You Decide: Breathing Treatments for Bronchiolitis?

When kids are having an asthma attack they generally have wheezing.  This asthma-associated wheezing can be treated with a breathing treatment that has a bronchodilator medication (like albuterol).  Since the breathing treatments make the wheezing better in asthma, some doctors have concluded that they might also help with wheezing in bronchiolitis.  Even though this sounds rational, there is absolutely no evidence that this approach has any benefit at all.  In fact, most of what I have read over the years seems to suggest the exact opposite.

What are Breathing Treatments?

Breathing treatments are medications that are “nebulized,” which means they are combined with water and oxygen to produce a fine mist.  This fine mist can then be inhaled when you take a breath so that the medicine can be delivered directly into the lungs.

There are several different types of breathing treatments, but the one used most often is albuterol.  This medicine helps to relax the muscle in the small airways of the lungs (called the bronchioles).  Kids who have asthma have three problems in their lungs: excess mucous, inflammation, and tight muscles around the bronchioles.  Since breathing treatments relax muscles, it makes sense that they will help patients with asthma.

If you review my post on bronchiolitis, you will note from the diagram below that the problem in bronchiolitis is one of mucous and inflammation in the small airways (bronchioles).  There is no problem with tight muscles.  Thus it seems unlikely that a medicine aimed at relaxing muscles would have much benefit.  Despite this many, many doctors give babies with bronchiolitis breathing treatments both in their office and at home.

Why Not Give the Breathing Treatments?

The medicine in the breathing treatment has all kinds of side-effects.  The most common ones are rapid heart rate, irritability, and jitteriness.  While none of these side-effects are life-threatening, why would you want to make your already sick baby more irritable and jittery, unless you had good reason to think the medicine was helpful in some way?  Then, to make things worse, you generally have to give these medicines to your baby with a mask over 10-15 minutes every 3-4 hours.  If you have ever had the chance to do this at home, you will know that most kids hate it.  Again, why would you want to do this to your already sick baby unless you had good reason to think it might help?

Is the Jury Still out on the Benefit of These Medicines?

Not really.  In this article published by The Cochrane Collaboration which reviews all studies related to the use of bronchodilators (like Albuterol), they come to this conclusion:

Given the lack of data clearly supporting the efficacy of these agents, bronchodilators (Albuterol) cannot be recommended for routine use in the treatment of bronchiolitis.

Is There Ever a Reason to Use These Medications for Kids with Bronchiolitis?

Perhaps.  Some kids will have asthma symptoms that are triggered by bronchiolitis or some other virus.  We call this reactive airways.  This is the exception however, not the rule.  Kids that have reactive airways may receive some benefit from the breathing treatments.  Kids who are likely to have reactive airways and bronchiolitis generally have a strong family history of asthma and wheezing. They also tend to be a little older and have had multiple episodes of “wheezing” every time they get a cold or runny nose.

With this in mind, some physicians advocate a “trial” of breathing treatments for all kids with bronchiolitis.  If you are convinced that a trial is in order, you should be very critical of the results.  If you and your doctor truly feel like the “trial” made your child better, you may be given a prescription for one of these machines to be delivered to your house.  If, on the other hand, you DO NOT feel that the treatment made any significant improvement, DO NOT use them at home.  You will only further deprive yourself and your baby of sleep by giving the treatments every 3-4 hours and subject your already sick baby to the unpleasant side-effects.

What I Do for My Patients in the ER

For small babies, say less than 6 months, I almost never use breathing treatments.  If they have lots of congestion in their nose then I treat the congestion with nasal saline followed by nasal suction.  If they have low oxygen levels, then I give them extra oxygen and admit them to the hospital.  For kids over 6 months old, I follow the same plan but will consider a breathing treatment “trial” if:

  1. They have a strong family history of asthma.
  2. They have a history of wheezing every time they get a cold.

I will then evaluate the child before and after the breathing treatment.  In most cases the breathing treatment does virtually nothing to improve their symptoms.  In which case I explain to the parents that breathing treatments are not helpful for their child.  In the rare case that there is some significant improvement after the breathing treatment “trial”, I will discuss the pros and cons of sending the patient home with breathing treatments.  Remember, though, this is very rare.  This year alone I have seen hundreds of kids with bronchiolitis, so far I have sent maybe one or two home with breathing treatments.

When I was a resident in Denver, this approach was studied at the county hospital.  Around 100 kids were divided into two groups.  One group got the breathing treatments and the other did not.  Those who did not get the breathing treatments were not any more likely to get admitted to the hospital or get sicker in any measurable way.  However, those who did NOT get the treatments spent roughly 75% less time in the ER and had a hospital bill that was about 90% less.

In an era where we as parents and physicians must demand responsible medical practice, I see little rational support for the routine use of breathing treatments.

What’s Next

Steroids and Bronchiolitis

References:

Cochrane Review 2006

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  1. [...] as with my discussion on the use of breathing treatments, in rare situation some kids may have bronchiolitis and asthma.  These children may benefit from [...]

  2. [...] to evaluate for dehydration, low oxygen levels, or to rule out some other more serious illness.  Breathing treatments, steroids, and antibiotics do not have a role in the treatment of routine [...]

  3. [...] Breathing Treatments for Bronchiolitis [...]

  4. [...] When kids are having an asthma attack they generally have wheezing.  This asthma-associated wheezing can be treated with a breathing treatment that has a bronchodilator medication (Albuterol or Xopenex).  Since the breathing treatments make the wheezing better in asthma, some doctors have concluded that they might also help with wheezing in bronchiolitis.  Even though this sounds rational, there is absolutely no evidence that this approach has any benefit at all.  In fact…  Read more… [...]

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