- Nebulized b-agonists
Evidence fails to show consistent benefit in the use of albuterol (or salbutamol) for infants and children with bronchiolitis.1 Although it is not recommended, its use persists in both outpatient and inpatient settings.42 A Canadian survey found that physicians commonly gave a trial of either salbutamol or epinephrine to patients with bronchiolitis.43 The 2014 CPG states that “if a clinical trial of bronchodilators is undertaken, clinicians should note that the variability of the disease process, the host’s airway, and the clinical assessments, particularly scoring, would limit the clinician’s ability to observe a clinically relevant response to bronchodilators.”1 The risks and benefits of using b-agonists must be weighed because of the adverse effects, including tachycardia, tremors, and hypoxemia.42 An inpatient multicenter collaborative to decrease overuse of bronchodilators and steroids for bronchiolitis has been found to be effective.
The use of nebulized epinephrine for acute bronchiolitis is also not recommended.1 Although epinephrine may improve clinical symptoms in the short-term, its use as standard ED treatment is controversial, as it would not be prescribed as a home medication. The National Institute for Health and Care Excellence’s clinical guidelines do commentthatepinephrine may be considered for its short-term benefit for severe respiratory distress.44 A systematic review and meta-analysis concluded that epinephrine reduces hospitalizations compared with placebo on the day of the ED visit but did not improve inpatient LOS.45 It is important to stress that the benefits of nebulized epinephrine are small and transient, but one could consider its use for those patients in severe respiratory distress as a bridge to more definitive treatment.
Nebulized hypertonic saline
The CPG does not recommend ED use of nebulized hypertonic saline (HS) in infants with acute bronchiolitis.1 Among infants in a pediatric emergency department with a first episode of acute moderate to severe bronchiolitis, an RCT comparing nebulized 3%HSwithnebulized 0.9% Normal saline did not significantly reduce the rate of hospital admission.46 Another study demonstrated prolonged hospitalization of children younger than 2 years with acute, nonsevere bronchiolitis when given nebulized 3%HS independent of age, clinical presentation of disease, or inclusion of other treatments in their management.
Noninvasive ventilatory strategies:
high-flow warm humidified oxygen Literature is evolving, but so far inconclusive regarding the use of high-flow nasal cannula (HFNC) as a preferable alternative to wall oxygen or continuous positive airway pressure in moderately severe bronchiolitis.53 The mechanism of action is thought to beviareductionofinspiratoryresistanceandimprovementofpulmonarycompliance.54 Recommendations for initial flow rates are not yet published, but suggestions are to initiate HFNC at 10 L/min with titration to effect. An Australian RCT comparing HFNC withstandardcoldwalloxygenfoundnobenefitregardingweaningstrategiesininfants with moderately severe disease butnoted arole inrescue therapyfrom standardtreatment to prevent escalation to intensive care treatment in some patients.55 Complications have been reported, such as pneumothorax. Limitations to its use could include availability of pediatric high-flow equipment at GEDs and knowledge of indications.