Use of nebulized bronchodilators in infants under 1 year of age: analysis of four forms of therapy

Systematic review of instruments aimed at evaluating the severity of bronchiolitis

OBJECTIVE

No recent studies have performed a systematic review of all available instruments aimed at evaluating the severity of bronchiolitis. The objective of the present study was to perform a systematic review of instruments aimed at evaluating the severity of bronchiolitis and to evaluate their measurement properties.

METHODS

A systematic search of the literature was performed in order to identify studies in which an instrument for evaluating the severity of bronchiolitis was described. Instruments were evaluated based on their reliability, validity, utility, endorsement frequency, restrictions in range, comprehension, and lack of ambiguity.

RESULTS

A total of 77 articles, describing a total of 32 different instruments were included in the review. The number of items included in the instruments ranged from 2 to 26. Upon analyzing their content, respiratory rate turned out to be the most frequently used item (in 26/32, 81.3% of the instruments), followed by wheezing (in 25/32, 78.1% of the instruments). In 18 (56.3%) instruments, there was a report of at least one of their measurement properties, mainly reliability and utility. Taking into consideration the information contained in the instruments, as well as their measurement properties, one was considered to be the best one available.

CONCLUSIONS

Among the 32 instruments aimed at evaluating the severity of bronchiolitis that were identified and systematically examined, one was considered to be the best one available. However, there is an urgent need to develop better instruments and to validate them in a more comprehensive and proper way.

Clinical respiratory scales: which one should we use?

INTRODUCTION

There are countless clinical respiratory scales for acute dyspnoea. Most healthcare professionals choose one based on previous personal experience or following local practice, unaware of the implications of their choice. The lack of critical comparisons between those different tools has been a widespread problem that only recently has begun to be addressed via score validation studies. Here we try to assess and compare the quality criteria of measurement properties of acute dyspnoea scores. Areas covered: A literature review was conducted by searching the PubMed database. Forty-five documents were deemed eligible as they reported the use or building of clinical scales, using at least two parameters, and applied these to an acute episode of respiratory dyspnoea. Our primary focus was the description of the validity, reliability and utility of 41 suitable scoring instruments. Differences in sample selection, study design, rater profiles and potential methodological shortcomings were also addressed. Expert commentary: All acute dyspnoea scores lack complete validation. In particular, the areas of measurement error and interpretability have not been addressed correctly by any of the tools reviewed. Frequent modification of pre-existing scores (in items composition and/or name), differences in study design and discrepancies in reviewed sources also hinder the search for an adequate tool.

Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis

This guideline is a revision of the clinical practice guideline, "Diagnosis and Management of Bronchiolitis," published by the American Academy of Pediatrics in 2006. The guideline applies to children from 1 through 23 months of age. Other exclusions are noted. Each key action statement indicates level of evidence, benefit-harm relationship, and level of recommendation. Key action statements are as follows:

Inhaled anticholinergics and short-acting beta(2)-agonists versus short-acting beta2-agonists alone for children with acute asthma in hospital

BACKGROUND

Inhaled anticholinergics given in addition to β2-agonists are effective in reducing hospital admissions in children presenting to the emergency department with a moderate to severe asthma exacerbation. It seems logical to assume a similar beneficial effect in children hospitalised for an acute asthma exacerbation.

OBJECTIVES

To assess the efficacy and safety of anticholinergics added to β2-agonists as inhaled or nebulised therapy in children hospitalised for an acute asthma exacerbation. To investigate the characteristics of patients or therapy, if any, that would influence the magnitude of response attributable to the addition of anticholinergics.

SEARCH METHODS

We identified trials from the Cochrane Airways Group Specialised Register of trials (CAGR), which is derived through systematic searches of bibliographic databases including the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, EMBASE, CINAHL, AMED and PsycINFO and through handsearching of respiratory journals and meeting abstracts. The search is current to November 2013.

SELECTION CRITERIA

Randomised trials comparing the combination of inhaled or nebulised anticholinergics and short-acting β2-agonists versus short-acting β2-agonists alone in children one to 18 years of age hospitalised for an acute asthma exacerbation were eligible.

DATA COLLECTION AND ANALYSIS

Two review authors independently assessed the methodological quality of trials and extracted data; disagreement was resolved by consensus or with the input of a third review author, when needed. Primary outcomes were duration of hospital stay and serious adverse events. Secondary outcomes included admission and duration of stay in the intensive care unit (ICU), ventilation assistance, time to short-acting β2-agonists spaced at four hours or longer, supplemental asthma therapy, duration of supplemental oxygen, change from baseline in asthma severity, relapse after discharge, adverse health effects and withdrawals.

MAIN RESULTS

Seven randomised trials were included, four of which reported usable data on 472 children with asthma one to 18 years of age who were admitted to paediatric wards. No trials included patients admitted to the ICU. The anticholinergic used, ipratropium bromide 250 μg, was given every one to eight hours over a period from four hours to the entire length of the hospital stay. Two of four trials (50%) contributing data were deemed of high methodological quality. The addition of anticholinergics to β2-agonists showed no evidence of effect on the duration of hospital admission (mean difference (MD) -0.28 hours, 95% confidence interval (CI) -5.07 to 4.52, 3 studies, 327 participants, moderate quality evidence) and no serious or non-serious adverse events were reported in any included trials. As a result of the similarity of trials, we could not explore the influence of age, admission site, intensity of anticholinergic treatment and co-interventions on primary outcomes. No statistically significant group difference was noted in other secondary outcomes, including the need for supplemental asthma therapy, time to short-acting β2-agonists spaced at four hours or longer, asthma clinical scores, lung function and overall withdrawals for any reason.

