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

Bronchiolitis: Safely Doing Less Is the Next Big Thing

Bronchiolitis is a viral lower respiratory tract infection primarily affecting children younger than 2 years; a common cause of health care encounters, including hospitalization; and a considerable economic burden for health care systems in the United States and worldwide. The American Academy of Pediatrics (AAP) most recently updated its bronchiolitis guideline in 2014 and reaffirmed supportive care as the mainstay of treatment. Despite these recommendations, there is still significant variability in care provided for these children, especially in bronchodilator usage, radiography, and high-flow nasal cannula. Since the 2014 AAP guideline, many pediatric hospitalists have undertaken quality initiatives to improve the adherence to published guidelines, yet a large gap remains between what is recommended and what is practiced. This article presents research on the efficacy of common interventions as well as an introduction to diagnostics and treatments potentially on the horizon. [Pediatr Ann. 2024;53(6):e223-e228.].

Critical reappraisal of short-acting bronchodilators for pediatric respiratory diseases

Short-acting bronchodilators are a class of medications commonly used to treat asthma, chronic obstructive pulmonary disease, and other respiratory conditions. The use of these medications has evolved over time as we have gained a better understanding of their effectiveness and safety in the pediatric population. This comprehensive review synthesizes the current understanding of short-acting β2-agonists and short-acting anticholinergics in children. It addresses indications, contraindications, safety considerations, and highlights areas where further research is needed to guide the most effective use of short-acting bronchodilators.

Bronchiolitis recovery and the use of High Efficiency Particulate Air (HEPA) Filters (The BREATHE Study): study protocol for a multi-center, parallel, double-blind, randomized controlled clinical trial

BACKGROUND

Acute viral bronchiolitis is the most common reason for hospitalization of infants in the USA. Infants hospitalized for bronchiolitis are at high risk for recurrent respiratory symptoms and wheeze in the subsequent year, and longer-term adverse respiratory outcomes such as persistent childhood asthma. There are no effective secondary prevention strategies. Multiple factors, including air pollutant exposure, contribute to risk of adverse respiratory outcomes in these infants. Improvement in indoor air quality following hospitalization for bronchiolitis may be a prevention opportunity to reduce symptom burden. Use of stand-alone high efficiency particulate air (HEPA) filtration units is a simple method to reduce particulate matter ≤ 2.5 µm in diameter (PM2.5), a common component of household air pollution that is strongly linked to health effects.

METHODS

BREATHE is a multi-center, parallel, double-blind, randomized controlled clinical trial. Two hundred twenty-eight children < 12 months of age hospitalized for the first time with bronchiolitis will participate. Children will be randomized 1:1 to receive a 24-week home intervention with filtration units containing HEPA and carbon filters (in the child's sleep space and a common room) or to a control group with units that do not contain HEPA and carbon filters. The primary objective is to determine if use of HEPA filtration units reduces respiratory symptom burden for 24 weeks compared to use of control units. Secondary objectives are to assess the efficacy of the HEPA intervention relative to control on (1) number of unscheduled healthcare visits for respiratory complaints, (2) child quality of life, and (3) average PM2.5 levels in the home.

DISCUSSION

We propose to test the use of HEPA filtration to improve indoor air quality as a strategy to reduce post-bronchiolitis respiratory symptom burden in at-risk infants with severe bronchiolitis. If the intervention proves successful, this trial will support use of HEPA filtration for children with bronchiolitis to reduce respiratory symptom burden following hospitalization.

TRIAL REGISTRATION

NCT05615870. Registered on November 14, 2022.

Expert consensus on the diagnosis, treatment, and prevention of respiratory syncytial virus infections in children

BACKGROUND

Respiratory syncytial virus (RSV) is the leading global cause of respiratory infections and is responsible for about 3 million hospitalizations and more than 100,000 deaths annually in children younger than 5 years, representing a major global healthcare burden. There is a great unmet need for new agents and universal strategies to prevent RSV infections in early life. A multidisciplinary consensus development group comprising experts in epidemiology, infectious diseases, respiratory medicine, and methodology aims to develop the current consensus to address clinical issues of RSV infections in children.

DATA SOURCES

The evidence searches and reviews were conducted using electronic databases, including PubMed, Embase, Web of Science, and the Cochrane Library, using variations in terms for "respiratory syncytial virus", "RSV", "lower respiratory tract infection", "bronchiolitis", "acute", "viral pneumonia", "neonatal", "infant" "children", and "pediatric".

RESULTS

Evidence-based recommendations regarding diagnosis, treatment, and prevention were proposed with a high degree of consensus. Although supportive care remains the cornerstone for the management of RSV infections, new monoclonal antibodies, vaccines, drug therapies, and viral surveillance techniques are being rolled out.

