Randomized trial of salbutamol in acute bronchiolitis

Salbutamol safety in children under 2 years of age with acute wheezing: a meta-analysis of randomised controlled trials

OBJECTIVE

To evaluate the safety of short-term use of inhaled salbutamol in children under 2 years of age with acute wheezing.

DATA SOURCES

Electronic databases (PubMed, Trip, MEDLINE) and the Cochrane Library were searched for studies published up to October 2022.

STUDY SELECTION

The search was restricted to randomised controlled trials published in English regarding the safety of inhaled salbutamol in wheezing children under the age of 2.

DATA EXTRACTION AND SYNTHESIS

The literature search strategy yielded 3532 references. The meta-analysis was conducted in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines.

MAIN OUTCOMES AND MEASURES

The incidence of adverse reactions associated with inhaled salbutamol administration compared with placebo.

RESULTS

A total of 24 records were included. In 7 studies involving 597 patients, inhaled salbutamol was compared with controls and no statistically significant difference in the incidence of adverse drug reactions was found between the two groups (OR 2.12, 95% CI 0.69 to 6.51; p=0.19). Salbutamol administration via nebulisation was associated with an increased incidence of adverse reactions (OR 6.76, 95% CI 2.01 to 22.71; p=0.002). None of the studies reported severe cardiac side effects that necessitated withdrawal from the study following salbutamol administration. Only one study reported a significant non-cardiac side effect (severe tremulousness) that necessitated withdrawal from therapy.

CONCLUSIONS

Inhaled salbutamol can be safely used in children under 2 years of age with acute wheeze with the administration via a metered-dose inhaler being potentially safer than a nebulised formulation. Neither of the formulations was associated with severe adverse effects.

The use of β2-adrenoreceptor agonists in viral bronchiolitis: scientific rationale beyond evidence-based guidelines

Despite scientific evidence proving that inhaled β₂-adrenergic receptor (β₂-AR) agonists can reverse bronchoconstriction in all ages, current guidelines advocate against the use of β₂-AR bronchodilators in infants with viral bronchiolitis because clinical trials have not demonstrated an overall clinical benefit. However, there are many different types of viral bronchiolitis, with variations occurring at an individual and viral level. To discard a potentially helpful treatment from all children regardless of their clinical features may be unwarranted. Unfortunately, the clinical criteria to identify the infants that may benefit from bronchodilators from those who do not are not clear. Thus, we summarised the current understanding of the individual factors that may help clinicians determine the highest probability of response to β₂-AR bronchodilators during viral bronchiolitis, based on the individual immunobiology, viral pathogen, host factors and clinical presentation.

There are several factors that may help clinicians determine the highest probability of response to β₂-AR bronchodilators during viral bronchiolitis, based on the individual immunobiology, viral pathogen, host factors and clinical presentationhttps://bit.ly/30CoHcH

Evaluating the Placebo Status of Nebulized Normal Saline in Patients With Acute Viral Bronchiolitis: A Systematic Review and Meta-analysis

IMPORTANCE

In therapeutic trials for acute viral bronchiolitis, consistent clinical improvement in groups that received nebulized normal saline (NS) as placebo raises the question of whether nebulized NS acts as a treatment rather than a placebo.

OBJECTIVE

To measure the short-term association of nebulized NS with physiologic measures of respiratory status in children with bronchiolitis by analyzing the changes in these measures between the use of nebulized NS and the use of other placebos and the changes before and after nebulized NS treatment.

DATA SOURCES

MEDLINE and Scopus were searched through March 2019, as were bibliographies of included studies and relevant systematic reviews, for randomized clinical trials evaluating nebulized therapies in bronchiolitis.

STUDY SELECTION

Randomized clinical trials comparing children 2 years or younger with bronchiolitis who were treated with nebulized NS were included. Studies enrolling a treatment group receiving an alternative placebo were included for comparison of NS with other placebos.

DATA EXTRACTION AND SYNTHESIS

Data abstraction was performed per PRISMA guidelines. Fixed- and random-effects, variance-weighted meta-analytic models were used.

MAIN OUTCOMES AND MEASURES

Pooled estimates of the association with respiratory scores, respiratory rates, and oxygen saturation within 60 minutes of treatment were generated for nebulized NS vs another placebo and for change before and after receiving nebulized NS.

RESULTS

A total of 29 studies including 1583 patients were included. Standardized mean differences in respiratory scores for nebulized NS vs other placebo (3 studies) favored nebulized NS by -0.9 points (95% CI, -1.2 to -0.6 points) at 60 minutes after treatment (P < .001). There were no differences in respiratory rate or oxygen saturation comparing nebulized NS with other placebo. The standardized mean difference in respiratory score (25 studies) after nebulized NS was -0.7 (95% CI, -0.7 to -0.6; I2 = 62%). The weighted mean difference in respiratory scores using a consistent scale (13 studies) after nebulized NS was -1.6 points (95% CI, -1.9 to -1.3 points; I2 = 72%). The weighted mean difference in respiratory rate (17 studies) after nebulized NS was -5.5 breaths per minute (95% CI, -6.3 to -4.6 breaths per minute; I2 = 24%). The weighted mean difference in oxygen saturation (23 studies) after nebulized NS was -0.4% (95% CI, -0.6% to -0.2%; I2 = 79%).

CONCLUSIONS AND RELEVANCE

Nebulized NS may be an active treatment for acute viral bronchiolitis. Further evaluation should occur to establish whether it is a true placebo.

Efficacy of salbutamol in the treatment of infants with bronchiolitis: A meta-analysis of 13 studies

BACKGROUND

To systematically evaluate the clinical efficacy of salbutamol treatment in infants with bronchiolitis.

METHODS

A systematic review and meta-analysis of randomized controlled trials (RCTs) investigating the use of salbutamol in infants with bronchiolitis was performed. The Cochrane Risk of Bias Assessment Tool was used to evaluate the quality of RCTs. Data were extracted and meta-analyzed using STATA version 12.0 (StataCorp, College Station, TX).

RESULTS

Thirteen RCTs, including a total of 977 participants, were assessed in the present meta-analysis. Results indicated that salbutamol therapy for bronchiolitis in infants led to an increase in respiratory rate (weighted mean difference [WMD] 2.26 [95% confidence interval {CI} 0.36-4.16]) and higher heart rate (WMD 12.15 [95% CI 9.24-15.07]). However, as a selective β2-agonist, salbutamol did not improve the clinical severity score of infants with bronchiolitis (WMD -0.11 [95% CI -0.26 to 0.03]), length of hospital stay (WMD 0.12 [95% CI -0.32 to 0.56]), or oxygen saturation (WMD 0.20 [95% CI -0.35 to 0.75]).

CONCLUSION

Based on the results of this systematic review, the use of salbutamol had no effect on bronchiolitis in children <24 months of age. Moreover, the treatment can also lead to side effects, such as high heart rate. As such, salbutamol should not be recommended for treatment of bronchiolitis in infants.

Dyspnea in Children as a Symptom of Acute Respiratory Tract Infections and Antibiotic Prescribing

BACKGROUND:

Dyspnea is an unpleasant feeling of breathing difficulty, shortness of breath and inability to satisfy the hunger for air. The role of family physicians is to be prepared to recognise dyspnea as a symptom of acute respiratory infections (ARI), to perform triage and managing of children with acute dyspnea and make continuous education of parents. In the treatment of acute dyspnea more important is to treat dyspnea as a symptom than the prescribing of antibiotics (AB). Nowadays, even more often large amount of children, because of the noncompliance in the treatment and the pressure from the parents, unnecessary is hospitalised and frequently used antibiotics: According to the guidelines, a small percentage of children with ARI should be treated with AB. The rate of antibiotic prescription should be around 15-20% and lower.

AIM:

To assess doctor’s AB prescriptions in Primary care practices in Macedonia, for ARI and dyspnea in children we use the data from a National project about antibiotic prescribing for acute respiratory tract infections, which has been run in 2014 November as a part of E - quality program.

