Should a child 24 months or younger who has been diagnosed with bronchiolitis be treated with an inhaled bronchodilator such as albuterol?
Albuterol does not improve any clinical outcomes in the outpatient or inpatient setting and should not be used in the treatment of bronchiolitis in a child 24 months or younger. (Strength of Recommendation: A, based on consistent, good-quality patient-oriented evidence.)
Bronchiolitis is a lower respiratory tract infection, generally of viral etiology, associated with bronchiolar congestion and inflammation that causes wheezing and oxygen desaturation. In children younger than 24 months, 0.5% will be hospitalized with bronchiolitis; the risk is as high as 2% in infants two months or younger.1 Other Cochrane analyses have concluded that inhaled racemic epinephrine and inhaled hypertonic saline may improve oxygen saturation or reduce length of hospital stay.2,3 Because older children and adults with wheeze can be treated effectively with inhaled bronchodilators, it is reasonable to presume these agents may be useful in the treatment of bronchiolitis.
This updated review added two new studies to bring the number of trials to 30, including a total of 1,992 children. Inpatient and outpatient outcomes were examined. Bronchodilators such as albuterol did not significantly improve the oxygen saturation (mean difference in oxygen saturation = −0.43; 95% confidence interval, −0.92 to 0.06). In outpatient studies, bronchodilator treatment did not reduce the rate of hospitalization, whereas in inpatient studies, treatment did not reduce the duration of hospitalization. Subgroup analysis of the treated children showed an improvement in clinical scores on the Respiratory Distress Assessment Instrument and the Respiratory Assessment Change Score. However, the improvement was small and the authors did not consider that outcome to be clinically relevant. An attempt to reduce heterogeneity by excluding trials considered to be at higher risk of bias did not allow any of these parameters of effectiveness to achieve statistical significance. Two reported adverse effects were statistically significant: children who received inhaled bronchodilators demonstrated increased tachycardia as well as decreased oxygen saturation.
This review concludes that bronchodilators are not an effective treatment for bronchiolitis in children 24 months or younger. The presumption that wheeze in a child may represent asthma and that asthma might respond to such therapy may explain why these agents are used despite the evidence. However, another review showed no benefit of bronchodilator therapy in children 24 months or younger with wheeze of any etiology.4 Current guidelines suggest that inhaled bronchodilators such as albuterol may be used in treating bronchiolitis if there is a history of asthma, but even these guidelines caution that such treatment should not be continued in children who do not demonstrate immediate clinical benefit.5
The practice recommendations in this activity are available at http://summaries.cochrane.org/CD001266.