Background International asthma guidelines recommend against epinephrine (adrenaline) administration in acute asthma unless associated with anaphylaxis or angio-oedema. However, administration of intramuscular epinephrine in addition to nebulised selective β2-agonist is recommended for acute severe or life-threatening asthma in many prehospital guidelines. We conducted a systematic review to determine the efficacy of epinephrine in comparison to selective β2-agonist in acute asthma.
Methods We included peer-reviewed publications of randomised controlled trials (RCTs) that enrolled children or adults in any healthcare setting and compared epinephrine by any route to selective β2-agonist by any route for an acute asthma exacerbation. The primary outcome was treatment failure, including hospitalisation, need for intubation or death.
Results Thirty-eight of 1140 studies were included. Overall quality of evidence was low. Seventeen studies contributed data on 1299 participants to the meta-analysis. There was significant statistical heterogeneity, I2=56%. The pooled Peto’s OR for treatment failure with epinephrine versus selective β2-agonist was 0.99 (0.75 to 1.32), p=0.95. There was strong evidence that recruitment age group was associated with different estimates of the odds of treatment failure; with studies recruiting adults-only having lower odds of treatment failure with epinephrine. It was not possible to determine whether epinephrine in addition to selective β2-agonist improved outcomes.
Conclusion The low-quality evidence available suggests that epinephrine and selective β2-agonists have similar efficacy in acute asthma. There is a need for high-quality double-blind RCTs to determine whether addition of intramuscular epinephrine to inhaled or nebulised selective β2-agonist improves outcome.
Epinephrine appeared underused in the management of children with seafood-induced anaphylaxis before they reached the hospital, according to a study published in Annals of Allergy, Asthma & Immunology.
Daniel Sehayek, an MD candidate at Université Laval in Québec, and colleagues reviewed the cases of 146 children aged 18 years and younger who presented with seafood-induced cases of suspected anaphylaxis at six emergency departments recruited through the Cross-Canada Anaphylaxis Registry between 2011 and 2020.
Data taken from Sehayek D, et al. Ann Allergy Asthma Immunol. 2022; doi:10.1016/j.janai.2022.02.003.
Overall, 75 of the children (51.4%; boys, n = 40; median age, 4 years; interquartile range [IQR], 2.4-8.86) experienced fish-induced anaphylaxis, primarily due to salmon in 16 cases (21.3%), and 71 (48.6%; boys, n = 39; median age, 8.2 years; IQR, 3.65-13.6) had shellfish-induced anaphylaxis, primarily due to shrimp in 50 cases (70.4%).
Most cases of fish-induced and shellfish-induced anaphylaxis were classified as moderate (61.3%; 74.6%), with mild (32%; 21.1%) and severe (6.7%; 4.23%) cases also tallied.
Symptoms in these cases were mucocutaneous (fish, 94.7%; shellfish, 97.2%), respiratory (54.7%; 62%) gastrointestinal (45.3%; 49.3%) and cardiovascular (1.33%; 2.8%).
Twenty-seven of the children reacting to fish (36%) had a known fish allergy, and 16 children reacting to shellfish (22.5%) had a known shellfish allergy.
Patients with comorbid asthma were more likely to experience respiratory symptoms with fish-induced reactions (adjusted OR = 1.18; 95% CI, 1.02-1.36).
Once reactions began, 34.7% of those with fish-induced anaphylaxis received prehospital epinephrine, 40% received in-hospital epinephrine and 30.7% received no epinephrine.
Of the patients with shellfish-induced anaphylaxis, 16.9% received prehospital epinephrine, 57.7% received in-hospital epinephrine and 26.8% received no epinephrine.
Thirteen patients with a known fish allergy (48.1%) and five children with a known shellfish allergy (31.3%) used an epinephrine autoinjector before arriving at the hospital.
One patient with a fish-induced reaction (1.3%) and one patient with a shellfish-induced reaction (1.4%) were admitted to a hospital ward, and one patient with a shellfish-induced reaction (1.4%) was admitted to the ICU.
Patients with a shellfish allergy history were less likely to experience reactions at home (aOR = 0.79; 95% CI, 0.65-0.97), whereas patients with a fish allergy history were more likely to have comorbid asthma (aOR = 1.64; 95% CI, 1.15-2.36).
The researchers also found an association between use of epinephrine and known asthma among patients with a known fish allergy (aOR = 1.39; 95% CI, 1.05-1.84) and patients with a known shellfish allergy (aOR = 1.25; 95% CI, 1.02-1.54).
According to the researchers, the underuse of epinephrine autoinjectors in prehospital settings highlights the need among patients, parents and prehospital personnel for educational programs to increase their use in all anaphylaxis cases.
Unfortunately, I do not find these results surprising, but they are significant. This study has shown that there is an underuse of prehospital and hospital epinephrine for moderate to severe systemic reactions to fish and shellfish in a large Canadian database. This is consistent with U.S. data.
