Determine whether dexamethasone treatment added to salbutamol reduces time to readiness for discharge in patients with bronchiolitis and possible asthma.
We compared efficacy and safety of dexamethasone, 1 mg/kg, then 0.6 mg/kg for 4 more days, with placebo for acute bronchiolitis in patients with asthma risk, as determined by eczema or a family history of asthma in a first-degree relative. All patients received inhaled salbutamol. Time to readiness for discharge was the primary efficacy outcome.
Two hundred previously healthy infants diagnosed with bronchiolitis, median age 3.5 months, were enrolled. Five placebo recipients needed admission to intensive care unit during infirmary treatment (P = .02). Among 100 dexamethasone recipients, geometric mean time to readiness for discharge was 18.6 hours (95% confidence interval [CI], 14.9 to 23.1 hours); among 90 control patients, 27.1 hours (95% CI, 21.8 to 33.8 hours). The ratio, 0.69 (95% CI, 0.51 to 0.93), revealed a mean 31% shortening of duration to readiness for discharge favoring dexamethasone (P = .015). Twenty-two dexamethasone and 19 control patients were readmitted to the short stay infirmary in the week after discharge (P = .9). No hospitalizations or side effects were reported during 7 days of surveillance.
Dexamethasone with salbutamol shortened time to readiness for infirmary discharge during bronchiolitis episodes in patients with eczema or a family history of asthma in a first-degree relative. Infirmary and clinic visits in the subsequent week occurred similarly for the 2 groups.
Dear editor,
We read the article of Alansari et al. about the use of oral steroid in bronchiolitis (1). The authors' conclusion are that steroid treatment at very high dosages allows a reduction of 8.5 hours of length of stay in a subgroup of children with bronchiolitis, eg those with a history of eczema and family allergy. Repeated and strong evidence from the literature already shows that steroid treatment is not effective in bronchiolitis and that even if a marginal benefit can be demonstrated in some patients (2) the cost benefit ratio of this approach cannot be recommended due to the high dosages (with possible side effects at a vulnerable age) and the high number needed to treat (3). As a rule bronchiolitis is a benign, self limiting disease and there is no evidence of the efficacy of steroids or epinephrine in preventing intensive care admission in the rare, most severe cases. This kind of research has saved by far more careers than children's life. We wonder if it can still be considered ethically correct.
1. Alansari K, Sakran M, Davidson BL, Ibrahim K, Alrefai M, Zakaria I. Oral dexamethasone for bronchiolitis: a randomized trial. Pediatrics. 2013 Oct;132(4):e810-6 2. Plint AC, Johnson DW, Patel H, Wiebe N, Correll R, Brant R, Mitton C, Gouin S, Bhatt M, Joubert G, Black KJ, Turner T, Whitehouse S, Klassen TP; Pediatric Emergency Research Canada (PERC). Epinephrine and dexamethasone in children with bronchiolitis. N Engl J Med. 2009 May 14;360(20):2079-89. 3. Fernandes RM, Bialy LM, Vandermeer B, Tjosvold L, Plint AC, Patel H, Johnson DW, Klassen TP, Hartling L. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database Syst Rev. 2013 Jun 4;6
Conflict of Interest:
None declared
After reading the Alansari et al paper on the use of dexamethasone in bronchiolitis patients, we considered necessary to provide some comments on their study limitations and debatable results (1). In this single centre study the authors have not taken into account the aetiological agent of bronchiolitis, which may be of importance, especially when different seasons are included. Salbutamol is routinely applied in all the patients despite the authors themselves stating in the paper that this practice is not supported by the literature (1). Furthermore, 19 to 31% of the subjects additionally receive epinephrine nebulization as needed. Importantly, fever is not controlled in the study and the antipyretic effect of dexamethasone might explain any difference found with placebo group. Aside of these considerations and even accepting the results of the study at face value, we are not sure about the clinical importance of the improvement found -8.7 hours less of stay in the infirmary with a 95% confidence interval of 5.9 to 10.7 hours- particularly when the discharge criteria applied or the kappa agreement score among nurses recruiting and assessing the patients in the study are not even mentioned. Additionally, the statistical analysis is not done by intention-to-treat, being a substantial source of bias.
Anti-inflammatory therapy might make sense if we were able to start it before clinical symptoms onset; otherwise by the time we arrive the epithelium is dead and corticosteroids useless (2). Presently, there is no controversy regarding corticosteroids in bronchiolitis: corticosteroids play no role in the treatment of acute bronchiolitis and may cause serious secondary effects (by the way, inadequately measured and poorly reported in this study).
Please, let's try different things in bronchiolitis therapy!
References
1. Alansari K, Sakran M, Davidson BL, Ibrahim K, Alrefai M, Zakaria I. Oral Dexamethasone for Bronchiolitis: A Randomized Trial. Pediatrics. 2013;132(4):e810-e6. Epub 2013/09/18.
2. Colby TV. Bronchiolitis. Pathologic considerations. Am J Clin Pathol 1998;109:101-109.
Conflict of Interest:
None declared