We read with interest the current guidelines on the management of bronchiolitis.1 Here we raise our concern with the recommendation that bronchodilators not be used.
The guideline authors imply that our randomized controlled trial in 703 children with bronchiolitis supports their assertion that “clinical scores may vary from between observers”.1,2 This is a selective reading of our Limitations section. The cited article in fact showed an 18% (adjusted relative risk: 1.18; 95% confidence interval [CI]: 1.02–1.36) relative increase in successful hospital discharges from the emergency department (ED) when albuterol rather than epinephrine was administered. This study also addressed the limitations of consecutive enrollment with random allocation, previous episodes, and study site effect.2 The severity of illness tool we used has been validated3 and has adequate interrater agreement (92%; κ = 0.676).
The guideline authors rely in part on older meta-analyses predating this work and on a meta-analysis from 2011 that systematically excluded studies showing a benefit to using albuterol over epinephrine.4 Therefore, these meta-analyses could provide only a limited view of what is known about bronchodilators in bronchiolitis.
The guideline’s assertion that bronchodilators should not be used must then rest on the meta-analysis in the Cochrane review library published by Gadomski5 in 2014. This meta-analysis included only placebo-controlled studies and consequently excluded some studies that showed a benefit between bronchodilators.
However, even this 2014 Cochrane review found a significant benefit to using bronchodilators (odds ratio [OR]: 0.18; 95% CI: 0.06–0.50) as measured by improved clinical scores.5 In the version cited, there were only 187 patients included in the analysis to address the most important question to emergency physicians and pediatric hospitalists: Does albuterol decrease admissions to the ED? This meta-analysis showed a nonsignificant trend toward decreased admissions (OR: 0.76; 95% CI: 0.38–1.53), as also shown in a subsequent analysis in 404 patients (OR: 0.77; 95% CI: 0.44–1.33).5 This 23% reduction in odds of admission is not dissimilar to the 18% decrease in the relative risk of admission that we found with albuterol.2 Neither nonsignificant underpowered studies nor meta-analyses should form the basis for treatment recommendations any more than null results should form the basis for concluding “no effect.”
Given that data from some studies finding a benefit to bronchodilators in the ED have been ignored, and given the actual findings of the 2014 Cochrane review, the recommendation that a bronchodilator not be used is charitably described as weak, particularly for the ED. This recommendation risks doing a disservice to our patients. It is not acceptable for the authors to seek refuge in the statement that this is a guideline and should not be used as the sole guidance for clinical management; experience tells us that that is exactly what will happen.
Available evidence clearly suggests that nebulized albuterol decreases hospital admissions to the ED. The guideline should be amended to reflect this.
Conflict of Interest:
- Ralston SL,
- Lieberthal AS,
- Meissner HC,
- et al
- Hartling L,
- Fernandes RM,
- Bialy L,
- et al
- Gadomski AM
- Copyright © 2015 by the American Academy of Pediatrics