AUTHORS' CONCLUSIONS

In children hospitalised for an acute asthma exacerbation, no evidence of benefit for length of hospital stay and other markers of response to therapy was noted when nebulised anticholinergics were added to short-acting β2-agonists. No adverse health effects were reported, yet the small number of trials combined with inadequate reporting prevent firm reassurance regarding the safety of anticholinergics. In the absence of trials conducted in ICUs, no conclusion can be drawn regarding children with impending respiratory failure. These findings support current national and international recommendations indicating that healthcare practitioners should refrain from using anticholinergics in children hospitalised for acute asthma.

Bronchodilators for bronchiolitis

BACKGROUND

Bronchiolitis is an acute, viral lower respiratory tract infection affecting infants and is sometimes treated with bronchodilators.

OBJECTIVES

To assess the effects of bronchodilators on clinical outcomes in infants (0 to 12 months) with acute bronchiolitis.

SEARCH METHODS

We searched CENTRAL 2013, Issue 12, MEDLINE (1966 to January Week 2, 2014) and EMBASE (1998 to January 2014).

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing bronchodilators (other than epinephrine) with placebo for bronchiolitis.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted data. We obtained unpublished data from trial authors.

MAIN RESULTS

We included 30 trials (35 data sets) representing 1992 infants with bronchiolitis. In 11 inpatient and 10 outpatient studies, oxygen saturation did not improve with bronchodilators (mean difference (MD) -0.43, 95% confidence interval (CI) -0.92 to 0.06, n = 1242). Outpatient bronchodilator treatment did not reduce the rate of hospitalization (11.9% in bronchodilator group versus 15.9% in placebo group, odds ratio (OR) 0.75, 95% CI 0.46 to 1.21, n = 710). Inpatient bronchodilator treatment did not reduce the duration of hospitalization (MD 0.06, 95% CI -0.27 to 0.39, n = 349).Effect estimates for inpatients (MD -0.62, 95% CI -1.40 to 0.16) were slightly larger than for outpatients (MD -0.25, 95% CI -0.61 to 0.11) for oximetry. Oximetry outcomes showed significant heterogeneity (I(2) statistic = 81%). Including only studies with low risk of bias had little impact on the overall effect size of oximetry (MD -0.38, 95% CI -0.75 to 0.00) but results were close to statistical significance.In eight inpatient studies, there was no change in average clinical score (standardized MD (SMD) -0.14, 95% CI -0.41 to 0.12) with bronchodilators. In nine outpatient studies, the average clinical score decreased slightly with bronchodilators (SMD -0.42, 95% CI -0.79 to -0.06), a statistically significant finding of questionable clinical importance. The clinical score outcome showed significant heterogeneity (I(2) statistic = 73%). Including only studies with low risk of bias reduced the heterogeneity but had little impact on the overall effect size of average clinical score (SMD -0.22, 95% CI -0.41 to -0.03).Sub-analyses limited to nebulized albuterol or salbutamol among outpatients (nine studies) showed no effect on oxygen saturation (MD -0.19, 95% CI -0.59 to 0.21, n = 572), average clinical score (SMD -0.36, 95% CI -0.83 to 0.11, n = 532) or hospital admission after treatment (OR 0.77, 95% CI 0.44 to 1.33, n = 404).Adverse effects included tachycardia, oxygen desaturation and tremors.

AUTHORS' CONCLUSIONS

Bronchodilators such as albuterol or salbutamol 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. Given the adverse side effects and the expense associated with these treatments, bronchodilators are not effective in the routine management of bronchiolitis. This meta-analysis continues to be limited by the small sample sizes and the lack of standardized study design and validated outcomes across the studies. Future trials with large sample sizes, standardized methodology across clinical sites and consistent assessment methods are needed to answer completely the question of efficacy.

Acute bronchiolitis

Bronchiolitis is the most common lower respiratory tract infection to affect infants and toddlers. High-risk patients include infants younger than 3 months, premature infants, children with immunodeficiency, children with underlying cardiopulmonary or neuromuscular disease, or infants prone to apnea, severe respiratory distress, and respiratory failure. Bronchiolitis is a self-limited disease in healthy infants and children. Treatment is usually symptomatic, and the goal of therapy is to maintain adequate oxygenation and hydration. Use of a high-flow nasal cannula is becoming common for children with severe bronchiolitis.

Bronchodilators for bronchiolitis

BACKGROUND

Bronchiolitis is an acute, viral lower respiratory tract infection affecting infants and often treated with bronchodilators.

OBJECTIVES

To assess the effects of bronchodilators on clinical outcomes in infants with acute bronchiolitis.

SEARCH STRATEGY

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 1) which contains the Acute Respiratory Infections Group's Specialized Register, MEDLINE (1966 to March week 2 2010) and EMBASE (2003 to March 2010).

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing bronchodilators (other than epinephrine) with placebo for bronchiolitis.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted data. Unpublished data were obtained from trial authors.

MAIN RESULTS

We included 28 trials (1912 infants) with bronchiolitis. In 10 inpatient and 10 outpatient studies, oxygen saturation did not improve with bronchodilators (mean difference (MD) -0.45, 95% confidence interval (CI) -0.96 to 0.05, n = 1182). Outpatient bronchodilator treatment did not reduce the rate of hospitalization (12% in bronchodilator group versus 16% in placebo, odds ratio (OR) 0.78, 95% CI 0.47 to 1.29, n = 650). Inpatient bronchodilator treatment did not reduce the duration of hospitalization (MD 0.06, 95% CI -0.27 to 0.39, n = 349). In seven inpatient and eight outpatient studies, average clinical score decreased slightly with bronchodilators (standardized mean difference (SMD) -0.37, 95% CI -0.62 to -0.13, n = 1006).Oximetry and clinical score outcomes showed significant heterogeneity. Including only studies at low risk of bias significantly reduced heterogeneity measures for oximetry (I(2) statistic = 17%) and average clinical score (I(2) statistic = 26%), while having little impact on the overall effect size of oximetry (MD -0.38, 95% CI -0.75 to 0.00, P = 0.05) and average clinical score (SMD -0.26, 95% CI -0.44 to -0.08, P = 0.005).Effect estimates for outpatients were slightly larger than for inpatients for oximetry (outpatients MD -0.57, 95% CI -1.13 to 0.00 versus inpatients MD -0.29, 95% CI -1.10 to 0.51) and average clinical score (outpatients SMD -0.49, 95% CI -0.86 to -0.11 versus inpatients SMD -0.20, 95% CI -0.43 to 0.03). Adverse effects included tachycardia and tremors.

