For which infants with viral bronchiolitis could it be deemed appropriate to use albuterol, at least on a therapeutic trial basis?

Abstract

Although there is increasing evidence showing that infants with viral bronchiolitis exhibit a high degree of heterogeneity, a core uncertainty shared by many clinicians is with regard to understanding which patients are most likely to benefit from bronchodilators such as albuterol. Based on our review, we concluded that older infants with rhinovirus (RV) bronchiolitis, especially those with a nasopharyngeal microbiome dominated by Haemophilus influenzae; those affected during nonpeak months or during non-respiratory syncytial virus (RSV) predominant months; those with wheezing at presentation; those with clinical characteristics such as atopic dermatitis or a family history of asthma in a first-degree relative; and those infants infected with RSV genotypes ON1 and BA, have the greatest likelihood of benefiting from albuterol. Presently, this patient profile could serve as the basis for rational albuterol administration in patients with viral bronchiolitis, at least on a therapeutic trial basis, and it could also be the starting point for future targeted randomized clinical trials (RCTs) on the use of albuterol among a subset of infants with bronchiolitis.

Something Is Changing in Viral Infant Bronchiolitis Approach

“…Many guidelines have been published by various scientific societies, which agree on minimal handling (i.e., hydration and the administration of oxygen as the only treatment options) ( 3 – 6 ). Unfortunately, this approach risks excluding some patients who might benefit from the bronchodilator treatment ( 48 ). However, as pointed out by the American Academy of Pediatrics, guidelines are intended to assist clinicians in decision making and are not intended to “ replace clinical judgment or establish a protocol for the care of all children with bronchiolitis ” ( 5 ).…”

“…In light of the data emerging from the scientific literature, acute bronchiolitis should no longer be considered as a single disease but rather as characterized by different phenotypes and endotypes ( 7 – 10 , 26 ). In particular, it seems that the phenotype characterized by older age, type 2 immune response, personal or family (first-degree) history of atopy, RSV genotypes (ON1 and BA) or RV etiology and infection during non-RSV-predominant or non-peak viral months may have a good response to a trial with bronchodilators ( 48 ).…”

“…One group may be formed by very young infants (<6 months of age) with RSV infection and increased risk of recurrent wheezing; instead, another group may comprise older children (>6 months of age) with RV infection, atopic predisposition, high risk of developing asthma ( 8 ) and, probably, a better response to bronchodilators. Although much more evidence is required, proposals were put forward for a more personalized treatment, based on the hypothesis of different entities of bronchiolitis ( 8 , 48 ). An interesting recent study by Rodríguez-Martínez et al ( 49 ) found out that therapeutic options based on a phenotypic-guided strategy are also more cost-effective than a guideline-guided strategy.…”

Effects of nebulized epinephrine in association with hypertonic saline for infants with acute bronchiolitis: A systematic review and meta‐analysis

“…That, alongside a high rate of studies with a moderate and high risk of bias, was responsible for relatively low quality of evidence. The umbrella term "acute bronchiolitis" may include a heterogenous group of patients with different phenotypes and endotypes as shown by Rodríguez-Martínez et al 51,52 This might also contribute to the heterogeneity in the meta-analyses. However, the point estimates of most of the trials showed the effects on both LOS and CSS in favor of nebulized epinephrine plus HS, suggesting that the heterogeneity between studies is quantitative rather than qualitative-that is, the results differ in magnitude but not effect direction.…”

Bronquiolitis aguda: hospitalización, complicaciones y manejo terapéutico en menores de dos años atendidos en un centro de referencia en 2017 y 2018. Estudio descriptivo

“…Aunque durante la evaluación de estos pacientes no estaban estandarizados los fenotipos y los criterios de uso del salbutamol (lactantes mayores con VSR, con colonización por Haemophilus influenzae, afectados en los meses sin pico de VSR, antecedentes familiares o personales de dermatitis atópica o asma) (30), se cumplieron las recomendaciones que había a la fecha para aquellos con sibilancias en la presentación y antecedente familiar o personal de atopia. Esto hizo que el porcentaje de uso del medicamento fuera más racional y direccionado, diferente a estudios previos donde se reportan nebulizaciones con salbutamol entre el 89,9 % y 98 % de los casos (31,32).…”