University of Michigan
Department of Pediatrics
Evidence-Based Pediatrics Web Site

Question

• In otherwise healthy patients with bronchiolitis, does nebulized albuterol, as compared with oxygen and supportive care alone, decrease hospital stay and improve respiratory distress and oxygenation?

Clinical Bottom Lines

1. Nebulized albuterol does not significantly decrease length of hospital admission in previously healthy infants with bronchiolitis.¹
2. Nebulized albuterol does not decrease the time until an infant with bronchiolitis returns to normal hydration, oxygenation, and has resolution of respiratory distress.^1,2

Summary of Key Evidence

1. 149 previously well infants 12 months hospitalized with acute bronchiolitis were randomized in a double-blinded parallel group controlled trial to receive either racemic epinephrine, nebulized albuterol, or saline placebo. Placebo and treatment groups had similar characteristics at onset of study.¹
2. Primary outcome measure was length of hospital stay (LOS).
3. Secondary outcome measures included time from admission until infant had normal hydration, oxygenation, and minimal respiratory distress.
4. No significant differences were seen in mean LOS (a 24 hour group difference was considered to be significant): racemic epinephrine 59.8 hrs, albuterol 61.4 hrs, placebo 63.3 hrs (p=0.95).
5. No significant differences were seen in mean time until O2 saturations were 95% in room air. racemic epinephrine 25 hrs, albuterol 33 hrs, placebo 36.6 hrs (p=0.5).
6. No significant difference in mean time until resolution of respiratory distress. racemic epinephrine 34.6 hrs, albuterol 45.7 hrs, placebo 34.8 hrs (p=0.4).

Additional Comments

• In bronchiolitis, terminal bronchiolar and alveolar inflammation with airway swelling and luminal debris create airway obstruction.²
• Albuterol, a bronchodilator, may not provide significant improvement in clinical course due to inadequate beta-agonist lung receptor sites or immature bronchiolar smooth muscle development.¹
• Prior to enrollment in the study, many patients received albuterol in the Emergency Departmen. This may select out good responders and patients who will develop asthma in the future.^1,2
• The Cochrane Database of Systematic Reviews with a meta-analysis of 394 children with bronchiolitis showed only a modest short-term improvement in clinical scores with use of bronchodilators, however the inclusion of patients with history of recurrent wheezes may have biased the results in favor of bronchodilators.²
• Minimal toxicity occurs with albuterol but may include tachycardia, mild hypertension, hyperactivity, and tremor.²
• Nebulized saline may act as a pulmonary irritant and induce hypoxia and bronchoconstriction.¹
  

Citation

1. Patel H, Platt RW, Pekeles GS, Ducharme FM. A randomized, controlled trial of the effectiveness of nebulized therapy with epinephrine compared with albuterol and saline in infants hospitalized for acute viral bronchiolitis. J Pediatr 2002;141: 818-24.
2. Kellner JD, Ohlsson A, Gadomski AM, Wang EEL. Bronchodilators for bronchiolitis. Cochrane Acute Respiratory Infections Group. Cochrane Database of Systematic Reviews 4, 2004.

CAT Author: Stephanie A. Zeskind, MD

CAT Appraisers: John Frohna, MD

Date appraised: February 9, 2005