The treatment of bronchiolitis.
ABSTRACT Bronchiolitis is the commonest reason for hospital admission in infancy and the most frequent cause of acute respiratory failure in children admitted to paediatric intensive care units in the UK and North America. The respiratory syncytial virus accounts for most cases of bronchiolitis, however, new virus isolation techniques have led to the discovery of previously unrecognised viruses, including the human metapneumovirus and bocavirus which also play a significant role. The main developments in bronchiolitis management in recent years relate to the use of immunoprophylaxis; a number of other therapies such as the use of heliox are currently being investigated. Supportive therapy remains the mainstay of management with limited or no evidence of benefit for most other pharmacological treatments. This article summarises the current understanding of the different bronchiolitis phenotypes, with a brief description of outcomes and a review of the evidence for the various therapeutic interventions.
Article: The Cochrane Library and the Treatment of Bronchiolitis in Children: An Overview of Reviews[show abstract] [hide abstract]
ABSTRACT: BackgroundBronchiolitis describes a viral inflammation of the bronchioles in the lower respiratory tract that is typically caused by infection with respiratory syncytial virus (RSV). Bronchiolitis is characterized by high morbidity and affects approximately one in three infants. Children are currently treated with a variety of therapies that may be ineffective or even harmful; potential therapies include antibiotics, bronchodilators, chest physiotherapy, epinephrine, extrathoracic pressure, glucocorticoids, heliox, hypertonic saline, immunoglobulin, inhaled corticosteroids and oxygen therapy.ObjectivesThis updated overview of reviews aims to synthesize evidence from the Cochrane Database of Systematic Reviews (CDSR) on the effectiveness and safety of 11 pharmacologic and non-pharmacologic treatments to improve bronchiolitis symptoms in outpatient, inpatient and intensive care populations.MethodsThe CDSR was searched using the term ‘bronchiolitis’ restricted to the title, abstract or keywords for all systematic reviews examining pharmacologic or non-pharmacologic interventions for the treatment of bronchiolitis in infants and children. Data were extracted, complied into tables, and synthesized using qualitative and quantitative methods.Main ResultsFor outpatients with bronchiolitis (defined as the first episode of wheezing in children under two), nebulized epinephrine decreased hospitalization rate on day one by 33% (RR: 0.67; 95% CI: 0.50, 0.89; 4 trials; 920 participants). With the addition of glucocorticoids, there was a reduction of similar magnitude for hospitalization rate within seven days (RR: 0.65; 95% CI: 0.44, 0.95; 1 trial; 400 participants). For inpatients, nebulized epinephrine versus bronchodilator and 3% hypertonic saline versus 0.9% saline each decreased length of stay: epinephrine decreased length of stay by seven hours (MD: − 0.28; 95% CI: − 0.46, − 0.09; 4 trials; 261 participants), and 3% hypertonic saline decreased length of stay by 28 hours (MD: − 1.16; 95% CI: − 1.55, − 0.77; 4 trials; 282 participants).Outpatients treated with epinephrine or epinephrine and glucocorticoid combined both had significantly lower clinical scores at 60 minutes (SMD: − 0.45; 95% CI: − 0.66, − 0.23; 4 trials; 900 participants, and SMD: − 0.34; 95% CI: − 0.54, − 0.14; 1 trial; 399 participants). For inpatients, epinephrine versus bronchodilator led to a significantly lower clinical score at both 60 minutes (SMD: − 0.79; 95% CI: − 1.45, − 0.13; 4 trials; 248 participants; I2: 79%) and 120 minutes (SMD: − 0.52; 95% CI: − 0.86, − 0.18; 1 trial; 140 participants). Inpatients treated with chest physiotherapy or 3% hypertonic saline both had significantly lower clinical scores at 1–3 days (SMD: − 0.55; 95% CI: − 0.98, − 0.12; 1 trial; 87 participants, and SMD: − 0.84; 95% CI: − 1.39, − 0.30; 3 trials; 183 participants).Authors' ConclusionsFor outpatients with bronchiolitis, nebulized epinephrine can be effective in avoiding hospitalization. Systemic glucocorticoids such as dexamethasone cannot be recommended as a routine therapy given the current level of evidence and potential for adverse events. For inpatients, regular nebulized hypertonic saline (3%) driven using oxygen may reduce the length of hospital stay. Chest physiotherapy, nebulized epinephrine and systemic and inhaled glucocorticoids cannot be recommended for inpatients given the weak level of evidence. For the sickest of patients in the intensive care unit, intravenous immunoglobulin, helium-oxygen mixtures (heliox) and extrathoracic pressure cannot be recommended due to lack of available evidence and/or methodological flaws of reviews. Copyright © 2011 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd. The Cochrane CollaborationEvidence-Based Child Health: A Cochrane Review Journal. 6(1):258-275.