One of the challenges with the bronchiolitis literature is that the studies are very heterogeneous and don't necessary reflect the population well. The basic science literature is increasingly identifying 2 subgroups of kids: the classic presentation of a younger infant with first time wheeze during RSV season, and older kids and toddlers who wheeze with rhinovirus infection and are at increased risk of ongoing wheeze. Most of the studies of bronchodilators (and the AAP Guideline) are focused on the first classic group, and the evidence there as summarized in the Gadomski review is pretty strong that there is minimal overall benefit. These are all small studies, so it's not possible to look at subgroups, such as older infants. In our ED we have dramatically reduced use of bronchodilators in those kids with no observable impact on outcomes. The second group is less well studied, and interesting new literature is suggesting that other factors may be involved, including possibly bacterial co-infection. The Walsh study mentioned in the prior post included kids up to 18 months with recurrent wheezing. Using albuterol and asthma-like treatments in those kids is reasonable, although there is less evidence to identify who are responders. One of the problems with doing your own trial in an individual patient is that generally these kids all get better over ED treatment, which we are prone to attribute to the treatments we gave, that's why you need RCTs to really know what is going on.
For sicker young infants with classic bronchiolitis, the evidence is stronger that there is more efficacy for epinephrine. I agree with Jim that it can still play a role as a rescue therapy, and that is mentioned in the AAP Guideline. The hospitalists prefer HFNC for admitted patients because they require less care and tending on the inpatient floor (although at high cost) and fewer calls to the bedside in the middle of the night. Giving standing bronchodilators in the inpatient setting appears to worsen outcomes, so they are best used selectively.
The Children's Hospital of Philadelphia
Gadomski AM. Bronchodilators for bronchiolitis. In: Scribani M, editor. Cochrane Acute Respiratory Infections Group: John Wiley & Sons; 2014
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.
Skjerven HO et al. Racemic adrenaline and inhalation strategies in acute bronchiolitis. N Engl J Med. 2013 Jun 13;368(24):2286-93.
Joseph Zorc MD, MSCE
Direct Reply: https://www.docmatter.com/josephzorc
Director, Emergency Information Systems; Emergency Medicine Attending Physician; Professor of Pediatrics
Children's Hospital of Philadelphia
This is a reply to the discussion started by Todd Zimmerman DO:
Few years old but nice letter.
The recommendation to not use bronchodilators is not supported by the...
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