Bronchodilators don't help bronchiolitis

Autumn brings the start of another
Respiratory Syncytial Virus (RSV) season in the U.S., a virus that can
cause bronchiolitis in younger children. The wheezing - and sometimes
decreased oxygen saturation - of bronchiolitis can be scary for parents
and physicians alike; since bronchodilators like albuterol help many
older kids and adults with wheezing, it seems intuitive that they would
help bronchiolitis as well. The November 1 issue of AFP discusses
a Cochrane update, however, demonstrating that bronchodilators don't
improve outcomes in most kids aged less than 2 years with bronchiolitis.

The Cochrane reviewers found
that, in children less than 24 months old with bronchiolitis who were
wheezing for the first time, bronchodilators didn't improve oxygen
saturation, didn't keep children in the Emergency Department from
getting admitted to the hospital, and didn't reduce the length of stay
in children already admitted to the hospital. Unfortunately,
bronchodilators also caused harm; children who received them were more
likely to have tachycardia and decreased oxygen saturation.

It can be frustrating to see child suffering with bronchiolitis and not be able to offer treatment with a medication, but a recent AFP article on RSV infection reinforces
that no studied pharmaceutical interventions have demonstrated a
meaningful impact on patient-oriented outcomes. Hydration and
supplemental oxygen remain the treatments of choice for the more than 90,000 children admitted with bronchiolitis in the U.S. every year; fewer children are being admitted in recent years than in the past, but the children who are being admitted are more likely to have high-risk conditions and require mechanical ventilation.

3
of the 5 Choosing Wisely recommendations from the Society of Hospital
Medicine - Pediatric Hospital Medicine relate to bronchiolitis and/or respiratory tract infections in young children:

1. Don't order chest radiographs in children with uncomplicated asthma or bronchiolitis.
2. Don't routinely use bronchodilators in children with bronchiolitis.
3. Don't use systemic corticosteroids in children under 2 years of age with an uncomplicated lower respiratory tract infection.

Pediatrics just published a clinical practice guideline on bronchiolitis that reinforces those points. 


If you'd like to read more, there's an AFP By Topic on Upper Respiratory Tract Infections that includes this risk stratification point-of-care guide for treatment of infants with bronchiolitis. You can follow RSV infection rates specific to your region of the U.S. at this CDC website. 

Will this Cochrane review change how you treat young children with bronchiolitis?