Manejo De Bronquiolitis

Update on management of bronchiolitis
Suzanne Schuha,b,c
Research Institute, The Hospital for Sick Children, Division of Paediatric Emergency Medicine and Department of Paediatrics, University of Toronto, Toronto, Ontario, Canada
b c a

Correspondence to Suzanne Schuh, The Hospital for Sick Children, 555 University Ave., Toronto, ON M5G 1X8, Canada Tel: +1 416 813 6239; fax: +1 416 813 5043;e-mail: suzanne.schuh@sickkids.ca Current Opinion in Pediatrics 2011, 23:110–114

Purpose of review Bronchiolitis impacts millions of infants worldwide. Although several therapeutic options stem from highly plausible theoretical rationales for success and some may even offer modest short-term symptom relief, none has been conclusively shown to alter the course of the disease or its majoroutcomes. However, several recent papers shed light on which treatments show promising preliminary evidence and offer insight into future research endeavors on this topic. This review will summarize bronchiolitis therapy in view of this recent evidence. Recent findings The agents in which theory promises but treatment does not deliver include systemic corticosteroids alone, inhaled bronchodilators aloneand antileukotrienes. The most promising combination to date appears to be that of oral dexamethasone and inhaled epinephrine but numerous related issues need to be clarified further. Caretakers need to be counselled about the usual protracted clinical course of bronchiolitis. Summary Because bronchiolitis is a highly heterogeneous entity, future research challenges should include detailedcharacterization of infants most likely to benefit from given interventions. In the meantime, stick with the good old time-honored supportive route! Keywords bronchiolitis, dexamethasone, epinephrine, heliox, respiratory distress
Curr Opin Pediatr 23:110–114 ß 2011 Wolters Kluwer Health | Lippincott Williams & Wilkins 1040-8703

Introduction
Bronchiolitis is the leading cause of infant hospitalizationsduring the first year of life [1]. It is usually defined as the first viral episode of respiratory distress, accompanied by coryza, cough, crepitations and wheezing [2]. The respiratory syncytial virus (RSV) accounts for the majority of cases [3], although other important viruses have also been implicated [4–6]. Several excellent reviews of the etiology and treatment approaches to bronchiolitis haverecently been published [7–11], all of which highlight importance of oxygenation, hydration and airway support if necessary [12,13]. However, no single pharmacological agent has been conclusively found to change the course of the disease. An important challenge is that bronchiolitis has wide etiologic heterogeneity, encompassing the only episode of viral-induced wheezing and the first attack ofepisodic wheezing without atopy/interval symptoms as well as the initial exacerbation of a multitrigger wheeze often associated with asthma [7]. The bad news is that these wheezing phenotypes respond differently to treatment [7]. Because it is impossible to reliably identify these subgroups during their initial presentation, interpretation of
1040-8703 ß 2011 Wolters Kluwer Health | LippincottWilliams & Wilkins

the results of therapeutic trials of bronchiolitis becomes challenging [14,15]. In 2006, the American Academy of Pediatrics (AAP) released a comprehensive evidence-based guideline on the management of bronchiolitis [16]. Since then, two large multicenter bronchiolitis trials have shed light on the management with oral dexamethasone with and without nebulized epinephrine [17,18]and raised several unanswered questions. Furthermore, several recent systematic reviews of various other inhaled therapies guide us when these interventions may be effective [19–21]. Two recent bronchiolitis papers have clarified predictors of the return for care after discharge from the emergency department (ED) [22] and highlighted the usual protracted course of this disease [9]. This review...