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

Factors Associated with Inhaled Bronchodilator and Oral Corticosteroid Use in Young Children with First Lower Respiratory Tract Infection

OBJECTIVES

To examine factors associated with claims for and potential overuse of inhaled bronchodilators (IBs) and oral corticosteroids (OCSs) for children <2 years old at first lower respiratory tract infections (LRTIs).

STUDY DESIGN

Retrospective cohort study using Colorado All Payer Claims data from 2009 through 2019. Children with asthma were excluded. Primary outcomes were 1) IB and 2) OCS claims within 7 days of index LRTI. Primary predictors were previous IB or OCS claims for each outcome respectively. Covariates included demographics, atopy, family history of asthma, complex chronic conditions, prior inhaled corticosteroid claim, and location of index LRTI. Separate multivariable logistic regression models were used for each outcome.

RESULTS

Of 10 194 eligible children, 1468 (14.4%) had an IB and 741 (7.3%) an OCS claim at or within 7 days of index LRTI. Index LRTIs were most often at outpatient visits (64%). Adjusting for covariates, prior IB prescription was associated with the IB outcome (aOR 1.9; 95% CI 1.3, 2.8), and prior OCS prescription was associated with the OCS outcome (AOR 2.2; 95% CI 1.7, 2.9). Other variables associated with either outcome included age, sex, insurance, location, and atopy. Prior inhaled corticosteroid claim, asthma family history, and complex chronic conditions were not associated with either outcome.

CONCLUSIONS

This study identifies factors that might serve as opportunities for de-implementation strategies for IB and OCS overuse in young children with LRTI.

Factors associated with nonadherence to the American Academy of Pediatrics 2014 bronchiolitis guidelines: A retrospective study

The latest guideline from the American Academy of Pediatrics for the management of bronchiolitis has helped reduce unnecessary interventions and costs. However, data on patients still receiving interventions are missing. In patients with acute bronchiolitis whose management was assessed and compared with current achievable benchmarks of care, we aimed to identify factors associated with nonadherence to guideline recommendations. In this single-centre retrospective study the management of bronchiolitis pre-guideline (Period 1: 2010 to 2012) was compared with two periods post-guideline (Period 2: 2015 to 2016, early post-guideline; and Period 3: 2017 to 2018, late post-guideline) in otherwise healthy infants aged less than 1 year presenting at the Children's University Hospitals of Geneva (Switzerland). Post-guideline, bronchodilators were more frequently administered to older (>6 months; OR 25.8, 95%CI 12.6-52.6), and atopic (OR 3.5, 95%CI 1.5-7.5) children with wheezing (OR 5.4, 95%CI 3.3-8.7). Oral corticosteroids were prescribed more frequently to older (>6 months; OR 5.2, 95%CI 1.4-18.7) infants with wheezing (OR 4.9, 95% CI 1.3-17.8). Antibiotics and chest X-ray were more frequently prescribed to children admitted to the intensive care unit (antibiotics: OR 4.2, 95%CI 1.3-13.5; chest X-ray: OR 19.4, 95%CI 7.4-50.6). Latest prescription rates were all below the achievable benchmarks of care. In summary, following the latest American Academy of Pediatrics guideline, older, atopic children with wheezing and infants admitted to the intensive care unit were more likely to receive nonevidence-based interventions during an episode of bronchiolitis. These patient profiles are generally excluded from bronchiolitis trials, and therefore not specifically covered by the current guideline. Further research should focus on the benefit of bronchiolitis interventions in these particular populations.

Les β2-agonistes pour la bronchiolite virale

Question

Au mois de février, un bébé de 9 mois est amené à ma clinique d’urgence rurale après un épisode de 2 jours de toux et de congestion, et de 1 jour de difficultés respiratoires. Une auscultation des poumons révèle des sons diffus, de faibles sibilances et des crépitants. En tenant compte de l’âge du bébé, de la symptomatologie et de la saison hivernale, le diagnostic probable est une bronchiolite. Les β2-agonistes inhalés sont-ils un traitement approprié pour un tel patient?