METHODS:

Eighty-six general practitioners from Macedonia have taken participation in it. The group of 3026 children, from 0-5 years of age, with symptoms of dyspnea, was analysed. We have found a rate of 54.6% antibiotic prescriptions (AB). From 3026 children with dyspnea, AB got 1519 children, 852 of which were prescribed by a specialist.

RESULTS:

The children were mostly diagnosed with upper ARI, in 57.7%. The most used AB is amoxicillin + clavulonic acid. We concluded that there was an increased and inappropriate prescribing of antibiotics in children with ARI, presented with dyspnea in Macedonia.

CONCLUSION:

Perceptions and the parent’s attitudes do not correlate with the severity of clinical picture of the disease in children and lack of use Evidence-based medicine (EBM), insecurity, fear, loss of patients effect on antibiotic prescribing of the doctors.

Systematic review of instruments aimed at evaluating the severity of bronchiolitis

OBJECTIVE

No recent studies have performed a systematic review of all available instruments aimed at evaluating the severity of bronchiolitis. The objective of the present study was to perform a systematic review of instruments aimed at evaluating the severity of bronchiolitis and to evaluate their measurement properties.

METHODS

A systematic search of the literature was performed in order to identify studies in which an instrument for evaluating the severity of bronchiolitis was described. Instruments were evaluated based on their reliability, validity, utility, endorsement frequency, restrictions in range, comprehension, and lack of ambiguity.

RESULTS

A total of 77 articles, describing a total of 32 different instruments were included in the review. The number of items included in the instruments ranged from 2 to 26. Upon analyzing their content, respiratory rate turned out to be the most frequently used item (in 26/32, 81.3% of the instruments), followed by wheezing (in 25/32, 78.1% of the instruments). In 18 (56.3%) instruments, there was a report of at least one of their measurement properties, mainly reliability and utility. Taking into consideration the information contained in the instruments, as well as their measurement properties, one was considered to be the best one available.

CONCLUSIONS

Among the 32 instruments aimed at evaluating the severity of bronchiolitis that were identified and systematically examined, one was considered to be the best one available. However, there is an urgent need to develop better instruments and to validate them in a more comprehensive and proper way.

Clinical respiratory scales: which one should we use?

INTRODUCTION

There are countless clinical respiratory scales for acute dyspnoea. Most healthcare professionals choose one based on previous personal experience or following local practice, unaware of the implications of their choice. The lack of critical comparisons between those different tools has been a widespread problem that only recently has begun to be addressed via score validation studies. Here we try to assess and compare the quality criteria of measurement properties of acute dyspnoea scores. Areas covered: A literature review was conducted by searching the PubMed database. Forty-five documents were deemed eligible as they reported the use or building of clinical scales, using at least two parameters, and applied these to an acute episode of respiratory dyspnoea. Our primary focus was the description of the validity, reliability and utility of 41 suitable scoring instruments. Differences in sample selection, study design, rater profiles and potential methodological shortcomings were also addressed. Expert commentary: All acute dyspnoea scores lack complete validation. In particular, the areas of measurement error and interpretability have not been addressed correctly by any of the tools reviewed. Frequent modification of pre-existing scores (in items composition and/or name), differences in study design and discrepancies in reviewed sources also hinder the search for an adequate tool.

A systematic review of the psychometric properties of bronchiolitis assessment tools

AIM

The aim of this study was to assess the psychometric properties of tools developed for the purpose of assessing infants with bronchiolitis.

BACKGROUND

Bronchiolitis is the leading cause of hospitalization in infants under the age of 1 year. Several bronchiolitis assessment tools have been developed primarily for use in randomized control trials of medical treatments for infants with bronchiolitis, however, the reliability and validity of many of these tools is not well reported.

DESIGN

Systematic review.

DATA SOURCES

CINAHL, MEDLINE, EMBASE and PubMed electronic databases were searched between January 1960-December 2015 using the key words 'bronchiolitis' and 'assessment' or 'screen' or 'tool' or 'scale' or 'score'.

REVIEW METHODS

A systematic review of the psychometric properties of bronchiolitis assessment tools was undertaken using the COSMIN checklist.

RESULTS

Fourteen studies meeting the inclusion criteria were reviewed and the methodological quality of the studies and reported psychometric properties of 11 instruments were assessed. Overall, the reliability and validity of bronchiolitis assessment tools was poorly established. Although several studies reported that their tools had good inter-rater reliability, the methodological quality of these studies was generally poor. Only one study underwent psychometric testing that was assessed as being of excellent quality. The Respiratory Distress Assessment Index was deemed to have undergone the most rigorous psychometric testing but had poor to moderate construct validity and considerable test-retest error.

CONCLUSION

Current bronchiolitis assessment tools lack clearly established reliability and validity and may not be sensitive to clinically meaningful outcomes for patients.

Bronchodilators for bronchiolitis

BACKGROUND

Bronchiolitis is an acute, viral lower respiratory tract infection affecting infants and is sometimes treated with bronchodilators.

OBJECTIVES

To assess the effects of bronchodilators on clinical outcomes in infants (0 to 12 months) with acute bronchiolitis.

SEARCH METHODS

We searched CENTRAL 2013, Issue 12, MEDLINE (1966 to January Week 2, 2014) and EMBASE (1998 to January 2014).

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing bronchodilators (other than epinephrine) with placebo for bronchiolitis.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted data. We obtained unpublished data from trial authors.

MAIN RESULTS

We included 30 trials (35 data sets) representing 1992 infants with bronchiolitis. In 11 inpatient and 10 outpatient studies, oxygen saturation did not improve with bronchodilators (mean difference (MD) -0.43, 95% confidence interval (CI) -0.92 to 0.06, n = 1242). Outpatient bronchodilator treatment did not reduce the rate of hospitalization (11.9% in bronchodilator group versus 15.9% in placebo group, odds ratio (OR) 0.75, 95% CI 0.46 to 1.21, n = 710). Inpatient bronchodilator treatment did not reduce the duration of hospitalization (MD 0.06, 95% CI -0.27 to 0.39, n = 349).Effect estimates for inpatients (MD -0.62, 95% CI -1.40 to 0.16) were slightly larger than for outpatients (MD -0.25, 95% CI -0.61 to 0.11) for oximetry. Oximetry outcomes showed significant heterogeneity (I(2) statistic = 81%). Including only studies with low risk of bias had little impact on the overall effect size of oximetry (MD -0.38, 95% CI -0.75 to 0.00) but results were close to statistical significance.In eight inpatient studies, there was no change in average clinical score (standardized MD (SMD) -0.14, 95% CI -0.41 to 0.12) with bronchodilators. In nine outpatient studies, the average clinical score decreased slightly with bronchodilators (SMD -0.42, 95% CI -0.79 to -0.06), a statistically significant finding of questionable clinical importance. The clinical score outcome showed significant heterogeneity (I(2) statistic = 73%). Including only studies with low risk of bias reduced the heterogeneity but had little impact on the overall effect size of average clinical score (SMD -0.22, 95% CI -0.41 to -0.03).Sub-analyses limited to nebulized albuterol or salbutamol among outpatients (nine studies) showed no effect on oxygen saturation (MD -0.19, 95% CI -0.59 to 0.21, n = 572), average clinical score (SMD -0.36, 95% CI -0.83 to 0.11, n = 532) or hospital admission after treatment (OR 0.77, 95% CI 0.44 to 1.33, n = 404).Adverse effects included tachycardia, oxygen desaturation and tremors.

AUTHORS' CONCLUSIONS

Bronchodilators such as albuterol or salbutamol do not improve oxygen saturation, do not reduce hospital admission after outpatient treatment, do not shorten the duration of hospitalization and do not reduce the time to resolution of illness at home. Given the adverse side effects and the expense associated with these treatments, bronchodilators are not effective in the routine management of bronchiolitis. This meta-analysis continues to be limited by the small sample sizes and the lack of standardized study design and validated outcomes across the studies. Future trials with large sample sizes, standardized methodology across clinical sites and consistent assessment methods are needed to answer completely the question of efficacy.

