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BET 2 IS NEBULISED SALBUTAMOL INDICATED IN BRONCHIOLITIS?

Emerg. Med. J. 2008;25;840-841 doi:10.1136/emj.2008.066894

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Bronchiolitis (161 articles) TB and other respiratory infections (1093 articles) Bronchitis (366 articles) Clinical diagnostic tests (8978 articles)

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Best evidence topic reports

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Clinical bottom line

Current evidence does not support bronchiolitis as an indication for oral steroids.

papers presented evidence addressing the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that oral steroids are not indicated in bronchiolitis.

Berger I, Argaman Z, Schwartz SB, et al. Efficacy of corticosteroids in acute bronchiolitis: short term and long term follow up. Pediatr Pulmonol 1998;26: 1626. Goebel J, Estrada B, Quinonez J, et al. Prednisolone plus albuterol versus albuterol alone in mild to moderate bronchiolitis. Clin Pediatr 2000;39:21320. Klassen TP, Sutcliffe T, Watters LK, et al. Dexamethasone in salbutamol-treated inpatients with acute bronchiolitis: a randomised controlled trial. J Pediatrics 1997;130:1916. van Woensel JB, Wolfs TF, van Aalderen WM, et al. Randomised double blind placebo controlled trial of prednisolone in children admitted to hospital with respiratory syncytial virus bronchiolitis. Thorax 1997;52:6347.

Clinical bottom line

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

(bronchiolitis or rsv bronchiolitis). Limit to human, English and randomised controlled trials.

SEARCH OUTCOME
There was a total of 68 hits, nine relevant papers were found.

THREE-PART QUESTION
In [infants with bronchiolitis] do [oral steroids] reduce [clinical severity or length of hospital stay].

COMMENTS
Emerg Med J 2008;25:839840. doi:10.1136/emj.2008.066886

BET 2
IS NEBULISED SALBUTAMOL INDICATED IN BRONCHIOLITIS? Report by: Jayachandran Panickar, Consultant Respiratory Paediatrician Search checked by: Michael Eisenhut, Consultant Paediatrician Institution: Central Manchester and Manchester Childrens University Hospital Luton and Dunstable Hospital A short-cut review was carried out to establish whether nebulised salbutamol is indicated in the management of bronchiolitis. From a search of 68 papers only nine presented trials addressing the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that on current evidence nebulised salbutamol is not indicated in patients with bronchiolitis.

CLINICAL SCENARIO
A 6-month-old baby is admitted to hospital with a 4-day history of coryzal symptoms, cough, wheeze and decrease in feeds. Respiratory syncytial virus is detected in nasopharyngeal secretions. She is needing oxygen and is on a nasogastric feed. You wonder whether starting oral steroids will improve her clinical condition.

SEARCH STRATEGY
Medline 19662008 Embase 19802008 Cochrane database of systematic reviews and Cochrane central register of controlled trials (Oral steroids or prednisolone) AND (bronchiolitis or RSV bronchiolitis) limit to human, english and randomised controlled trials.

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 with 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. That study showed that there was a significantly greater improvement in respiratory rate and accessory muscle score after nebulised salbutamol compared with placebo. Gadomski et al found a significant increase in heart rate in patients treated with nebulised salbutamol compared with oral placebo.
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SEARCH OUTCOME
There was a total of 35 hits, with six relevant papers.

COMMENTS
The largest of the studies (Corneli et al) was conducted in the emergency department. Neither the primary outcome measure (hospital admission) nor the secondary outcomes (length of hospital stay and clinical score) showed any significant improvement with steroids. In the first 2 days of treatment prednisolone seems to accelerate the improvement of clinical scores transiently without impact on overall outcomes, such as duration of hospitalisation or chronic symptoms.
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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.
c

Zhang L, Ferruzzi E, Bonfanti T, et al. Long and short-term effect of prednisolone in hospitalized infants with acute bronchiolitis J Paediatr Child Health 2003;39:54851. Corneli HM, Zorc JJ, Majahan P, et al. of the Bronchiolitis Study Group of the Pediatric Emergency Care Applied Reserach Network (PECARN). A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med 2007;357:3319.

SEARCH STRATEGY
Medline 19662008, Embase 19802008, Cochrane database of systematic reviews and Cochrane central register of controlled trials. (Nebulised salbutamol or salbutamol or bronchodilators) AND
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Schuh S, Canny G, Reismann JJ, et al. Nebulised albuterol in acute bronchiolitis. J Pediatr 1990;117: 6337. Klassen TP, Rowe PC, Sutcliffe T, et al. Randomised trial of salbutamol in acute bronchiolitis. J Pediatr 1991;118:80711. Gadomski AM, Aref GH, El Din OB, et al. Oral versus nebulised albuterol in the management of bronchiolitis in Egypt. J Pediatr 1994;124:1318. Gadomski AM, Lichenstein R, Horton L, et al. Efficacy of albuterol in the management of bronchiolitis. Pediatrics 1994;93:90712. Chowdhury D, Al Howasi M, Khalil M, et al. The role of bronchodilators in the management of bronchiolitis: a clinical trial. Ann Trop Paediatr 1995;15:7784. Goh A, Chay OM, Foo AL, et al. Efficacy of bronchodilators in the treatment of bronchiolitis. Singapore Med J 1997;38:3268. Dobson JV, Stephen-Groff SM, McMahon SR, et al. The use of albuterol in hospitalised infants with bronchiolitis. Pediatrics 1998;101:3618. Ho L, Collis G, Landau LI, et al. Effect of salbutamol on oxygen saturation in bronchiolitis. Arch Dis Child 1991;66:10614. Wang EE, Milner R, Allen U, et al. Bronchodilators for treatment of mild bronchiolitis: a factorial randomised trial. Arch Dis Child 1992;67:28993.

