Similarly, use of two other nebulized therapies, epinephrine and hypertonic saline, is discouraged in the emergency department. Using the same language regarding lack of effectiveness, the authors found no value from use, or trial, of nebulized epinephrine compared with placebo. Nebulized hypertonic saline has had a slightly more favorable evaluation in the recent literature. Unfortunately, the pooled data from multiple trials finds the best—yet still weak—evidence for benefit was by decreasing the length of stay of patients whose hospitalization might exceed three days. This is clearly the exception to the cohort evaluated in the emergency department, and given the lack of prognostic tools at our disposal, there is no reason to routinely consider nebulized hypertonic saline.

Finally, the last pharmacological intervention covered by this clinical policy recommends against use of systemic corticosteroids. Outside of one aberrant and controversial trial showing an unexpected reduction in hospitalization for patients receiving both nebulized epinephrine and oral dexamethasone, multiple other reviews and meta-analyses of corticosteroids alone observed no benefit.

Despite all of our advances in the evaluation and treatment in other areas of medicine, we’ve simply circled back to square one with bronchiolitis: no useful testing and no effective interventions. Just as our ancestors assessed and treated these patients, clinical evaluation should guide hospitalization, and supportive care, hydration, nutrition, and respiratory support remain the most important elements of management.

So, in summary:

• Do not perform chest radiography or viral testing routinely as part of individual patient clinical evaluation.
• There is no routine role for use of albuterol, nebulized epinephrine, or nebulized hypertonic saline in the emergency department. The use of steroids is likewise not indicated.
• Pulse oximetry alone should not determine the need for admission, and patients are unlikely to have tissue effects of hypoxemia at 90 percent or above.
• As challenging as it may be to present our limited and lacking treatment options to parents and families, the prudent course is the simplest one.

Dr. Radecki is assistant professor of emergency medicine at The University of Texas Medical School at Houston. He blogs at Emergency Medicine Literature of Note (emlitofnote.com)and can be found on Twitter @emlitofnote.

References

1. Ralston SL, Lieberthal AS, Meissner HC, et al. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134:e1474-502.
2. Schuh S, Freedman S, Coates A, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014;312:712-8.