Effects of nebulized fenoterol, associated with ipratropium or steroids, on the heart rate of infants under one year of age with acute wheezing

Glucocorticoids for acute viral bronchiolitis in infants and young children

BACKGROUND

Previous systematic reviews have not shown clear benefit of glucocorticoids for acute viral bronchiolitis, but their use remains considerable. Recent large trials add substantially to current evidence and suggest novel glucocorticoid-including treatment approaches.

OBJECTIVES

To review the efficacy and safety of systemic and inhaled glucocorticoids in children with acute viral bronchiolitis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL 2012, Issue 12), MEDLINE (1950 to January week 2, 2013), EMBASE (1980 to January 2013), LILACS (1982 to January 2013), Scopus® (1823 to January 2013) and IRAN MedEx (1998 to November 2009).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing short-term systemic or inhaled glucocorticoids versus placebo or another intervention in children under 24 months with acute bronchiolitis (first episode with wheezing). Our primary outcomes were: admissions by days 1 and 7 for outpatient studies; and length of stay (LOS) for inpatient studies. Secondary outcomes included clinical severity parameters, healthcare use, pulmonary function, symptoms, quality of life and harms.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data on study and participant characteristics, interventions and outcomes. We assessed risk of bias and graded strength of evidence. We meta-analysed inpatient and outpatient results separately using random-effects models. We pre-specified subgroup analyses, including the combined use of bronchodilators used in a protocol.

MAIN RESULTS

We included 17 trials (2596 participants); three had low overall risk of bias. Baseline severity, glucocorticoid schemes, comparators and outcomes were heterogeneous. Glucocorticoids did not significantly reduce outpatient admissions by days 1 and 7 when compared to placebo (pooled risk ratios (RRs) 0.92; 95% confidence interval (CI) 0.78 to 1.08 and 0.86; 95% CI 0.7 to 1.06, respectively). There was no benefit in LOS for inpatients (mean difference -0.18 days; 95% CI -0.39 to 0.04). Unadjusted results from a large factorial low risk of bias RCT found combined high-dose systemic dexamethasone and inhaled epinephrine reduced admissions by day 7 (baseline risk of admission 26%; RR 0.65; 95% CI 0.44 to 0.95; number needed to treat 11; 95% CI 7 to 76), with no differences in short-term adverse effects. No other comparisons showed relevant differences in primary outcomes.

AUTHORS' CONCLUSIONS

Current evidence does not support a clinically relevant effect of systemic or inhaled glucocorticoids on admissions or length of hospitalisation. Combined dexamethasone and epinephrine may reduce outpatient admissions, but results are exploratory and safety data limited. Future research should further assess the efficacy, harms and applicability of combined therapy.

Glucocorticoids for acute viral bronchiolitis in infants and young children

BACKGROUND

Previous systematic reviews have not shown clear benefit of glucocorticoids for acute viral bronchiolitis, but their use remains considerable. Recent large trials add substantially to current evidence and suggest novel glucocorticoid-including treatment approaches.

OBJECTIVES

To review the efficacy and safety of systemic and inhaled glucocorticoids in children with acute viral bronchiolitis.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (The Cochrane Library 2009, issue 4); MEDLINE (1950 to November 2009); EMBASE (1980 to Week 47 2009); LILACS (1982 to November 2009); Scopus® (1823 to November 2009); and IRAN MedEx (1998 to November 2009).

SELECTION CRITERIA

Randomised controlled trials (RCTs) comparing short-term systemic or inhaled glucocorticoids versus placebo or another intervention in children < 24 months with acute bronchiolitis (first episode with wheezing). Our primary outcomes were: admissions by days 1 and 7 for outpatient studies; and length of stay (LOS) for inpatient studies. Secondary outcomes included clinical severity parameters, healthcare use, pulmonary function, symptoms, quality of life and harms.

DATA COLLECTION AND ANALYSIS

Two authors independently extracted data on study and participant characteristics, interventions and outcomes. We assessed risk of bias and graded strength of evidence. Inpatient and outpatient results were meta-analysed separately using random-effects models. We pre-specified subgroup analyses, including the combined use of protocolised bronchodilators.

