n e w e ng l a n d j o u r na l
m e dic i n e
Epinephrine and Dexamethasone
in Children with Bronchiolitis
Amy C. Plint, M.D., M.Sc., David W. Johnson, M.D., Hema Patel, M.D., M.Sc.,
Natasha Wiebe, M.Math., Rhonda Correll, H.B.Sc.N., Rollin Brant, Ph.D.,
Craig Mitton, Ph.D., Serge Gouin, M.D., Maala Bhatt, M.D., M.Sc.,
Gary Joubert, M.D., Karen J.L.Black, M.D., M.Sc., Troy Turner, M.D.,
Sandra Whitehouse, M.D., and Terry P. Klassen, M.D., M.Sc.,
for Pediatric Emergency Research Canada (PERC)
A BS T R AC T
Although numerous studies have explored the benefit of using nebulized epinephrine
or corticosteroids alone to treat infants with bronchiolitis, the effectiveness of combining these medications is not well established.Methods
We conducted a multicenter, double-blind, placebo-controlled trial in which 800 infants (6 weeks to 12 months of age) with bronchiolitis who were seen in the pediatric
emergency department were randomly assigned to one of four study groups. One
group received two treatments of nebulized epinephrine (3 ml of epinephrine in a
1:1000 solution per treatment) and a total of six oral dosesof dexamethasone (1.0 mg
per kilogram of body weight in the emergency department and 0.6 mg per kilogram
for an additional 5 days) (the epinephrine–dexamethasone group), the second group
received nebulized epinephrine and oral placebo (the epinephrine group), the third
received nebulized placebo and oral dexamethasone (the dexamethasone group),
and the fourth received nebulized placebo andoral placebo (the placebo group). The
primary outcome was hospital admission within 7 days after the day of enrollment
(the initial visit to the emergency department).
The authors’ affiliations are listed in the
Appendix. Address reprint requests to
Dr. Plint at the Children’s Hospital of
Eastern Ontario, 401 Smyth Ave., Ottawa,
ON K1H 8L1, Canada, or at plint@cheo.
N Engl J Med2009;360:2079-89.
Copyright © 2009 Massachusetts Medical Society.
Baseline clinical characteristics were similar among the four groups. By the seventh
day, 34 infants (17.1%) in the epinephrine–dexamethasone group, 47 (23.7%) in the
epinephrine group, 51 (25.6%) in the dexamethasone group, and 53 (26.4%) in the
placebo group had been admitted to the hospital. In the unadjustedanalysis, only the
infants in the epinephrine–dexamethasone group were significantly less likely than
those in the placebo group to be admitted by day 7 (relative risk, 0.65; 95% confidence interval, 0.45 to 0.95, P = 0.02). However, with adjustment for multiple comparisons, this result was rendered insignificant (P = 0.07). There were no serious adverse events.
Among infants withbronchiolitis treated in the emergency department, combined
therapy with dexamethasone and epinephrine may significantly reduce hospital admissions. (Current Controlled Trials number, ISRCTN56745572.)
n engl j med 360;20
may 14, 2009
The New England Journal of Medicine
Downloaded from nejm.org on April 24, 2011. For personal use only. No other uses without permission.
Copyright© 2009 Massachusetts Medical Society. All rights reserved.
n e w e ng l a n d j o u r na l
n infancy, bronchiolitis is the most
common acute infection of the lower respiratory tract, characterized by rhinorrhea, cough,
wheezing, respiratory distress, and hypoxemia,1,2
and is most often caused by the respiratory syncytial virus (RSV). Hospital admissions forbronchiolitis have almost doubled over the past 10 to
15 years in both Canada and the United States.3,4
In the United States, annual hospital costs for RSVassociated bronchiolitis were estimated at $365
million to $691 million in 1998.5
The current treatment of bronchiolitis is controversial. Bronchodilators and corticosteroids are
widely used but not routinely recommended.6
A meta-analysis of the...