Systematic review: insufficient validation of clinical scores for the assessment of acute dyspnoea in wheezing children

BACKGROUND

A reliable, valid, and easy-to-use assessment of the degree of wheeze-associated dyspnoea is important to provide individualised treatment for children with acute asthma, wheeze or bronchiolitis.

OBJECTIVE

To assess validity, reliability, and utility of all available paediatric dyspnoea scores.

METHODS

Systematic review. We searched Pubmed, Cochrane library, National Guideline Clearinghouse, Embase and Cinahl for eligible studies. We included studies describing the development or use of a score, assessing two or more clinical symptoms and signs, for the assessment of severity of dyspnoea in an acute episode of acute asthma, wheeze or bronchiolitis in children aged 0-18 years. We assessed validity, reliability and utility of the retrieved dyspnoea scores using 15 quality criteria.

RESULTS

We selected 60 articles describing 36 dyspnoea scores. Fourteen scores were judged unsuitable for clinical use, because of insufficient face validity, use of items unsuitable for children, difficult scoring system or because complex auscultative skills are needed, leaving 22 possibly useful scores. The median number of quality criteria that could be assessed was 7 (range 6-11). The median number of positively rated quality criteria was 3 (range 1-5). Although most scores were easy to use, important deficits were noted in all scores across the three methodological quality domains, in particular relating to reliability and responsiveness.

CONCLUSION

None of the many dyspnoea scores has been sufficiently validated to allow for clinically meaningful use in children with acute dyspnoea or wheeze. Proper validation of existing scores is warranted to allow paediatric professionals to make a well balanced decision on the use of the dyspnoea score most suitable for their specific purpose.

Validity of respiratory scores in bronchiolitis

OBJECTIVE

The primary objective of this study was to establish the validity and reliability of 2 respiratory scores, the Respiratory Distress Assessment Instrument (RDAI) and the Children's Hospital of Wisconsin Respiratory Score (CHWRS), in bronchiolitis. A secondary objective was to identify the respiratory score components that most determine overall respiratory status.

METHODS

This was a prospective cohort study in infants aged < 1 year seen at Children's Hospital of Wisconsin for bronchiolitis. We evaluated: (1) discriminative validity (the score's ability to discriminate between 2 different outcomes) of the respiratory scores to identify emergency department (ED) disposition by using receiver operating characteristic curves; and (2) construct validity (the score's ability to measure what it is thought to measure, overall respiratory status) by using length of stay (LOS) as a proxy for disease severity and comparing correlations between changes in respiratory scores and LOS. Interrater reliability was established by using intraclass correlation. The contribution of individual respiratory score components to determine ED disposition was studied by using multivariate logistic regression.

RESULTS

A total of 195 infants were included. The area under the receiver operating characteristic curve was 0.68 for CHWRS versus 0.51 for RDAI in predicting disposition. There was no correlation between initial respiratory scores or change in respiratory scores over the first 24 hours and LOS. Item analysis revealed that oxygen delivery, subcostal retractions, and respiratory rate were independently correlated with ED disposition. The CHWRS was more reliable than the RDAI.

CONCLUSIONS

The CHWRS had modest discriminative validity in predicting ED disposition. Neither the CHWRS nor the RDAI had good construct validity. Respiratory rate, oxygen need, and presence of retractions were most useful in predicting ED disposition.

Acute bronchiolitis

Bronchiolitis is the most common lower respiratory tract infection to affect infants and toddlers. High-risk patients include infants younger than 3 months, premature infants, children with immunodeficiency, children with underlying cardiopulmonary or neuromuscular disease, or infants prone to apnea, severe respiratory distress, and respiratory failure. Bronchiolitis is a self-limited disease in healthy infants and children. Treatment is usually symptomatic, and the goal of therapy is to maintain adequate oxygenation and hydration. Use of a high-flow nasal cannula is becoming common for children with severe bronchiolitis.

Respiratory syncytial virus: diagnosis, treatment and prevention

Respiratory Syncytial Virus (RSV) is a common virus that infects children and adults; however, children younger than two years of age tend to develop more serious respiratory symptoms. RSV is responsible for thousands of outpatient visits (e.g., emergency room/primary care physician), hospitalizations and can result in death. Treatment is primarily supportive care and the illness resolves without complications in most children. RSV prophylaxis with palivizumab is an option for high-risk infants and children, which can decrease hospitalization and length of stay. Immunocompromised patients are a special population of which ribavirin and palivizumab may be used for treatment. Currently, no medication or vaccine available has been able to show a reduction in mortality from RSV. Future vaccines are in the developmental stage and will hopefully decrease the symptomatic and economic burden of this disease.

Management of acute bronchiolitis in emergency wards in Spain: variability and appropriateness analysis (aBREVIADo Project)

Most patients with acute bronchiolitis have a mild course and only require outpatient care. However, some of them have to go to emergency departments, because they have respiratory distress or feeding problems. There, they frequently receive diagnostic and therapeutic procedures. We want to know the variability and appropriateness of these procedures. A cross-sectional study (October 2007 to March 2008) was carried out on 2,430 diagnosed cases of bronchiolitis in hospital emergency departments, which required no hospitalization. An analysis of the appropriateness of the treatments was made in 2,032 cases gathered in ten departments with at least 100 cases, using as criterion the recommendations of a consensus conference. We estimated the adjusted percentages of each department. Most of the bronchiolitis were mild, in spite that they underwent multiple diagnostic and therapeutic procedures. In the acute phase, different treatments were used: inhaled beta 2 agonists (61.4%), antipyretics (17.1%), oral steroids (11.3%), and nebulized adrenaline (9.3%). In the maintenance phase, the most common treatments were: inhaled beta 2 agonists (50.5%), oral steroids (17%), oral beta 2 agonists (14.9%), and antibiotics (6.1%). The 64% of the treatments used in the acute phase and the 55.9% in the maintenance phase were considered inappropriate in the appropriateness analysis; a great heterogeneity among centers was found.

CONCLUSIONS

There are discrepancies between clinical practice and evidence-based management of bronchiolitis in Spanish emergency departments. Inappropriate treatments were used in more than half of patients. The wide variation between centers shows the influence of local prescribing habits and reveals the scope for improvement.

Pharmacological management of acute bronchiolitis

This article reviews the current knowledge base related to the pharmacological treatments for acute bronchiolitis. Bronchiolitis is a common lower respiratory illness affecting infants worldwide. The mainstays of therapy include airway support, supplemental oxygen, and support of fluids and nutrition. Frequently tried pharmacological interventions, such as ribavirin, nebulized bronchodilators, and systemic corticosteroids, have not been proven to benefit patients with bronchiolitis. Antibiotics do not improve the clinical course of patients with bronchiolitis, and should be used only in those patients with proven concurrent bacterial infection. Exogenous surfactant and heliox therapy also cannot be recommended for routine use, but surfactant replacement holds promise and should be further studied.

Bronchodilators for bronchiolitis

BACKGROUND

Bronchiolitis is an acute, viral lower respiratory tract infection affecting infants and often treated with bronchodilators.

OBJECTIVES

To assess the effects of bronchodilators on clinical outcomes in infants with acute bronchiolitis.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 1) which contains the Acute Respiratory Infections Group's Specialized Register, MEDLINE (1966 to March week 2 2010) and EMBASE (2003 to March 2010).

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing bronchodilators (other than epinephrine) with placebo for bronchiolitis.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted data. Unpublished data were obtained from trial authors.

