Correspondence

Treatment of Bronchiolitis

N Engl J Med 2003; 349:1384-1385October 2, 2003

Article

To the Editor:

More than 20 years have elapsed since Wohl and Chernick speculated about the possible clinical efficacy of inhaled epinephrine in the treatment of infants with acute bronchiolitis.1 It turns out, according to the study reported by Wainwright et al. (July 3 issue),2 that this intervention, which seemed sensible, provides little benefit. Now, physiologically orientated Wohl and Chernick are at it again, speculating in an accompanying editorial that α-adrenergic nose drops before feeding might be helpful.3 Because the authors and the Journal are so highly respected, our fear is that this conjecture will be taken as a recommendation. Perhaps this theory, too, should undergo a clinical trial before it is implemented. How simple.

Robert G. Zwerdling, M.D.
Brian P. O'Sullivan, M.D.
UMass Memorial Health Care, Worcester, MA 01655
zwerdlir@ummhc.org

3 References

1. 1

   Wohl ME, Chernick V. State of the art: bronchiolitis. Am Rev Respir Dis 1978;118:759-781
   Web of Science | Medline

2. 2

   Wainwright C, Altamirano L, Cheney M, et al. A multicenter, randomized, double blind, controlled trial of nebulized epinephrine in infants with acute bronchiolitis. N Engl J Med 2003;349:27-35
   Full Text | Web of Science | Medline

3. 3

   Wohl MEB, Chernick V. Treatment of acute bronchiolitis. N Engl J Med 2003;349:82-83
   Full Text | Web of Science | Medline

Author/Editor Response

Nasal vasoconstrictor drops have been used for many years as over-the-counter medicines, including α-adrenergic agents such as imidazoline derivatives and agents with mixed α and β effects, such as ephedrine. Although there are no data from randomized, controlled trials that suggest that these agents may be useful in managing colds or bronchiolitis in young children, there are many reports of their dangers, including apnea, hypertension, bradycardia, lactic acidosis, and coma.1-4 We agree with Drs. Zwerdling and O'Sullivan that the speculation by Drs. Wohl and Chernick on the use of α-adrenergic nose drops before feeding in the management of bronchiolitis in infants should not be taken as a recommendation until it has been tested in a properly designed clinical trial.

Claire Wainwright, M.B., B.S., M.D.
Paul Francis, M.B., B.S., M.D.
Royal Children's Hospital, Brisbane, Queensland 4029, Australia

4 References

1. 1

   Taverner D, Bickford L, Draper M. Nasal decongestants for the common cold. Cochrane Database Syst Rev 2000;2:CD001953-CD001953
   Medline

2. 2

   Claudet I, Fries F. Danger des vasoconstricteurs nasaux chez le nourrisson: à propos d'une observation. Arch Pediatr 1997;4:538-541
   CrossRef | Web of Science | Medline

3. 3

   Garnier R, Castot A, Zemmoura M, Efthymiou M-L. Incidents et accidents liés à l'emploi de vasoconstricteurs rhino-pharyngés: a propos de 122 cas personnels. Therapie 1982;37:461-469
   Web of Science | Medline

4. 4

   Blake KD, Fertleman CR, Meates MA. Dangers of common cold treatments in children. Lancet 1993;341:640-640[Erratum, Lancet 1993;341:842.]
   CrossRef | Web of Science | Medline

Author/Editor Response

Our endorsement of the study by Wainwright et al. was related to their choice of outcome measures. It is true that interventions that shorten the length of stay in the hospital are desirable, but these investigators did not observe a significant reduction in the length of stay in their study of nebulized epinephrine in infants with acute bronchiolitis. However, it does not seem justified to abandon treatment with either the use of epinephrine early in the course of the disease or the use of nose drops, a recommendation made with tongue in cheek at the end of our editorial. The main points of our editorial are that there are no indications for treatment with albuterol and that one might try either nose drops or nebulized epinephrine to relieve an infant's distress. The site of the reduction in airway resistance may well be the nose, but we are not recommending a clinical trial of nose drops. On the basis of our experience, we do recommend that, before an infant requires intubation and intensive care, a course of nebulized epinephrine be given on a trial basis and that such therapy may be used in the emergency department, where there is clear evidence of its efficacy.1 The study by Wainwright et al. also points out how important it is to use the appropriate outcome measure. Energy and attention to detail must go into the design of clinical trials; this energy should not be invested in trivial issues.

Mary Ellen Wohl, M.D.
Harvard Medical School, Boston, MA 02115

Victor Chernick, M.D.
University of Manitoba, Winnipeg, MB R3A 1S1, Canada

1 References

1. 1

   Menon K, Sutcliffe T, Klassen TP. A randomized trial comparing the efficacy of epinephrine with salbutamol in the treatment of acute bronchiolitis. J Pediatr 1995;126:1004-1007
   CrossRef | Web of Science | Medline