INTRODUCTION:

Bronchiolitis is the most common lower respiratory tract infection in infants, occurring in a seasonal pattern, with highest incidence in the winter in temperate climates and in the rainy season in warmer countries. Bronchiolitis is a common reason for attendance at and admission to hospital.

METHODS AND OUTCOMES:

We conducted a systematic review and aimed to answer the following clinical questions: What are the effects of prophylactic interventions for bronchiolitis in high-risk children? What are the effects of measures to prevent transmission of bronchiolitis in hospital? What are the effects of treatments for children with bronchiolitis? We searched: Medline, Embase, The Cochrane Library, and other important databases up to July 2010 (Clinical Evidence reviews are updated periodically, please check our website for the most up-to-date version of this review). We included harms alerts from relevant organisations such as the US Food and Drug Administration (FDA) and the UK Medicines and Healthcare products Regulatory Agency (MHRA).

RESULTS:

We found 59 systematic reviews, RCTs, or observational studies that met our inclusion criteria. We performed a GRADE evaluation of the quality of evidence for interventions.

CONCLUSIONS:

In this systematic review we present information relating to the effectiveness and safety of the following interventions: antibiotics, bronchodilators (oral, inhaled salbutamol, inhaled adrenaline [epinephrine], hypertonic saline), chest physiotherapy, continuous positive airway pressure, corticosteroids, fluid management, heliox, montelukast, nasal decongestants, nursing interventions (cohort segregation, hand washing, gowns, masks, gloves, and goggles), oxygen, respiratory syncytial virus immunoglobulins, pooled immunoglobulins, or palivizumab (monoclonal antibody), ribavirin, or surfactants.

BACKGROUND:

Bronchiolitis is an acute, viral lower respiratory tract infection affecting infants and is sometimes treated with bronchodilators.

OBJECTIVES:

To assess the effects of bronchodilators on clinical outcomes in infants (0 to 12 months) with acute bronchiolitis.

SEARCH METHODS:

We searched CENTRAL 2013, Issue 12, MEDLINE (1966 to January Week 2, 2014) and EMBASE (1998 to January 2014).

SELECTION CRITERIA:

Randomized controlled trials (RCTs) comparing bronchodilators (other than epinephrine) with placebo for bronchiolitis.

DATA COLLECTION AND ANALYSIS:

Two authors assessed trial quality and extracted data. We obtained unpublished data from trial authors.

MAIN RESULTS:

We included 30 trials (35 data sets) representing 1992 infants with bronchiolitis. In 11 inpatient and 10 outpatient studies, oxygen saturation did not improve with bronchodilators (mean difference (MD) -0.43, 95% confidence interval (CI) -0.92 to 0.06, n = 1242). Outpatient bronchodilator treatment did not reduce the rate of hospitalization (11.9% in bronchodilator group versus 15.9% in placebo group, odds ratio (OR) 0.75, 95% CI 0.46 to 1.21, n = 710). Inpatient bronchodilator treatment did not reduce the duration of hospitalization (MD 0.06, 95% CI -0.27 to 0.39, n = 349).
Effect estimates for inpatients (MD -0.62, 95% CI -1.40 to 0.16) were slightly larger than for outpatients (MD -0.25, 95% CI -0.61 to 0.11) for oximetry. Oximetry outcomes showed significant heterogeneity (I2 statistic = 81%). Including only studies with low risk of bias had little impact on the overall effect size of oximetry (MD -0.38, 95% CI -0.75 to 0.00) but results were close to statistical significance.
In eight inpatient studies, there was no change in average clinical score (standardized MD (SMD) -0.14, 95% CI -0.41 to 0.12) with bronchodilators. In nine outpatient studies, the average clinical score decreased slightly with bronchodilators (SMD -0.42, 95% CI -0.79 to -0.06), a statistically significant finding of questionable clinical importance. The clinical score outcome showed significant heterogeneity (I2 statistic = 73%). Including only studies with low risk of bias reduced the heterogeneity but had little impact on the overall effect size of average clinical score (SMD -0.22, 95% CI -0.41 to -0.03).
Sub-analyses limited to nebulized albuterol or salbutamol among outpatients (nine studies) showed no effect on oxygen saturation (MD -0.19, 95% CI -0.59 to 0.21, n = 572), average clinical score (SMD -0.36, 95% CI -0.83 to 0.11, n = 532) or hospital admission after treatment (OR 0.77, 95% CI 0.44 to 1.33, n = 404).
Adverse effects included tachycardia, oxygen desaturation and tremors.