MAIN RESULTS

We included 28 trials (1912 infants) with bronchiolitis. In 10 inpatient and 10 outpatient studies, oxygen saturation did not improve with bronchodilators (mean difference (MD) -0.45, 95% confidence interval (CI) -0.96 to 0.05, n = 1182). Outpatient bronchodilator treatment did not reduce the rate of hospitalization (12% in bronchodilator group versus 16% in placebo, odds ratio (OR) 0.78, 95% CI 0.47 to 1.29, n = 650). Inpatient bronchodilator treatment did not reduce the duration of hospitalization (MD 0.06, 95% CI -0.27 to 0.39, n = 349). In seven inpatient and eight outpatient studies, average clinical score decreased slightly with bronchodilators (standardized mean difference (SMD) -0.37, 95% CI -0.62 to -0.13, n = 1006).Oximetry and clinical score outcomes showed significant heterogeneity. Including only studies at low risk of bias significantly reduced heterogeneity measures for oximetry (I(2) statistic = 17%) and average clinical score (I(2) statistic = 26%), while having little impact on the overall effect size of oximetry (MD -0.38, 95% CI -0.75 to 0.00, P = 0.05) and average clinical score (SMD -0.26, 95% CI -0.44 to -0.08, P = 0.005).Effect estimates for outpatients were slightly larger than for inpatients for oximetry (outpatients MD -0.57, 95% CI -1.13 to 0.00 versus inpatients MD -0.29, 95% CI -1.10 to 0.51) and average clinical score (outpatients SMD -0.49, 95% CI -0.86 to -0.11 versus inpatients SMD -0.20, 95% CI -0.43 to 0.03). Adverse effects included tachycardia and tremors.

AUTHORS' CONCLUSIONS

Bronchodilators do not improve oxygen saturation, do not reduce hospital admission after outpatient treatment, do not shorten the duration of hospitalization and do not reduce the time to resolution of illness at home. The small improvements in clinical scores for outpatients must be weighed against the costs and adverse effects of bronchodilators.

[Consensus conference on acute bronchiolitis (VI): prognosis of acute bronchiolitis. Review of scientific evidence]

We present a review of the evidence on prognosis of acute bronchiolitis, risk factors for severe forms, symptom or severity scores and risk of post-bronchiolitis asthma. Documented risk factors of long stay or PICU admission in hospitalized patients are: bronchopulmonary dysplasia and/or chronic lung disease, prematurity, congenital heart disease and age less than 3 months. Other less well documented risk factors are: tobacco exposure, history of neonatal mechanical ventilation, breastfeeding for less than 4 months, viral co-infection and other chronic diseases. There are several markers of severity: toxic appearance, tachypnea, hypoxia, atelectasis or infiltrate on chest radiograph, increased breathing effort, signs of dehydration, tachycardia and fever. Although we have some predictive models of severity, none has shown sufficient predictive validity to recommend its use in clinical practice. While there are different symptom or severity scores, none has proven to be valid or accurate enough to recommend their preferable application in clinical practice. There seems to be a consistent and strong association between admission due to bronchiolitis and recurrent episodes of wheezing in the first five years of life. However it is unclear whether this association continues in subsequent years, as there are discordant data on the association between bronchiolitis and asthma.

Epinephrine and dexamethasone in children with bronchiolitis

BACKGROUND

Although numerous studies have explored the benefit of using nebulized epinephrine or corticosteroids alone to treat infants with bronchiolitis, the effectiveness of combining these medications is not well established.

METHODS

We conducted a multicenter, double-blind, placebo-controlled trial in which 800 infants (6 weeks to 12 months of age) with bronchiolitis who were seen in the pediatric emergency department were randomly assigned to one of four study groups. One group received two treatments of nebulized epinephrine (3 ml of epinephrine in a 1:1000 solution per treatment) and a total of six oral doses of dexamethasone (1.0 mg per kilogram of body weight in the emergency department and 0.6 mg per kilogram for an additional 5 days) (the epinephrine-dexamethasone group), the second group received nebulized epinephrine and oral placebo (the epinephrine group), the third received nebulized placebo and oral dexamethasone (the dexamethasone group), and the fourth received nebulized placebo and oral placebo (the placebo group). The primary outcome was hospital admission within 7 days after the day of enrollment (the initial visit to the emergency department).

RESULTS

Baseline clinical characteristics were similar among the four groups. By the seventh day, 34 infants (17.1%) in the epinephrine-dexamethasone group, 47 (23.7%) in the epinephrine group, 51 (25.6%) in the dexamethasone group, and 53 (26.4%) in the placebo group had been admitted to the hospital. In the unadjusted analysis, only the infants in the epinephrine-dexamethasone group were significantly less likely than those in the placebo group to be admitted by day 7 (relative risk, 0.65; 95% confidence interval, 0.45 to 0.95, P=0.02). However, with adjustment for multiple comparisons, this result was rendered insignificant (P=0.07). There were no serious adverse events.

CONCLUSIONS

Among infants with bronchiolitis treated in the emergency department, combined therapy with dexamethasone and epinephrine may significantly reduce hospital admissions. (Current Controlled Trials number, ISRCTN56745572.)

A prospective randomized controlled blinded study of three bronchodilators in infants with respiratory syncytial virus bronchiolitis on mechanical ventilation

OBJECTIVE

To study patients with respiratory syncytial virus bronchiolitis in respiratory failure to make specific measurements reflecting airway resistance before and after treatment with commonly used agents. We hypothesized that racemic epinephrine would decrease airways resistance more effectively than levalbuterol, and levalbuterol would decrease airways resistance more effectively than racemic albuterol. Normal saline was used as a control.

DESIGN

Prospective, randomized, controlled, blinded study.

SETTING

Tertiary Pediatric Intensive Care Unit in a University affiliated hospital in the northeastern United States.

PATIENTS

Twenty-two patients with respiratory syncytial virus bronchiolitis and in respiratory failure were enrolled. All were intubated and ventilated in a volume control mode and sedated.

INTERVENTIONS

In a randomized, blinded fashion patients were given four agents: norepinephrine, levalbuterol, racemic albuterol, and normal saline at 6 hr intervals.

MEASUREMENTS

As indicators of bronchodilation, peak inspiratory pressure and inspiratory respiratory system resistance were measured before and 20 mins after each agent was given. Thus, each patient acted as his/her own control.

MAIN RESULTS

There were small but statistically significant decreases in peak inspiratory pressure after racemic epinephrine treatment, levalbuterol, and racemic albuterol. There was no change in peak inspiratory pressure after inhaled normal saline. Inspiratory respiratory system resistance fell significantly after all treatments, including saline. Heart rate rose significantly after inhaled bronchodilator treatments (p < 0.05 for all treatments).

CONCLUSIONS

Similar statistically significant bronchodilation occurred after all three bronchodilators as indicated by a decrease in peak inspiratory pressure and respiratory system resistance, but these changes were small and probably clinically insignificant. However, side effects of bronchodilators, such as tachycardia, also occurred, and these may be clinically significant. Thus the benefit of bronchodilator treatment in these patients is small, does not differ among the drugs we studied and of questionable value.

A single versus multiple doses of dexamethasone in infants wheezing for the first time

RATIONALE

Corticosteroid therapy is not routinely recommended in true bronchiolitis. However, since bronchiolitis and the first asthma attack are impossible to distinguish, some infants with the first wheezing episode receive corticosteroids. Optimal duration of corticosteroid therapy in this scenario is unknown. This study compared efficacy of multiple administrations and a single dose of dexamethasone in bronchiolitis.

METHODS

In this randomized double blind trial, previously healthy outpatients 2-23 months of age with bronchiolitis and Respiratory Disease Assessment Instrument (RDAI) score 6 or more received 1 mg/kg of oral dexamethasone in the Emergency Department. Prior to discharge at 4 hr they were randomized to either 4 daily doses of dexamethasone 0.15 mg/kg or placebo equivalent. Primary outcome was the proportion of subsequent hospitalizations or prescribed trials of bronchodilator/corticosteroid therapy for dyspnea by day 6 in the groups. Secondary outcomes were changes in the RDAI to day 6, and proportions with unscheduled visits by days 6 and 28.

RESULTS

The rate of primary outcome in the single dose group (SDG, N = 64) was 9/64 or 14.1% versus 7/61 or 11.5% in the multiple dose group (MDG, N = 61) [95% CI 0.09; 0.14]. Twelve (18.8%) children in the SDG had unscheduled medical visits by day 6 versus 11 (18.0%) children in the MDG [95% CI 0.13; 0.14]. On day 6 the RDAI decreased from 9.5 +/- 2.1 to 2.1 +/- 2.4 in the SDG and from 9.8 +/- 2.2 to 1.6 +/- 2.3 in the MDG [95% CI 0.36; 2.06]. Between days 7-28, 24/64 (37.5%) SDG infants returned for care versus 20/61 (32.8%) of the MDG [95% CI 0.12; 0.21].