AUTHORS' CONCLUSIONS

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. The small improvements in clinical scores for outpatients must be weighed against the costs and adverse effects of bronchodilators.

Chronic respiratory symptoms and diseases among indigenous children

Children from Indigenous populations experience more frequent, severe, and recurrent lower respiratory infections as infants and toddlers. The consequences of these infections are chronic lung disorders manifested by recurrent wheezing and chronic productive cough. These symptoms are aggravated more frequently by active and passive tobacco smoke exposure among Indigenous groups. Therapies for these symptoms, although not specific to children of Indigenous origins, are described as is the evidence for their use.

Asthma

Asthma has been recognized as a disease since the earliest times. In the Corpus Hippocraticum, Hippocrates used the term “ασθμα” to indicate any form of breathing difficulty manifesting itself by panting. Aretaeus of Cappadocia, a well-known Greek physician (second century A.D.), is credited with providing the first detailed description of an asthma attack [13], and to Celsus it was a disease with wheezing and noisy, violent breathing. In the history of Rome, we find many members of the Julio-Claudian family affected with probable atopic respiratory disorders: Caesar Augustus suffered from bronchoconstriction, seasonal rhinitis as well as a highly pruritic skin disease. Claudius suffered from rhinoconjunctivitis and Britannicus was allergic to horse dander [529]. Maimonides (1136–1204) warned that to neglect treatment of asthma could prove fatal, whereas until the 19th century, European scholars defined it as “nervous asthma,” a term that was given to mean a defect of conductivity of the ninth pair of cranial nerves.

Diagnosis and management of bronchiolitis

Bronchiolitis is a disorder most commonly caused in infants by viral lower respiratory tract infection. It is the most common lower respiratory infection in this age group. It is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, increased mucus production, and bronchospasm. The American Academy of Pediatrics convened a committee composed of primary care physicians and specialists in the fields of pulmonology, infectious disease, emergency medicine, epidemiology, and medical informatics. The committee partnered with the Agency for Healthcare Research and Quality and the RTI International-University of North Carolina Evidence-Based Practice Center to develop a comprehensive review of the evidence-based literature related to the diagnosis, management, and prevention of bronchiolitis. The resulting evidence report and other sources of data were used to formulate clinical practice guideline recommendations. This guideline addresses the diagnosis of bronchiolitis as well as various therapeutic interventions including bronchodilators, corticosteroids, antiviral and antibacterial agents, hydration, chest physiotherapy, and oxygen. Recommendations are made for prevention of respiratory syncytial virus infection with palivizumab and the control of nosocomial spread of infection. Decisions were made on the basis of a systematic grading of the quality of evidence and strength of recommendation. The clinical practice guideline underwent comprehensive peer review before it was approved by the American Academy of Pediatrics. This clinical practice guideline is not intended as a sole source of guidance in the management of children with bronchiolitis. Rather, it is intended to assist clinicians in decision-making. It is not intended to replace clinical judgment or establish a protocol for the care of all children with this condition. These recommendations may not provide the only appropriate approach to the management of children with bronchiolitis.

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.

The response to β-agonists in wheezy infants: three methods compared

BACKGROUND

Studies into the effects of salbutamol in the treatment of wheeze in infancy have been conflicting, possibly due to differences in outcome variables. We aimed to assess the response to salbutamol using indices derived from passive and forced expiration.

METHODS

We recruited 39 infants who had a history of wheezing (mean age 43 weeks) and measured maximum flow at functional residual capacity (V'(max FRC)) by rapid thoracoabdominal compression (RTC), and forced expired volume at 0.4s (FEV0.4) using the raised-volume RTC technique (RV-RTC). We calculated passive compliance (C(rs)), resistance (R(rs)) and time constant (tau) from relaxed expirations that followed the augmented inspirations delivered during RV-RTC. Measurements were repeated after aerosol salbutamol (800 mcg).

RESULTS

Data were obtained in 32 infants for V'(max FRC), 22 for FEV0.4 and 19 for passive mechanics. There were no mean changes in any index of forced expiration after salbutamol. Some individuals showed significant changes (improvement or worsening) in one or other index. Overall, there was a small increase in C(rs) after salbutamol but no change in R(rs) or tau.

CONCLUSIONS

We found no consistent pattern of response in either index of forced expiration. Validated clinical scores or alternative physiological techniques may be preferable to respiratory mechanics in assessing bronchodilator response.

Use of a respiratory clinical score among different providers

Respiratory assessment of children with asthma or bronchiolitis is problematic because both the components of the assessment and their relative importance vary among care providers. Use of a systematic standard assessment process and clinical score may reduce interobserver variation. Our objective was to determine observer agreement among physicians (MD), nurses (RN), and respiratory therapists (RT), using a standard respiratory clinical score. A clinical score was developed incorporating four physiologic parameters: respiratory rate, retractions, dyspnea, and auscultation. One hundred and sixty-five provider pairs (e.g., MD-MD, RN-RT) independently assessed a total of 55 patients admitted for asthma, bronchiolitis, or wheezing at an urban tertiary-care hospital. A weighted kappa statistic measured agreement beyond chance. Rater pairs had high observed agreement on total score of 82-88% and weighted kappas ranging from 0.52 (MD-RN; 95% CI, 0.19, 0.79) to 0.65 (RN-RN; 95% CI, 0.46, 0.87). Observed agreement on individual components of the score ranged from 58% (auscultation) to 74% (dyspnea), with unweighted kappas of 0.36 (respiratory rate; 95% CI, 0.26, 0.46) to 0.53 (dyspnea; 95% CI, 0.41, 0.65). In conclusion, this respiratory clinical score demonstrates good interobserver agreement between MDs, RNs, and RTs. Future research is needed to examine validity and responsiveness in clinical settings. By standardizing respiratory assessments, use of a clinical score may facilitate care coordination by physicians, nurses, and respiratory therapists and thereby improve care of children hospitalized with asthma and bronchiolitis.

