Nebulized epinephrine does not help bronchiolitis
The Journal of Family Practice. 2003 November;52(11):828-848
November 1, 2003|The Journal of Family Practice
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- BACKGROUND: Bronchiolitis is a common viral infection of the lower respiratory tract, accounting for hospitalization of approximately 1% of healthy infants. Because of bronchiolar swelling, the use of bronchodilators and anti-inflammatory agents makes sense in managing bronchiolitis. However, steroids have not shown clear evidence of benefit, and studies of epinephrine have had mixed results.
- POPULATION STUDIED: Infants (aged <1 year) were enrolled if they were admitted to any of 4 Queensland, Australia, hospitals with bronchiolitis. The diagnosis of bronchiolitis was made based on history and clinical findings consistent with bronchiolitis, including wheezing with or without crackles and respiratory distress with retractions.
- STUDY DESIGN AND VALIDITY: This was a multicenter, randomized, double blind, placebo-controlled study. Allocation appears to have been adequately concealed. Patients were randomly assigned to receive three doses of nebulized epinephrine 1% solution or placebo at 4-hour intervals within 24 hours after their admission to the hospital.
- OUTCOMES MEASURED: The 2 primary outcomes were the length of the hospital stay and the time until the infant was ready for discharge. The second time was defined by a criterion standard, and may more accurately reflect the clinical response, as other factors—such as transportation—might affect the actual time of discharge.
- RESULTS: The groups were essentially equal at study entry. Treatment with epinephrine, compared with placebo, had no significant effect on the length of the hospital stay (58.4 vs 69.5 hours) or the time until the infant was ready for discharge (46.5 vs 47.7 hours). There was no significant difference between the groups in the time receiving supplemental oxygen or in the rates of intensive care or ventilatory support. In those patients who required both oxygen and intravenous fluids, the use of epinephrine appeared to prolong the time until ready for discharge (135.9 vs 80.2 hours; P=.02).
PRACTICE RECOMMENDATIONS
Nebulized epinephrine does not improve clinical status or reduce the length of the hospital stay in infants aged <1 year with acute bronchiolitis. It also does not reduce clinical scores during or shortly after medication administration.
In this study, infants requiring oxygen and intravenous fluids—presumably the sickest infants in the study—required longer hospital stays if they received epinephrine. A wheezing infant may be presenting with a first episode of asthma, so a trial of bronchodilators would seem reasonable; however, it appears that the primary intervention for bronchiolitis is supportive treatment, with supplemental oxygen, intravenous fluids, and ventilatory support when needed.
