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 4th
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.
