Bronchiolitis Medication

  • Author: John Udeani, MD, FAAEM; Chief Editor: Zab Mosenifar, MD   more...
 
Updated: Jun 9, 2011
 

Medication Summary

Treatment is mainly supportive and should consist of supplemental humidified oxygen, fluids, and optional bronchodilator therapy. The most important therapy is humidified oxygen.

Medications have a limited role in the management of bronchiolitis. Several drugs are commonly used, but little or inconclusive evidence supports the routine use of any drug in the management of bronchiolitis. For example, Amirav et al reported in 2008 on a randomized, double-blind, placebo-controlled trial that indicated montelukast did not improve the clinical course of acute bronchiolitis; when given early in the acute phase, montelukast had no significant effect on the TH1/TH2 ratio.[19]

Some patients have abnormal changes on their chest radiographs. Ascribing the abnormality to a bacterial or viral infection should be based on factors pertinent to each patient.

In patients who are febrile, have bronchiolitis, and are at high risk, including those with nosocomial RSV infection or who appear toxic at presentation, the rate of secondary bacterial infection is increased but small. The decision to start antibiotics should be individualized.

Older studies of nebulized epinephrine had indicated superior benefit in comparison with the beta-agonist albuterol (Salbutamol). Menon et al[20] showed that infants treated with nebulized epinephrine in the emergency department have a lower hospitalization rate than those treated with albuterol (Salbutamol). A study that measured combined pulmonary and upper airway resistance in infants with bronchiolitis reported that resistance was reduced with epinephrine in comparison to albuterol (Salbutamol). This improvement in resistance may be related to the effects of epinephrine on the upper airway because some infants with bronchiolitis have nasal coryza and edema. When used in patients with bronchiolitis who required mechanical ventilation, improvement in respiratory system resistance was still demonstrable, but without any improvement of oxygenation or ventilation indices. However, several of these studies involved only a small number of patients.

More recently, a large multicenter, randomized, double-blinded, placebo-controlled study[21] of hospitalized infants demonstrated no benefit of nebulized epinephrine regarding length of hospital stay, time until ready for discharge, or other secondary endpoints. Based on the findings of this study, the routine use of nebulized epinephrine cannot be recommended for patients with acute bronchiolitis.

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Bronchodilators

Class Summary

This is one of the most commonly used therapies. Studies have reported that the use of bronchodilators varies from approximately 50% to more than 90%. Most controlled studies have failed to show a benefit in terms of oxygen saturation, rate of hospitalization, or length of hospital stay, but some studies have demonstrated an improvement in short-term surrogate measures. Bronchiolitis and asthma have similar symptoms and signs, and some concern exists that patients with asthma could be misdiagnosed with bronchiolitis. The pathology of bronchiolitis involves edema of the airway wall rather than bronchoconstriction, as in asthma. Although the use of bronchodilators in patients with bronchiolitis remains widespread, no convincing evidence supports this approach as routine practice. One practical approach is to continue the use of bronchodilators only in patients who demonstrate clinical improvement.

Treatment of bronchiolitis is unsatisfactory because the cause is often uncertain. A systematic review by Hartling et al provides an excellent analysis of another way of treating bronchiolitis with steroids and bronchodilators.[22]

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Albuterol (Proventil, Ventolin)

 

Beta-agonist for bronchospasm refractory to epinephrine. Stimulates adenyl cyclase to convert ATP to cAMP and causes bronchodilation. Relaxes bronchial smooth muscle by action on beta-2 receptors with little effect on cardiac muscle contractility. May inhibit airway microvascular leakage.

Frequency may be increased. Institute regular schedule in patients receiving anticholinergic drugs who remain symptomatic. Available as liquid for nebulizer, MDI, and dry-powder inhalers.

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Corticosteroids

Class Summary

Several placebo-controlled trials of corticosteroid therapy in different formulations did not show any benefit for important outcomes such as duration of hospitalization or time to resolution of clinical symptoms. In one study, 8-61% of patients who presented to several hospitals were treated with corticosteroids. Administering inhaled budesonide for 2 wk to infants with acute bronchiolitis conferred no short- or long-term clinical benefit in comparison with placebo. In addition, an 8-wk course of budesonide by metered-dose inhaler in a placebo-controlled study was not beneficial on postbronchiolitis coughing and wheezing up to 12 mo later. A recent double-blind, randomized trial[23] comparing a single dose of oral dexamethasone (1 mg/kg body weight) with placebo in 600 children with moderate-to-severe bronchiolitis revealed no change in hospital admission, length of hospital stay, or subsequent admissions.

Parenteral corticosteroid treatment in comparison with placebo was also not beneficial in patients mechanically ventilated for RSV lower respiratory tract infection for the endpoints of duration of mechanical ventilation, length of stay in the PICU and the hospital, and the duration of oxygen supplementation. However, a post hoc analysis suggested that corticosteroid therapy reduced the duration of mechanical ventilation and oxygen supplementation in the subset of patients with bronchiolitis. Additional studies are needed to support this finding.