With the recently updated anaphylaxis practice parameters, it is imperative that epinephrine be the go-to drug to treat anaphylaxis in all children and adults regardless of the setting. It is also scary to see that in fish-allergic patients, 12% required two or more injections, outlining the severity of reactions and that some patients experienced potentially near-fatal events.
We as a medical system need to be more comfortable prescribing, utilizing, training and educating regarding epinephrine use in our communities and within our practice. Epinephrine autoinjectors should be available in every first aid/emergency kit, and providers, family members, patients and community members should be able to use them instinctively in schools and other community settings.
To improve care, doctors need to educate as many people as possible — especially patients and their families — that epinephrine is the only lifesaving go-to drug in anaphylaxis. Antihistamines and steroids are no longer recommended, and anaphylaxis should be treated with epinephrine autoinjectors as first-line treatment and as rapidly as possible.
Within the community, the next steps in research should aim to understand the facilitators and barriers of epinephrine use within community settings and how we can campaign for the use of epinephrine more instinctively in a variety of community settings.
Within the medical system, we need to actively educate regarding the new anaphylaxis practice parameters and the risks associated with the delay of epinephrine use in a variety of inpatient, emergency and outpatient settings.
Andrea Pappalardo, MD, FAAAAI
Assistant professor of medicine and pediatrics, University of Illinois at Chicago
Medical director, Coordinated Healthcare for Complex Kids
Epinephrine appeared underused in the management of children with seafood-induced anaphylaxis before they reached the hospital, according to a study published in Annals of Allergy, Asthma & Immunology.
Daniel Sehayek, an MD candidate at Université Laval in Québec, and colleagues reviewed the cases of 146 children aged 18 years and younger who presented with seafood-induced cases of suspected anaphylaxis at six emergency departments recruited through the Cross-Canada Anaphylaxis Registry between 2011 and 2020.
Data taken from Sehayek D, et al. Ann Allergy Asthma Immunol. 2022; doi:10.1016/j.janai.2022.02.003.
Overall, 75 of the children (51.4%; boys, n = 40; median age, 4 years; interquartile range [IQR], 2.4-8.86) experienced fish-induced anaphylaxis, primarily due to salmon in 16 cases (21.3%), and 71 (48.6%; boys, n = 39; median age, 8.2 years; IQR, 3.65-13.6) had shellfish-induced anaphylaxis, primarily due to shrimp in 50 cases (70.4%).
Most cases of fish-induced and shellfish-induced anaphylaxis were classified as moderate (61.3%; 74.6%), with mild (32%; 21.1%) and severe (6.7%; 4.23%) cases also tallied.
Symptoms in these cases were mucocutaneous (fish, 94.7%; shellfish, 97.2%), respiratory (54.7%; 62%) gastrointestinal (45.3%; 49.3%) and cardiovascular (1.33%; 2.8%).
Twenty-seven of the children reacting to fish (36%) had a known fish allergy, and 16 children reacting to shellfish (22.5%) had a known shellfish allergy.
Patients with comorbid asthma were more likely to experience respiratory symptoms with fish-induced reactions (adjusted OR = 1.18; 95% CI, 1.02-1.36).
Once reactions began, 34.7% of those with fish-induced anaphylaxis received prehospital epinephrine, 40% received in-hospital epinephrine and 30.7% received no epinephrine.
Of the patients with shellfish-induced anaphylaxis, 16.9% received prehospital epinephrine, 57.7% received in-hospital epinephrine and 26.8% received no epinephrine.
Thirteen patients with a known fish allergy (48.1%) and five children with a known shellfish allergy (31.3%) used an epinephrine autoinjector before arriving at the hospital.
One patient with a fish-induced reaction (1.3%) and one patient with a shellfish-induced reaction (1.4%) were admitted to a hospital ward, and one patient with a shellfish-induced reaction (1.4%) was admitted to the ICU.
Patients with a shellfish allergy history were less likely to experience reactions at home (aOR = 0.79; 95% CI, 0.65-0.97), whereas patients with a fish allergy history were more likely to have comorbid asthma (aOR = 1.64; 95% CI, 1.15-2.36).
The researchers also found an association between use of epinephrine and known asthma among patients with a known fish allergy (aOR = 1.39; 95% CI, 1.05-1.84) and patients with a known shellfish allergy (aOR = 1.25; 95% CI, 1.02-1.54).
According to the researchers, the underuse of epinephrine autoinjectors in prehospital settings highlights the need among patients, parents and prehospital personnel for educational programs to increase their use in all anaphylaxis cases.
Unfortunately, I do not find these results surprising, but they are significant. This study has shown that there is an underuse of prehospital and hospital epinephrine for moderate to severe systemic reactions to fish and shellfish in a large Canadian database. This is consistent with U.S. data.
