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Is nebulised salbutamol indicated in bronchiolitis?

Three Part Question

In [infants with bronchiolitis] will a [treatment with nebulised salbutamol] reduce [the length of hospitalisation and clinical severity].

Clinical Scenario

A 6 month old baby is admitted to hospital with a 4 day history of coryzal symptoms, cough, wheeze and poor feeding. Your clinical diagnosis is bronchiolitis. You wonder whether treatment with nebulised salbutamol would improve the clinical condition.

Search Strategy

Medline 1966-2008, Embase 1980-2008, Cochrane database of systematic reviews and Cochrane central register of controlled trials.
(Nebulised salbutamol or salbutamol or bronchodilators ) AND (bronchiolitis or rsv bronchiolitis) Limit to human, English and randomised controlled trials.

Search Outcome

68 Hits, 9 relevant papers found.

Relevant Paper(s)

Author, date and country Patient group Study type (level of evidence) Outcomes Key results Study Weaknesses
Schuh S. et al
1990
Canada
40 infants (6 weeks - 2 years) Nebulised salbutamol vs placeboRandomised double blind placebo controlled trialRespiratory rateSignificantly greater improvement with salbutamolNo microbiological confirmation of diagnosis in 16/40 (40%) patients. Clinical score inadequate to reflect the respiratory distress of the child. No information on statistical analysis of base line characterstics.
Heart rateSignificantly improved after second dose of salbutamol
Accessory muscle scoreSignificantly greater improvement with salbutamol
Wheezing scoreNo significant difference
Oxygen saturationSignificantly greater improvement with salbutamol
KlassenTP. et al
1991
Canada
83 children (1-21 months) Nebulised salbutamol vs placeboRandomised double blind placebo controlled trialClinical scoreNo significant difference after 1 hourExclusion of patients with severe disease. No microbiological confirmation of diagnosis in 42 % of patients.
Respiratory rateNo significant difference
Oxygen saturationNo significant difference
Gadomski AM .et al
1994
Egypt
128 infants (less than 18 months). Nebulised salbutamol vs nebulised saline vs oral salbutamol vs oral placebo.Double blind placebo controlled trialRespiratory rateNo significant differenceMicrobiological confirmation of diagnosis in only 42% of patients. No data regarding individual or family history of atopy.
Clinical scoreNo significant difference
Oxygen saturationNo significant difference
Heart rateSignificant increase in nebulised salbutamol group compared to placebo
Gadomski AM. et al
1994
USA
88 infants (median age - 5.5 months) Nebulised salbutamol vs nebulised saline vs oral salbutamol vs oral placebo.Randomised double blind placebo controlled trialRespiratory rateNo significant differenceNo statistical information about comparison of base line characterstics. State (falling asleep, waking up) of infant not controlled.
Heart rateNo significant difference
Clinical scoreNo significant difference
Oxygen saturationNo significant difference
Chowdhury D. et al
1995
Saudi Arabia
89 children (23 days-11 months). Nebulised salbutamol vs nebulised ipratropium bromide vs nebulised saline & ipratropium bromide vs saline.Randomised placebo controlled clinical trialClinical scoreNo significant differenceNo blinding. Not all patients included.
Length of hospital stayNo significant difference
Goh A. et al
1997
Singapore
120 children (age less than 2 years). Nebulised salbutamol vs nebulised ipratropium bromide vs nebulised saline vs humidified oxygen.Randomised double blind placebo controlled trialLength of hospital stayNo significant differenceSecond control group added later.
Clinical severity scoreNo significant difference
Dobson JV. et al
1998
USA
52 patients (age less than 2 years). Nebulised salbutamol vs saline.Randomised double blind placebo controlled trialClinical severity scoreNo significant differenceStudy too small for adequately powered survival analysis.
Length of hospital stayNo significant difference
Frequency of adverse eventsNo significant difference
Improvement in oxygen saturationNo significant difference
Ho L. et al
1991
Australia
21 infants (3 weeks-6 months). Nebulised salbutamol vs placebo.Randomised double blind placebo controlled trialOxygen saturation profileSignificant desaturation after salbutamolArbitary choice of 4% drop in saturation as a tool for statistical analysis. Definition of excluded severely ill children not mentioned.
Time for saturation to normailseSignificantly longer time after salbutamol
Time to reach minimum saturationnNo significant difference
Wang EE.et al
1992
Canada
62 children (2 months- 2 years). Nebulised salbutamol or placebo vs ipratropium or placebo.Randomised double blind placebo controlled trialOxygen saturationNo significant differenceSelection bias. Use of variety of different significance levels. No microbiological confirmation of diagnosis in 73% of patients.
Clinical severity scoreNo significant difference
Length of hospital stayNo significant difference

Comment(s)

All the studies compared the clinical severity score. Seven of these studies showed no significant difference between the salbutamol and placebo group. Three studies looked at the length of hospital stay and showed no significant difference between the salbutamol group and the placebo group. The study by Ling Ho et. al showed significant desaturation after nebulised salbutamol compared to placebo. They also showed that the patients in the salbutamol group took longer to normalise their oxygen saturation levels after a desaturation. The only study showing a clinical benefit of salbutamol was the study of Schuh et al. This study showed that there was a significantly greater improvement in respiratory rate and accessory muscle score after nebulised salbutamol compared to placebo. Gadomski. et. al found a significant increase in heart rate in patients treated with nebulised salbutamol compared to oral placebo.

Clinical Bottom Line

Current evidence does not support the use of nebulised salbutamol in patients with bronchiolitis.

References

  1. Schuh S, Canny G, Reismann JJ, Kerem E, Bentur L, Petric M, Levison H. Nebulised albuterol in acute bronchiolitis. Journal of Pediatrics. 1990;117(4):633-637.
  2. Klassen TP, Rowe PC, Sutcliffe T, Ropp LJ, McDowell IW, Li MM. Randomised trial of salbutamol in acute bronchiolitis. The Journal of Pediatrics. 1991;118(5):807-811.
  3. Gadomski AM, Aref GH, EL Din OB, EL Sawy IH, Khallaf N, Black RE. Oral versus nebulised albuterol in the management of bronchiolitis in Egypt. The Journal of Pediatrics. 1994;124(1):131-138.
  4. Gadomski AM, Lichenstein R, Horton L, King J, Keane V, Permutt T. Efficacy of albuterol in the management of bronchiolitis. Pediatrics. 1994;93(6 Pt 1);907-912.
  5. Chowdhury D, Al Howasi M, Khalil M, Al-Frayh AS, Chowdhury S, Ramia S. The role of bronchodilators in the management of bronchiolitis: a clinical trial Annals of Tropical Paediatrics. 1995;15(1):77-84.
  6. Goh A, Chay OM, Foo AL, Ong EK. Efficacy of bronchodilators in the treatment of bronchiolitis. Singapore Medical Journal. 1997;38(8):326-328.
  7. Dobson JV, Stephen -Groff SM, McMahon SR, Stemmler MM, Brallier SL, Bay C. The use of albuterol in hospitalised infants with bronchiolitis. Pediatrics. 1998;101(3 Pt 1):361-368.
  8. Ho L, Collis G, Landau LI, Le Souf PN. Effect of salbutamol on oxygen saturation in bronchiolitis. Archives of Disease in Childhood. 1991;66(9):1061-1064.
  9. Wang EE, Milner R, Allen U, Maj H. Bronchodilators for treatment of mild bronchiolitis : a factorial randomised trial. Archives of Disease of Childhood. 1992;67(3):289-293.