Réponse

Il n’est pas indiqué d’utiliser des β2-agonistes inhalés chez les enfants de 2 ans et moins souffrant de bronchiolite. La sibilance fait le plus souvent partie des critères diagnostiques d’une bronchiolite, qui est une infection virale des voies respiratoires inférieures chez les jeunes enfants. Au contraire de l’asthme, la bronchiolite ne compte pas parmi ses symptômes la contraction des muscles lisses du poumon. Le traitement de la bronchiolite exige des soins de soutien, et il n’a pas été démontré que les interventions pharmacologiques, comme les β2-agonistes, les corticostéroïdes et les antibiotiques, raccourcissaient la durée de la maladie, diminuaient sa gravité ou réduisaient les taux d’hospitalisation. Il pourrait y avoir un sous-groupe de nourrissons souffrant de bronchiolite qui répondraient à un traitement aux β2-agonistes; toutefois, ce groupe n’a pas encore été entièrement défini dans la littérature jusqu’ici.

[Not Available]

Question

A 9-month-old baby presented to my rural emergency department with 2 days of cough and congestion and 1 day of breathing difficulties in the month of February. An auscultation examination of the lungs indicated there were scattered, faint wheezes and coarse sounds. Based on the baby’s age, symptomatology, and the winter season, the likely diagnosis was bronchiolitis. Are inhaled β₂-agonists an appropriate treatment for this patient?

Answer

The use of inhaled β₂-agonists in children younger than 2 years of age with bronchiolitis is not indicated. Wheezing is most commonly part of the diagnosis of bronchiolitis, a lower respiratory viral infection in young children. Unlike with asthma, smooth muscle constriction in the lungs is not a symptom of bronchiolitis. Treatment of bronchiolitis requires supportive care, but pharmaceutical interventions such as β₂-agonists, steroids, and antibiotics have not been shown to decrease length of illness, illness severity, or hospitalization rates. There may be a subgroup of infants with bronchiolitis who respond to β₂-agonists treatment; however, this group has not been fully identified in the literature to date.

Which Wheezing Preschoolers Should be Treated for Asthma?

Wheezing disorders in children younger than 5 years are common, but lack of clarity remains about which children should be treated to prevent symptoms and acute episodes. The aim of this review was to discuss a practical approach to deciding which children younger than 5 years with asthma should be treated, and if so, with which strategy. The importance of having a clear definition of "asthma" for this age group, determined by a collection of presenting respiratory symptoms, without assumptions about underlying mechanisms is addressed. Subsequent consideration should be given to timing, severity, and frequency of symptoms, together with assessment of objective biomarkers, including aeroallergen sensitization and blood eosinophils, to inform whether or not a preschooler with recurrent wheezing requires treatment. Numerous unanswered questions remain about the optimal management of nonallergic preschool wheezing and asthma, and areas of specific unmet need and future directions for research are highlighted.

Cost-effectiveness analysis of phenotypic-guided versus guidelines-guided bronchodilator therapy in viral bronchiolitis

OBJECTIVES

Although recent evidence suggests that management of viral bronchiolitis requires something other than guidelines-guided therapy, there is a lack of evidence supporting the economic benefits of phenotypic-guided bronchodilator therapy for treating this disease. The aim of the present study was to compare the cost-effectiveness of phenotypic-guided versus guidelines-guided bronchodilator therapy in infants with viral bronchiolitis.

METHODS

A decision analysis model was developed to compare the cost-effectiveness of phenotypic-guided versus guidelines-guided bronchodilator therapy in infants with viral bronchiolitis. Phenotypic-guided bronchodilator therapy was defined as the administration of albuterol in infants exhibiting a profile of increased likelihood of response to bronchodilators. The effectiveness parameters and costs of the model were obtained from systematic reviews of the literature with meta-analyses and electronic medical records. The main outcome was the avoidance of hospital admission after initial care in the emergency department.

RESULTS

Compared to guidelines-guided strategy, treating patients with viral bronchiolitis with the phenotypic-guided bronchodilator therapy strategy was associated with lower total costs (US$250.99; 95% uncertainty interval [UI]: US$184.37 to $336.51 vs. US$263.46; 95% UI: US$189.81 to $349.19 average cost per patient) and a higher probability of avoidance of hospital admission (0.7902; 95% UI: 0.7315-0.8356 vs. 0.7638; 95% UI: 0.7062-0.8201), thus leading to dominance. Results were robust to deterministic and probabilistic sensitivity analyses.

CONCLUSIONS

Compared to guidelines-guided strategy, treating infants with viral bronchiolitis using the phenotypic-guided bronchodilator therapy strategy is a more cost-effective strategy, because it involves a lower probability of hospital admission at lower total treatment costs.