Salbutamol or mist in acute bronchiolitis

Abstract Background : The role of bronchodilators in the treatment of bronchiolitis remains controversial.
Methods : A double-blind, placebo controlled trial was performed to evaluate the clinical response to nebulized salbutamol. One hundred and fifty-six infants aged between 7 weeks and 24 months who had had an episode of wheezing and other signs and symptoms of bronchiolitis were randomized to three groups as follows: (i) nebulized salbutamol was administered to 52 patients in group I at a dose of 0.15 mg/kg in 2 mL saline; (ii) saline was nebulized to 52 patients in group II and (iii) in group III 52 patients received mist in a tent. All three groups were administered oxygen during the procedures. Treatment was repeated with the same agent after 30 min if the respiratory score was 5 or more. Respiratory rate, heart rate, oxygen saturation and presence of cyanosis, wheezing, retractions were recorded before and after each treatment.
Results : The decrease in the respiratory score was 5.2 ± 1.8, 0.82 ± 2.4 and 1.7 ± 1.3 in group I, II and III, respectively. The decrease in group I was significantly higher than in the other groups. Heart rate was similar between groups. Oxygen saturation decreased in group I without reaching statistical significance.
Conclusions: Salbutamol was shown to be effective and safe in the treatment of acute bronchiolitis.     

Short term effects of adrenaline in bronchiolitis: a randomised controlled trial

Background: Airway narrowing in acute bronchiolitis does not respond to inhaled bronchodilators but does to adrenaline when compared to bronchodilators. Influences of supportive care were not considered in previous treatment studies. Methods: Short term effects of nebulised adrenaline and saline placebo were compared in infants with moderately severe acute bronchiolitis. Thirty eight infants were recruited, 19 in each treatment group. After stabilisation, infants received a single 3 ml dose of either levo-adrenaline (3 mg) or 0.9% saline placebo via Pari-BABY nebuliser driven with 6 l/min oxygen for three minutes. Changes in respiratory rate (RR), heart rate (HR), oxygen saturation (SpO₂), Respiratory Distress Assessment Instrument (RDAI), and activity levels were assessed at 20 minutes intervals at times -20, 0, 20, 40, and 60 minutes around treatment. Respiratory virology and chest x ray were performed. Results: Supportive therapy prior to study treatment resulted in significant reductions in RR (by 4.3 breaths/min) and HR (by 4.6 beats/min); there were no changes in SpO₂ or RDAI. There were no further changes in any parameter in either treatment group at any assessment time after treatment. Conclusion: No improvement was shown with inhaled adrenaline in acute bronchiolitis, when compared with supportive care or placebo. Improvements noted pretreatment question whether prior noted improvements were through supportive care or pharmacological interventions.     

Wheezing in infants: the response to epinephrine

There is significant controversy about the role of bronchodilator therapy for wheezing in infants. A double-blind, randomized trial of subcutaneous epinephrine upsilon normal saline was conducted in children less than 24 months of age evaluated at Yale-New Haven Hospital. Respiratory assessments using a newly developed Respiratory Distress Assessment Instrument were made at baseline and 15 minutes after each of two injections. Relief of respiratory distress was assessed using strict a priori criteria based on changes in respiratory rate, wheezing, and retractions as scored in the Respiratory Distress Assessment Instrument. Significantly more children improved their respiratory status with epinephrine (nine of 16) than placebo (one of 14) (Fisher exact test, P = .0067). Paired data in individuals receiving placebo and then epinephrine confirmed this (Wilcoxon signed ranks test, P less than .01). Sixty-three percent of patients less than 12 months and 92% of those 12 to 24 months improved with epinephrine, as did seven of ten children with respiratory syncytial virus bronchiolitis. In many children, response to the initial epinephrine injection was not indicative of final response. Results of this study demonstrate the effectiveness of epinephrine in the treatment of acute wheezing in children less than 24 months of age.     

