Parts I through IV are in the books, so let’s move onto another therapy that has been tossed around as a potential solution to bronchiolitis – Corticosteroids. In the early ‘aughts many of you may have given steroids to bronchiolitics, but now you don’t. Perhaps it will help if I frame things as A Tale of Three Studies. Disclaimer: Yes, I know that there are many more, but I hope to illustrate my point succinctly, plus one of these three is a Cochrane Review, which if you’ve been reading the series you know I’m fond of.
Schuch et al, 2002
This study examined 70 infants with bronchiolitis with moderate or severe respiratory distress and randomized them to 1mg/kg dexamethasone or placebo. The authors noted that 44% of the placebo group were admitted as compared with only 19% of the dexamethasone group (p=0.039). That’s great – a significant difference is significant, right? Well, these results were from a single institution, and there were only 70 of them.
Corneli et al, 2007
Here is an example where the old maxim “strength in numbers” comes into play. This multi-center study from PECARN (The Pediatric Emergency Care Applied Research Network) asked the same question as the Schuch study, but this time with 600 patients. This time 41% of the placebo group were admitted as opposed to 39.7% of the dex group (p=0.74).
Fernandes et al, Cochrane 2010
To seemingly answer the question once and for all let’s now take a look at the meta analyses. The authors looked at several outcomes, and I’ll go over a few here and report risk ratios and 95% CI.
- Hospital admission: No difference at Day 1 0.92 [0.78, 1.08] or Day 7 0.86 [0.70, 1.06]
- Inpatient length of stay: No difference -0.18 [-0.39, 0.04]
- Clinical score: No difference at multiple time points
- 60 minutes -0.04 [-0.16, 0.09]
- 120 minutes -0.17 [-0.55, 0.21]
- 3-6 hours -0.34 [-0.50, 0.21]
- 12-24 hours 0.13 [-0.51, 0.76]
- 3-10 days -0.20 [-0.61, 0.21]
So case closed right?
You’d think so right? Well, the and though the world keeps on turning inexorably and new clinical questions keep cropping up the current evidence does not support the use of steroids in bronchiolitis. There is no difference in the risk of admission, length of stay, nor wheezing/clinical scores. Even if you have a patient with eczema or previous wheezing there is still no difference in the inpatient length of stay Patel et al. Cochrane, 2004 or the risk of admission Corneli et al NEJM, 2007. There was, however an interesting study from NEJM in 2009 by Plint et al that looked at the combination of racemic epinephrine and dexamethasone. In this multicenter double-blinded placebo RCT study the authors noted that the combo of Dex/Epi may reduce the risk for admission for infants (6 weeks to 12 months of age) with bronchiolitis who were seen in the pediatric emergency department. When these results were adjusted for multiple comparisons they did not hold up.
Where does that leave us?
Well, I’m still not convinced 100%. We are heading into an era where we will likely better understand which patients will better respond to corticosteroids through biologic testing. Until then, the best we can do is use our clinical smarts and rely on the best available evidence.
See you next time – thanks again to, you guessed it, Todd Florin, MD, MSCE.
