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Bronchodilators Do not alter the Clinical Course of Bronchiolitis

Question

  • In previously healthy infants with bronchiolitis, does the administration of bronchodilators when compared to placebo result in improvement in respiratory distress, oxygen saturation, and length of hospital stay?

Clinical Bottom Lines

  1. Bronchodilator use decreases the clinical score when compared to placebo within the first 24 hours of use in infants with bronchiolitis. 1
  2. Bronchodilator use increases the oxygen saturation when compared to placebo within the first 24 hours of use in infants with bronchiolitis.1
  3. Bronchodilator use does not alter the length of hospital admission in infants with bronchiolitis. 1,2


Summary of Key Evidence

  1. 69 previously healthy infants at their first episode of wheezing or crepitations in the chest were enrolled in a prospective, double-blind, placebo controlled trial to receive either nebulized salbutamol, nebulized ipratroprium bromide, or nebulized saline placebo. Treatment and placebo groups had similar characteristics 1
  2. Inclusion criteria included age <1 year, first wheezing episode, acute onset of respiratory distress, and x-ray of the chest compatible with bronchiolitis.1
  3. Exclusion criteria included prematurity, chronic neurologic or cardiopulmonary disease, proven or suspected bacterial infection, previous treatment with bronchodilators or corticosteroids, age <4 weeks and ventilation during the neonatal period, presence of symptoms >7 days, fever >38.5 degrees celsius, and mild bronchiolitis(clinical score <6).1
  4. Primary outcomes included differences in clinical scores and oxygen saturations between treatment and placebo groups at 0.5, 8, 24, and 48 hours. Secondary outcome was duration of hospitalization.1
  5. The bronchodilator groups had better clinical scores when compared to placebo at 0.5 hours(p<0.0001), 8 hours(p=0.0001), and 24 hours(p=0.006).1
  6. The bronchodilator groups had better oxygen saturations when compared to placebo at 8 hours(p<0.0001) and 24 hours(p<0.0001 1
  7. The duration of hospitalization was similar between the bronchodilator and placebo groups(p=0.85).1
  8. The validity of the article was challenged by the small sample size, the unvalidated clinical scoring system, the unclear clinical significance of the change in the score, and the difficulty in standardizing the secondary outcome.1

Additional Comments

  • The clinical score was based on four parameters, including respiratory rate, degree of wheezing, degree of accessory muscle use, and general condition. It was intended to represent the severity of respiratory distress in the included patients.1
  • A Cochrane Review on Bronchodilators in Bronchiolitis was conducted in 2006. This included 22 trials with 1428 infants. There was a statistically significant but clinically modest improvement in overall average clinical score of infants treated with bronchodilators compared to infants treated with placebo. There was no statistically significant improvement in oxygenation overall. Bronchodilator recipients showed no improvement in the rate of hospital admission after treatment as outpatients or duration of hospitalization for inpatients.2
  • Adverse side effects of bronchodilators may include tachycardia, agitation, and tremor.2

Citation

  1.  Karadag B, Ceran O, Guven G, et al. Efficacy of Salbutamol and Ipratroprium Bromide in the Management of Acute Bronchiolitis – A Clinical Trial. Respiration 2008; 76(3): 283-287. 
    Gadomski AM, Bhasale AL. Bronchodilators for bronchiolitis. Cochrane Database of Systematic Reviews 2006, Issue 3. Art. No.: CD001266. DOI: 10.1002/14651858.CD001266.pub2.

CAT Author: Jennifer Dalton, MD

CAT Appraisers: James Gurney, PhD.

Date appraised: June 24, 2009

Last updated November 9, 2009
Department of Pediatrics and Communicable Diseases
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