Acute bronchiolitis-recent advances in treatment

Conclusion Bronchiolitis in an acute inflammation of the airways. In infancy, it usually results from viral infection, with RSV the most common agent. It typically begins as an upper respiratory tract infection, followed by wheezing, tachypnea, and chest retractions. Ausculation often reveals fine inspiratory crackles. Chest film findings include hyperinflation and patchy atelectasis. Oxygen saturation, as measured by pulse oximetry, may be the best clinical predictor of disease severity. The mainstays of therapy include oxygen supplementation and fluid resuscitation, and other modalities remain controversial. There are no studies to support the use of corticosteroids alone in the treatment of bronchiolitis, but several recent reports demonstrate the value of bronchodilator therapy in some patients. Anti-viral agents, such as ribavirin, may be indicated for those with severe RSV illness and those who are at increased risk for complications, such as patients with chronic lung disease. Oxygen is vitally important in bronchiolitis and there is little convincing evidence that any other therapy is consistently useful…     

Short term effects of adrenaline in bronchiolitis: a randomised controlled trial.

BACKGROUND: Airway narrowing in acute bronchiolitis does not respond to inhaled bronchodilators but does to adrenaline when compared to bronchodilators. Influences of supportive care were not considered in previous treatment studies. METHODS: Short term effects of nebulised adrenaline and saline placebo were compared in infants with moderately severe acute bronchiolitis. Thirty eight infants were recruited, 19 in each treatment group. After stabilisation, infants received a single 3 ml dose of either levo-adrenaline (3 mg) or 0.9% saline placebo via Pari-BABY nebuliser driven with 6 l/min oxygen for three minutes. Changes in respiratory rate (RR), heart rate (HR), oxygen saturation (SpO(2)), Respiratory Distress Assessment Instrument (RDAI), and activity levels were assessed at 20 minutes intervals at times -20, 0, 20, 40, and 60 minutes around treatment. Respiratory virology and chest x ray were performed. RESULTS: Supportive therapy prior to study treatment resulted in significant reductions in RR (by 4.3 breaths/min) and HR (by 4.6 beats/min); there were no changes in SpO(2) or RDAI. There were no further changes in any parameter in either treatment group at any assessment time after treatment. CONCLUSION: No improvement was shown with inhaled adrenaline in acute bronchiolitis, when compared with supportive care or placebo. Improvements noted pretreatment question whether prior noted improvements were through supportive care or pharmacological interventions.     

Metapneumovirus and its place in childhood

Human metapneumovirus (hMPV) was recently identified as a cause of acute upper and lower respiratory tract infection in children and adults. The epidemiology is similar to that exhibited by respiratory syncytial virus, with most episodes occurring during the winter months. The virus likely has a worldwide distribution. Almost all children have been infected by five years of age. The suspicion of hMPV infection should be higher in infants or children presenting with symptoms compatible with a viral etiology and in whom screening tests for other common viral pathogens have been negative. Clinical manifestations may be subtle or severe, including life-threatening bronchiolitis or pneumonia. Fever, rhinorrhea, cough, retractions, tachypnea and wheezing are common findings. Bronchiolitis is perhaps the most common manifestation among hospitalized children. Currently, there is no antiviral treatment or vaccine available and management is simply supportive.     

A randomized trial of nebulized epinephrine vs albuterol in the emergency department treatment of bronchiolitis

