Investigators from multiple institutions in Australia and New Zealand conducted a pragmatic, open-label, randomized trial to assess the effectiveness of treatment with corticosteroids and nebulized epinephrine on duration of positive pressure support (PPS) among children with bronchiolitis admitted to the intensive care unit (ICU). Study participants were children <18 months old with bronchiolitis who were enrolled within 4 hours of admission to 1 of 3 ICUs in Australia and New Zealand between 2013 and 2019 and received PPS. Bronchiolitis was defined using specific clinical criteria, and PPS included high-flow nasal prong oxygen, nasopharyngeal continuous positive airway pressure, or mechanical ventilation. At enrollment, study patients were randomized to standard care (control) or the intervention, consisting of the equivalent of 13 mg/kg prednisolone for 3 days, followed by 1 mg/kg/day for 3 days, and nebulized epinephrine (0.05 mL/kg of 1% solution), provided via a jet nebulizer every 30 minutes for 5 doses, followed by a decreasing frequency for up to 6 days. The primary study outcome was duration of PPS from time of randomization until ICU discharge; secondary outcomes included length of ICU stay from time of randomization and length of hospital stay from time of randomization. Subgroup analyses limited to participants who tested positive or negative for respiratory syncytial virus (RSV) also were conducted. Log-linear regression analyses were performed to compare outcomes among children in the 2 treatment groups.
Data were analyzed on 210 patients, including 107 randomized to the intervention group and 103 controls. The median age of children in the intervention and control groups were 4.2 and 3.8 months, respectively. Among 197 children tested, 117 (59%) were RSV-positive. The median duration of PPS was 27 hours in patients in the intervention group compared to 38 hours in controls (ratio, 0.66; 95% CI, 0.51, 0.84; P = 0.001). Median length of ICU stay after randomization was 49 hours for those in the intervention group vs 60 hours for control (ratio, 0.84; 95% CI, 0.69, 1.00; P = 0.053), and median length of hospital stay was 96 and 97 hours, respectively (ratio, 0.96; 95% CI, 0.80, 1.47; P = 0.607). In the subgroup analyses, duration of PPS was significantly shorter in children who were RSV-positive and received the intervention than in controls (median, 24 and 56 hours, respectively; ratio, 0.49; 95% CI, 0.36, 0.68; P <0.001), but there was no significant difference between treatment groups in patients who were RSV-negative (median, 34 and 33 hours, respectively; ratio, 0.91; 95% CI, 0.62, 1.35; P = 0.652).
The authors conclude that in children with severe bronchiolitis, treatment with corticosteroids and nebulized epinephrine reduced the duration of PPS.
Dr Flaherty has disclosed no financial relationship relevant...