CONCLUSIONS

Our study suggests that, in outpatients with bronchiolitis who receive dexamethasone, continuation of this agent beyond the initial dose does not provide significant benefit.

Comparison of nebulized epinephrine to albuterol in bronchiolitis

OBJECTIVES

To compare the effect of nebulized racemic epinephrine to nebulized racemic albuterol on successful discharge from the emergency department (ED).

METHODS

Children up to their 18th month of life presenting to two teaching hospital EDs with a clinical diagnosis of bronchiolitis who were ill enough to warrant treatment but did not need immediate intubation were eligible for this double-blind randomized controlled trial (RCT). Patients received either three doses of racemic albuterol or one dose of racemic epinephrine plus two saline nebulizers. Disposition was decided 2 hours after the first nebulizer. Successful discharge was defined as not requiring additional bronchodilators in the ED after study drug administration and not subsequently admitted within 72 hours. Adjusted relative risks (aRR) were estimated using the modified Poisson regression with successful discharge as the dependent variable and study drug and severity of illness as exposures. Secondary analysis was performed for patients aged less than 12 months and first presentation.

RESULTS

The authors analyzed 703 patients; 352 patients were given albuterol and 351 epinephrine. A total of 173 in the albuterol group and 160 in the epinephrine group were successfully discharged (crude RR = 1.08, 95% confidence interval [CI] = 0.92 to 1.26). When adjusted for severity of illness, patients who received albuterol were significantly more likely than patients receiving epinephrine to be successfully discharged (aRR = 1.18, 95% CI = 1.02 to 1.36). This was also true among those with first presentation and in those less than 12 months of age.

CONCLUSIONS

In children up to the 18th month of life, ED treatment of bronchiolitis with nebulized racemic albuterol led to more successful discharges than nebulized epinephrine.

Inhaled furosemide in hospitalized infants with viral bronchiolitis: a randomized, double-blind, placebo-controlled pilot study

OBJECTIVE

To evaluate the short and long-term clinical effects and the treatment-feasibility of inhaled-furosemide (IF) as compared with placebo via hood in hospitalized infants with viral-bronchiolitis (VB).

STUDY-DESIGN

A randomized, double-blind, placebo-controlled pilot-study was performed in previously healthy infants (0-12 months). Enrolled infants were randomized to receive either IF (2 mg/kg), or placebo nebulized by hood three times daily throughout the hospitalization. Clinical assessment (respiratory distress assessment instrument [RDAI]) was performed before, 30 and 60 min after the 1st daily inhalation. The short-term effects were evaluated by the RDAI, respiratory assessment change score (RACS) and oxygen requirement and the long-term effects by time to be weaned off oxygen, time to full enteral feeding, length of stay, and "ready to discharge" time.

RESULTS

Both groups (16 infants each) had comparable characteristics at study entry. Mean (+/-SD) age was 72 +/- 43 days, and 29/32 infants were RSV positive. Oxygen requirement (FiO(2)) decreased significantly at 30 min post-inhalation (30 +/- 9.2% to 26 +/- 7.1%, P < 0.05) only in the IF group. RACSs and long-term effects of both groups were comparable. Analysis of IF particles generated by the hood-nebulizer demonstrated that 36% and 49% of the particles were <3 and 5 microm, respectively. No side effects were observed during IF treatment.

CONCLUSION

Based on our pilot study, IF has no significant clinical effects in hospitalized infants with VB. IF via hood seems to be feasible and safe.

Computerized acoustic assessment of treatment efficacy of nebulized epinephrine and albuterol in RSV bronchiolitis

Aim

We evaluated the use of computerized quantification of wheezing and crackles compared to a clinical score in assessing the effect of inhaled albuterol or inhaled epinephrine in infants with RSV bronchiolitis.

Methods

Computerized lung sounds analysis with quantification of wheezing and crackles and a clinical score were used during a double blind, randomized, controlled nebulized treatment pilot study. Infants were randomized to receive a single dose of 1 mgr nebulized l-epinephrine or 2.5 mgr nebulized albuterol. Computerized quantification of wheezing and crackles (PulmoTrack^®) and a clinical score were performed prior to, 10 minutes post and 30 minutes post treatment. Results were analyzed with Student's t-test for independent samples, Mann-Whitney U test and Wilcoxon test.

Results

15 children received albuterol, 12 received epinephrine. The groups were identical at baseline. Satisfactory lung sounds recording and analysis was achieved in all subjects. There was no significant change in objective quantification of wheezes and crackles or in the total clinical scores either within the groups or between the groups. There was also no difference in oxygen saturation and respiratory distress.

Conclusion

Computerized lung sound analysis is feasible in young infants with RSV bronchiolitis and provides a non-invasive, quantitative measure of wheezing and crackles in these infants.

Trial registration number: ClinicalTrials.gov NCT00361452

Evaluation of the utility of radiography in acute bronchiolitis

OBJECTIVES

To determine the proportion of radiographs inconsistent with bronchiolitis in children with typical presentation of bronchiolitis and to compare rates of intended antibiotic therapy before radiography versus those given antibiotics after radiography.

STUDY DESIGN

We conducted a prospective cohort study in a pediatric emergency department of 265 infants aged 2 to 23 months with radiographs showing either airway disease only (simple bronchiolitis), airway and airspace disease (complex bronchiolitis), and inconsistent diagnoses (eg, lobar consolidation).

RESULTS

The rate of inconsistent radiographs was 2 of 265 cases (0.75%; 95% CI 0-1.8). A total of 246 children (92.8%) had simple radiographs, and 17 radiographs (6.9%) were complex. To identify 1 inconsistent and 1 complex radiograph requires imaging 133 and 15 children, respectively. Of 148 infants with oxygen saturation >92% and a respiratory disease assessment score <10 of 17 points, 143 (96.6%) had a simple radiograph, compared with 102 of 117 infants (87.2%) with higher scores or lower saturation (odds ratio, 3.9; 95% CI, 1.3-14.3). Seven infants (2.6%) were identified for antibiotics pre-radiography; 39 infants (14.7%) received antibiotics post-radiography (95% CI, 8-16).

CONCLUSIONS

Infants with typical bronchiolitis do not need imaging because it is almost always consistent with bronchiolitis. Risk of airspace disease appears particularly low in children with saturation higher than 92% and mild to moderate distress.

Beta2-agonists for asthma: the pediatric perspective

Inhaled beta-agonists are commonly prescribed for the treatment of wheezing disorders in infants and children. Despite this, there are concerns that these medications have potentially detrimental effects on lung health and symptoms. We will review the ontogeny of beta-agonist receptor and smooth muscle development from fetal life through infancy and childhood as well as the evidence supporting the clinical utility of beta-agonists in wheezing infants and asthmatic children. Finally, the potential detrimental effects of long- and short-acting beta-agonists in infants and children are discussed.

Efficacy of Nebulised Epinephrine versus Salbutamol in Hospitalised Children with Bronchiolitis

BACKGROUND

The use of bronchodilators in bronchiolitis lacks consensus. The efficacy of nebulised epinephrine versus salbutamol in bronchiolitis and the safety profile of the bronchodilators was studied.

METHODS

Effects of nebulised epinephrine and salbutamol were compared in children with moderate to severe acute bronchiolitis. Thirty children between 2 to 24 months of age were recruited, 15 in each treatment group. Children received periodic (0,30,60 minutes followed by 4 hourly) doses of either 1:1000 laevo- epinephrine (0.5ml/kg subject to a maximum of 2.5ml with 3ml saline) or salbutamol (0.15mg/kg with 3ml saline) via nebuliser with oxygen. Changes in heart rate (HR), respiratory rate (RR), respiratory distress assessment instrument (RDAI), oxygen saturation (SpO2), oxygen requirement, duration of hospital stay and the side effects were studied.

