Abstract 1 of 2

Colette C. Mull, MD; Richard J. Scarfone, MD; Lara R. Ferri, MD; Teresa Carlin, MD; Christy Salvaggio, MD; Kirsten A. Bechtel, MD; Mary Ann Hanes Trephan, MD; Raquel L. Rissman, MD; Edward J. Gracely, PhD

Arch Pediatr Adolesc Med. 2004;158:113-118.

Objective  To determine if nebulized epinephrine is more efficacious than nebulized albuterol in the emergency department (ED) treatment of moderately ill infants with bronchiolitis.

Methods  Sixty-six patients between 0 and 12 months of age with new-onset wheezing, an antecedent upper respiratory tract infection, and a clinical score (Respiratory Distress Assessment Instrument) of 8 to 15 were randomized in a double-blind fashion to receive either 0.9 mg/kg of nebulized 2.25% racemic epinephrine (n = 34) or 0.15 mg/kg of nebulized 0.5% albuterol sulfate (n = 32) at 0, 30, and 60 minutes.

Main Outcome Measures  Primary outcome measures were clinical score and respiratory rate. Secondary outcome measures were room air oxygen saturation, elapsed time to meeting clinical criteria for ED discharge, hospitalization rate, and proportion of patients relapsed within 72 hours of ED discharge (relapse rate).

Results  Both treatment groups experienced a similar pattern of change in mean clinical score, respiratory rate, and room air saturation over time. There were no significant differences between the groups by these same measures at any time. The median time at which infants were well enough for ED discharge was 90 minutes in the epinephrine-treated group vs 120 minutes in the albuterol-treated group (P = .01). Sixteen infants (47.1%) in the epinephrine-treated group were hospitalized compared with 12 infants (37.5%) in the albuterol-treated group (relative risk, 1.25; 95% confidence interval, 0.71-2.22). Relapse rate was 18.8% (3/16) in the epinephrine-treated group and 42.1% (8/19) in the albuterol-treated group (relative risk, 0.45; 95% confidence interval, 0.14-1.41). Adverse effects occurred infrequently.

Conclusions  Although the patients treated with epinephrine were judged well enough for ED discharge significantly earlier than the patients treated with albuterol, epinephrine was not found to be more efficacious than albuterol in treating moderately ill infants with bronchiolitis.

From the Division of Emergency Medicine, Alfred I. duPont Hospital for Children, Wilmington, Del (Dr Mull); Emergency Department, Children ' s Hospital of Philadelphia, Philadelphia, Pa (Dr Scarfone); Division of Emergency Medicine, Children ' s Hospital, Boston, Mass (Dr Ferri); Department of Emergency Medicine, The Johns Hopkins University, Baltimore, Md (Dr Carlin); Section of Emergency Medicine, St Christopher ' s Hospital for Children, Philadelphia (Dr Salvaggio); Section of Emergency Medicine, Yale–New Haven Children ' s Hospital, New Haven, Conn (Dr Bechtel); Emergency Department, Kaiser Permanente Medical Group, Woodland Hills, Calif (Dr Hanes Trephan); Department of Pediatrics, Children ' s Hospital of Orange County (California), Orange (Dr Rissman); and the Department of Community and Preventive Medicine, Drexel University College of Medicine, Philadelphia (Dr Gracely).

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Abstract 2 of 2

A Systematic Review

Valerie J. King, MD, MPH; Meera Viswanathan, PhD; W. Clayton Bordley, MD, MPH; Anne M. Jackman, MSW; Sonya F. Sutton, BSPH; Kathleen N. Lohr, PhD; Timothy S. Carey, MD, MPH

Arch Pediatr Adolesc Med. 2004;158:127-137.

Background  Bronchiolitis is the most common lower respiratory tract infection in infants. Up to 3% of all children in their first year of life are hospitalized with bronchiolitis. Bronchodilators and corticosteroids are commonly used treatments, but little consensus exists about optimal management strategies.

Objective  To conduct a systematic review of the effectiveness of commonly used treatments for bronchiolitis in infants and children.

Data Sources  We searched MEDLINE and the Cochrane Controlled Trials Register for references to randomized controlled trials of bronchiolitis treatment published since 1980.

Study Selection  Randomized controlled trials of interventions for bronchiolitis in infants and children were included if they were published in English between 1980 and November 2002 and had a minimum sample size of 10.

Data Extraction  We abstracted data on characteristics of the study population, interventions used, and results of studies meeting entry criteria into evidence tables and analyzed them by drug category.

Data Synthesis  Interventions were grouped by drug category and qualitatively synthesized.

Results  Of 797 abstracts identified in the literature search, we included 54 randomized controlled trials. This review includes 44 studies of the most common interventions: epinephrine (n = 8), 2-agonist bronchodilators (n = 13), corticosteroids (n = 13), and ribavirin (n = 10). Studies were, in general, underpowered to detect statistically significant outcome differences between study groups. Few studies collected data on outcomes that are of great importance to parents and clinicians, such as the need for and duration of hospitalization.

Conclusions  Overall, little evidence supports a routine role for any of these drugs in treating patients with bronchiolitis. A sufficiently large, well-designed pragmatic trial of the commonly used interventions for bronchiolitis is needed to determine the most effective treatment strategies for managing this condition.

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