CONCLUSIONS

This consensus, based on international and national scientific evidence, reinforces the current recommendations and integrates the recent advances for optimal care and prevention of RSV infections. Further improvements in the management of RSV infections will require generating the highest quality of evidence through rigorously designed studies that possess little bias and sufficient capacity to identify clinically meaningful end points.

Safety outcomes of salbutamol: A systematic review and meta-analysis

PURPOSE

Salbutamol has been used to alleviate bronchospasm in airway disease for decades, while its potential risks have not been systematically investigated yet. The risk of any potential adverse events (AEs) in patients treated with salbutamol was assessed through systematic review and meta-analysis.

METHODS

A systematic search of the literature was conducted, using EMBASE, PubMed and Cochrane library, until 3 April 2023. Once the AE incidence was evaluated, randomized controlled trials (RCTs) were eligible for review. The endpoints included the incidence of total AEs, severe AEs, treatment discontinuation and specific AEs. The pooled AEs incidence was analysed via random-effects model in a single-arm meta-analysis. A subgroup study was carried out to examine whether the pooled incidence of AE differed by indications or formulations.

RESULTS

Of the 8912 studies that were identified, 58 RCTs met the inclusion criteria and involved 12 961 participants. The analysis showed the pooled incidences of total AEs, severe AEs and treatment discontinuation in patients treated with salbutamol were 34%, 2% and 3%, respectively. Subgroup analysis indicated that premature labour users and intravenous salbutamol users were more likely associated with total AEs. The most frequently observed specific AEs were palpitations or tachycardia.

CONCLUSION

This meta-analysis indicated that salbutamol was associated with a very common risk of palpitations or tachycardia. Clinical vigilance and research efforts are needed to optimize the safe use of salbutamol.

Bronchodilator-responsive bronchiolar obstruction in term neonates: a case series

BACKGROUND

Bronchiolar obstruction, which causes airway obstruction in hyperresponsive airways, often results from the contraction of the airway's smooth muscles, increased viscid mucous secretions, and mucosal oedema consequent upon a reduced cyclic 3,5-adenosine monophosphate (c-AMP). These processes respond to bronchodilators. The six cases presented to us, in Edward Francis Small Teaching Hospital (EFSTH), Banjul, The Gambia, in the newborn period with clinical features suggesting obstruction with airway reactivity with response to bronchodilator treatment are presented here. Our capacity-limited literature search did not show any such report in neonates. This report highlights the need for this condition to be sought in neonates, medically managed in resource-poor countries without resorting to high-cost equipment use, and for its possible future classification.

CASE PRESENTATION

We report six cases of Gambian neonates consisting of four males and two females ages 2-27 days who presented to us with histories of fast breathing of a few hours duration and expiratory respiratory distress. All were term babies with rhonchi and demonstrable prolonged expiration with terminal effort. They all had a diagnosis of hyperreactive airway disease with bronchiolar obstruction. Five cases were first-time wheezers, while one was a recurrence. All were eventually treated with bronchodilators and steroids with good results. The median duration for resolution of most symptoms with treatment was two days, with a range of 1-5 days.

CONCLUSION

Clinically determined bronchiolar obstructions in term neonates can be relieved with bronchodilators and steroids, and this treatment modality, if employed where the pathological process can be established, can reduce the demand on scarce resources in resource-poor countries.

Severe bronchiolitis profiling as the first step towards prevention of asthma

Bronchiolitis is the most common respiratory infection leading to hospitalization and constitutes a significant healthcare burden. The two main viral agents causing bronchiolitis, respiratory syncytial virus (RSV) and rhinovirus (RV), have distinct cytopathic, immune response, and clinical characteristics. Different approaches have been suggested for subtyping bronchiolitis based on viral etiology, atopic status, transcriptome profiles in blood, airway metabolome, lipidomic data, and airway microbiota. The highest risk of asthma at school age has been in a subgroup of bronchiolitis characterized by older age, high prevalence of RV infection, previous breathing problems, and/or eczema. Regarding solely viral etiology, RV-bronchiolitis in infancy has been linked to a nearly three times higher risk of developing asthma than RSV-bronchiolitis. Although treatment with betamimetics and systemic corticosteroids has been found ineffective in bronchiolitis overall, it can be beneficial for infants with severe RV bronchiolitis. Thus, there is a need to develop a more individualized therapeutic approach for bronchiolitis and follow-up strategies for infants at higher risk of asthma in the future perspective.

Effects of nebulized epinephrine in association with hypertonic saline for infants with acute bronchiolitis: A systematic review and meta‐analysis

Background

Nebulized epinephrine and hypertonic saline have been extensively studied in infants with acute bronchiolitis, with conflicting results.