AUTHORS' CONCLUSIONS:

Bronchodilators such as albuterol or salbutamol do not improve oxygen saturation, do not reduce hospital admission after outpatient treatment, do not shorten the duration of hospitalization and do not reduce the time to resolution of illness at home. Given the adverse side effects and the expense associated with these treatments, bronchodilators are not effective in the routine management of bronchiolitis. This meta-analysis continues to be limited by the small sample sizes and the lack of standardized study design and validated outcomes across the studies. Future trials with large sample sizes, standardized methodology across clinical sites and consistent assessment methods are needed to answer completely the question of efficacy.

ANTECEDENTES:

Los broncodilatadores se usan comúnmente para la bronquiolitis aguda, a pesar de que su efectividad es incierta.

OBJETIVOS:

Analizar la eficacia y la seguridad de la epinefrina en niños menores de dos años de edad con bronquiolitis viral aguda.

ESTRATEGIA DE BÚSQUEDA:

Se realizaron búsquedas en CENTRAL (2010, Número 3) que contiene el Registro Especializado de Ensayos Controlados del Grupo Cochrane de Infecciones Respiratorias Agudas (Acute Respiratory Infections Group's Specialized Register), MEDLINE (1950 hasta la segunda semana de septiembre, 2010), EMBASE (1980 a setiembre de 2010), Scopus (1823 a setiembre de 2010), PubMed (marzo de 2010), LILACS (1985 a setiembre de 2010) e Iran MedEx (1998 a setiembre de 2010).

CRITERIOS DE SELECCIÓN:

Se incluyeron ensayos controlados con asignación aleatoria que comparaban la epinefrina con placebo u otra intervención que incluía a niños menores de dos años con bronquiolitis viral aguda. Los estudios se incluyeron cuando los ensayos presentaban datos sobre al menos una medida de resultado cuantitativa de interés.
Se seleccionaron las medidas de resultado primarias a priori, sobre la base de la relevancia clínica: tasa de ingreso en los días uno y siete de la presentación para los pacientes ambulatorios, y duración de la estancia hospitalaria para los pacientes hospitalizados. Las medidas de resultado secundarias incluyeron puntuaciones clínicas de la gravedad, la función pulmonar, los síntomas, la calidad de vida y los eventos adversos.

OBTENCIÓN Y ANÁLISIS DE LOS DATOS:

Dos revisores analizaron las búsquedas, aplicaron los criterios de inclusión, evaluaron el riesgo de sesgo y calificaron las pruebas de forma independiente. Se realizaron análisis separados para los diferentes grupos de comparación (placebo, broncodilatadores sin epinefrina, glucocorticoides) y para el ámbito clínico (hospitalario, ambulatorio).

RESULTADOS PRINCIPALES:

Se incluyeron 19 estudios (2 256 participantes). La epinefrina versus placebo entre los pacientes ambulatorios mostró una reducción significativa de los ingresos en el Día 1 (cociente de riesgos [CR] 0,67; intervalo de confianza [IC] del 95%: 0,50 a 0,89) pero no en el Día 7 después de la visita al servicio de urgencias. No hubo diferencias en la duración de la estancia hospitalaria para los pacientes hospitalizados. La epinefrina versus salbutamol no mostró ninguna diferencia entre los pacientes ambulatorios en cuanto a los ingresos en el Día 1 o 7. Los pacientes hospitalizados que recibieron epinefrina tuvieron duraciones de la estancia hospitalaria significativamente más cortas en comparación con el salbutamol (diferencia de medias −0,28; IC del 95%: −0,46 a −0,09). Un ECA amplio mostró una tasa de ingresos significativamente más corta en el Día 7 para la combinación de epinefrina y esteroide versus placebo (CR 0,65; IC del 95%: 0,44 a 0,95). No hubo diferencias importantes en los eventos adversos.

