oral dexamethasone for bronchiolitis: a randomized trial journal club 20/2/14 alansari k et al. oral...
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Oral Dexamethasone for Bronchiolitis: A randomized TrialJournal club 20/2/14
Alansari K et al. Oral dexamethasone for bronchiolitis: a randomised trial. Pediatrics 2013 Oct;132(4):e810-6.
Population• Qatar• 2010- 2012 (bronchiolitis seasons)• Infants ≤ 18 months• “moderate to severe” bronchiolitis (Wang score ≥ 4) • Bronchiolitis defined as viral URTI followed by wheezing
or crackles on auscultation• Hx of eczema or 1st degree relative with asthma• Exclusions:- any previous wheeze, 02 sats ≤85%
“Standard” Care• Salbutamol Nebs at 0, 30, 60, 120 minutes then every 2
hours throughout admission• Nebulsied Epinephrine 2.5- 5ml, if needed up to hourly
Primary Outcome• Time from randomisation to ready for discharge as
deemed fit by Dr on call (all patients get 6hrly review)
- Decided does not need O2, ? Sats ≥ 94% - Feeding adequately
- Minimal or absent wheezing, crackles or chest recessions
Are the results valid?3. Were all the patients who entered the trial
accounted for at its conclusion?
Is it worth continuing?4. Were patients, health workers and study personel “blind” to the treatment?
Yes
Will the results help locally??9. Can the results be applied in your context?
No• Not our standard care• Not our definition of bronchiolitis• Not same Dr levels/ review rates• Primary outcome definition unclear
Bronchiolitis Research• Many studies/ meta analyses• Many definitions of bronchiolitis• Many age ranges• Many populations• Many confounding factors• Many outcomes (scores/ length of treatment/ length of
stay
Definitions of BronchiolitisUK
• “a seasonal viral illness characterised by fever, nasal discharge, dry, wheezy cough”.
• On examination there are fine inspiratory crackles and/ or high pitched expiratory wheeze
• Infants under 1 year of age
USA
“a constellation of of clinical symptoms and signs including a viral upper respiratory prodrome followed by increased
respiratory effort and wheezing in children less than 2 years”
Schuh et al, 2007 (J Pediatr)• 265 infants with simple bronchiolitis, all had CXR• Only 2 CXRs not consistent with bronchiolitis (& neither
case changed management)• More likely to treat with abx after reviewing CXRs
(although not indicated)
Aetiology• Viral upper -> Lower
respiratory infection• Bronchiolar epithelial
inflammation• Peribronchial infiltration of
WBCs• Submucosal oedema• Airway narrowing through
oedema and blockage with mucus (not smoothe muscle constriction)
Bronchodilators• 8 trials, 468 infants• No improvement in score in 43% treated with
bronchodilators (57% in controls)• Modest, short term effect in scores• No change in other clinical measures (eg oxygenation)• Authors conclude bronchodilators not recommended
Authors’ Conclusions• Insufficient evidence to support use for inpatients.• Possibly some benefit as outpatients• Variety of definitions, outcomes and patient groups
Corticosteroids• Howard M et al, 2007• 600 infants 2-12 months• Randomised to dex or
placebo• No difference in scores,
admission rates, clinical outcomes
? Benefit combined?
• Hartling et al 2011• Controversial meta-
analysis• Accused of selection bias• Included children up to 2
yrs
Hypertonic saline• Zhang et al, 2013• Hypertonic vs 0.9% saline • Infants <2 years• Conclude that length of
stay reduced by hypertonic saline
• But many confounding factors in studies analysed
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