Randomized controlled trial of nebulized adrenaline in acute bronchiolitis

Use of both l-epinephrine and racemic epinephrine (adrenaline) has improved clinical symptoms and composite respiratory scores in acute bronchiolitis. The objective of this randomized double-blind placebo-controlled study was to assess whether there was sufficient improvement in clinical state to reduce hospital admissions. Seventy-five infants aged 1 month to 1 year with a clinical diagnosis of acute bronchiolitis were treated with either 2 ml of 1:1000 nebulized adrenaline or 2 ml of nebulized normal saline administered after baseline assessment and 30 min later. Clinical respiratory parameters were recorded at 15-min intervals for a period of 2 h following the baseline assessment. Admission to hospital was the primary end-point and changes in respiratory parameters were secondary end-points. Fifty percent (19/38) of infants treated with adrenaline were discharged home compared with 38 percent (14/37) of those treated with saline. This 12 percent reduction in rate of admission is not statistically significant (95% CI of difference: -10% to 35%). There was no difference between treated and placebo groups in respiratory rate, oxygen saturation, heart rate or a composite respiratory distress score at 30, 60 or 120 min post-treatment. In this study, nebulized epinephrine did not confer a significant advantage over nebulized saline in the emergency room treatment of acute bronchiolitis.

Beclomethasone dipropionate and salbutamol by metered dose inhaler in infants and small children with recurrent wheezing

The efficacy of beclomethasone dipropionate (BDP) to control respiratory symptoms was evaluated in 31 children under age 2 years with recurrent wheezing. The study was conducted in a double-blind, parallel, and placebo-controlled fashion. The two study groups received either salbutamol plus BDP 200 microg bid by metered dose inhaler (MDI) with a spacer, or salbutamol MDI plus a placebo. Inhaled corticosteroid (IC) and placebo were administered for 8 weeks. Patients were seen every 2 weeks as outpatients, and their progress was evaluated by clinical examination and a daily symptom score card. At the end of the study, patients in both groups had significantly decreased symptoms. No significant difference was found between BDP and placebo groups regarding clinical score, number of salbutamol doses, sleep disturbances, number of symptom-free days, feelings of insecurity of mothers regarding the infants' life due to wheezing, and mothers' perceptions of progress in their infants' respiratory symptoms. We conclude that salbutamol plus 200 microg bid of BDP inhaled from an MDI with a spacer for 8 weeks is no better than salbutamol alone for decreasing recurrent wheezing in small children under age 24 months.

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.

Short acting beta agonists for recurrent wheeze in children under 2 years of age

BACKGROUND

Wheeze is a common symptom in infancy and is a common cause for both primary care consultations and hospital admission. Beta2-adrenoceptor agonists (b2-agonists) are the most frequently used as bronchodilator but their efficacy is questionable.

OBJECTIVES

To determine the effectiveness of b2-agonist for the treatment of infants with recurrent and persistent wheeze.

SEARCH STRATEGY

Relevant trials were identified using the Cochrane Airways Group database (CENTRAL), Medline and Pubmed. The database search used the following terms: Wheeze or asthma and Infant or Child and Short acting beta-agonist or Salbutamol (variants), Albuterol, Terbutaline (variants), Orciprenaline, Fenoterol

SELECTION CRITERIA

Randomised controlled trials comparing the effect of b2-agonist against placebo in children under 2 years of age who had had two or more previous episodes of wheeze, not related to another form of chronic lung disease.

DATA COLLECTION AND ANALYSIS

Eight studies met the criteria for inclusion in this meta-analysis. The studies investigated patients in three settings: at home (3 studies), in hospital (2 studies) and in the pulmonary function laboratory (3 studies). The main outcome measure was change in respiratory rate except for community based studies where symptom scores were used.

MAIN RESULTS

The studies were markedly heterogeneous and between study comparisons were limited. Improvement in respiratory rate, symptom score and oxygen saturation were noted in one study in the emergency department following two salbutamol nebulisers but this had no impact on hospital admission. There was a reduction in bronchial reactivity following salbutamol. There was no significant benefit from taking regular inhaled salbutamol on symptom scores recorded at home.

REVIEWER'S CONCLUSIONS

There is no clear benefit of using b2-agonists in the management of recurrent wheeze in the first two years of life although there is conflicting evidence. At present, further studies should only be performed if the patient group can be clearly defined and there is a suitable outcome parameter capable of measuring a response.

Prednisolone plus albuterol versus albuterol alone in mild to moderate bronchiolitis

To evaluate combination therapy of mild to moderate bronchiolitis with bronchiodilators and corticosteroids, we treated 51 young children with first-time wheezing and symptoms of respiratory tract infection with albuterol plus either prednisolone or placebo for 5 days. Disease severity was scored on days 0, 2, 3, and 6. On day 2, prednisolone resulted in significantly lower scores (2.7 +/- 1.4 vs. 4.0 +/- 1.5 in all patients evaluated, p < 0.05) than placebo, whereas there was no detectable difference on day 6, suggesting that addition of prednisolone to albuterol transiently accelerates recovery from bronchiolitis. The clinical significance of this effect needs to be evaluated in further studies.

Inhaled steroids for episodic viral wheeze of childhood

BACKGROUND

Recurrent episodic wheeze in association with viral upper respiratory tract infection (URTI) is a specific clinical illness distinct from persistent atopic asthma.