Emerg Med J 2008;25:840841. doi:10.1136/emj.2008.066894 Emerg Med J December 2008 Vol 25 No 12

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Best evidence topic reports

Table 1 Relevant papers
Author, date and country Schuh et al, 1990, Canada Patient group Study type (level of evidence) Outcomes Oxygen saturation Key results Significantly greater improvement with salbutamol No significant difference Significantly greater improvement with salbutamol Significantly improved after second dose of salbutamol Significantly greater improvement with salbutamol No significant difference No significant difference after 1 h No significant difference No significant difference No significant difference No significant difference Significant increase in nebulised salbutamol group compared with placebo No significant difference No significant difference No significant difference No significant difference Study weaknesses No 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 baseline characterstics.

40 Infants (6 weeks2 years). Randomised double blind placebo Nebulised salbutamol vs controlled trial placebo

Wheezing score Respiratory rate

Heart rate

Accessory muscle score Klassen et al, 1991, Canada 83 Children (121 months). Nebulised salbutamol vs placebo 128 Infants (,18 months). Nebulised salbutamol vs nebulised saline vs oral salbutamol vs oral placebo Randomised double blind placebo controlled trial Double blind placebo controlled trial Respiratory rate Clinical score Oxygen saturation Clinical score Respiratory rate Oxygen saturation Heart rate

Exclusion of patients with severe disease. No microbiological confirmation of diagnosis in 42% of patients. Microbiological confirmation of diagnosis in only 42% of patients. No data regarding individual or family history of atopy.

Gadomski et al, 1994, Egypt

Gadomski et al, 1994, USA

Chowdhury et al, 1995, Saudi Arabia

Goh et al, 1997, Singapore

Dobson et al, 1998, USA

88 Infants (median age 5.5 months). Nebulised salbutamol vs nebulised saline vs oral salbutamol vs oral placebo 89 Children (23 days 11 months). Nebulised salbutamol vs nebulised ipratropium bromide vs nebulised saline and ipratropium bromide vs saline 120 Children (age ,2 years). Nebulised salbutamol vs nebulised ipratropium bromide vs nebulised saline vs humidified oxygen 52 Patients (age ,2 years). Nebulised salbutamol vs saline

Randomised double blind placebo controlled trial

Heart rate Clinical score Oxygen saturation Respiratory rate

Randomised placebo Clinical score No significant difference controlled clinical trial Length of hospital stay No significant difference

No statistical information about comparison of baseline characterstics. State (falling asleep, waking up) of infant not controlled. No blinding. Not all patients included.

Randomised double blind placebo controlled trial

Length of hospital stay No significant difference Clinical severity score No significant difference

Second control group added later.

Randomised double blind placebo controlled trial

Ho et al, 1991, Australia

21 Infants (3 weeks 6 months). Nebulised salbutamol vs placebo

Randomised double blind placebo controlled trial

Wang et al, 1992, Canada

62 Children (2 months2 years). Nebulised salbutamol or placebo vs ipratropium or placebo

Randomised double blind placebo controlled trial

Clinical severity score Improvement in oxygen saturation Frequency of adverse events Length of hospital stay Time for saturation to normalise Oxygen saturation profile Time to reach minimum saturation Length of hospital stay Clinical severity score Oxygen saturation

No significant difference No significant difference No significant difference No significant difference Significantly longer time after salbutamol Significant desaturation after salbutamol No significant difference No significant difference No significant difference No significant difference

Study too small for adequately powered survival analysis.

Arbitrary choice of 4% drop in saturation as a tool for statistical analysis. Definition of excluded severely ill children not mentioned. Selection bias. Use of variety of different significance levels. No microbiological confirmation of diagnosis in 73% of patients.

BET 3
WHATS THE EVIDENCE FOR EVIDENCEBASED MEDICINE? Report by: Rick Body, SpR in Emergency Medicine Search checked by: Bernard A Foe x, Consultant in Emergency Medicine
Emerg Med J December 2008 Vol 25 No 12

Institution: Emergency Department, Manchester Royal Infirmary, Manchester, UK A short-cut review was carried out to establish whether there really is any evidence to show that evidence-based medicine is better than old-fashioned expert opinion. From a search of 238 papers none presented a comparison of the two.

THREE-PART QUESTION
In [medicine] is [evidence better than expert opinion] for choosing the [most effective therapy]?

CLINICAL SCENARIO
During a lull in the action over the festive season, an academic ST trainee and a
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