OBJECTIVE: To determine if nebulized epinephrine is more efficacious than nebulized albuterol in the emergency department (ED) treatment of moderately ill infants with bronchiolitis. METHODS: Sixty-six patients between 0 and 12 months of age with new-onset wheezing, an antecedent upper respiratory tract infection, and a clinical score (Respiratory Distress Assessment Instrument) of 8 to 15 were randomized in a double-blind fashion to receive either 0.9 mg/kg of nebulized 2.25% racemic epinephrine (n = 34) or 0.15 mg/kg of nebulized 0.5% albuterol sulfate (n = 32) at 0, 30, and 60 minutes. MAIN OUTCOME MEASURES: Primary outcome measures were clinical score and respiratory rate. Secondary outcome measures were room air oxygen saturation, elapsed time to meeting clinical criteria for ED discharge, hospitalization rate, and proportion of patients relapsed within 72 hours of ED discharge (relapse rate). RESULTS: Both treatment groups experienced a similar pattern of change in mean clinical score, respiratory rate, and room air saturation over time. There were no significant differences between the groups by these same measures at any time. The median time at which infants were well enough for ED discharge was 90 minutes in the epinephrine-treated group vs 120 minutes in the albuterol-treated group (P =.01). Sixteen infants (47.1%) in the epinephrine-treated group were hospitalized compared with 12 infants (37.5%) in the albuterol-treated group (relative risk, 1.25; 95% confidence interval, 0.71-2.22). Relapse rate was 18.8% (3/16) in the epinephrine-treated group and 42.1% (8/19) in the albuterol-treated group (relative risk, 0.45; 95% confidence interval, 0.14-1.41). Adverse effects occurred infrequently. CONCLUSIONS: Although the patients treated with epinephrine were judged well enough for ED discharge significantly earlier than the patients treated with albuterol, epinephrine was not found to be more efficacious than albuterol in treating moderately ill infants with bronchiolitis.     

Randomized trial of salbutamol in acute bronchiolitis

To test whether nebulized salbutamol (albuterol) is safe and efficacious for the treatment of young children with acute bronchiolitis, we enrolled 83 children (median age 6 months, range 1 to 21 months) in a randomized, double-blind clinical trial. Participants received two treatments at 30-minute intervals of either nebulized salbutamol (0.10 mg/kg in 2 ml 0.9% saline solution) or a similar volume of 0.9% saline solution placebo. Outcome measures were the respiratory rate, pulse oximetry, and a clinical score based on the degree of wheezing and retractions. Patients in the salbutamol arm had significantly greater improvement in clinical scores after the initial treatment (p = 0.04). There was no difference between the groups in oxygen saturation (p = 0.74); patients treated with salbutamol had a small increase in heart rate after two treatments (159 +/- 16 vs 151 +/- 16; p = 0.03). We conclude that salbutamol is safe and effective for the initial treatment of young children with acute bronchiolitis.     

Randomised controlled trial of budesonide for the prevention of post-bronchiolitis wheezing

BACKGROUND—Previous studies suggest that recurrent episodes of coughing and wheezing occur in up to 75% of infants after acute viral bronchiolitis.AIM—To assess the efficacy of budesonide given by means of a metered dose inhaler, spacer, and face mask in reducing the incidence of coughing and wheezing episodes up to 12 months after acute viral bronchiolitis.METHODS—Children under the age of 12 months admitted to hospital with acute viral bronchiolitis were randomised to receive either budesonide or placebo (200 µg or one puff twice daily) for the next eight weeks. Parents kept a diary card record of all episodes of coughing and wheezing over the next 12months.RESULTS—Full follow up data were collected for 49 infants. There were no significant differences between the two study groups for the number of infants with symptom episodes up to six months after hospital discharge. At 12 months, 21 infants in the budesonide group had symptom episodes compared with 12 of 24 in the placebo group. The median number of symptom episodes was 2 (range, 0-13) in those who received budesonide and 1 (range, 0-11) in those who received placebo. Because there is no pharmacological explanation for these results, they are likely to be caused by a type 1 error, possibly exacerbated by there being more boys in the treatment group.CONCLUSION—Routine administration of budesonide by means of a metered dose inhaler, spacer, and face mask system immediately after acute viral bronchiolitis cannot be recommended.     

