Bronchodilators for bronchiolitis—should they be used routinely?

…reducing waste in child health one intervention at a time

Authors


Abstract

Eco-paediatrics is an occasional feature in Evidence-Based Child Health: A Cochrane Review Journal. Our goal is to contribute to the worldwide discussion on reducing waste in health care. In each instalment, we will select a recent Cochrane review highlighting a practice, still in use, which the available evidence tells us should be discontinued.

Excerpts from: Gadomski AM, Brower M. Bronchodilators for bronchiolitis. Cochrane Database of Systematic Reviews 2010, Issue 12. Art. No.: CD001266. DOI: 10.1002/14651858.CD001266.pub3.

Bronchiolitis

Bronchiolitis is an acute, viral, lower respiratory tract infection common in infants. It causes infants to become breathless, wheezy and short of oxygen owing to blocked airways.

Bronchodilators

Bronchodilators are used to widen the air passages by relaxing the bronchial muscle, and are effective in infants and adults with asthma.

What should we do in practice?

Infants with bronchiolitis are often wheezing for the first time owing to blocked airways, and therefore, do not respond to bronchodilators which are more effective for patients with asthma. Bronchodilators do not improve oxygen saturation, do not reduce hospital admission after outpatient treatment, do not shorten the duration of hospitalization and do not reduce the time to resolution of illness at home. Side effects of bronchodilators include rapid heartbeat and shakiness. Given these side effects and little evidence that they are effective, bronchodilators are not helpful in the management of bronchiolitis.

What do the guidelines suggest?

American Academy of Pediatrics (1)Bronchodilators should not be used routinely in the management of bronchiolitis (recommendation: evidence level B; randomized controlled trials with limitations; preponderance of harm of use over benefit). Studies assessing the impact of bronchodilators on long-term outcomes have found no impact on the overall course of the illness.
Scottish Intercollegiate Guidelines Network (2)Inhaled β2-agonist bronchodilators are not recommended for the treatment of acute bronchiolitis in infants.

Evidence-Based Child Health, Editorial Office*

*Correspondence to: Evidence-Based Child Health Canadian editorial office. E-mail: child@ualberta.ca

Commentary by Gary A. Emmett

Clearly bronchodilators do not help in bronchiolitis, but they do help in asthma. Asthma does occur in the first 2 years of life, but the younger the child the more likely it is bronchiolitis and the less likely it is asthma when children present with tachypnea, breathlessness and wheezing, especially in winter.

So what is the practitioner to do in a child with bronchiolitic symptoms? Practitioners want to do something when confronted with an ill child and they know how to treat asthma, which also has wheezing. Unfortunately, bronchiolitis has no diagnostic imaging study or lab test to confirm the diagnosis. Bronchodilators do cause uncomfortable side effects as mentioned above and should be avoided if not indicated.

  • (1)When the clinical picture fits with bronchiolitis, do not use broncholidators especially in infants who are febrile or younger than 6 months and who have no personal or family history of asthma or significant respiratory disease of the newborn.
  • (2)If there is a possibility of asthma (especially strong personal or family history of asthma or history of respiratory problems in a preterm delivery), just use the bronchodilator once and see if there is a clinical change. If no improvement with these medications, then stop using.
  • (3)If bronchodilators are not indicated, systemic or inhaled steroids are probably not indicated also. Steroids often do not work before the first birthday even in asthma.
  • (4)There is evidence that nebulized hypertonic saline is effective in some bronchilitic patients and is very safe.
  • (5)Oxygen is indicated if a child cannot maintain a good oxygen level.

Osler said everything that wheezes is not asthma (3), so if bronchiolitis is diagnosed, it should not be treated as asthma.

Declaration of interest

There is no conflict of interest to declare.

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