OBJECTIVES

The objective of this review was to identify whether corticosteroid treatment, given episodically or daily, is beneficial to children with viral episodic wheeze.

SEARCH STRATEGY

We searched the Cochrane Airways Group trials register and reference lists of articles.

SELECTION CRITERIA

Randomised controlled trials (RCTs) of corticosteroid treatment versus placebo in children under 17 years of age who suffer from 'episodic viral wheeze', which is defined by wheeze in association with coryzal symptoms with minimal or no intercurrent lower respiratory tract symptoms.

DATA COLLECTION AND ANALYSIS

Trial quality was assessed independently by two reviewers. Study authors were contacted for missing information. Studies were categorised according to whether treatment was given episodically or daily (maintenance). The primary outcome was episodes requiring oral corticosteroids. Secondary outcomes addressed episode severity, frequency and duration and parental treatment preference.

MAIN RESULTS

Five randomised controlled trials in children with a history of mild episodic viral wheeze were identified. Most of the children had previously required no or infrequent oral corticosteroids and had very infrequent hospital admissions. There were three studies of preschool children given episodic high dose inhaled corticosteroid (1.6 - 2.25 mg per day), two using a crossover and one a parallel design. The two studies of maintenance corticosteroid (400 micrograms per day) were parallel in design, one of pre-school children the other of children aged 7 -9 years. Results from the two cross-over studies of episodic high dose inhaled corticosteroids showed a reduced requirement for oral corticosteroids (Relative risk (RR)=0.53, 95% CI: 0.27, 1.04). In these 2 double blind studies, this treatment was preferred by the children's parents over placebo (RR=0.64, 95% CI: 0.48,0.87). Maintenance low dose inhaled corticosteroids did not show any clear reduction over placebo in the proportion of episodes requiring oral corticosteroids (N=2 trials, RR=0.82, 95%CI: 0.23,2.90) or in those requiring hospital admission (N=1 trial, RR=0.21, 95% CI: 0.01,4.11).

REVIEWER'S CONCLUSIONS

Episodic high dose inhaled corticosteroids provide a partially effective strategy for the treatment of mild episodic viral wheeze of childhood. There is no current evidence to favour maintenance low dose inhaled corticosteroids in the prevention and management of episodic mild viral induced wheeze.

Bronchodilators for bronchiolitis

OBJECTIVES

Bronchiolitis is an acute, highly communicable lower respiratory tract infection. Bronchodilators are commonly used in the management of bronchiolitis in North America, but not in the United Kingdom. The objective of this review was to assess the effects of bronchodilators for bronchiolitis.

SEARCH STRATEGY

We searched MEDLINE, EMBASE, Reference Update, reference lists of articles, and the files of two of the authors up to June 1998.

SELECTION CRITERIA

Randomised trials comparing bronchodilators with placebo in the treatment of bronchiolitis.

DATA COLLECTION AND ANALYSIS

Two reviewers independently assessed trial quality and extracted data. Unpublished data were requested from authors when necessary.

MAIN RESULTS

In eight trials with 394 children, 46% demonstrated an improved clinical score with bronchodilators compared to 75% with placebo (odds ratio for no improvement 0.29, 95% confidence interval 0.19 to 0.45). However, the inclusion of studies that enrolled people with recurrent wheezes may have biased these results in favour of bronchodilators. Bronchodilator recipients did not show improvement in measures of oxygenation, the rate of hospitalisation (18% versus 26%, odds ratio 0.70, 95% confidence interval 0.36 to 1.35) or duration of hospitalisation (weighted mean difference 0.12, 95% confidence interval -0.3 to 0.5).

REVIEWER'S CONCLUSIONS

Bronchodilators produce modest short-term improvement in clinical scores. This small benefit must be weighed against the costs of these agents.

Efficacy of bronchodilators administered by nebulizers versus spacer devices in infants with acute wheezing

The aim of this study was to compare the response of infants with acute wheezing to treatments with inhaled terbutaline when administered by nebulizer or by metered-dose inhaler and spacer device (MDI-spacer). Thirty-four infants between the ages of 1 and 24 months who were seen in our emergency department for acute wheezing were studied in a double-blind, randomized trial. The participants received two treatments of terbutaline at 20-min intervals, either by a nebulizer (2 mg/dose in 2.8 mL of 0.9% saline solution) or by an MDI-spacer device (0.5 mg/dose). The outcome measure was a clinical score, based on respiratory rate, degree of wheezing, retractions, degree of cyanosis, color, and pulse oximetry data measured before treatment, 20 min after the first treatment, and again 20 min after the second treatment. There was no difference in the rate of improvement in the clinical score between infants who received terbutaline by nebulizer and those who received it by MDI-spacer. We conclude that MDI-spacers and nebulizers are equally effective means of delivering beta-2 agonists to infants and small children with acute wheezing.

Bronchodilator responsiveness testing using raised volume forced expiration in recurrently wheezing infants

We hypothesized that a new test of infant lung function, less affected by shifts in lung volume, might better detect bronchodilator effects. Using the raised volume forced expiration technique (RVFET), the effect of a bronchodilator on lung function was studied in 22 infants with a history of recurrent wheeze and five healthy infants. Forced expiratory volume in 0.75 s (FEV0.75), forced expiratory vital capacity (FVC), and forced expiratory flow at 75% of FVC (FEF75%) were measured by forcing expiration, using an inflatable jacket from a lung volume set by an inspiratory pressure of 20 cm H2O. A minimum of five measurements were made at baseline and following the administration of 500 microg of salbutamol from a metered dose inhaler via a small volume metal spacer. Changes in lung function in the group of 25 infants who received salbutamol were compared to seven infants who received placebo aerosol. No significant changes occurred in measures of lung function following salbutamol administration when compared to baseline or placebo despite a significant increase in heart rate. A shift in lung volume is unlikely the reason why infants do not demonstrate a change in forced expiration following bronchodilator administration.