RESULTS

The respiratory status was better with significant improvement in RR, RDAI score and SpO2, decreased oxygen requirement and shorter hospital stay in the epinephrine group. There were no significant side effects in either group.

CONCLUSION

Nebulised epinephrine is a useful and safe drug for moderate/severe bronchiolitis and is superior to salbutamol.

Diagnosis and management of bronchiolitis

Bronchiolitis is a disorder most commonly caused in infants by viral lower respiratory tract infection. It is the most common lower respiratory infection in this age group. It is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, increased mucus production, and bronchospasm. The American Academy of Pediatrics convened a committee composed of primary care physicians and specialists in the fields of pulmonology, infectious disease, emergency medicine, epidemiology, and medical informatics. The committee partnered with the Agency for Healthcare Research and Quality and the RTI International-University of North Carolina Evidence-Based Practice Center to develop a comprehensive review of the evidence-based literature related to the diagnosis, management, and prevention of bronchiolitis. The resulting evidence report and other sources of data were used to formulate clinical practice guideline recommendations. This guideline addresses the diagnosis of bronchiolitis as well as various therapeutic interventions including bronchodilators, corticosteroids, antiviral and antibacterial agents, hydration, chest physiotherapy, and oxygen. Recommendations are made for prevention of respiratory syncytial virus infection with palivizumab and the control of nosocomial spread of infection. Decisions were made on the basis of a systematic grading of the quality of evidence and strength of recommendation. The clinical practice guideline underwent comprehensive peer review before it was approved by the American Academy of Pediatrics. This clinical practice guideline is not intended as a sole source of guidance in the management of children with bronchiolitis. Rather, it is intended to assist clinicians in decision-making. It is not intended to replace clinical judgment or establish a protocol for the care of all children with this condition. These recommendations may not provide the only appropriate approach to the management of children with bronchiolitis.

A randomized trial of home oxygen therapy from the emergency department for acute bronchiolitis

OBJECTIVE

Hypoxia is a common reason for hospital admission in infants and children with acute bronchiolitis. No study has evaluated discharge from the emergency department (ED) on home oxygen. This study evaluated the feasibility and safety of ED discharge on home oxygen in the treatment of acute bronchiolitis.

METHODS

This was a prospective, randomized trial of infants and children with acute bronchiolitis and hypoxia (room-air saturations of < or =87%) aged 2 to 24 months presenting to an urban, academic, tertiary care children's hospital ED from December 1998 to April 2001. Subjects received inpatient admission or home oxygen after an 8-hour observation period in the ED. We measured the failure to meet discharge criteria during the observation period, return for hospital admission, and incidence of serious complications.

RESULTS

Ninety-two patients were enrolled. Fifty three (58%) were randomly assigned to home and 39 (42%) to inpatient admission. There were no differences between the groups in age, initial room-air saturation, and respiratory distress severity score. Of 53 patients, 37 (70%) randomly assigned to home oxygen completed the observation period and were discharged from the hospital. The remaining 16 patients were excluded from the study (6), resolved their oxygen requirement (5), or failed to meet the discharge criteria and were admitted (5). One discharged patient (2.7%) returned to the hospital and was admitted for a cyanotic spell at home after the 24-hour follow-up appointment. The patient had an uncomplicated hospital course with a length of stay of 45 hours. The remaining 36 patients (97%) were treated successfully as outpatients with home oxygen. Satisfaction with home oxygen was high from the caregiver and the primary care provider.

CONCLUSIONS

Discharge from the ED on home oxygen after a period of observation is an option for patients with acute bronchiolitis. Secondary to the low incidence of complications, the safety of this practice will require a larger study.

Hood versus mask nebulization in infants with evolving bronchopulmonary dysplasia in the neonatal intensive care unit

OBJECTIVE

To compare infants' discomfort, nursing-time and caregiver preference, and assess the clinical efficiency (as a secondary outcome) of hood versus facemask nebulization in infants with evolving bronchopulmonary dysplasia (BPD) in the neonatal intensive care unit.

STUDY DESIGN

A prospective, open, randomized, controlled crossover clinical trial. In total, 10 infants with BPD who were on inhaled beta-agonist bronchodilators and corticosteroids were randomly assigned to receive their nebulized treatments either by a facemask, or by a hood for 2-3 days, and then crossover to receive the same treatments with the other technique for another 2-3 days. Infants' discomfort, nursing-time, caregiver preference and clinical efficiency were compared.

RESULTS

At baseline there was no significant clinical difference between the groups. Nurse-time required for administering the hood nebulization (mean+/-s.e.m.: 1.9+/-0.1 min) was significantly shorter than the time for mask nebulization (12.0+/-0.6 min, P<0.0001). Infants' discomfort score was significantly lower (0.1+/-0.04) for hood versus mask nebulization (2.5+/-0.2, P<0.0001). Nurses and parents unequivocally preferred the hood treatment. During both mask and hood nebulization therapies (2-3 days) clinical efficiency was comparable. While both methods caused an immediate (20 min post) clinical improvement, the immediate respiratory assessment change score was significantly greater for the hood versus the mask nebulization (0.62+/-0.27 versus 0.13+/-0.14, P<0.05).

CONCLUSIONS

Nebulization of aerosolized medications in infants with evolving BPD by hood was less time-consuming for caregivers and was much better tolerated by the infants while being at least as effective as the conventional facemask nebulization.

Response to bronchodilator in infants with bronchiolitis can be predicted from wheeze characteristics

OBJECTIVE

Lung sounds analysis has been used for clinical care. Our objectives were to characterize the spectral pattern of lung sounds and their relation to bronchodilator effects in acute bronchiolitis (AB). We hypothesized that patients with sinusoidal wheezes (SW) would show a more significant bronchodilator response.

METHODOLOGY

We studied 22 asleep hospitalized infants (14 boys, eight girls), aged 5.2 +/- 1 months, 16 with a positive respiratory syncytial virus test, during their first 3 days after admission. Patients breathed spontaneously through a face mask connected to a pneumotachograph during normal breathing, and only target flows of 0.1 +/- 0.02 L/s were analyzed. Sounds were obtained using two contact sensors attached over both posterior lower lobes. For inspiratory and expiratory sounds, we determined the frequencies below which 25% (F25), 50% (F50), 75% (F75) and 99% (SEF99) of the spectral power between 100 and 1000 Hz was contained. We repeated the measurements 20 min after bronchodilator therapy in all patients.

RESULTS

We found classic SW in 11 patients, while the other 11 had complex wheezes (CW). There were positive bronchodilator responses in 9/11 with SW and 3/11 with CW (P < 0.01). Patients who responded to salbutamol showed an increase in power at low frequencies after medication (P < 0.01), and a positive correlation between wheezing and the increase in the power spectra measured by F50 and SEF99 (P < 0.001).

CONCLUSIONS

We conclude that sinusoidal and complex wheezes occur in patients with AB, that a positive response to bronchodilator is significantly more common in those with classic SW and that lung sounds analysis is a reproducible, safe and non-invasive method for assessing wheeze in infants.

Aerosol delivery in respiratory syncytial virus bronchiolitis: hood or face mask?

OBJECTIVES

To compare the utility of the hood versus the face mask for delivery of inhaled medications to infants hospitalized with viral bronchiolitis.

STUDY DESIGN

Randomized, double-blinded, controlled trial; 49 hospitalized infants with viral bronchiolitis, age 2.75 +/- 2.2 months (mean +/- SD), were grouped to either the hood (n = 25) or the mask (n = 24). Each subject received inhalation treatments with the use of both devices. Half of the Hood Group received the active drug treatment (1.5 mg epinephrine in 4 mL saline [3%]) via hood followed immediately by placebo treatment (normal saline) via mask, whereas the other half received the opposite order. Half of the Mask Group received the active drug treatment via mask followed immediately by placebo treatment via hood, whereas the other half received the opposite order. Therapy was repeated 3 times daily until discharge. Outcome measures included clinical scores and parental preference.

