Emergent Management of Pediatric Bronchiolitis Medication

  • Author: Mark Louden, MD, FACEP; Chief Editor: Richard G Bachur, MD   more...
 
Updated: Apr 22, 2011
 

Adrenergic agents

Class Summary

The use of bronchodilators is controversial. These agents relieve reversible bronchospasm by relaxing smooth muscles of the bronchi. Meta-analyses of clinical studies show little or no benefit from treatment with inhaled beta-adrenergic agents (with or without ipratropium bromide). These are plagued by the heterogeneous methods of the studies included. However, one meta-analysis by Hartling et al found that epinephrine alone leads to superior outcomes among outpatients with bronchiolitis compared with other interventions.[4] The systematic review assessed 48 trials to evaluate and compare the efficacy and safety of bronchodilators and steroid in treating children aged 2 years or younger. Empiric treatment with beta-agonists seems to be the standard of care. Such treatment is most reasonable in the child with documented improvement after initial treatment with bronchodilators. Drugs and dosages are the same as those for asthma. Nebulized epinephrine may occasionally be useful.

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Albuterol (Proventil, Ventolin, Salbutamol)

 

Beta-agonist for bronchospasm refractory to epinephrine. Relaxes bronchial smooth muscle by action on beta2-receptors with little effect on cardiac muscle contractility. May inhibit airway microvascular leakage. Administered by nebulizer or metered dose inhaler (MDI).

Epinephrine (Adrenalin) or racemic epinephrine (microNefrin)

 

No proven advantage over inhaled beta2-agonists exists.

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Corticosteroids

Class Summary

Clinical trials demonstrate that corticosteroids have no benefit in the treatment of bronchiolitis, and thus they should not be used routinely. However, one study (with a treatment group of 8 patients) showed some clinical improvement with the combination of dexamethasone and salbutamol. A larger and more recent double-blind, placebo-controlled trial of the same agents revealed no difference from placebo.

Plint et al found the combined used of dexamethasone and epinephrine for infants with bronchiolitis treated in the emergency department may significantly reduce hospital admissions. In this multicenter, double-blind trial, 800 infants with bronchiolitis were assigned to 1 of 4 treatment groups (nebulized epinephrine and oral dexamethasone, nebulized epinephrine and oral placebo, nebulized placebo and oral dexamethasone, or nebulized placebo and oral placebo). Only infants in the epinephrine and dexamethasone group were significantly less likely to be admitted to the hospital within 7 days of treatment compared with placebo (unadjusted analysis P=0.02; adjustment for multiple comparisons was insignificant P=0.07).[5, 4]

Nebulized steroid treatment has not been proven efficacious.

A subsequent study of prednisolone treatment of inpatients appeared to show a small benefit in a subgroup of 14 intubated patients. Corticosteroids may be useful in patients with history of reactive airway disease.

Steroid treatment has not been shown to decrease the long-term incidence of wheezing or asthma after RSV infection.

Sumner et al, using data from the Canadian Bronchiolitis Epinephrine Steroid Trial, found epinephrine and dexamethasone the most cost-effective treatment for bronchiolitis in infants aged 6 weeks to 12 months. Note that this study's conclusions run counter to some other studies and position statements such as PECARN and AAP; the use dexamethasone and epinephrine may reduce hospitalization within 7 days of its use.[6]

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Prednisone (Deltasone)

 

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

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Methylprednisolone (Medrol, Solu-Medrol)

 

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

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Nucleoside analog

Class Summary

These agents inhibit viral replication by inhibiting DNA and RNA synthesis.

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Ribavirin (Virazole)

 

May be used for inpatients who have, or who are at high risk for, severe RSV infection. In early trials, 3-7 d of ribavirin therapy produced significant reduction in mortality, length of hospitalization, and duration of mechanical ventilation. However, recent studies demonstrate no clinical benefit. Furthermore, this therapy is very expensive. Use of aerosolized ribavirin in mechanically ventilated patients requires administration by physicians and support staff familiar with this mode of administration and the specific ventilator.

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Contributor Information and Disclosures
Author

Mark Louden, MD, FACEP  Assistant Medical Director, Emergency Department, Duke Raleigh Hospital

Mark Louden, MD, FACEP is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Specialty Editor Board

Kirsten A Bechtel, MD  Associate Professor, Department of Pediatrics, Yale University School of Medicine; Attending Physician, Department of Pediatric Emergency Medicine, Yale-New Haven Children's Hospital

Kirsten A Bechtel, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Wayne Wolfram, MD, MPH  Associate Professor, Department of Emergency Medicine, Mercy St Vincent Medical Center

Wayne Wolfram, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American Academy of Pediatrics, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Richard G Bachur, MD  Associate Professor of Pediatrics, Harvard Medical School; Associate Chief and Fellowship Director, Attending Physician, Division of Emergency Medicine, Children's Hospital of Boston

Richard G Bachur, MD is a member of the following medical societies: American Academy of Pediatrics, Society for Academic Emergency Medicine, and Society for Pediatric Research

Disclosure: Nothing to disclose.

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