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

Question

• In children with acute bronchiolitis, is epinephrine more effective than beta-agonists in terms of clinical improvement and hospitalization?

Clinical Bottom Lines

1. Epinephrine does not seem to more effective than beta-agonists in increasing oxygen saturation, decreasing respiratory rate, or improving Respiratory Distress Assessment Instrument (RDAI) score in infants with acute bronchiolitis
2. Epinephrine may be effective in the outpatient setting in preventing hospitalization of infants with acute bronchiolitis. (NNT=2 compared to salbutamol)
3. Epinephrine costs twice as much as albuterol per dose.

Summary of Key Evidence

1. The study took place at a tertiary care center. 42 children (age 6 weeks to 1 year) were randomized to receive either inhaled Epinephrine or Salbutamol. Patients were excluded for the following: chronic lung or heart disease, previous diagnosis of asthma, previous bronchodilator use, severe disease, or use of steroids within the past 24 hours.¹
2. Patients were given with Salbutamol (.3cc + 2.7cc of normal saline) or 3cc of 1:1000 epinephrine. RDAI, respiratory rate, heart rate, and oxygen saturation were measured at baseline, 30 minutes, 60 minutes, and 90 minutes. Adverse effects (tremors, pallor, and emesis) were noted by the participating physicians. Secondary outcomes were admission and length of stay.
3. Patients in the Epinephrine group were found to have a higher oxygen saturation at 60 minutes as compared to the Salbutamol group. This difference disappeared by 90 minutes. In addition the epinephrine-treated group had a lower heart rate at 90 minutes.
4. 81% of the patients in the Salbutamol group were admitted vs. 33% in the Epinephrine group (p=0.033). The ARR is 49% and the NNT is 2.
5. Adverse effects were similar for both groups.

Additional Comments

• The admission criteria were not stated anywhere in the paper.
• The authors did not provide us with any demographic information. They stated that the two groups were similar based on demographic and clinical variables, but we do not know if the two groups had similar gestational ages at birth, similar levels of hydration, similar oral intake, etc.
• The participating physicians failed to call the study team to approach 33 eligible patients (40.7%), which brings up a question about the validity of the study.
• This was an outpatient study and does not really give us any information about whether epinephrine is more effective than beta-agonists in the inpatient treatment of infants with bronchiolitis.

Citation

1. Menon K, Sutcliffe T, Kallsen T. Clinical and laboratory observations: A randomized trial comparing the efficacy of epinephrine with salbutamol in the treatment of acute bronchiolitis. The Journal of Pediatrics 1995, 126(6):1004-1007.

CAT Author: Sharon Kileny, MD

CAT Appraisers: Jonathan Fliegel, MD

Date appraised: February 29, 2001