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Epinephrine for bronchiolitis
L Hartling1, N Wiebe, K Russell
1Department of Pediatrics, University of Alberta, Aberhart Centre One, 11402 University Avenue, Room 9424, Edmonton, Alberta, Canada, T6G 2J3.
Insights
Epinephrine may offer benefits for outpatient bronchiolitis treatment compared to placebo and salbutamol, but evidence for inpatients is insufficient. Further large trials are needed to confirm effectiveness and develop better assessment tools for this common infant respiratory illness.
Area of Science:
- Pediatrics
- Respiratory Medicine
- Evidence-Based Medicine
Background:
- Bronchodilators are standard treatment for bronchiolitis in infants.
- Previous reviews indicate modest short-term benefits for mild to moderate cases.
Purpose of the Study:
- To compare the efficacy of epinephrine against placebo and other bronchodilators in infants under two years old diagnosed with bronchiolitis.
Main Methods:
- Systematic review of randomized controlled trials (RCTs) from multiple databases (CENTRAL, MEDLINE, EMBASE).
- Inclusion criteria: RCTs comparing epinephrine to placebo or other bronchodilators in infants with bronchiolitis, with quantitative outcomes.
- Study quality assessed using Jadad scale; data extracted and analyzed separately for placebo and non-epinephrine bronchodilator control groups, and for inpatient vs. outpatient settings.
Main Results:
- Fourteen RCTs were included; study quality varied.
- Inpatient studies: Epinephrine showed a significant improvement in clinical score at 60 minutes versus placebo (SMD -0.52).
- Outpatient studies: Epinephrine favored clinical score, oxygen saturation, respiratory rate, and improvement versus placebo. Compared to salbutamol, epinephrine improved oxygen saturation, heart rate, respiratory rate, and "improvement," but increased pallor.
Conclusions:
- Insufficient evidence supports epinephrine use for inpatient bronchiolitis.
- Some evidence suggests outpatient epinephrine may be more effective than salbutamol and placebo.
- Large, multi-center trials are needed to confirm outpatient efficacy, and a validated scoring system for bronchiolitis is required.
Background:
Bronchodilators are commonly used in the management of bronchiolitis. A recent systematic review showed that bronchodilators produce modest short-term benefit among patients with mild or moderate bronchiolitis.
Objectives:
To compare epinephrine versus placebo and other bronchodilators in infants less than 2 years of age with bronchiolitis.
Search Strategy:
Electronic searches were conducted on the following bibliographic databases: The Cochrane Central Register of Controlled Trials (CENTRAL) (issue 1, 2003), MEDLINE (January 1966 to May 2003), and EMBASE (January 1988 to May 2003). The reference lists of all selected articles were examined for relevant studies. Primary authors were contacted for information on additional trials.
Selection Criteria:
Studies were included if they: 1) were RCTs comparing epinephrine with placebo or other bronchodilator; 2) involved children less than two years with bronchiolitis; 3) presented at least one quantitative outcome.
Data Collection And Analysis:
Searches were screened and inclusion criteria applied independently by two reviewers. Quality was assessed by two reviewers using the Jadad scale and allocation concealment. Data were extracted by one reviewer using a structured form and checked by a second. Separate analyses were conducted for the two types of control groups (placebo, non-epinephrine bronchodilators) and for patient status (inpatient, outpatient).
Main Results:
Fourteen studies were included. Quality ranged from one to five (Jadad scale) with a median of three (inter-quartile range: two to three). Allocation concealment was adequate in six trials and unclear in eight. Among inpatient studies comparing epinephrine and placebo (n = five), there was one significant outcome favouring epinephrine: change in clinical score at 60 minutes post-treatment (SMD -0.52; 95% CI -1.00,-0.03). For outpatient studies (n = three), change in clinical score at 60 minutes (SMD -0.81; -1.56,-0.07), change in oxygen saturation at 30 minutes (WMD 2.79;1.50,4.08), respiratory rate at 30 minutes (WMD -4.54;-8.89-0.19), and "improvement" (OR 25.06; 4.95,126.91) favoured epinephrine. Heart rate at 60 minutes post-treatment favoured placebo (WMD 11.80; 5.20,18.40). Admission rates and change in oxygen saturation at 60 minutes post-treatment were not significantly different. For inpatient studies comparing epinephrine and salbutamol (n = four), only one of the seven outcomes was statistically significant: respiratory rate at 30 minutes favoured epinephrine (WMD -5.12; -6.83;-3.41). Among outpatient studies (n = four), change in oxygen saturation at 60 minutes (WMD 1.91; 0.38,3.44), heart rate at 90 minutes (WMD -14.00; -22.95;-5.05), respiratory rate at 60 minutes (WMD -7.76; -11.35,-4.17) post-treatment and "improvement" (OR 4.51; 1.93,10.53) favoured epinephrine. Admission rates were not significantly different (OR 0.40; 0.12,1.33). Pallor at 30 minutes post-treatment was significantly higher in the epinephrine group (OR 6.00; 1.33,27.00).
Reviewer'S Conclusions:
There is insufficient evidence to support the use of epinephrine for the treatment of bronchiolitis among inpatients. There is some evidence to suggest that epinephrine may be favourable to salbutamol and placebo among outpatients. A number of large, multi-centered trials are required to examine the effectiveness of epinephrine compared to placebo and salbutamol for infants presenting to outpatient settings. There is a need to develop a validated, reliable scoring system that is sensitive to important clinical changes in patients with bronchiolitis.
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