The winter in Australia is at an end, which means we hope we have seen the last of those wheezy, crackly, sick looking babies for the moment. Bronchiolitis is the bread and butter of a lot of Paeds wards and EDs over the winter, we all know how to diagnose it and what the normal course is. But I think we are mostly treatment nihlists. My teaching to the JMOS and students has always been simple – keep them in if they are small, sick or have unreliable carers; keep them hydrated; and give ’em oxygen to relieve their dyspnoea and try to normalise hypoxia. However – I fear I am a bit outdated – maybe too simple…
There have been a heap of trials and reviews in the last 5 years looking at what might work in bronchiolitis – and what doesn’t. So I thought I would do a quick review of the literature and find out the evidence circa 2011….
So what works?
Inhaled bronchodilators
Nope. Cochrane review basically showed no consistent benefit in important outcomes – admission, length of stay.. There was a possible mild improvement in clinical severity scores in children treated as outpatients in some studies – not sure how this translates into practice. There is a risk:benefit[side effect vs. mild improvement with B2agonists] trade-off, so bronchodilators are at best unhelpful on balance.
Nebulised hypertonic saline
Yes, it does according to recent studies and the
Cochrane analysis of the studies which all agree – it works. If you would like a well thought out and detailed review of the literature – go to WA’s own
EMPEM website and listen to Colin Parker (
no relation) and his team go over the numbers. In practice this is an inpatient intervention, though you could use it in the ED. The studies showed a decrease in the length of admission as the main outcome of benefit. Check out
the NNT review on the topic for more info
For me this is the big new thing in bronchiolitis – so cheap and easy, the evidence looks good and I think this is practice changing for our hospital – any comments?
Inhaled adrenaline
HArd to say, the
NEJM published this study in 2009 looking at inhaled adrenaline and high doses of Dexamethasone orally – the jury is still out. I have heard a number of doctors interpret this study in a number of ways – it looks promising, but then the fine print taketh away. The dose of dex was 1mg/kg (big), and the use of inhaled adrenaline is not always a fun intervention – so big guns were used and the benefits were mild if there. Don’t tink this is going to change my practice. If used – I think it is in the ED, the goal being to prevent admission – I cannot imagine the ward staff being happy to do this outside of a well monitored bed.
Antibiotics
Well – not a lot of data. Only
one true RCT to look at it. In my experience a lot of kids get them – but no good improvement. So – no, I never have used them in the straight bronchiolitic, and I still won’t.
CPAP
Well – not a lot to go on – it did improve PaCO2 in
this study, but not really a patient oriented-outcome sort of way. This seems to be the cool new thing for the little ones with bad bronchiolitis. I have little experience with it, so we will see…
Montelukast (leukotriene receptor antagonist)
Steroids
Well – we saw the mixed results from the dex/adrenaline trial out of NEJM in 2009. Was there any other evidence for roids? The
Cochrane group looked at the big trails and found no benefit.
So those are the interventions we as Docs have looked at and tried. Traditionally there are few interventions that help other than a tincture of time and watchful waiting. My review has shown me one possible addition to the armament – super salty nebs seem to be helpful.
Anyone out there got any other tricks they use in the bronchiolitics?
Casey
About The Author
Casey Parker
I am a GP working in Broome, NW of Western Australia. I work as a hospital DMO (District Med Officer) doing Emergency, Anaesthestics, some Obstetrics and a lot of miscellaneous primary care. Also on the web as @broomedocs | + Casey Parker | Contact
We found a few benefits. In a systematic review, there was an NNT of 15 for admission for inhaled adrenaline/epi and agree, hypertonic saline probably decreases hospital stay by a day.