All of us want to treat patients who have viral bronchiolitis with medications, and we continue to search for treatments that might be effective.
This week in Pediatrics, we are early releasing the results of a network meta-analysis that compares the effectiveness of various therapies for bronchiolitis (10.1542/peds.2020-040816). Dr. Sarah Elliott and colleagues in Canada and Portugal analyzed 150 randomized controlled trials to compare the use of bronchodilators, steroids, hypertonic saline, antibiotics, helium-oxygen, and high-flow oxygen, both alone and in combination. They looked at hospital admission on day 1 and day 7 of illness, and at hospital length of stay (LOS).
Although they found that nebulized hypertonic saline plus salmeterol was most effective at reducing hospitalization rates on day 1, and that nebulized epinephrine was also more effective than placebo in reducing hospitalization rates on day 1, they also assessed the level of confidence in these findings as low. You will want to read the details of this network meta-analysis to learn if any of these treatments decreased day 7 hospitalization rates or LOS.
In an accompanying commentary (10.1542/peds.2020-048645), Dr. Matthew Lipshaw and Dr. Todd Florin from Cincinnati Children’s and Lurie Children’s respectively, note that studies on bronchiolitis treatment continue to be published, even though, over the course of 50 years, the strength of evidence for all treatments is low.
Why do we want to use medical treatment so badly for patients who have bronchiolitis, much more than for patients with other viral illnesses? Part of it is that some of them get so ill, and we all just want to do something. Part of it, I think, is also that when patients are wheezing, even if it’s because of a viral infection, you want to treat them as if they have asthma – because the same treatment should work for someone who has the same symptoms.
Drs. Lipshaw and Florin suggest that we should stop searching for the holy grail. Just accept the fact that bronchiolitis, like most other viral infection, has to run its course, and offer the appropriate supportive therapies. If you or your team are struggling to decrease use of medications in your care of patients with bronchiolitis, you may also want to check out a separate quality report by Dr. Javier Benito and colleagues that we are also publishing in the May issue of Pediatrics, entitled “Reducing Unnecessary treatments for Acute Bronchiolitis through an Integrated Care Pathway.”(REF) This quality improvement project used multiple interventions, and you may get some good ideas to implement in your practice.
