In response to the concerns raised by Walsh and Rothenberg that the guideline ignores the potential clinical benefit of bronchodilators in bronchiolitis, the committee respectfully disagrees and reiterates our logic. To recommend the use of a medication in any disease, the preponderance of benefit should outweigh the likelihood of harm across the entire population for whom the medication is prescribed. Although we clearly acknowledged in the guideline that a small proportion of children may appear to get a clinical benefit from bronchodilators (and there is significant disagreement as to whether the magnitude of said benefit is clinically meaningful), the majority of children with bronchiolitis do not stand to benefit. The pathology of early viral wheezing is hypothesized to result from the concomitant effects of virus-induced edema and debris in airways that are already small in diameter. A minority of patients with early viral wheezing will also exhibit airway obstruction due to smooth muscle contraction, which may be at least partially reversible with bronchodilators. Unfortunately, there is no way to reliably distinguish which patients who suffer early wheezing will have reversible airway obstruction. Therefore, a recommendation to use albuterol in all patients with first-time viral wheezing would mean that the majority of patients given the medication would have no chance of benefiting from it. Such a recommendation would still be acceptable if the consequences of failing to administer the medication to the cohort who is expected to benefit were grave. In the case of bronchiolitis, there is no evidence to suggest that such a situation exists, that is, there is no convincing evidence that albuterol alters meaningful outcomes in bronchiolitis. Although a small change in respiratory scores has been interpreted by some to justify the use of the medication in the entire cohort of patients with bronchiolitis, the bronchiolitis committee saw no evidence to suggest that the change in scores was clinically meaningful or that the absence of providing such treatment would substantially harm anyone. Furthermore, the committee felt the harm suffered, including significant side effects and costs, for the majority of patients who would not benefit from the medication outweighed the potential benefit to the much smaller cohort who might respond.
In response to the other concerns raised in their letter, we also disagree with the authors’ interpretation of the existing literature. We would like to point out that evaluation of a therapy against a placebo is considered the highest quality study design and not a weakness; therefore, we fail to see the significance of that particular critique, or of comparing albuterol to epinephrine when placebo-controlled trials are available. Finally, we offer no response to Walsh and Rothenberg’s nonstandard use of the term “trend” to describe clearly negative results in hypothesis testing on the impact of albuterol on hospitalization rates except to note that such usage is expressly forbidden in the instructions to authors for this and most other high-quality medical journals.
Conflict of Interest:
- Copyright © 2015 by the American Academy of Pediatrics