CONCLUSIONES DE LOS AUTORES:

Esta revisión demuestra la superioridad de la epinefrina comparada con el placebo en cuanto a los resultados a corto plazo para los pacientes ambulatorios, en particular en las primeras 24 horas de atención. Las pruebas exploratorias de un único estudio indican los beneficios de la combinación de epinefrina y esteroide para los puntos temporales posteriores. Se necesita más investigación para confirmar los beneficios de la combinación de epinefrina y esteroides entre los pacientes ambulatorios. No existen pruebas de efectividad para las dosis repetidas o el uso prolongado de epinefrina o epinefrina más dexametasona en pacientes hospitalizados.

Bronchiolitis is a disorder most commonly caused in infants by viral lower respiratory tract infection. It is the most common lower respiratory infection in this age group. It is characterized by acute inflammation, edema, and necrosis of epithelial cells lining small airways, increased mucus production, and bronchospasm. The American Academy of Pediatrics convened a committee composed of primary care physicians and specialists in the fields of pulmonology, infectious disease, emergency medicine, epidemiology, and medical informatics. The committee partnered with the Agency for Healthcare Research and Quality and the RTI International-University of North Carolina Evidence-Based Practice Center to develop a comprehensive review of the evidence-based literature related to the diagnosis, management, and prevention of bronchiolitis. The resulting evidence report and other sources of data were used to formulate clinical practice guideline recommendations. This guideline addresses the diagnosis of bronchiolitis as well as various therapeutic interventions including bronchodilators, corticosteroids, antiviral and antibacterial agents, hydration, chest physiotherapy, and oxygen. Recommendations are made for prevention of respiratory syncytial virus infection with palivizumab and the control of nosocomial spread of infection. Decisions were made on the basis of a systematic grading of the quality of evidence and strength of recommendation. The clinical practice guideline underwent comprehensive peer review before it was approved by the American Academy of Pediatrics. This clinical practice guideline is not intended as a sole source of guidance in the management of children with bronchiolitis. Rather, it is intended to assist clinicians in decision-making. It is not intended to replace clinical judgment or establish a protocol for the care of all children with this condition. These recommendations may not provide the only appropriate approach to the management of children with bronchiolitis.

Infants admitted to health-care centers with acute bronchiolitis are frequently monitored with a pulse oximeter, a noninvasive method commonly used for measuring oxygen saturation. The decision to hospitalize children with bronchiolitis has been largely influenced by pulse oximetry, despite its questionable diagnostic value in delineating the severity of the illness. Many health-care providers lack the appropriate clinical fundamentals and limitations of pulse oximetry. This deficiency in knowledge might have been linked to changes in the management of bronchiolitis. The aim of this paper is to provide the current evidence on the role of pulse oximetry in bronchiolitis. We discuss the history, fundamentals of operation, and limitations of the apparatus. A search of the Google Scholar, Embase, Medline, and PubMed databases was carried out for published articles covering the use of pulse oximetry in bronchiolitis.

La bronquiolitis es una patología prevalente en niños menores de dos años que conlleva importante morbimortalidad. No obstante, aún existe controversia sobre el manejo más adecuado. Se ha planteado el uso de los inhibidores de leucotrienos como opción terapéutica, sin embargo no está clara su real utilidad clínica. Utilizando la base de datos Epistemonikos, la cual es mantenida mediante búsquedas en múltiples bases de datos, identificamos dos revisiones sistemáticas que en conjunto incluyen seis estudios aleatorizados controlados pertinentes a la pregunta. Extrajimos los datos, realizamos un metanálisis y preparamos tablas de resumen de los resultados utilizando el método GRADE. Concluimos que los inhibidores de leucotrienos podrían no disminuir la mortalidad en pacientes con bronquiolitis y no está claro si disminuyen los días de hospitalización. Podrían disminuir las recurrencias de cuadros sibilantes en pacientes con bronquiolitis, pero la certeza de la evidencia es baja y, por otra parte, aumentan los efectos adversos.

