bronchopneumonia 27 Beclomethasone inh Dispnoeic episode A, CR, MS, 25 during MD bronchopneumonia 27 Amoxycillin Acute bronchitis A, CR, 9 (suppurative) NCR, PC/CC, MD 27 Co-trimoxazole Acute bronchitis A, CR, 9 (suppurative) NCR, PC/CC, MD 27 Smoking Cessation Purulent chronic A, single 22 bronchitis trial, CC, CD 27 Amoxycillin Purulent chronic A, CR, 9, 26 bronchitis NCR, PC/CC, MD 27 Co-trimoxazole Purulent chronic A, CR, 9, 26 bronchitis NCR, PC/CC, MD The Evidence Base to Treatment in the Guide For The Treatment Of Respiratory Diseases At District Level 10 Report prepared for WHO by Health Reviews Ltd

Page Intervention Problem Evidence Reference (strength and setting) 27 Amoxycillin+ Purulent chronic A, single 11 Clavulanate bronchitis (>60 years trial, MS of age) 27 Benzylpenicillin IM Suspected A, single 11, 13 pneumonia trials PC D+ 27 Procaine Suspected A, single 11, 13 Benzylpenicillin IM pneumonia trials PC D+ 27 Erythromicin Suspected I pneumonia 27 Amoxycillin Suspected TB I 31 Salbutamol inh Intermittent asthma A, NCR, 5 SC, CD 31 Salbutamol inh Persistent benign A, NCR, 5 asthma SC, CD 31 Beclomethasone inh Persistent benign A, CR, SC, 27 asthma CD 31 Salbutamol inh Persistent moderate A, NCR, 5 asthma SC, CD 31 Beclomethasone inhPersistent moderate A, CR, SC, 27 asthma CD 31 Theophylline retard Persistent moderate A, CR, H 28 asthma 31 Salbutamol inh Persistent severe A, NCR, 5 asthma SC, CD 31 Beclomethasone inh Persistent severe A, CR, SC, 27 asthma CD 31 Theophylline retard Persistent severe A, CR, H 28 asthma 31 Prednisolone Persistent severe A, CR, SC, 7, 8 asthma CD 31 Salbutamol inh Chronic obstructive A, NCR, 5 pulmonary disease SC, CD (COPD) 31 Ipatropium Bromide COPD See note in references 31 Prednisolone COPD I, CR 24 31 Beclomethasone inh COPD A, CR, SC, 27 CD 31 Salbutamol inh COPD A, NCR, 5 High dose +cyanosis+dyspnoea SC, CD The Evidence Base to Treatment in the Guide For The Treatment Of Respiratory Diseases At District Level 11 Report prepared for WHO by Health Reviews Ltd

Page Intervention Problem Evidence Reference (strength and setting) 31 Beclomethasone inh COPD A, CR, SC, 27 high dose +cyanosis+dyspnoea CD 31 Prednisolone high COPD I, CR 24 dose +cyanosis+dyspnoea 31 Amoxycillin COPD, A, CR, 26 cyanosis+dyspnoea NCR, +aggravation PC/CC, MD 31 Co-trimoxazole COPD A, CR, 26 +cyanosis+dyspnoea NCR, +aggravation PC/CC, MD 31 Amoxycillin+ COPD A, single 11 Clavulanate +cyanosis+dyspnoea trial, MS +aggravation 31 O2 COPD A, CR, CC 6 +cyanosis+dyspnoea (Domicilary O2) +aggravation 31 Furosemide IV COPD I +cyanosis+dyspnoea +aggravation 35 INAH+RIF+PYRAZ+ TB (treatment) A, CR, 14, 15 ETHAMB (various NCR, PC, regimens) MD 43 Procaine Retropharyngeal A, single 29 Benzylpenicillin IM abscess trial, PC 43 Hydrocortisone IV Severe asthma attack A, CR, SC, 7, 8 CD 43 Dexamethazone Severe asthma attack A, CR, SC, 7, 8 CD 43 Adrenaline Severe asthma attack A, CR, SC, 7, 8 CD 59 Penicillin Pneumonia A, single 31 +HIV/AIDS trial, SC, CD 59 Amoxycillin Pneumonia I +HIV/AIDS 59 Co-trimoxazole Pneumonia A, single 32, 33 +HIV/AIDS trials, SC, CD+ 59 INAH+RIF+PYRAZ+ TB pneumonia A, single 34 ETHAMB (various +HIV/AIDS trials, MS, regimens) - anti retroviral Tx CD+ 60 Aspirin Pain relief (palliation) A, CR, 1 PC/CC, MS 60 Paracetamol Pain relief (palliation) A, CR, 1 PC/CC, MS The Evidence Base to Treatment in the Guide For The Treatment Of Respiratory Diseases At District Level 12 Report prepared for WHO by Health Reviews Ltd

Page Intervention Problem Evidence Reference (strength and setting) 60 Ibuprofen Single trial 35, 35a CR, MS, CD 60 Codeine I 60 Dihydrocodeine I, CR 36 60 Morphine o/sc I 60 Pethidine o/sc I 60 Buprenorphine o I 66 Saline Humidifying products I 66 Menthol etc Humidifying products I 66 Chlorexedine etc Local antiseptic A, single 37 trial, TC CD

66 Ephedrine etc Decongestants I 66 Lidocaine Local anaeshetic A, CR, MS, 38 MD 66 Atropine Midriatics I

66 Adrenaline I 67 Chlorpheniramine Antiallergics I 39 etc 11 Chest injury Bandage I

Table. Evidence of effect of interventions listed in the Guide for the Treatment of Respiratory Diseases at District Level (August 1999 version) by source and setting.

Key: pt = (pre-referral treatment)

* = in children

A = Presence evidence of effect superior to either placebo, control or specified comparator X = Presence of evidence of effect not superior to either placebo, control or specified comparator H = Presence of evidence of harmful effect

I = Insufficient evidence from systematic reviews

PC - in bold = Primary care SC – in bold = Secondary care TC – in bold = Tertiary care CC – in bold = Community care MS - in bold = Mixed setting MD = mostly or completely (CD) in developed country or countries MD+ = mostly or completely (CD+) in developing country or countries.