, et al
Racemic adrenaline and inhalation strategies in acute bronchiolitis
N Engl J Med.
; doi:

Investigators from multiple institutions in Norway studied the effectiveness of inhaled racemic epinephrine compared to inhaled saline for treatment of children with acute bronchiolitis. They also assessed the effectiveness of administering treatments on a fixed schedule versus an as-needed basis. Eligible study participants were infants <12 months old hospitalized with bronchiolitis. Diagnosis of bronchiolitis was based on defined clinical criteria. The severity of illness was estimated with a scoring system assessing severity of the following findings: general condition, skin color, auscultation findings, and retractions. The severity of each finding was rated from 0 to 2, with 0 indicating a normal finding and 2 indicative of severe illness. Scores for each finding were summed; only children with scores ≥4 were eligible for the study. At enrollment, participants were randomized to nebulized racemic epinephrine mixed in normal saline solution or normal saline alone; within each group infants were randomized to receive nebulized treatments on a fixed schedule or on an as-needed basis. The primary outcome was the length of hospital stay (LOS) and secondary outcomes included change in clinical score 30 minutes after the first study treatment and need for supplemental oxygen or ventilator support. Outcomes were compared between those randomized to epinephrine or saline, and between those receiving treatments on a fixed or as-needed schedule (regardless of medication in treatments). Finally, PCR assay for respiratory viruses was performed on participants at 1 study site.

A total of 404 infants with a mean age of 4.2 months were enrolled in the study. Of the initial 404 infants, 36 were dropped in the epinephrine arm and 47 in the saline arm. Treatment failure was the most common reason for discontinuance. Respiratory viral assays were performed on 123 study participants; 99 (80.5%) were positive for respiratory syncytial virus, 21 (17.1%) were positive for another virus, and 5 (4.1%) were positive for 2 viruses. The mean LOS for all infants was 80±67 hours.

There was no significant difference in LOS between children treated with saline and those treated with racemic epinephrine, nor any difference in change in clinical score, use of supplemental oxygen, or ventilatory support. However, LOS was significantly shorter for those receiving either racemic epinephrine or normal saline treatment on an as-needed basis compared to the group receiving these treatments on a fixed schedule. There was also significantly less use of supplemental oxygen and less need for ventilator support for infants randomized to the as-needed dosing versus fixed schedule dosing.

The authors conclude that in hospitalized infants <12 months of age, inhaled racemic epinephrine is not more effective than inhaled saline. However, the use of inhalation therapy on an as-needed basis appears to shorten hospital stays compared to treatments administered on a fixed schedule.

Dr Schiff has disclosed no financial relationship relevant to...

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