MAIN RESULTS

We included 17 trials (2596 participants); only two had low overall risk of bias. Baseline severity, glucocorticoid schemes, comparators and outcomes were heterogeneous. Glucocorticoids did not significantly reduce outpatient admissions by days 1 and 7 when compared to placebo (pooled risk ratios (RRs) 0.92; 95% CI 0.78 to 1.08; and 0.86; 95% CI 0.7 to 1.06, respectively). There was no benefit in LOS for inpatients (mean difference -0.18 days; 95% CI -0.39 to 0.04). Unadjusted results from a large factorial low risk of bias RCT found combined high-dose systemic dexamethasone and inhaled epinephrine reduced admissions by day 7 (baseline risk of admission 26%; RR 0.65, 95% CI 0.44 to 0.95; number needed to treat 11, 95% CI 7 to 76), with no differences in short-term adverse effects. No other comparisons showed relevant differences in primary outcomes.

AUTHORS' CONCLUSIONS

Current evidence does not support a clinically relevant effect of systemic or inhaled glucocorticoids on admissions or length of hospitalization. Combined dexamethasone and epinephrine may reduce outpatient admissions, but results are exploratory and safety data limited. Future research should further assess the efficacy, harms and applicability of combined therapy.

Anticholinergic drugs for wheeze in children under the age of two years

BACKGROUND

Wheeze in infancy and early childhood is common and appears to be increasing though the magnitude of any increase is unclear. Most wheezing episodes in infancy are precipitated by respiratory viral infections. Treatment of very young children with wheeze remains controversial. Anti-cholinergics are often prescribed but practice varies widely and the efficacy of this form of therapy remains the subject for debate.

OBJECTIVES

Wheeze in infancy and early childhood is common and appears to be increasing. Most wheezing episodes in infancy are a result of viral infection. Bronchodilator medications such as beta2-agonists and anti-cholinergic agents are often used to relieve symptoms, but patterns of use vary. The objective of this review was to assess the effects of anti-cholinergic therapy in the treatment of wheezing infants. This is a second update of this review.

SEARCH STRATEGY

We searched the Cochrane Airways Group Specialised Register of trials and the reference lists of articles. We contacted researchers in the field and industry sources. Searches were current as of June 2004.

SELECTION CRITERIA

Randomised trials that compared anti-cholinergic therapy with placebo or beta2-agonists in wheezing children under two years of age. Children with acute bronchiolitis and chronic lung disease were excluded.

DATA COLLECTION AND ANALYSIS

Eligibility for inclusion and quality of trials were assessed independently by two reviewers.

MAIN RESULTS

Six trials involving 321 infants in three different settings were included. Compared with beta2-agonist alone, the combination of ipratropium bromide and beta2-agonist was associated with a reduced need for additional treatment, but no difference was seen in treatment response, respiratory rate or oxygen saturation improvement in the emergency department. There was no significant difference in length of hospital stay between ipratropium bromide and placebo; or between ipratropium bromide and beta2-agonist combined compared with beta2-agonist alone. However, combined ipratropium bromide and beta2-agonist compared to placebo showed significantly improved clinical scores at 24 hours. Parents preferred ipratropium bromide over nebulised water or placebo for relief of their children's symptoms at home. A further updated search conducted in June 2004 did not yield any new studies.

AUTHORS' CONCLUSIONS

There is not enough evidence to support the uncritical use of anti-cholinergic therapy for wheezing infants, although parents using it at home were able to identify benefits.

Anticholinergic drugs for wheeze in children under the age of two years

BACKGROUND

Wheeze in infancy and early childhood is common and appears to be increasing though the magnitude of any increase is unclear. Most wheezing episodes in infancy are precipitated by respiratory viral infections. Treatment of very young children with wheeze remains controversial. Anti-cholinergics are often prescribed but practice varies widely and the efficacy of this form of therapy remains the subject for debate.

OBJECTIVES

Wheeze in infancy and early childhood is common and appears to be increasing. Most wheezing episodes in infancy are a result of viral infection. Bronchodilator medications such as beta2-agonists and anti-cholinergic agents are often used to relieve symptoms, but patterns of use vary. The objective of this review was to assess the effects of anti-cholinergic therapy in the treatment of wheezing infants.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register and the reference lists of articles. We contacted researchers in the field and industry sources.

SELECTION CRITERIA

Randomised trials that compared anti-cholinergic therapy with placebo or beta2-agonists in wheezing children under two years of age. Children with acute bronchiolitis and chronic lung disease were excluded.

DATA COLLECTION AND ANALYSIS

Eligibility for inclusion and quality of trials were assessed independently by two reviewers.