Este artículo no tiene resumen

INTRODUCCIÓN:

La bronquiolitis corresponde a una inflamación aguda de las vías aéreas pequeñas secundaria a infección viral y es una patología frecuente en menores de dos años. Se ha propuesto que el uso de corticoides inhalatorios durante una bronquiolitis podría reducir la recurrencia de sibilancias o el desarrollo de asma, sin embargo, existe controversia al respecto.

MÉTODOS:

Para responder a esta interrogante utilizamos Epistemonikos, la mayor base de datos de revisiones sistemáticas en salud, la cual es mantenida mediante búsquedas en múltiples fuentes de información, incluyendo MEDLINE, EMBASE, Cochrane, entre otras. Extrajimos los datos desde las revisiones identificadas, reanalizamos los datos de los estudios primarios, realizamos un metanálisis y preparamos una tabla de resumen de los resultados utilizando el método GRADE.

RESULTADOS Y CONCLUSIONES:

Identificamos tres revisiones sistemáticas que en conjunto incluyen 11 ensayos aleatorizados. Concluimos que el uso de corticoides inhalatorios no reduce la recurrencia de sibilancias o asma en pacientes con bronquiolitis.

Objetivo. Formular un criterio para la detección temprana de las epidemias de bronquiolitis en Guadalupe, a fin de aplicar de manera más oportuna mejores estrategias de prevención y control. Métodos. Se usaron las cifras semanales de los casos de bronquiolitis notificados desde julio del 2005 hasta julio del 2010 por la red de vigilancia de Guadalupe. El criterio para detectar las epidemias se estableció con los datos de las temporadas de bronquiolitis del 2005 al 2009. En primer lugar, se predijo el nivel basal de bronquiolitis ajustando una regresión periódica a los casos observados fuera de las epidemias; luego se pusieron a prueba nueve posibles criterios para definir las epidemias combinando un umbral estadístico establecido a diferentes niveles y un número de semanas consecutivas con las observaciones ubicadas por encima y por debajo de ellos; por último, se seleccionó el criterio óptimo conforme a su desempeño, usando el asesoramiento de expertos como criterio de referencia. El criterio seleccionado se validó con los datos de la temporada 2009­2010. Resultados. El nivel basal de bronquiolitis presentaba una tendencia lineal y dos funciones sinusoidales de 52 y 26 semanas (R2 = 45%). Según el criterio de epidemia seleccionado, se fijó el umbral estadístico en el límite superior del intervalo de confianza de 95% unilateral del nivel basal de bronquiolitis previsto; para establecer el comienzo de una epidemia se requerían 2 semanas consecutivas con casos por encima de él, y 3 semanas con casos por debajo para determinar su finalización. La mediana del retraso para lanzar las alertas fue 2 semanas; hubo una alerta falsa; y la sensibilidad, la especificidad y el valor predictivo positivo para detectar las semanas de epidemia fueron 98%, 96% y 95%, respectivamente. Durante el período de validación se emitió, según el criterio, una alerta falsa y se detectó la epidemia con 4 semanas de retraso. Conclusiones. Este criterio ayuda a los epidemiólogos a interpretar de manera oportuna los datos epidemiológicos de bronquiolitis a fin de tomar decisiones en Guadalupe. En el futuro, debe actualizarse según las tendencias en la epidemiología de la bronquiolitis, y mejorarse mediante su integración con indicadores virológicos. También debe promoverse su inclusión en una estrategia integrada de manejo para la prevención y el control de la bronquiolitis, apoyada por una red de salud pública relacionada con la bronquiolitis

BACKGROUND:

Bronchiolitis is the leading cause of hospitalisation among infants in high-income countries. Acute viral bronchiolitis is associated with airway obstruction and turbulent gas flow. Heliox, a mixture of oxygen and the inert gas helium, may improve gas flow through high-resistance airways and decrease the work of breathing. In this review, we selected trials that objectively assessed the effect of the addition of heliox to standard medical care for acute bronchiolitis.

