Correspondence
Dexamethasone for Bronchiolitis
N Engl J Med 2007; 357:1659-1660October 18, 2007
- Article
To the Editor:
The prospective trial of dexamethasone for bronchiolitis in infants, conducted by the Bronchiolitis Study Group of the Pediatric Emergency Care Applied Research Network (PECARN) and reported by Corneli et al. (July 26 issue),1 appears to demonstrate a lack of efficacy of oral dexamethasone in infants with a first episode of wheezing diagnosed as bronchiolitis. Although the authors aptly conclude that dexamethasone did not provide a benefit in the first 7 days after treatment, they fail to address the fact that treatment with oral steroids may prevent recurrent wheezing in the months after infection, particularly in first-time wheezing induced by rhinovirus.2 This is significant, given that rhinovirus-induced wheezing is the second most common cause of early wheezing and is an emerging risk factor for recurrent wheezing.3,4 Are there follow-up data on the condition of the children studied that can address this question?
4 ReferencesMark S. La Shell, M.D.
Christopher W. Calabria, M.D.
Wilford Hall Medical Center, San Antonio, TX 78236
mark.lashell@lackland. af. mil 1
Corneli HM ,Zorc JJ ,Majahan P , et al. A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med 2007;357:331-339
Full Text | Web of Science | Medline2
Lehtinen P ,Ruohola A ,Vanto T ,Vuorinen T ,Ruuskanen O ,Jartti T . Prednisolone reduces recurrent wheezing after a first wheezing episode associated with rhinovirus infection or eczema. J Allergy Clin Immunol 2007;119:570-575
CrossRef | Web of Science | Medline3
Papadopoulos NG ,Moustaki M ,Tsolia M , et al. Association of rhinovirus infection with increased disease severity in acute bronchiolitis. Am J Respir Crit Care Med 2002;165:1285-1289
CrossRef | Web of Science | Medline4
Lemanske RF Jr ,Jackson DJ ,Gangnon RE , et al. Rhinovirus illnesses during infancy predict subsequent childhood wheezing. J Allergy Clin Immunol 2005;116:571-577
CrossRef | Web of Science | Medline
To the Editor:
In Corneli and colleagues' description of the inclusion and exclusion criteria for their study, it is not clear whether other drugs had been used to treat the bronchiolitis. It may be useful to know whether patients received, either before or during the study, treatment with macrolide antibiotics. In a recent study, treatment with clarithromycin had significant effects on the clinical and laboratory findings in patients with respiratory syncytial virus bronchiolitis.1
1 ReferencesGian Luca Casoni, M.D.
Venerino Poletti, M.D.
GB Morgagni Hospital, 47100 Forlì, Italy
casonig1970@libero.it 1
Tahan F ,Ozcan A ,Koc N . Clarithromycin in the treatment of RSV bronchiolitis: a double-blind, randomised, placebo-controlled trial. Eur Respir J 2007;29:91-97
CrossRef | Web of Science | Medline
To the Editor:
In the trial reported by Corneli et al., infants with bronchiolitis did not benefit from oral dexamethasone, but the case definition required wheezing. In the United Kingdom and Australia, wheezing is a nonobligate diagnostic sign, whereas widespread fine crepitations constitute the hallmark of the disease. The important subgroup of children with bilateral crackles only was excluded from the study, and it is possible that such children would have a different response.1 Differences between U.S. and non-U.S. definitions of bronchiolitis make generalization of the findings difficult.
1 ReferencesPatrick Stafler, B.Sc., M.Sc.
Royal London Hospital, London E1 1BB, United Kingdom
pstafler@yahoo.co. uk 1
van Woensel JB ,van Aalderen WM . Treatment for bronchiolitis: the story continues. Lancet 2002;360:101-102
CrossRef | Web of Science | Medline
Author/Editor Response
In response to La Shell and Calabria: we did not collect follow-up data on the patients in our study beyond 7 to 10 days. We note that rhinovirus is not a common cause of bronchiolitis. The widespread use of glucocorticoid medication for this common condition is not without risks, which would have to be considered against any possible benefit.
In response to Casoni and Poletti: we did not ascertain which medications (other than those affecting inclusion) the patients received before enrollment in the study. The use of macrolide antibiotics is not common in the treatment of viral bronchiolitis in the United States.
Finally, we agree with Stafler that different definitions of disease have been a problem in past research on bronchiolitis. In typical U.S. usage, however, the term “wheezes,” when used in reference to infants with bronchiolitis, encompasses expiratory noises that could be described as fine crackles or crepitations. We believe that our findings are likely to pertain to patients with bronchiolitis worldwide.
Howard M. Corneli, M.D.
University of Utah School of Medicine, Salt Lake City, UT 84158Joseph J. Zorc, M.D.
Children's Hospital of Philadelphia, Philadelphia, PA 19104Nathan Kuppermann, M.D., M.P.H.
University of California, Davis, Medical Center, Sacramento, CA 95817- Citing Articles (1)
Citing Articles
1
Panickar, Jayachandran, Lakhanpaul, Monica, Lambert, Paul C., Kenia, Priti, Stephenson, Terence, Smyth, Alan, Grigg, Jonathan, . (2009) Oral Prednisolone for Preschool Children with Acute Virus-Induced Wheezing. New England Journal of Medicine 360:4, 329-338
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