Using low-frequency oscillation to detect bronchodilator responsiveness in infants

The potential of the low-frequency forced oscillation technique (FOT) to measure the response to inhaled salbutamol was studied in 13 infants with a history of recurrent wheeze and nine healthy infants. The input impedance of the respiratory system (Zrs) between 0.5 and 20 Hz was measured at a transrespiratory pressure of 20 cm H2O during a brief Hering-Breuer reflex-induced pause in breathing. Parameters representing the airway resistance (Raw) and inertance (law), and a constant-phase tissue damping (G) and elastance (H) were estimated from the Zrs spectra. Lung function was measured before and after the administration of 500 microg of salbutamol via a small-volume metal spacer. Six of these infants also received a placebo aerosol. A fall in Raw (13% for the entire group) occurred following treatment with salbutamol (p < 0.008) but not placebo. There was no significant difference in the response to salbutamol between the normal infants (7.65% +/- 5.49%) and those with recurrent wheeze (17.58% +/- 8.67%). On grouped data, the fall in G just failed to reach statistical significance (p = 0.05) after correcting the significance level for multiple tests. No significant change occurred in law or H. We conclude that the low-frequency FOT is a suitable methodology for studying bronchodilator responsiveness in infants.

Development of a clinical asthma score for use in hospitalized children between 1 and 5 years of age

The objective of this study was to develop a clinical asthma score (CAS) for use in hospitalized children between 1 and 5 years of age. Formal approaches to item selection and reduction, reliability, discriminatory power, validity, and responsiveness were used. The final CAS consisted of five clinical characteristics: respiratory rate, wheezing, indrawing, observed dyspnea, and inspiratory-to-expiratory ratio. Interrater reliability was high (weighted kappa = 0.82), and the CAS was discriminatory (Ferguson's delta = 0.92). The CAS was valid, with a strong correlation with length of hospital stay (Spearman's correlation = 0.47, p < 0.05) and drug dosing interval (Spearman's correlation = -0.58, p < 0.01). The CAS was responsive, with a significant change in CAS from admission to discharge (Wilcoxon signed rank test, p < 0.01). This score, for use in hospitalized preschool children, is reliable, discriminatory, valid, and responsive.

Treatment of recurrent acute wheezing episodes in infancy with oral salbutamol and prednisolone

The aim of this study was to investigate the role of oral salbutamol and prednisolone in the treatment of acute episodes of wheezing in infants under 15 months of age. Sixty-two acute episodes of wheezing were studied in 59 babies (age range 3-14 months; mean 7 months), who had all suffered at least one previous wheezy episode. Patients were randomised to receive either salbutamol and prednisolone, salbutamol and placebo or double placebo. Parents were requested to keep a diary card record of twice daily scoring of their baby's symptoms over the next 14 days. A significantly greater number of treatment failures occurred in the placebo group compared to babies treated with oral salbutamol (relative risk 2.51; 95% confidence intervals for relative risk 1.09-5.79). There was no difference in the number of treatment failures between babies treated with a combination of salbutamol and placebo and those treated with salbutamol and prednisolone (relative risk 0.71; 95% confidence intervals for relative risk 0.18-2.80).

CONCLUSION

This study demonstrates that oral salbutamol is beneficial in the treatment of acute episodes of wheezing in infancy. A combination of oral salbutamol and oral prednisolone appeared to have no additional benefit over treatment with oral salbutamol alone.

Nebulized flunisolide in infants and young children with asthma: a pilot study

The role of nebulized flunisolide solution in controlling recurrent respiratory symptoms was assessed in a double-blind placebo-controlled parallel study on 23 infants and small children (mean age, 14.2 months) with bronchial asthma. Five of the 12 children in the placebo group and 1 of the 11 patients on active treatment had to be withdrawn from the study. Flunisolide significantly improved symptom scores of wheezing and cough. The rescue treatments with salbutamol did not differ between the two groups during the study. Parents considered the active treatment effective in all the patients, while the placebo was considered useful in 4 of 7 children. No side effects were detected with either treatments. This study indicates that nebulized flunisolide may be an effective treatment for infants with recurrent wheezing and cough.

Aerosol deposition in infants with cystic fibrosis

Twenty asymptomatic infants with cystic fibrosis (CF) were studied to determine the amount of radiolabeled aerosol [99m technetium diethylenetriamine penta acetic acid (Tc99m DTPA)] deposited in the respiratory system and its distribution. Aerosols were generated by jet nebulization systems that were used in the wards and the laboratory. Subjects were studied in three groups: group A (n = 10) was sedated with chloral hydrate; children inhaled an aerosol of 7.7 microns mass median diameter (MMD); group B (n = 5) was not sedated, using the same nebulization system (same aerosol particle size as group A); and group C (n = 5) was not sedated; these children inhaled an aerosol with an MMD of 3.6 microns. Normal saline plus 4 mCi of Tc99m bound to DTPA was added to each nebulizer. A closed system was used to collect the expired aerosol. Radioactivity in each infant and in the equipment was measured with a gamma camera on completion of nebulization. In groups A and B, the percentages of the total dose deposited in the lung were 0.97 +/- 0.35% and 0.76 +/- 0.36%, respectively. In group C, 2.0 +/- 0.71% was deposited in the lung (P < 0.01). Deposition in the nose, mouth, and pharynx was least in group C (P < 0.01). In groups A and B, the intrathoracic deposition occurred predominantly in the trachea and main bronchi, whereas in group C, significantly more aerosol was deposited in the lung region. There was marked inter-subject variability in the percentage of aerosol deposition within the three groups. There was no correlation between percentage of aerosol deposited in the respiratory system and age, height, or weight. Sedation did not have a significant effect on deposition of aerosol in infants. This study indicates that only a small proportion of nebulized solution is deposited in the lungs of infants and that this proportion is influenced by the particle size of the aerosol. The smaller particle size (3.6 microns MMD) was deposited in the lung better than large particles.