Aims

To evaluate the efficacy on length of stay (LOS), clinical severity scores (CSS), oxygen saturation (SaO₂), and safety profile of nebulized epinephrine plus hypertonic saline (HS) in infants with acute bronchiolitis.

Materials & Methods

This is a systematic review and meta‐analysis. Outcomes were represented by mean differences (MD) or standard mean differences (SMD) and 95% confidence intervals (CIs) were utilized.

Results

Eighteen trials were systematically selected and 16 of them contributed to the meta‐analysis (1756 patients). Overall, a modest but significant positive impact was observed of the combination therapy on LOS (MD of –0.35 days, 95% CI −0.62 to −0.08, p = 0.01, I² = 91%). Stratification by time of CSS assessment unveiled positive results in favor of the combination therapy in CSS assessed 48 and 72 h after the admission (SMD of −0.35, 95% CI −0.62 to −0.09, p = 0.008, I² = 41% and SMD of −0.27, 95% CI −0.50 to −0.04, p = 0.02, I² = 0%, respectively). No difference in SaO₂ was observed. Additional data showed a consistent safety profile, with a low rate of adverse events (1%), most of them mild and transient.

Conclusion

Low‐quality evidence from this systematic review suggests that nebulized epinephrine plus HS may be considered as a safe and efficient therapy for decreasing LOS and CSS in infants with acute bronchiolitis, especially in those who require hospitalization for more than 48 h.

An overview on the RSV-mediated mechanisms in the onset of non-allergic asthma

Respiratory syncytial virus (RSV) infection is recognized as an important risk factor for wheezing and asthma, since it commonly affects babies during lung development. While the role of RSV in the onset of atopic asthma is widely recognized, its impact on the onset of non-atopic asthma, mediated via other and independent causal pathways, has long been also suspected, but the association is less clear. Following RSV infection, the release of local pro-inflammatory molecules, the dysfunction of neural pathways, and the compromised epithelial integrity can become chronic and influence airway development, leading to bronchial hyperreactivity and asthma, regardless of atopic status. After a brief review of the RSV structure and its interaction with the immune system and neuronal pathways, this review summarizes the current evidence about the RSV-mediated pathogenic pathways in predisposing and inducing airway dysfunction and non-allergic asthma development.

Inhaled Pharmacotherapy for Neonates: A Narrative Review

The inhaled route for drug administration in neonates offers several advantages over the systemic routes, since it delivers medications directly to the diseased organ, enabling higher doses locally with less systemic toxicity. Respiratory drugs can be administered in both ventilated and non-ventilated term and preterm infants. This review was carried out using selected literature, with a focus on the most used inhaled pharmacological agents in neonatal care, summarizing, with levels of evidence (LoE), their indications, doses, administration schedules, and main adverse effects. Information is given on several inhaled drugs, namely albuterol, budesonide, ipratropium bromide, sodium cromoglycate, racemic epinephrine, nitric oxide, treprostinil, iloprost, epoprostenol, colistin, rhDNase, hypertonic saline, and calfactant. A summary of the main and most recent published studies on each of these inhaled pharmacological agents is also presented.

Patient, Provider, and Health Care System Characteristics Associated With Overuse in Bronchiolitis

BACKGROUND AND OBJECTIVES

The American Academy of Pediatrics recommends against the routine use of β-agonists, corticosteroids, antibiotics, chest radiographs, and viral testing in bronchiolitis, but use of these modalities continues. Our objective for this study was to determine the patient, provider, and health care system characteristics that are associated with receipt of low-value services.

METHODS

Using the Virginia All-Payers Claims Database, we conducted a retrospective cross-sectional study of children aged 0 to 23 months with bronchiolitis (code J21, International Classification of Diseases, 10th Revision) in 2018. We recorded medications within 3 days and chest radiography or viral testing within 1 day of diagnosis. Using Poisson regression, we identified characteristics associated with each type of overuse.

RESULTS

Fifty-six percent of children with bronchiolitis received ≥1 form of overuse, including 9% corticosteroids, 17% antibiotics, 20% β-agonists, 26% respiratory syncytial virus testing, and 18% chest radiographs. Commercially insured children were more likely than publicly insured children to receive a low-value service (adjusted prevalence ratio [aPR] 1.21; 95% confidence interval [CI]: 1.15-1.30; P < .0001). Children in emergency settings were more likely to receive a low-value service (aPR 1.24; 95% CI: 1.15-1.33; P < .0001) compared with children in inpatient settings. Children seen in rural locations were more likely than children seen in cities to receive a low-value service (aPR 1.19; 95% CI: 1.11-1.29; P < .0001).

CONCLUSIONS

Overuse in bronchiolitis remains common and occurs frequently in emergency and outpatient settings and rural locations. Quality improvement initiatives aimed at reducing overuse should include these clinical environments.

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