Written by Hannah Harp
Spoon Feed
Albuterol, hypertonic saline (HTS), and nebulized epinephrine for outpatient bronchiolitis were associated with decreased rates of hospitalization and improved clinical severity scores in some of the meta-analyses reviewed.
The great debate
Bronchiolitis is the leading cause of hospitalization in infants, though most cases are dealt with on an outpatient basis. The AAP clinical practice guidelines were last updated in 2014 and recommended against routine use of inhaled albuterol, epinephrine, and hypertonic saline (HTS). This umbrella review examined the efficacy of these deimplemented treatments in preventing hospitalization and reducing clinical severity scores in the outpatient setting. The review included 6 meta-analyses for albuterol, 4 for epinephrine, and 11 for HTS. Meta-analyses revealed mixed evidence. For epinephrine, 3/4 analyses revealed reduced admissions on the day of administration, but not at day 7 (RR 0.67, 95%CI 0.50–0.89), and some showed improved clinical scores. Many meta-analyses did not distinguish between HTS alone vs. HTS plus bronchodilator use, and none comparing HTS alone vs. NS showed a significant decrease in hospitalization. HTS plus bronchodilator was favorable for reducing hospitalization: OR 0.44 (CI 0.23 – 0.84), and some showed improvement in clinical scores with HTS alone. Regarding albuterol, a few errors were highlighted from studies included in the 2014 Cochrane review, which was referenced in the AAP guidelines. After reanalysis with corrections, the authors found decreased clinical scores for two subanalyses: -0.42 (CI -0.85 -0.01) and -0.58 (CI -0.96 –0.2). Overall, 4 meta-analyses showed clinical score improvement, but none showed reduced hospitalization. Limitations include significant data overlap between the meta-analyses included and the lack of high-quality RCTs in general. While the HTS studies mention no adverse effects, there is no mention of adverse effects such as tachycardia, tremors, or agitation with albuterol or epinephrine. Lastly, clinical scoring is largely subjective and heterogeneous, with a high potential for observer bias. Contrary to the 2014 AAP guidelines, the authors suggest a trial of bronchodilator with or without HTS.
How will this change my practice?
It will not yet. It’s important to follow guidelines and understand why they exist, but it’s also important to use your clinical judgment about which treatments are worth the potential side effects. Can’t wait for more detailed research into why these treatments seem to help select patients.
Editor’s Note: When reading this article, the tension between the authors and the AAP bronchiolitis subcommittee is palpable, and there seems to be a disagreement in the interpretation of available evidence. While striving to provide high-value, evidence-based care, this article hasn’t convinced me to reach for medications for the majority of bronchiolitis patients, though I agree that larger RCTs are needed. – Kelsey Hart
Source
Outpatient Medications Deimplemented by the AAP Bronchiolitis Guidelines: An Umbrella Review of Meta-Analyses. Pediatr Pulmonol. 2025 Jan;60(1):e27391. doi: 10.1002/ppul.27391. Epub 2024 Nov 27. PMID: 39601617