[Treatment of acute bronchiolitis in infants. Role of bronchodilators and steroids]

The management of infant bronchiolitis with bronchodilators and steroids is controversial. A literature review on this topic allows to determine the influence of these medications on the first episode of viral bronchiolitis. The effect of alpha and beta adrenergic drugs is undoubtful but it is not possible to anticipate a positive or negative response based on the age of the child nor on a family history of atopic disease. Systemic steroid therapy has no immediate effect but inhaled steroids may be tried during the recovery period to reduce short term morbidity.

[Comparative study of nebulized sambutol against placebo in the acute phase of bronchiolitis in 33 infants aged 1 to 6 months]

BACKGROUND

The therapeutic role of bronchodilators in bronchiolitis remains controversial. The aim of this study is to evaluate the safety and the clinical response to nebulized salbutamol in infants with mild acute bronchiolitis.

PATIENTS AND METHODS

Thirty-three infants, aged 1 month to 5 months and 22 days (mean: 92.4 days) were included in the study. Patients received either nebulized salbutamol (0.15 mg/kg per dose: 16 infants) or a placebo (normal saline aerosol: 17 infants), delivered by an oxygen propellent, three times at intervals of 1 hour, as part of a double-blind randomized trial. Effect of treatment was evaluated by measuring respiratory and heart rate, clinical scores based on the degree of retraction and wheezing, and oxygen saturation. Clinical assessment was repeated 30 minutes after each nebulization. A nasopharyngeal swab was obtained for detection of respiratory syncytial virus (VRS) antigens by immunofluorescence assay in all patients.

RESULTS

Patients in the salbutamol group exhibited significantly greater improvement in respiratory rate (P = 0.01), accessory muscle score (P < 0.001) and wheezing score (P < 0.001). There was no significant difference in oxygen saturation between both groups. Infants treated with salbutamol exhibited a non-significant increase in heart rate after the three sprays; no other adverse effects were noted. VRS was identified in 78% of the children tested.

CONCLUSIONS

Salbutamol is safe and effective in relieving the respiratory distress of young infants with acute bronchiolitis. Our study confirms previous observations that infants younger than six months of age respond as well as older children when given three doses of nebulized salbutamol. Responders could not be differentiated from non responders by personal or family histories of atopy and VRS isolation. A longitudinal study could establish a correlation between response to bronchodilator therapy and later development of asthma.

Viral respiratory infections

Viral infections constitute more than 60% of acute lower respiratory illnesses. Respiratory syncytial virus (RSV) and parainfluenza viruses are the most frequent etiologic agents. After transmission by large droplet aerosol or direct contact, the viruses gain entry into host cells through specific viral surface proteins; subsequently, pathogenetic mechanisms cause tissue injury and result in clinical disease. In the intensive care unit the mainstay of treatment is primarily supportive. Nonspecific treatment may include nebulized beta-agonists, aminophylline, and steroids. Ribavarin is the only specific antiviral agent approved for respiratory syncytial virus infection but its efficacy remains controversial. New therapies and vaccines offer hope for improved outcome from viral respiratory infections such as RSV.

Clinical scores for acute asthma in pre-school children. A review of the literature

The objective of this paper was to evaluate the applicability in research and clinical practice of clinical scores for acute asthma in pre-school children. All instruments were reviewed according to a standardized set of criteria: purpose of the score, suitability for use in children, inter-observer agreement, validity and responsiveness. A Medline literature research resulted in 16 different clinical asthma scores, which have been developed to assess the severity of acute asthma, to predict the outcome of an attack, or to evaluate the response to treatment. Most asthma scores could be easily obtained in children. Three scores have been modified to facilitate application in a younger age-category. Inter-observer agreement has received little attention, although all scores contained items that require subjective judgement. The predictive validity was insufficient to justify the application of clinical scores as a decision rule for the admission or discharge of children with acute asthma. Asthma scores seem to be useful for assessing the severity of an attack and evaluating the response to therapy, but as yet there is insufficient information on the performance of the scores to justify a preference. Wheezing and retractions appear to be important items of any useful score for acute asthma.

A comparison between nebulized terbutaline, nebulized corticosteroid and systemic corticosteroid for acute wheezing in children up to 18 months of age

One hundred and twenty-three children, aged 1.5-18 months, participated in a randomized, double-blind, placebo-controlled multicentre study comparing different treatments for acute wheezing. The children were admitted to one of five participating paediatric departments. They were randomized into one of four treatment groups: (1) soluble prednisolone+placebo inhalation+terbutaline inhalation; (2) soluble placebo+budesonide inhalation+terbutaline inhalation; (3) soluble placebo+placebo inhalation+terbutaline inhalation; and (4) soluble placebo+placebo inhalation+normal saline inhalation. On admission, measurements of temperatures, respiratory rate and heart rate were made and once-a-day thereafter. Wheezing, accessory respiratory muscle use, prolonged expiration and general condition were scored on a scale ranging from 0 to 3. Significantly more treatment failures were recorded in the placebo group. Children from both steroid groups were discharged earlier than children from the terbutaline group. Compared with children from the placebo group, children from all three treatment groups had a greater improvement in symptom score, but this was significant for the budesonide group only.

The effect of age on bronchodilator responsiveness

The relationship between age and bronchodilator responsiveness (BDR) in children has not been studied using objective parameters. The aim of this study was to seek such a relationship in young asthmatic children using dose-response curves (DRC). Fourteen asthmatic subjects (age 3-9 years) with a forced expiratory volume in 1 sec (FEV1) less than 80% predicted were studied after being trained to use a spirometer reliably. Each subject completed a DRC by inhaling 5 doses of salbutamol (albuterol) at 15 min intervals until a cumulative total of 6.84 mg of salbutamol had been administered. FEV1, forced vital capacity (FVC), and forced expiratory flow at mid vital capacity (FEF25-75) were measured before and after each nebulization. In addition, arterial oxygen saturation (SaO2) and heart rate (HR) were measured in some of the subjects. All lung function parameters, SaO2 and HR increased significantly between baseline and completion of the DRC. A significant age effect on BDR was detected in FEV1 and FVC, with older children showing a greater response than young ones. The response had plateaued after the maximum dose in the younger but not in the older children. These findings suggest that the level of response to a bronchodilator increases significantly with increasing age in young asthmatics.