RESULTS

Percent improvement in clinical severity scores after inhalation was significant in both groups on days 1, 2, and 3 after admission (Hood Group: 15%, 15.4%, and 16.4%, respectively; Mask Group: 17.5%, 12.1%, and 12.7%, respectively; P < .001). No significant difference in clinical scores improvement between groups was observed. Eighty percent (39/49) of parents favored the hood over the mask; 18% (9/49) preferred the mask and 2% (1/49) were indifferent.

CONCLUSIONS

In infants hospitalized with viral bronchiolitis and in whom aerosol treatment is considered, aerosol delivery by hood is as effective as by mask. However, according to parents, the tolerability of the hood is significantly better than that of a mask.

Respiratory viruses in the pediatric intensive care unit: prevalence and clinical aspects

A survey was conducted in two pediatric intensive care units in hospitals in Porto Alegre, Brazil, in order to monitor the main respiratory viruses present in bronchiolitis and/or pneumonia and their involvement in the severity of viral respiratory infections. Viral respiratory infection prevalence was 38.7%. In bronchiolitis, respiratory syncytial virus (RSV) was detected in 36% of the cases. In pneumonia, the prevalence rates were similar for adenovirus (10.3%) and RSV (7.7%). There was a difference among the viruses detected in terms of frequency of clinical findings indicating greater severity. Frequency of crackles in patients with RSV (47.3%) showed a borderline significance (p = 0.055, Fisher's exact test) as compared to those with adenovirus (87.5%). The overall case fatality rate in this study was 2.7%, and adenovirus showed a significantly higher case fatality rate (25%) than RSV (2.8%) (p = 0.005). Injected antibiotics were used in 49% of the children with RSV and 60% of those with adenovirus. Adenovirus was not detected in any of the 33 children submitted to oxygen therapy.

Rhinovirus-associated wheezing in infancy: comparison with respiratory syncytial virus bronchiolitis

BACKGROUND

There is increasing evidence that rhinoviruses (RV) are able to cause lower airway infections and to induce wheezing in young children. There are few data on the clinical characteristics of RV infections in infants.

OBJECTIVE

The aim of the study was to compare clinical characteristics of infantile RV infection associated with wheezing and respiratory syncytial virus (RSV) bronchiolitis.

MATERIAL AND METHODS

During a 22-month study period in 1992-1993, 100 children younger than 24 months old were hospitalized with respiratory tract infection-associated wheezing. Viral etiology was originally assessed by antibody and antigen assays. Etiologic studies were later supplemented by polymerase chain reaction for RVs (in 2000) and for RSV (in 2002), studied in frozen respiratory samples. There were 81 children with adequate determinations for both RVs and RSV. Twenty-six children had RV and 24 had RSV infection, and these 50 cases form the material of the present study. Atopic dermatitis, oxygen saturation, respiratory rates and clinical scores based on wheezing and retractions and total serum IgE concentrations and blood eosinophil counts were studied in all cases on admission.

RESULTS

The children with RV infection, compared with RSV patients, were older (median, 13 versus 5 months), presented more often with atopic dermatitis (odds ratio, 16.7; 95% confidence interval, 2.22-100) and blood eosinophilia (odds ratio, 2.22; 95% confidence interval, 1.04-50). The groups did not differ from each other with regard to total serum IgE. Oxygen saturation values were lower in children with RSV infection. There were no significant differences in respiratory rates or scores combining wheezing and retractions.

CONCLUSION

RV-associated wheezing and RSV bronchiolitis, although having rather similar clinical characteristics, differ significantly with regard to age, presence of atopic dermatitis and eosinophilia during infection.

Additive effects of dexamethasone in nebulized salbutamol or L-epinephrine treated infants with acute bronchiolitis

BACKGROUND

Although it is the most common lower respiratory infection of infancy, the optimal treatment for acute bronchiolitis is still controversial. The aim of this study was to compare the early and late effects of nebulized L-epinephrine (EPI) and intramuscular dexamethasone (DEX) combination therapy with nebulized salbutamol (SAL) and dexamethasone combination and bronchodilators alone in outpatients with acute bronchiolitis.

METHODS

A total of 69 infants aged 2-21 months who were admitted to the Pediatrics Department of the Faculty of Medicine, Mersin University, with acute bronchiolitis were included in a randomized, placebo-controlled, prospective trial study. Patients were assigned to receive either nebulized L-epinephrine (3 mg) or salbutamol (0.15 mg/kg) and 15 min later, either dexamethasone 0.6 mg/kg or placebo (PLA), intramuscularly, in a double-blind randomized fashion. The study groups were: epinephrine + dexamethasone group (group 1, n=23), salbutamol + dexamethasone group (group 2, n=23), epinephrine + placebo group (group 3, n=11), and salbutamol + placebo group (group 4, n=12). The outcome measures were heart rate, respiratory rate and Respiratory Distress Assessment Instrument (RDAI) score determined at 30, 60, 90 and 120 min, 24 h, and 5 days after the first therapy. Patients were then followed-up during the subsequent 2 months for the prevalance of respiratory complaints regarding bronchial hyperreactivity.

RESULTS

There were no significant differences between the outcome variables of the four groups within the first 120 min and at 24 hours, or between the rates of requirement of a second dose of the same bronchodilator. However, fifth day RDAI score values of both DEX groups were significantly lower than that of SAL + PLA group (P=0.000 and P=0.01, respectively). The fifth day score value of group 1 was also significantly better than that value of EPI + PLA group but not different from group 2.

CONCLUSIONS

A single dose of intramuscular dexamethasone added to nebulized L-epinephrine, or salbutamol therapies resulted in better outcome measures than bronchodilators alone in the late phase (fifth day) of mild to moderate degree bronchiolitis attack. However, effects of EPI + DEX combination was not different from SAL + DEX combination.

Practice variation among pediatric emergency departments in the treatment of bronchiolitis

OBJECTIVES

Bronchiolitis is the most common disease of the lower respiratory tract in the first year of life. Treatment is controversial, with studies giving conflicting views on the benefits of bronchodilators and steroids. The objectives of this study were 1) to characterize the management of bronchiolitis in pediatric emergency departments (PEDs) in Canada, 2) to determine patient outcomes following emergency department (ED) visits, and 3) to provide descriptive data regarding bronchiolitis symptoms and family/personal medical history of these patients.

METHODS

A prospective consecutive cohort of children with bronchiolitis presenting to seven Canadian PEDs was enrolled during a seven-to-21-day period. Standardized interviews with parents provided data regarding symptoms, previous treatment, and past history. Charts were reviewed for treatment, investigations, and disposition. Telephone follow-up at two to three weeks collected information regarding duration of illness and return visits.

RESULTS

Two hundred thirty-seven (91%) of 260 eligible patients were enrolled. One hundred eighty-nine patients (80%) had both an interview and chart review, and 48 (20%) had only chart reviews; follow-up was completed for 163 (69%) patients. One hundred fifteen (63%) had seen their primary care provider during their illness prior to the ED visit. Seventy-three percent of patients (range per site 59-100%) were treated in the ED with bronchodilators (usually salbutamol or epinephrine) and 5% (range per site 0-14%) with oral steroids. Twenty-four percent (58/237) were prescribed bronchodilators on discharge, 3% (7/237) inhaled steroids, and 2% (5/237) oral steroids. Chi-square tests indicated significant practice variation by site in ED bronchodilator use (p < 0.001) and bronchodilator use at discharge (p = 0.0003). Admission rate was 31% (range by site 22-43%), 17% of patients had more than one ED visit, and 1% were admitted more than once. Admission rates were increased in younger children, children with comorbidities, and children with lower oxygen saturation. Viral studies were obtained in 53%, with 76% of these positive for respiratory syncytial virus (RSV). Median duration of cough was 12 days, poor sleeping and irritability eight days, and wheeze and poor feeding seven days.

CONCLUSIONS

This study prospectively describes the treatment of bronchiolitis in the pediatric ED. The findings are consistent with the literature regarding the reported use of bronchodilators; however, use of steroids was found to be much lower than reported in other studies. Bronchodilator use in the ED and at discharge varied significantly by site. The results capture variation in treatment practices in Canadian PEDs, which may be the result of discordant randomized controlled trial evidence. Further research is needed to establish best practices.

