RESPIRATORY DISEASES

Health Evidence Bulletins - Wales
Team Leader: Dr Michael Burr Date of completion: 5/3/98

The contents of this bulletin are likely to be valid for approximately one year, by which time significantly new research evidence may become available


3. Acute bronchiolitis and bronchitis

(Users are advised to consult the supporting evidence for a consideration of all the implications of a recommendation)

The Statements The Evidence
3a. The incidence of bronchiolitis and bronchitis in children under the age of 5 is correlated with passive smokingi.
(Health gain notation - 6 "likely to be harmful")
i. DiFranza JR, Lew RA. Morbidity and mortality in children associated with the use of tobacco products by other people. Pediatrics 1996; 97(4): 560-568
(Type IV evidence - systematic review of case-control and cohort studies)
3b. The evidence regarding anti-inflammatory therapy in bronchiolitis is unclear; intramuscular dexamethasone does not affect the course of the acute disease (as measured by clinical progress, symptoms and readmission to hospital)i, but nebulized cromoglycates or budesonide reduce the risk of subsequent illnessii.
(Health gain notation - 4 "unknown")
caveat: There is some evidence that children with asthma were included in the trials aboveiii.
Further research to evaluate anti-inflammatory treatment in acute bronchiolitis of infancy (using a strict definition for diagnosis) would be valuable.
i. Roosevelt G, Sheehan K, Grupp-Phelan J, Tanz RR, Listernick R. Dexamethasone in bronchiolitis: a randomised controlled trial. Lancet 1996; 348: 292-295
(Type II evidence - randomised controlled trial);
ii. Reijonen T, Korppi M, Kuikka L, Remes K. Anti-inflammatory therapy reduces wheezing after bronchiolitis. Archives of Pediatric and Adolescent Medicine 1996; 150: 512-517
(Type II evidence - randomised controlled trial);
iii. Internal Review Group (see contributors)
(Type V evidence - expert opinion)
3c. It is unclear as to whether antibiotics are beneficial in the treatment of bronchiolitis and acute bronchitis in infants and young children. These conditions are usually caused by viruses, and antibiotics are indicated only if there is likely to be secondary bacterial infectioni.
(Health gain notation - 4 "unknown")
caveat: Since it is difficult to distinguish between viral and bacterial infection, and young children can deteriorate rapidly, it is good practice to consider antibiotic therapy, particularly in vulnerable groups or if there is any sign of deteriorationiii,iv.
There is a need for research to identify those patients who will respond to antibiotic treatment for acute bronchiolitis and bronchitis.
In older children and adults, antibiotics have a modest beneficial effect, at least in some patients; adverse effects are mild and temporary
ii.
(Health gain notation - 2 "likely to be beneficial")
i. Friis B, Andersen P, Brenĝe E et al. Antibiotic treatment of pneumonia and bronchiolitis. Archives of Disease in Childhood 1984; 59; 1038-1045
(Type II evidence - randomised controlled trial);
ii. Rakshi K, Couriel JM. Management of acute bronchiolitis. Archives of Disease in Childhood 1994; 71: 463-469
(Type V evidence - expert opinion);

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iii. Welsh Medicines Resource Centre. Lower respiratory tract infections and their treatment. June 1994 No. 1.
(Type V evidence - expert opinion);
iv. Becker L, Glazier R, McIsaac W, Smucny J. Antibiotics for acute bronchitis. Cochrane Database of Systematic Reviews. Cochrane Library 1998 Issue 1.
(Type I evidence - systematic review)

 

3d. Ribavirin (Tribavirin) is an expensive treatment for bronchiolitis which (from a meta-analysis of three trials) does not significantly reduce mortality (Odds Ratio OR = 0.53, 95% CI 0.11 to 2.49) or lower the probability of respiratory deterioration (OR = 0.36, 95% CI 0.08 to 1.49) in infants with respiratory syncytial virus lower respiratory tract infection. However, studies carried out so far lack sufficient power to rule out a potential reduction in mortality or respiratory deterioration and a large randomized controlled trial of ribavirin for ventilated and other high risk patients is neededi.
(Health gain notation - 4"unknown")
i. Randolph AG, Wang EEL. Ribavirin for respiratory syncytial virus lower respiratory tract infection. Cochrane Database of Systematic Reviews. Cochrane Library 1998 Issue 1.
(Type I evidence - systematic review and meta-analysis)
3e. Guidelines for practice in the United Kingdom are well-considered but now out of date in some respectsi. i. Rakshi K, Couriel JM. Management of acute bronchiolitis. Archives of Disease in Childhood 1994; 71: 463-469
(Type V evidence - expert opinion)
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Health Evidence Bulletins: Wales, Duthie Library, UWCM, Cardiff CF14 4XN. e-mail: weightmanal@cardiff.ac.uk