Clinical Pearl 80: Does Albuterol help in Bronchiolitis?

An 11 month old male is having difficulty breathing. The baby appears comfortable but with intercoastal retractions, and nasal congestion. His RR is 42 bmp,  SpO2 is 93% on RA, HR is 120bpm. He has wheezing throughout both lung fields and mother tells you that this is his 4^th day with this symptoms. Would Albuterol be your next step in treatment?

The scenario clearly shows a child that meets criteria for bronchiolitis; for years we’ve been trying to figure out what can we do to make this patient better, and for years bronchodilators have been one of the first line treatments, but does it really work?

Scribani MB et al. (Bronchodilators for bronchiolitis. Cochrane Database Syst Rev. 2014.) suggests that bronchodilators may provide modest short-term clinical improvement but do not affect overall outcome, may have adverse effects, and increase the cost of care. This is a meta-analysis of randomized trials and systematic reviews that included 30 trials representing 1992 infants with bronchiolitis. It demonstrated that oxygen saturation did not improve with bronchodilators. Outpatient bronchodilator treatment did not reduce the rate of hospitalization, and inpatient bronchodilator treatment did not reduced length of stay in the hospital. The clinical score and oximetry outcome showed significant heterogeneity with questionable clinical importance. Multiple adverse effects where recorded such as tachycardia, oxygen desaturation and tremors. The review concluded that given the adverse side effects and the expense associated with these treatments, bronchodilators are not effective in the routine management of bronchiolitis.

Per American Academy of Pediatrics most recent guidelines (Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. 2014) Clinicians should not administer albuterol or epinephrine to infants and children with a diagnosis of bronchiolitis (Evidence Quality: B; Recommendation Strength: Strong Recommendation)

But, should I at least try it?

A one-time trial of inhaled bronchodilators (albuterol or epinephrine) may be warranted for infants and children with bronchiolitis and severe disease, as this group generally was excluded from trials evaluating inhaled bronchodilators in children with bronchiolitis.

In addition, a subset of young children with the clinical syndrome of bronchiolitis may have virus-induced wheezing or asthma and may benefit from inhaled bronchodilator therapy. In a prospective multicenter study by Jonathan M. Mansbach et al. (Children hospitalized with rhinovirus bronchiolitis have asthma-like characteristics. J Pediatr. 2016 May) of children hospitalized with bronchiolitis, children with rhinovirus-associated bronchiolitis were more likely than those with respiratory syncytial virus-associated bronchiolitis to respond to bronchodilators as they present similar to asthmatic patients, and are usually excluded from other studies as it is more common on patients >12 months of age. 

In conclusion, after reviewing the available literature, the use of albuterol in patients with bronchiolitis might be attempted once and evaluate for response, but if no desirable response, the continued use of bronchodilators will only increase side effects and cost with no added benefit, and will give wrong reassurance to parents that there is an effective treatment for Bronchiolitis besides letting the disease run its course.