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Steroids and bronchodilators for acute bronchiolitis in the first two years of life: systematic review and
Lisa Hartling1, Ricardo M Fernandes, Liza Bialy
1Alberta Research Centre for Health Evidence, Department of Pediatrics, University of Alberta, 11402 University Avenue, Edmonton, AB, Canada T6G 2J3. hartling@ualberta.ca
Insights
Adrenaline (epinephrine) is effective in reducing hospital admissions for infants with acute bronchiolitis. Combined dexamethasone and adrenaline show promise for reducing later admissions, though length of stay was not improved.
Area of Science:
- Pediatrics
- Respiratory Medicine
- Evidence-Based Medicine
Background:
- Bronchiolitis is a common viral respiratory infection in infants.
- Management often involves symptomatic treatment, but the role of bronchodilators and steroids is debated.
- Optimal acute management strategies for bronchiolitis require clear evidence.
Purpose of the Study:
- To systematically review and compare the efficacy and safety of bronchodilators and steroids for acute bronchiolitis in children under 2 years.
- To identify interventions that reduce hospital admissions and length of stay.
- To provide evidence for optimal treatment strategies in the acute phase.
Main Methods:
- Systematic review and meta-analysis of randomized controlled trials.
- Inclusion of trials involving children aged 24 months or less with first-episode bronchiolitis.
- Use of random effects models for direct meta-analyses and Bayesian network models for mixed treatment comparisons.
Main Results:
- 48 trials with 4897 patients were analyzed.
- Adrenaline (epinephrine) significantly reduced day 1 admissions compared to placebo (NNT 15).
- Combined dexamethasone and adrenaline showed potential for reducing day 7 admissions (NNT 11) in one trial; no intervention improved inpatient length of stay.
Conclusions:
- Adrenaline (epinephrine) is the most effective intervention for reducing outpatient admissions in acute bronchiolitis.
- Combined adrenaline and dexamethasone may offer further benefits for later admissions.
- Current evidence does not support the use of these interventions for reducing inpatient length of stay.
Objective:
To evaluate and compare the efficacy and safety of bronchodilators and steroids, alone or combined, for the acute management of bronchiolitis in children aged less than 2 years.
Design:
Systematic review and meta-analysis.
Data Sources:
Medline, Embase, Central, Scopus, PubMed, LILACS, IranMedEx, conference proceedings, and trial registers. Inclusion criteria Randomised controlled trials of children aged 24 months or less with a first episode of bronchiolitis with wheezing comparing any bronchodilator or steroid, alone or combined, with placebo or another intervention (other bronchodilator, other steroid, standard care).
Review Methods:
Two reviewers assessed studies for inclusion and risk of bias and extracted data. Primary outcomes were selected by clinicians a priori based on clinical relevance: rate of admission for outpatients (day 1 and up to day 7) and length of stay for inpatients. Direct meta-analyses were carried out using random effects models. A mixed treatment comparison using a Bayesian network model was used to compare all interventions simultaneously.
Results:
48 trials (4897 patients, 13 comparisons) were included. Risk of bias was low in 17% (n = 8), unclear in 52% (n = 25), and high in 31% (n = 15). Only adrenaline (epinephrine) reduced admissions on day 1 (compared with placebo: pooled risk ratio 0.67, 95% confidence interval 0.50 to 0.89; number needed to treat 15, 95% confidence interval 10 to 45 for a baseline risk of 20%; 920 patients). Unadjusted results from a single large trial with low risk of bias showed that combined dexamethasone and adrenaline reduced admissions on day 7 (risk ratio 0.65, 0.44 to 0.95; number needed to treat 11, 7 to 76 for a baseline risk of 26%; 400 patients). A mixed treatment comparison supported adrenaline alone or combined with steroids as the preferred treatments for outpatients (probability of being the best treatment based on admissions at day 1 were 45% and 39%, respectively). The incidence of reported harms did not differ. None of the interventions examined showed clear efficacy for length of stay among inpatients.
Conclusions:
Evidence shows the effectiveness and superiority of adrenaline for outcomes of most clinical relevance among outpatients with acute bronchiolitis, and evidence from a single precise trial for combined adrenaline and dexamethasone.
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