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Prednisone (Orasone, Sterapred, Meticorten)

 

Blocks release of inflammatory mediators by inhibition of phospholipase A2. May be useful in patients with asthma or with bronchiolitis with asthmatic qualities.

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Antiviral drugs

Class Summary

Ribavirin is licensed by the US Food and Drug Administration for the management of RSV bronchiolitis and pneumonia, but clinically relevant benefit has been difficult to demonstrate. Early studies showed that it can reduce RSV titers in nasopharyngeal secretions. When used, it has usually been in children with bronchiolitis at high risk. However, placebo-controlled studies have not reproduced clinical benefit. In one multicenter placebo-controlled study of infants admitted for bronchiolitis with risk factors for severe disease, ribavirin demonstrated a lack of clinical effectiveness. Long-term follow-up studies of ribavirin have not consistently shown a benefit to pulmonary function. Given its high cost and lack of proven benefit, its use is difficult to justify.

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Ribavirin (Virazole)

 

Synthetic nucleoside analog that resembles guanosine and inosine. Appears to interfere with expression of messenger RNA and inhibit viral protein synthesis. Appears safe but is expensive. Efficiency and effectiveness have not been clearly demonstrated in large, randomized, placebo-controlled trials. Routine use at this time cannot be recommended. Presently, the recommendations of the AAP are that ribavirin aerosol therapy may be considered in the following list of selected infants and young children at high risk for serious RSV disease:

(1) Those with complicated congenital heart disease including pulmonary hypertension and those with bronchopulmonary dysplasia, cystic fibrosis, and other chronic lung disease

(2) Those with underlying immunosuppressive disease and those who are severely ill with or without mechanical ventilation

(3) Hospitalized patients who are younger than 6 wk or who have underlying conditions such as multiple congenital anomalies or certain neurological metabolic diseases

In adults, ribavirin can be used for the treatment of other infections, including hepatitis C.

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Respiratory agents

Class Summary

Healthy children with bronchiolitis usually have limited disease. These patients usually do well with supportive care only.

Helium-oxygen (Heliox)

 

Has been used in patients with acute asthma. May be a beneficial addition to conventional therapy in critically ill children with RSV bronchiolitis. However, further clinical studies of this agent are required to assess the efficacy of this therapy. May be useful in intubated patients whose condition is not responding to conventional treatment.

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Contributor Information and Disclosures
Author

John Udeani, MD, FAAEM  Assistant Professor, Department of Emergency Medicine, Charles Drew University of Medicine and Science, University of California, Los Angeles, David Geffen School of Medicine

John Udeani, MD, FAAEM is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

Charles I Ojielo, MD  Assistant Professor of Medicine, Rush Medical College; Consulting Staff, Resident Education Coordinator, Department of Pulmonary and Critical Care Medicine, John H Stroger Hospital of Cook County/Rush University Medical Center

Charles I Ojielo, MD is a member of the following medical societies: American College of Physicians, American Medical Association, and American Thoracic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

Stephen P Peters, MD, PhD, FACP, FAAAAI, FCCP, FCPP  Professor of Genomics and Personalized Medicine Research, Internal Medicine, and Pediatrics, Associate Director, Center for Genomics and Personalized Medicine Research, Director of Research, Section on Pulmonary, Critical Care, Allergy and Immunologic Diseases, Wake Forest University School of Medicine

Stephen P Peters, MD, PhD, FACP, FAAAAI, FCCP, FCPP is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American Association of Immunologists, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Thoracic Society, and Sigma Xi

Disclosure: See below for list of all activities None None

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Om Prakash Sharma, MD, FRCP, FCCP, DTM&H  Professor, Department of Medicine, Division of Pulmonary and Critical Care Medicine, University of Southern California Keck School of Medicine

Om Prakash Sharma, MD, FRCP, FCCP, DTM&H is a member of the following medical societies: American Academy of Allergy Asthma and Immunology, American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, American Osler Society, American Thoracic Society, New York Academy of Medicine, and Royal Society of Medicine

Disclosure: Nothing to disclose.

Timothy D Rice, MD  Associate Professor, Departments of Internal Medicine and Pediatrics and Adolescent Medicine, St Louis University School of Medicine

Timothy D Rice, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Physicians

Disclosure: Nothing to disclose.

Chief Editor

Zab Mosenifar, MD  Director, Division of Pulmonary and Critical Care Medicine, Director, Women's Guild Pulmonary Disease Institute, Professor and Executive Vice Chair, Department of Medicine, Cedars Sinai Medical Center, University of California, Los Angeles, David Geffen School of Medicine

Zab Mosenifar, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Federation for Medical Research, and American Thoracic Society

Disclosure: Nothing to disclose.

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