Use of a respiratory clinical score among different providers

Respiratory assessment of children with asthma or bronchiolitis is problematic because both the components of the assessment and their relative importance vary among care providers. Use of a systematic standard assessment process and clinical score may reduce interobserver variation. Our objective was to determine observer agreement among physicians (MD), nurses (RN), and respiratory therapists (RT), using a standard respiratory clinical score. A clinical score was developed incorporating four physiologic parameters: respiratory rate, retractions, dyspnea, and auscultation. One hundred and sixty-five provider pairs (e.g., MD-MD, RN-RT) independently assessed a total of 55 patients admitted for asthma, bronchiolitis, or wheezing at an urban tertiary-care hospital. A weighted kappa statistic measured agreement beyond chance. Rater pairs had high observed agreement on total score of 82-88% and weighted kappas ranging from 0.52 (MD-RN; 95% CI, 0.19, 0.79) to 0.65 (RN-RN; 95% CI, 0.46, 0.87). Observed agreement on individual components of the score ranged from 58% (auscultation) to 74% (dyspnea), with unweighted kappas of 0.36 (respiratory rate; 95% CI, 0.26, 0.46) to 0.53 (dyspnea; 95% CI, 0.41, 0.65). In conclusion, this respiratory clinical score demonstrates good interobserver agreement between MDs, RNs, and RTs. Future research is needed to examine validity and responsiveness in clinical settings. By standardizing respiratory assessments, use of a clinical score may facilitate care coordination by physicians, nurses, and respiratory therapists and thereby improve care of children hospitalized with asthma and bronchiolitis.

Randomized, double-blind, placebo-controlled trial of oral albuterol in infants with mild-to-moderate acute viral bronchiolitis

OBJECTIVE

To determine whether oral albuterol is effective in reducing symptomatology of acute viral bronchiolitis in infants with mild-to-moderate illness.

STUDY DESIGN

In a randomized, double-blind trial, previously well infants were randomized upon discharge from the emergency department to receive either albuterol (0.1 mg/kg/dose) three times per day or placebo three times per day for 7 days. Daily standardized telephone interviews were conducted for as long as 14 days. The primary outcome was the time to resolution of illness. Secondary outcomes included time to normal feeding, normal sleeping, quiet breathing, resolved cough, and coryza.

RESULTS

We studied 129 infants (albuterol, n = 64; placebo, n = 65). Baseline characteristics were similar between groups. The overall mean age was 5.3 months, 60% were male, and 49 of 61 tested infants were positive for respiratory syncytial virus. The median (95% confidence interval) time to resolution of illness (days) was similar: albuterol, 9.0 (8-13); placebo, 8.0 (7-9); P =.3) (log-rank test). There were no significant group differences in any secondary outcome. Health care revisit and admission rates were similar between groups.

CONCLUSIONS

No significant group differences in either primary or secondary outcomes in infants treated with oral albuterol versus placebo were found. The widespread use of oral albuterol in this patient group is not recommended.

Randomized controlled trial of nebulized adrenaline in acute bronchiolitis

Use of both l-epinephrine and racemic epinephrine (adrenaline) has improved clinical symptoms and composite respiratory scores in acute bronchiolitis. The objective of this randomized double-blind placebo-controlled study was to assess whether there was sufficient improvement in clinical state to reduce hospital admissions. Seventy-five infants aged 1 month to 1 year with a clinical diagnosis of acute bronchiolitis were treated with either 2 ml of 1:1000 nebulized adrenaline or 2 ml of nebulized normal saline administered after baseline assessment and 30 min later. Clinical respiratory parameters were recorded at 15-min intervals for a period of 2 h following the baseline assessment. Admission to hospital was the primary end-point and changes in respiratory parameters were secondary end-points. Fifty percent (19/38) of infants treated with adrenaline were discharged home compared with 38 percent (14/37) of those treated with saline. This 12 percent reduction in rate of admission is not statistically significant (95% CI of difference: -10% to 35%). There was no difference between treated and placebo groups in respiratory rate, oxygen saturation, heart rate or a composite respiratory distress score at 30, 60 or 120 min post-treatment. In this study, nebulized epinephrine did not confer a significant advantage over nebulized saline in the emergency room treatment of acute bronchiolitis.

Nonalcoholic steatohepatitis and insulin resistance: interface between gastroenterologists and endocrinologists

Nonalcoholic steatohepatitis (NASH), along with other forms of nonalcoholic fatty liver disease, is an increasingly common clinico-pathological syndrome. It is frequently associated with obesity, especially visceral fat, and type 2 diabetes, and is intimately related to markers of the insulin resistance syndrome. Both the prevalence and the severity of liver steatosis are related to body mass index, waist circumference, hyperinsulinaemia, hypertriglyceridemia and impaired glucose tolerance. The pathophysiology of NASH involves two steps: 1) insulin resistance, which causes steatosis; 2) and oxidative stress, which produces lipid peroxidation and activates inflammatory cytokines. The identification of subjects who may progress from fatty liver to NASH, and from NASH to fibrosis/cirrhosis is an important clinical challenge as well as the finding of appropriate therapy that could prevent such deleterious process. Substantial weight loss is accompanied by a marked attenuation of insulin resistance and related metabolic syndrome and, concomitantly, by an important regression of liver steatosis in most patients, although mild inflammation may be detected in some subjects. Thus, NASH may be considered as another disease of affluence, as is the insulin resistance syndrome and perhaps being part of it.

Bronchiolitis management preferences and the influence of pulse oximetry and respiratory rate on the decision to admit

OBJECTIVE

High incidence, rising admission rates, and relatively ineffective therapies make the management of bronchiolitis controversial. Since 1980, the rate of hospitalization for children with bronchiolitis has increased by nearly 250%, whereas mortality rates for the disease have remained constant. It has been speculated that the increasing use of pulse oximetry has lowered the threshold for admission and may have contributed to the rise in bronchiolitis-related admissions. The objective of this study was to describe pediatric emergency medicine physicians' management preferences regarding infants with moderately severe bronchiolitis and to assess the influence of specific differences in oxygen saturation as measured by pulse oximetry (SpO2) and respiratory rate (RR) on the decision to admit.

METHODS

Physicians who are members of the American Academy of Pediatrics Section of Emergency Medicine and living in the United States were randomized into 4 groups and mailed a survey that contained 1 of 4 vignettes. Vignettes were identical except for given SpO2 values (94% or 92%) and RR (50/min or 65/min). Subjects were asked to answer questions regarding laboratory tests, treatment options, and the decision to admit for the patient in their vignette.

RESULTS

We received completed surveys from 519 (64%) of the 812 physicians contacted. Most respondents recommended use of bronchodilators (96%), nasal suction (82%), and supplemental oxygen (57%). Few respondents recommended decongestants (9%), steroids (8%), or antibiotics (2%). When asked to rank therapies, respondents gave nasal suction 182 number 1 votes; bronchodilators received 164. The decision to admit varied with SpO2 and RR. Forty-three percent of respondents who received a vignette featuring SpO2 of 94% and a RR of 50/min recommended admission for the infant in their vignette. Fifty-eight percent recommended admission when the vignette SpO2 was 94% and RR was 65/min (chi2 = 5.021). Respondents who received a vignette with SpO2 of 92% were nearly twice as likely to recommend admission: 83% recommended admission when vignette RR was 50/min, and 85% recommended admission when vignette RR was 65/min (chi2 = 0.126).

CONCLUSIONS

When treating infants with moderately severe bronchiolitis, pediatricians who work in emergency departments frequently use bronchodilators and nasal suction, 2 practices for which supporting data are either conflicting (bronchodilators) or nonexistent (nasal suction). In addition, their decisions to admit differ markedly on the basis of only a 2% difference in SpO2. It is possible that increased reliance on pulse oximetry has contributed to the increase in bronchiolitis hospitalization rates seen during the past 2 decades.