MAIN RESULTS

Six trials involving 321 infants in three different settings were included. Compared with beta2-agonist alone, the combination of ipratropium bromide and beta2-agonist was associated with a reduced need for additional treatment, but no difference was seen in treatment response, respiratory rate or oxygen saturation improvement in the emergency department. There was no significant difference in length of hospital stay between ipratropium bromide and placebo; or between ipratropium bromide and beta2-agonist combined compared with beta2-agonist alone. However, combined ipratropium bromide and beta2-agonist compared to placebo showed significantly improved clinical scores at 24 hours. Parents preferred ipratropium bromide over nebulised water or placebo for relief of their children's symptoms at home.

REVIEWER'S CONCLUSIONS

There is not enough evidence to support the uncritical use of anti-cholinergic therapy for wheezing infants, although parents using it at home were able to identify benefits.

Relation between pulse oximetry and clinical score in children with acute wheezing less than 24 months of age

The aim of this study was to determine the relation between transcutaneous hemoglobin oxygen saturation, measured by pulse oximetry (SpO2), and clinical score values in 138 infants (mean+/-SD, 6.6+/-5.5 months of age) with acute wheezing episodes presenting in a primary care outpatient setting. A single investigator evaluated the severity of the acute wheezing episodes by assigning a clinical score and was unaware of the SpO2 values. Another investigator measured SpO2 values on all subjects. The mean (+/-SD) SpO2 value was 98.2+/-1.1% for children with clinical scores of 2-5 (n = 32); 95.4+/-1.5% for those with scores of 6-7 (n = 82), and 92.9+/-2% for children with scores of 8-10 (n = 24), (P < 0.001 by Bonferroni's multiple comparison, when all two-way comparisons were done for each pair of results). The clinical score showed a good correlation with SpO2 (r = -0.76; 95% CI, -0.83 to -0.68). We conclude that if pulse oximetry is not available, it is advisable to include oxygen in the therapy of wheezy infants with clinical scores values >8.

Continuous subcutaneous infusion of beta 2-agonists in infantile asthma

Eleven infants presenting with an asthmatic syndrome were treated with subcutaneous infusions of a beta 2-agonist (beta 2A) during an acute episode. This treatment was used after difficulties with or failure of beta 2A infusions and IV nebulizations. No local or general adverse reactions were observed. The serum concentrations of salbutamol obtained at a dose of 0.1 micrograms/kg/min were measured in six infants and found to be within the generally accepted therapeutic range. This mode of administration proved extremely useful, both by itself and as part of a therapeutic protocol, combined with an antibiotic, a corticosteroid, and theophylline. It avoids the difficulties of administering beta 2A intravenously or by nebulization, while preserving some degree of freedom and better general care for the child. The preferred indication is in treatment of severe acute asthmatic episodes after failure of nebulizations. The exact place in the therapeutic arsenal of infantile asthma remains to be defined.

Ipratropium bromide for symptomatic preterm infants

Twelve preterm infants, median gestational age 31.5 weeks, were entered into a randomised, placebo-controlled trial of bronchodilator therapy. Their postnatal age was a median of 17.5 months and all suffered from recurrent respiratory symptoms. The infants received either inhaled placebo or 40 micrograms of ipratropium bromide (active therapy) three times a day utilising a coffee cup as a spacer device. Each therapy was administered for 2 weeks. The symptom score during the active period was reduced by 59% compared to the placebo period (P less than 0.01) and this was associated with 38% improvement in lung function in the active period compared to a 20% change in functional residual capacity over the placebo period (P less than 0.01). We conclude inhaled ipratropium bromide appears to be an effective treatment for symptomatic infants at follow up.

Effect of salbutamol on oxygen saturation in bronchiolitis

Inhaled sympathomimetic agents are often used in bronchiolitis with little objective evidence of benefit. The arterial oxygen saturation (SaO2) reflects the adequacy of ventilation-perfusion balance. The aim of the current study was to determine the effect of inhaled salbutamol on SaO2. In a randomised, double blind study, 21 infants, admitted with bronchiolitis positive for respiratory syncytial virus, had continuous SaO2 measurements made before and after nebulised salbutamol or placebo. SaO2 was recorded over 30 minutes for a baseline, then during the 10 minutes of first nebulisation with either salbutamol or saline, then over 30 minutes after nebulisation, the 10 minutes of second nebulisation with the alternate regime, and another 30 minutes after this second nebulisation. Desaturation occurred after salbutamol and saline nebulisation. The fall in SaO2 with salbutamol was seen whether infants received it as the first or second nebulisation. The fall in SaO2 after saline was seen when given first, but not when given after salbutamol. The decrease in SaO2 was greater and more prolonged with salbutamol than with saline. Routine nebulised aerosol sympathomimetic treatment during acute bronchiolitis cannot be recommended.