Effect of racemic epinephrine and salbutamol on clinical score and pulmonary mechanics in infants with bronchiolitis

To test the efficacy of a combined alpha- and beta-receptor agonist in acute bronchiolitis, we compared inhaled racemic epinephrine with salbutamol in a double-blind, crossover, randomized protocol. Twenty-four infants, 4.6 +/- 0.5 (mean +/- SEM) months of age, with their first episode of bronchiolitis were tested. After sedation with chloral hydrate, a clinical score and pulmonary mechanics measurements using simultaneous signals of airflow volume and transpulmonary pressure were recorded. After baseline measurements, infants received either nebulized salbutamol, 0.03 ml/kg, or racemic epinephrine, 0.1 ml/kg. Thirty minutes later, there was a significant decrease in clinical score after treatment with racemic epinephrine compared with the baseline score (p < 0.001); this difference was not present after salbutamol inhalation (p = 0.42). Only 13 patients had a decrease in clinical score after salbutamol therapy, in comparison with 20 infants treated with racemic epinephrine (p < 0.01). Both drug decreased respiratory rate, but the decrease was greater after the use of racemic epinephrine (p < 0.001). There was a significant decrease in inspiratory, expiratory, and total pulmonary resistance after treatment with racemic epinephrine compared with baseline values (p < 0.01) but no significant change after salbutamol inhalation. There was no significant correlation between the clinical score and pulmonary mechanics either at baseline or after drug treatment. We conclude that racemic epinephrine is superior to salbutamol in the treatment of infants with their first episode of acute bronchiolitis.

Transcutaneous blood gas monitoring during salbutamol inhalations in young children with acute asthmatic symptoms

The effect of salbutamol inhalations on transcutaneous blood gases was investigated in 23 children (aged 11 months-2.5 years) with asthmatic symptoms. After one salbutamol inhalation there was a mean increase in transcutaneous PO2 (tcPO2) of 0.5 kPa (P less than 0.01); after a second dose given 30 minutes later, the mean increase was 1.2 kPa (P less than 0.001). The increase in tcPO2 after only one dose of salbutamol was significantly correlated to age (P less than 0.01). No such correlation was observed after a second dose. The overall increase in tcPO2 after two salbutamol inhalations showed a negative correlation to the duration of the current symptomatic period (P less than 0.05). We conclude that salbutamol inhalations have beneficial effects in young children with acute asthmatic symptoms, even below the age of 18 months, provided that an adequate dose reaches the lung and preferably at an early stage of obstruction.

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.

Randomized trial of salbutamol in acute bronchiolitis

To test whether nebulized salbutamol (albuterol) is safe and efficacious for the treatment of young children with acute bronchiolitis, we enrolled 83 children (median age 6 months, range 1 to 21 months) in a randomized, double-blind clinical trial. Participants received two treatments at 30-minute intervals of either nebulized salbutamol (0.10 mg/kg in 2 ml 0.9% saline solution) or a similar volume of 0.9% saline solution placebo. Outcome measures were the respiratory rate, pulse oximetry, and a clinical score based on the degree of wheezing and retractions. Patients in the salbutamol arm had significantly greater improvement in clinical scores after the initial treatment (p = 0.04). There was no difference between the groups in oxygen saturation (p = 0.74); patients treated with salbutamol had a small increase in heart rate after two treatments (159 +/- 16 vs 151 +/- 16; p = 0.03). We conclude that salbutamol is safe and effective for the initial treatment of young children with acute bronchiolitis.

Do wheezy infants recovering from bronchiolitis respond to inhaled salbutamol?

Wheezy infants, less than 6 months of age, were given either inhaled salbutamol or saline in a double-blind study. A significant change in maximal flow at functional residual capacity (VmaxFRC) was defined as being greater than twice the coefficient of variation of the baseline measurements. There was no difference in the infants' response to saline or salbutamol. Wheezy infants, less than 6 months of age, do not have an increase in VmaxFRC following a single dose of inhaled salbutamol.

Acute viral bronchiolitis in infancy: epidemiology and management

Acute bronchiolitis due to viral agents (RSV, parainfluenza, influenza, adenovirus) is a relatively frequent disease of infancy. Seasonal epidemic pattern have been recognized, and nosocomial infections in pediatric wards occur. Until age 2 years most children have experienced some form of airway disease attributable to RSV. Some patients require hospital treatment; about 15% of our patients had to be transferred to the intensive care unit. Bronchiolitis seems to be frequently the first manifestation of asthma and we found higher IgG antibody titers to viruses causing bronchiolitis in children with asthma than in controls. Retrospective analysis of the charts of 147 cases of bronchiolitis revealed considerable uncertainty regarding therapeutic concepts. Mainstays of conservative therapy include oxygen, adequate hydration (often IV), and sometimes bronchodilators (based on the clinical impression of effectiveness in the individual patient). Mist therapy and secretolytic agents remain popular, although no clinical effect has been demonstrated. Attention should be directed toward the relief of upper airway obstruction caused by swelling, secretions, and nasogastric tubes. Oxygen administration in infants with coexisting chronic airway disease (e.g., BPD) and bronchiolitis may cause CO2 retention. Bronchodilators can cause hypoxia and increase bronchial compressibility by reducing smooth muscle tone. However, in severe cases a trial under pulse oximetry control seems worthwhile. Steroids seem to bring no clinical improvement, except in infants with protracted wheezing after bronchiolitis and patients with preexisting BPD.