毛细支气管炎与哮喘的关系

毛细支气管炎是引起2岁以下婴幼儿喘息发作的主要病因,多由病毒感染引起,其中呼吸道合胞病毒（RSV）和鼻病毒（RV）是最常见的病原体。近年来,研究发现生后早期RSV和RV感染诱发的毛细支气管可能与患儿日后反复喘息发作甚至发展为哮喘密切相关。该文拟对RSV和RV感染后诱发的毛细支气管炎与日后反复喘息发作及发展为哮喘的关系、病毒感染后对肺功能的长期影响、发展为哮喘可能的发病机制和危险因素及预防策略等方面问题进行介绍。     

毛细支气管炎的病原学及临床流行病学特征

毛细支气管炎是婴幼儿常见的急性下呼吸道感染性疾病。毛细支气管炎主要由病毒感染引起,其中呼吸道合胞病毒（RSV）最常见,肺炎支原体、 肺炎衣原体、沙眼衣原体等感染也可引起毛细支气管炎。毛细支气管炎主要发生于 2 岁以下婴幼儿,发病高峰年龄为 2～6 月龄。毛细支气管炎是导致婴儿住院的最常见原因,6月龄以下的婴儿入院率最高。由于毛细支气管炎主要是 RSV 感染所致,所以其季节特征与当地RSV的流行特征相似。毛细支气管炎是一种发病率高但病死率低的疾病。年龄＜3月龄、早产儿、先天性心脏病等是重症毛细支气管炎的危险因素。     

Association between multiple respiratory viral infections and pediatric intensive care unit admission among infants with bronchiolitis

BackgroundIt is unclear whether multiple respiratory viral infections are associated with more severe bronchiolitis requiring pediatric intensive care unit (PICU) admission. We aimed to identify the association between multiple respiratory viral infections and PICU admission among infants with bronchiolitis.MethodsWe performed a 1:1 case-control study enrolling previously healthy full-term infants (≤12 months) with bronchiolitis admitted to the PICU as cases and those to the general pediatric ward as controls from 2015 to 2017. Multiplex polymerase chain reaction (PCR) was used for detection of the respiratory viruses. We summarized the characteristics of infants admitted to the PICU and the general pediatric unit. Multivariable logistic regression analysis was used to fit the association between multiple respiratory viral infections (≥2 strains) and PICU admission.ResultsA total of 135 infants admitted to the PICU were compared with 135 randomly selected control infants admitted to the general pediatric unit. The PICU patients were younger (median: 2.2 months, interquartile range: 1.3–4.2) than the general ward patients (median: 3.2 months, interquartile range: 1.6–6.4). Respiratory syncytial virus (74.1%), rhinovirus (28.9%), and coronavirus (5.9%) were the most common viruses for bronchiolitis requiring PICU admission. Patients with bronchiolitis admitted to the PICU tended to have multiple viral infections compared with patients on the general ward (23.0% vs. 10.4%, P < 0.001). In the multivariable logistic regression analysis, bronchiolitis with multiple viral infections was associated with higher odds of PICU admission (adjusted odds ratio: 2.56, 95% confidence interval: 1.17–5.57, P = 0.02).ConclusionInfants with multiviral bronchiolitis have higher odds of PICU admission compared with those with a single or nondetectable viral infection.     

Bronchiolitis in young infants: is it a risk factor for recurrent wheezing in childhood?

Background

Acute bronchiolitis in infancy is considered a risk factor for recurrent wheezing episodes in childhood. The present study assessed prevalence, clinical manifestations and risk factors for recurrent wheezing events during the first 3 years of life and persistent wheezing events beyond this age in children hospitalized as young infants with acute bronchiolitis.

Methods

Two groups of children aged 6 years were included. The study group comprised 150 children with a history of hospitalization for bronchiolitis, with the first event at <6 months of age. The control group comprised 66 age- and sex-matched children with no history of bronchiolitis before 6 months of age. Children in both groups had been followed until 6 years of age by their pediatricians; data were obtained retrospectively by reviewing ambulatory records during children’s visits in pediatricians’ clinics. The data included epidemiological parameters, prevalence, age at onset, number of and treatments given for episodes of wheezing events prior to 6 years of age, pathogens detected, and severity of acute bronchiolitis in the study group.

