Bronchodilators don't help bronchiolitis

- Jennifer Middleton, MD, MPH

Autumn brings the start of another Respiratory Syncytial Virus (RSV) season in the U.S., a virus that can cause bronchiolitis in younger children. The wheezing - and sometimes decreased oxygen saturation - of bronchiolitis can be scary for parents and physicians alike; since bronchodilators like albuterol help many older kids and adults with wheezing, it seems intuitive that they would help bronchiolitis as well. The November 1 issue of AFP discusses a Cochrane update, however, demonstrating that bronchodilators don't improve outcomes in most kids aged less than 2 years with bronchiolitis.

The Cochrane reviewers found that, in children less than 24 months old with bronchiolitis who were wheezing for the first time, bronchodilators didn't improve oxygen saturation, didn't keep children in the Emergency Department from getting admitted to the hospital, and didn't reduce the length of stay in children already admitted to the hospital. Unfortunately, bronchodilators also caused harm; children who received them were more likely to have tachycardia and decreased oxygen saturation.

It can be frustrating to see child suffering with bronchiolitis and not be able to offer treatment with a medication, but a recent AFP article on RSV infection reinforces that no studied pharmaceutical interventions have demonstrated a meaningful impact on patient-oriented outcomes. Hydration and supplemental oxygen remain the treatments of choice for the more than 90,000 children admitted with bronchiolitis in the U.S. every year; fewer children are being admitted in recent years than in the past, but the children who are being admitted are more likely to have high-risk conditions and require mechanical ventilation.

3 of the 5 Choosing Wisely recommendations from the Society of Hospital Medicine - Pediatric Hospital Medicine relate to bronchiolitis and/or respiratory tract infections in young children:

1. Don't order chest radiographs in children with uncomplicated asthma or bronchiolitis.
2. Don't routinely use bronchodilators in children with bronchiolitis.
3. Don't use systemic corticosteroids in children under 2 years of age with an uncomplicated lower respiratory tract infection.

Pediatrics just published a clinical practice guideline on bronchiolitis that reinforces those points. 

If you'd like to read more, there's an AFP By Topic on Upper Respiratory Tract Infections that includes this risk stratification point-of-care guide for treatment of infants with bronchiolitis. You can follow RSV infection rates specific to your region of the U.S. at this CDC website. 

Will this Cochrane review change how you treat young children with bronchiolitis?