OBJECTIVES:

To assess heliox inhalation therapy in addition to standard medical care for acute bronchiolitis in infants with respiratory distress, as measured by clinical endpoints (in particular the rate of endotracheal intubation, the rate of emergency department discharge, the length of treatment for respiratory distress) and pulmonary function testing (mainly clinical respiratory scores).

SEARCH METHODS:

We searched CENTRAL (2015, Issue 2), MEDLINE (1966 to March week 3, 2015), EMBASE (1974 to March 2015), LILACS (1982 to March 2015) and the National Institutes of Health (NIH) website (May 2009).

SELECTION CRITERIA:

Randomised controlled trials (RCTs) and quasi-RCTs of heliox in infants with acute bronchiolitis.

DATA COLLECTION AND ANALYSIS:

Two review authors independently extracted data and assessed trial quality.

MAIN RESULTS:

We included seven trials involving 447 infants younger than two years with respiratory distress secondary to viral bronchiolitis. All children were recruited from a paediatric intensive care unit (PICU; 378 infants), except in one trial (emergency department; 69 infants). All children were younger than two (under nine months in two trials and under three months in one trial). Positive tests for respiratory syncytial virus (RSV) were required for inclusion in five trials. The two other trials were carried out in the bronchiolitis seasons. Seven different protocols were used for inhalation therapy with heliox.When heliox was used in the PICU, we observed no significant reduction in the rate of intubation: risk ratio (RR) 2.73 (95% confidence interval (CI) 0.96 to 7.75, four trials, 408 infants, low quality evidence). When heliox inhalation was used in the emergency department, we observed no increase in the rate of discharge: RR 0.51 (95% CI 0.17 to 1.55, one trial, 69 infants, moderate quality evidence).There was no decrease in the length of treatment for respiratory distress: mean difference (MD) -0.19 days (95% CI -0.56 to 0.19, two trials, 320 infants, moderate quality evidence). However, in the subgroup of infants who were started on nasal continuous positive airway pressure (nCPAP) right from the start, because of severe respiratory distress, heliox therapy reduced the length of treatment: MD -0.76 days (95% CI -1.45 to -0.08, one trial, 21 infants, low quality evidence). No adverse events related to heliox inhalation were reported.We found that infants treated with heliox inhalation had a significantly lower mean clinical respiratory score in the first hour after starting treatment when compared to those treated with air or oxygen inhalation: MD -1.04 (95% CI -1.60 to -0.48, four trials, 138 infants, moderate quality evidence). This outcome had statistical heterogeneity, which remained even after removing the study using a standard high-concentration reservoir mask. Several factors may explain this heterogeneity, including first the limited number of patients in each trial, and the wide differences in the baseline severity of disease between studies, with the modified Wood Clinical Asthma Score (m-WCAS) in infants treated with heliox ranging from less than two to more than seven.

AUTHORS' CONCLUSIONS:

Current evidence suggests that the addition of heliox therapy may significantly reduce a clinical score evaluating respiratory distress in the first hour after starting treatment in infants with acute RSV bronchiolitis. We noticed this beneficial effect regardless of which heliox inhalation protocol was used. Nevertheless, there was no reduction in the rate of intubation, in the rate of emergency department discharge, or in the length of treatment for respiratory distress. Heliox could reduce the length of treatment in infants requiring CPAP for severe respiratory distress. Further studies with homogeneous logistics in their heliox application are needed. Inclusion criteria must include a clinical severity score that reflects severe respiratory distress to avoid inclusion of children with mild bronchiolitis who may not benefit from heliox inhalation. Such studies would provide the necessary information as to the appropriate place for heliox in the therapeutic schedule for severe bronchiolitis.