Results

Overall, 58% and 27% of children in the study and control groups, respectively (P=0.001) had recurrent wheezing episodes prior to the age of 3 years. Children in the study group had earlier onset of recurrent wheezing, had more episodes of wheezing, and required more bronchodilator and systemic steroids treatments compared to the control group.

Conclusion

Hospitalization within the first six months of life for acute bronchiolitis is an independent risk factor for recurrent wheezing episodes during the first 3 years of life.

     

毛细支气管炎预后影响因素及出院后管理

毛细支气管炎是婴幼儿常见的一种下呼吸道感染性疾病,有较高的发病率,严重影响儿童身体健康。多种因素可影响毛细支气管炎预后,针对影响其预后的因素,采取一定的预防和治疗措施,能减少部分患儿再次喘息的发生。     

毛细支气管炎治疗新观点

毛细支气管炎是婴幼儿较常见的下呼吸道感染,多由呼吸道合胞病毒引起。目前的治疗主要为包括氧疗、控制喘息、维持内环境稳定等的综合治疗。多数毛细支气管炎尚缺乏特异性的病原治疗药物。探讨毛细支气管炎治疗新方法有助于改善患儿症状、缩短住院日,改善中重度毛细支气管炎患儿、尤其是＜6月龄且有高危因素的患儿预后。     

Bronchiolitis in infants

Bronchiolitis is a common cause of wheezing among infants. Respiratory syncytial virus (RSV) is the most common infectious agent to cause bronchiolitis, and RSV infection accounts for more than 125,000 hospitalizations per year in the United States. Beyond supportive measures, the care of infants with bronchiolitis remains controversial. Practitioners continue to treat infants with a variety of pharmacologic agents, despite limited evidence of their efficacy. Investigators continue to search for the safest and most cost-effective methods to treat infants with bronchiolitis, not only to overcome obstructive symptoms during the acute illness, but also to prevent recurrent symptoms of airway obstruction that occur in some children for years after their initial episode of bronchiolitis. Improved understanding of the pathogenesis of RSV infection and of virus-host interactions may one day lead to the development of agents that alter the initial inflammatory response and strategies that help prevent recurrent episodes of wheezing and the development of asthma after acute bronchiolitis.     

From acute viral bronchiolitis in infancy to asthma in childhood]

Bronchiolitis and wheezy bronchitis are frequently associated with viral infection of the respiratory tract in infants. They play an important role in the natural history of chronic obstructive airway disease, not only in children, but also in adults. The risk of early recurrent wheezing and subsequent asthma or chronic bronchitis (with anatomical sequelae such as obliterans bronchiolitis) is significant. The precise pathogenic mechanisms of virus-induced wheezing and its sequelae are not clear. Whether airway hyperreactivity is inherited and airway hyperreactivity is present prior to, or is the result of bronchiolitis is not clear. Nevertheless the evidence for viral trigger of wheezing and long-term pulmonary sequelae must be considered and prevention must be undertaken at the first episode.     

Parainfluenza virus bronchiolitis. Epidemiology and pathogenesis

An investigation of the epidemiology and pathogenesis of bronchiolitis due to parainfluenza virus (PV) was carried out. Bronchiolitis due to PV occurred most commonly in non-Caucasian males. Breast-fed infants exhibited a reduced risk of developing bronchiolitis. Once an episode of PV bronchiolitis occurred, both exposure to cigarette smoke and bottle feeding were associated with an increased frequency of recurrent wheezing, and subsequent infection with respiratory virus almost uniformly resulted in wheezing. Cell-mediated immune responses to PV antigen and titers of PV-specific IgE were greater among patients with bronchiolitis than among patients with upper respiratory tract infection. The epidemiology and pathogenesis of bronchiolitis due to PV is similar to that of respiratory syncytial virus. Lower respiratory tract infection may predispose to episodes of bronchoconstriction on subsequent exposure to cigarette smoke or other viral infections.