2014 Update

Though meta-analyses and systematic reviews – see below – have shown that beta agonists may improve symptoms scores they certainly don’t affect disease resolution. Thus, since clinical scores are subjective and don’t necessarily correlate with objective measurements. When sensitivity analysis is used to weed out weaker studies any effects towards benefit in the meta analyses is mitigated. Thus, the AAP recommended that albuterol not be used as a trial therapy in its latest clinical practice guideline. You’ll see that my original post and recommendation aligns with what the AAP says.

If you haven’t checked out Part 1 of the Bronchiolitis series do so here – otherwise, let us trudge onward. This time, towards a potential therapy that is used in many institutions for bronchiolitis – Albuterol. This Beta-agonist relaxes airway smooth muscle thus improving wheezing – sound good right? Bronchiolitics are super wheezy after all. Well, not so fast my friends – let’s take a look at the evidence, which has been looked at in both inpatient and outpatient settings.

In outpatients Schweich et al & Schuh et al saw improvement in O2 sat and clinical score after 2 albuterol treatments. Klassen et al noted that there were improved clinical scores at 30 minutes – but no difference at one hour. Finally, Gadomski et al saw no benefit. Two noteworthy inpatient studies by Dobson et al and Flores et al showed no benefit either. With the former noting no improvement in patients with moderate or serve illness, and the latter lead investigators to conclude that albuterol did not reduce the length of inpatient stay.

That’s not all. For those of you that prefer your plots to be all “foresty” there have been multiple systematic reviews, including a Cochrane Review that all paint a less than conclusive picture. There is no difference in the rates of hospital admission,time to illness resolution, and hospital length of stay. So why do we keep giving them, well…

There does seem to be a short-term improvement in clinical score in approximately 25% of outpatients (the ED included).

Bronchiolitis Cochrane Albuterol

So what do I do? First, I would only use Albuterol in a moderate or severe bronchiolitic. Then, I’d consider the potential benefits and communicate a clear understanding of the limitations with the parents. In general I tell them that there is a small chance that it will improve their child’s breathing temporarily, and that this may make them look better, and perhaps sleep or feed more willingly. I tell them that if it helps that they could use it at home, but make no guarantees that it will continue to work. I also spend extra time going over the usual illness course. All in all I find that I’m using it less than I used to, especially now with mounting evidence.

I’ll leave you with a quote from Gadomski’s Cochrane Review in order to help drive home the points I discussed here;

[quote align=”center” color=”black”]Bronchodilators produce small short-term improvements in clinical scores among infants with bronchiolitis treated as outpatients. However, given their high cost, adverse effects and lack of effect on oxygen saturation and other outcomes included in this meta-analysis, bronchodilators cannot be recommended for routine management of first-time wheezers who present with the clinical findings of bronchiolitis, in either inpatient or outpatient settings.

-Gadomski et al[/quote]

Thanks again to Todd Florin, MD, MSCE – he’s a cool dude