Few years old but nice letter.
The recommendation to not use bronchodilators is not supported by the evidence.Paul Walsh, Pediatric Emergency PhysicianOther Contributors:Stephen J Rothenberg, EpidemiologistDear Editor:We read with interest the current guidelines on the management of bronchiolitis.(1) Here we raise our concern with the recommendation that bronchodilators not be used.The guideline authors imply that our RCT of 703 children with bronchiolitis to supports their assertion that "clinical scores may vary from between observers".(1,2) This is a very selective reading of our limitations section. The cited article in fact showed an 18% (aRR 1.18, (95% CI1.02-1.36) relative increase in successful hospital discharges from the emergency department (ED) when albuterol rather than epinephrine was administered. This study also addressed the limitations of consecutive enrollment with random allocation, prior episodes, and study site effect.(2) The severity of illness tool we used has been validated(3) and has adequate interrater agreement (92%;kappa 0.676).The guideline authors' rely in part on older metanalyses predating this work and on a meta-analysis from 2011 that systematically excluded studies showing a benefit to using albuterol over epinephrine.(4) Therefore these meta-analyses could provide only a limited view of what is known about bronchodilators in bronchiolitis.The guideline's assertion that bronchodilators should not be used must then rest on the meta-analysis in the Cochrane review library published by Gadomski et al. in 2014.(5) This meta-analysis included only placebo-controlled studies and consequently excluded some studies which showed a benefit between bronchodilators.However even this 2014 Cochrane review did find a significant benefit to using bronchodilators, OR 0.18 (95%CI 0.06-0.50) as measured by improved clinical scores. (5) In the version cited there were only 187 patients included in the analysis addressing the most important question to emergency physicians and pediatric hospitalists; does albuterol decrease admission from the emergency department. The answer in this meta- analysis showed a non-significant trend towards decreased admission (OR 0.76 (95%CI 0.38-1.53). Even a subsequent analysis with a 404 patients shows (OR 0.77 95%CI 0.44-1.33).(5) This 23% reduction in odds of admission is not dissimilar to the 18% decrease in the relative risk of admission that we found with albuterol.(2)Neither non-significant underpowered studies nor metanalyses should form the basis for treatment recommendations, any more than null results should form the basis for concluding "no effect".Given that data from some studies finding a benefit to bronchodilators in the ED has been ignored, and given the actual findings of the 2014 Cochrane review, the recommendation that a bronchodilator not be used is charitably described as weak, particularly for the ED. This recommendation risks doing a disservice to our patients. It is not acceptable for the authors to seek refuge in the statement that this is a guideline and should not be used as the sole guidance for clinical management; experience tells us that is exactly what will happen.Available evidence clearly suggests that nebulized albuterol decreases hospital admissions from the ED. The guideline should be amended to reflect this.Yours faithfullyPaul WalshStephen J Rothenberg1. Ralston SL, Lieberthal AS, Meissner HC, Alverson BK, Baley JE, Gadomski AM, et al. Clinical Practice Guideline: The Diagnosis, Management, and Prevention of Bronchiolitis. Pediatrics. 2014;134:e1474- e15022. Walsh P, Caldwell J, McQuillan KK, Friese S, Robbins D, Rothenberg SJ. Comparison of nebulized epinephrine to albuterol in bronchiolitis. Academic emergency medicine : official journal of the Society for Academic Emergency Medicine. 2008;15(4):305-313.3. Walsh P, Rothenberg SJ, O'Doherty S, Hoey H, Healy R. A validated clinical model to predict the need for admission and length of stay in children with acute bronchiolitis. European Journal of Emergency Medicine. 2004;11(5):265.4. Hartling L, Fernandes RM, Bialy L, Milne A, Johnson D, Plint A, et al. Steroids and bronchodilators for acute bronchiolitis in the first two years of life: systematic review and meta-analysis. BMJ. 2011;342:d1714.5. Gadomski AM. Bronchodilators for bronchiolitis. In: Scribani M, editor. Cochrane Acute Respiratory Infections Group: John Wiley & Sons; 2014.Conflict of Interest:None declared
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