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Review: commonly used pharmacological

treatments for bronchiolitis in children do not seem
to be effective
James D Kellner

Arch. Dis. Child. Ed. Pract. 2004;89;79-

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EVIDENCE-BASED MEDICINE

Review: commonly used pharmacological treatments for

bronchiolitis in children do not seem to be effective
King VJ, Viswanathan M, Bordley WC, et al. Pharmacologic treatment of bronchiolitis in infants and children: a systematic review.
Arch Pediatr Adolesc Med 2004;158:127–37. ep79
Clinical impact ratings GP/FP/Primary care wwwwwqq Paediatrics wwwwwqq
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Q In children with bronchiolitis, what is the effectiveness of commonly used pharmacological treatments?
METHODS
Commentary
Data sources: Medline (January 1980 to November 2002),

K
ing et al collated the English language literature for common
Cochrane Central Register of Controlled Trials, reference lists, pharmacological treatments of bronchiolitis and justifiably con-
and technical experts. cluded that the routine use of these agents does not reliably improve
Study selection and assessment: single or double blinded clinical features, nor do they influence hospital admission or duration of
randomised controlled trials (RCTs) published in English that hospital stay.
evaluated pharmacological treatments for bronchiolitis in >10 Why, then, do clinicians in some countries commonly treat children
children. with bronchiolitis with bronchodilators? In part, it may be because
unnecessary treatment is given for a condition that closely resembles
Outcomes: death, short and long term morbidity, and use of asthma (despite a different pathogenesis).1 Thus, it is necessary to
health services. increase awareness of the lack of reliable benefit of these treatments in
bronchiolitis.
However, it also may be in part because short term improvements are
frequently seen, albeit not consistently. For example, King et al described
MAIN RESULTS short term improvements in clinical scores in 4 of 7 studies where
44 RCTs of commonly used interventions met the selection criteria. epinephrine was compared with placebo or albuterol. Also, 1 of 2
Study quality was rated as excellent in 7 RCTs, good in 20 RCTs, fair previous meta-analyses of bronchodilator treatment studies pooled
in 15 RCTs, and poor in 2 RCTs. Nebulised epinephrine (8 RCTs, 660 clinical score data and found that the proportion of children with
children). Epinephrine was better than salbutamol for reducing improved scores was higher in those receiving bronchodilators than in
hospital admission or length of stay in 2 of 3 RCTs but did not differ those receiving placebo.2 The improvements may be related to non-
from albuterol (1 of 1 RCT) or placebo (2 of 2 RCTs). 3 of 5 RCTs bronchodilator effects, such as reduced airway resistance1 or changes in
showed better clinical scores immediately after epinephrine treat- state from sleep to wakefulness.2 It is possible that short term
ment than after control treatment, but the difference did not persist improvements may be associated with other benefits such as improved
at 24 and 36 hours (1 RCT). b2 agonist bronchodilators (13 RCTs, 956 feeding and reduced restlessness. Such improvements may be desired by
children). None of 7 RCTs showed a benefit for b2 agonists in clinicians and families even if the overall duration of illness is not
admission rates or duration of hospital stay. 3 of 12 RCTs showed reduced.
Future clinical trials could address whether a trial of pharmacological
short term improvement in clinical scores 30–60 minutes after
treatment (particularly bronchodilators) with defined short term evalua-
nebulised bronchodilator therapy, and 1 RCT showed worse scores.
tion of benefit (and discontinuation if none is found) improves overall
Groups did not differ for hospitalisation when nebulised ipratropium quality of life during bronchiolitis. Given the lack of certain benefit of any
bromide was compared with nebulised salbutamol (1 RCT) or used in pharmacological treatment, any future clinical trial must compare
combination with salbutamol or albuterol and compared with either treatment(s) with placebo.
drug alone or placebo (2 RCTs). Parenteral corticosteroids (2 RCTs James D Kellner, MD
[dexamethasone], 147 children). Groups did not differ for hospita- University of Calgary
lisation or clinical scores. Oral corticosteroids (5 RCTs, 273 children). 1 Calgary, Alberta, Canada
of 2 RCTs comparing dexamethasone with placebo showed a lower 1 Wohl ME, Chernick V. Treatment of acute bronchiolitis [editorial]. N Engl J
hospital admission rate for dexamethasone. 1 of 2 RCTs comparing Med 2003;349:82–3.
prednisolone with placebo showed more hospital admissions with 2 Kellner JD, Ohlsson A, Gadomski AM, et al. Bronchodilators for
bronchiolitis. Cochrane Database Syst Rev 2000;(2):CD001266.
prednisolone. 1 RCT showed short term improvement in clinical
scores for prednisolone plus albuterol compared with albuterol plus
placebo, but the effect was not apparent at 3 or 6 days. Inhaled
of healthcare services. 1 RCT that showed improvement used sterile
corticosteroids (6 RCTs, 492 children). 2 of 5 RCTs comparing
water as the placebo which may itself induce bronchospasm. For
budesonide with placebo or control showed longer term worsening
clinical scores (6 RCTs), 1 RCT showed that ribavirin was better than
of symptoms for budesonide (more wheezing and coughing at 12 mo
placebo for time to improvement in cough or crepitations but not for
and more hospital readmissions for respiratory problems at 6 mo). 1
wheezing or feeding. 2 RCTs showed better clinical scores for
RCT showed that 2 months of budesonide use reduced the need for
ribavirin than for placebo on some days but not on others. 1 long
asthma inhalation therapy at 2 years when compared with 7 days of
term RCT showed that fewer children had >2 wheezing episodes at
budesonide use or usual symptomatic treatment. Fluticasone by
years 1–6 after ribavirin than after water placebo, but groups did not
metered dose inhaler (1 RCT) for 3 months led to less coughing at
differ for overall respiratory illness or symptoms. Another RCT
night at 36 weeks than did placebo, but the effect was not apparent at
showed that ribavirin led to fewer episodes of reactive airways
3, 6, 12, or 24 weeks. Ribavirin (10 RCTs, 320 children). None of 4
disease and upper and lower respiratory disease than did usual
placebo controlled RCTs showed a difference between groups for use
treatment at 1 year.
.............................................................
For correspondence: Dr V J King, University of North Carolina at Chapel Hill, CONCLUSION
Chapel Hill, NC, USA In children with bronchiolitis, the evidence does not consistently
Source of funding: Agency for Healthcare Research and Quality. show that commonly used pharmacological treatments are effective.

Reproduced with permission from Evidence-Based Medicine 2004;9:141

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