With the recently updated anaphylaxis practice parameters, it is imperative that epinephrine be the go-to drug to treat anaphylaxis in all children and adults regardless of the setting. It is also scary to see that in fish-allergic patients, 12% required two or more injections, outlining the severity of reactions and that some patients experienced potentially near-fatal events.
We as a medical system need to be more comfortable prescribing, utilizing, training and educating regarding epinephrine use in our communities and within our practice. Epinephrine autoinjectors should be available in every first aid/emergency kit, and providers, family members, patients and community members should be able to use them instinctively in schools and other community settings.
To improve care, doctors need to educate as many people as possible — especially patients and their families — that epinephrine is the only lifesaving go-to drug in anaphylaxis. Antihistamines and steroids are no longer recommended, and anaphylaxis should be treated with epinephrine autoinjectors as first-line treatment and as rapidly as possible.
Within the community, the next steps in research should aim to understand the facilitators and barriers of epinephrine use within community settings and how we can campaign for the use of epinephrine more instinctively in a variety of community settings.
Within the medical system, we need to actively educate regarding the new anaphylaxis practice parameters and the risks associated with the delay of epinephrine use in a variety of inpatient, emergency and outpatient settings.
Andrea Pappalardo, MD, FAAAAI
Assistant professor of medicine and pediatrics, University of Illinois at Chicago
Medical director, Coordinated Healthcare for Complex Kids
It is the second time in a week that EMS has brought a child with an allergic reaction to your pediatric emergency department (ED). The first was an 11-month-old girl who ate hummus for the first time.
She developed lip swelling and hives and had intermittent stridor and oxygen saturation in the low 90s when EMS first arrived, although her oxygenation quickly improved. The second child was a 9-year-old girl who was out with her family at the lake when she developed generalized hives and chest pain. One thing both patients had in common was that EMS gave them benadryl and transported them. No epinephrine.
These were two different EMS crews from two different counties. When asked why epinephrine was not administered they both cited oxygenation above 95% and absence of wheezing as the reason that epinephrine was not given, despite other indicators of respiratory involvement. But what was even more interesting was the way they reacted when you asked about epinephrine. Of course we would not do anything that extreme or drastic, both crews seemed to say.
Recognize Anaphylaxis and Give Epinephrine
It is widely recognized that anaphylaxis can be life threatening and requires prompt treatment. Epinephrine is the consensus first drug of choice in every guideline for the treatment of anaphylaxis. Delay in the administration of epinephrine has been associated with fatal reactions. But providers do not always recognize anaphylaxis. There is also a lack of understanding about when and how to use epinephrine among patients and providers.
Physicians don’t always recognize anaphylaxis when we see it. At least half of anaphylactic episodes are misdiagnosed in the ED when current diagnostic criteria from standard guidelines are not employed. In a recent study of the management of anaphylaxis in U.S. EDs, only 9% of ED physicians reported that they used the guideline criteria to diagnose anaphylaxis. The authors of the study mention it doesn’t help that these guidelines are published mainly in allergy and immunology journals.
Not only are physicians failing to use guidelines for diagnosing anaphylaxis, they are also failing to follow guidelines, such as the International Consensus on Anaphylaxis or theNational Institute of Allergy and Infectious Diseases criteria for anaphylaxis, for treatment. The same study of U.S. ED providers showed that only 42% of them reported giving epinephrine in the ED for most anaphylactic episodes. The majority of them also fail to comply with guideline-based recommendations to prescribe an epinephrine auto-injector, provide a written anaphylaxis treatment plan and refer patients to a allergist at the time of discharge.
There is a paucity of literature regarding provider attitudes toward epinephrine. In adults, some physicians may hesitate to use epinephrine due to concerns about coronary disease. However, allergists say that there is not much risk to giving epinephrine to otherwise healthy children. Most serious side effects have been associated with overly large doses or intravenous administration. Giving the recommended 0.01 mg/kg IM, up to a maximal dose of 0.30 mg is associated with tremor, pallor, anxiety, and palpitations that are transient and well-tolerated in kids.
You are trying to do the right thing. You use the National Institute of Allergy and Infectious Diseases criteria to make the diagnosis of anaphylaxis. You recognize that giving children IM epinephrine as early as possible is the treatment of choice and antihistamines and steroids are only adjunct therapies. You plan to treat both of these patients with IM epinephrine, observe them in the ED and give them epinephrine auto-injectors, personalized discharge plans and allergy clinic referrals at the time of discharge. How is this likely to go?
Educate your Patients
One study looked at children coming in for their first allergy clinic appointment after such a referral. 86% of the families said they carried their epinephrine auto-injector with them “at all times” but only 71% of these could produce it at the clinic visit and 10% had a device that was past its expiration date. Only 32% could demonstrate that they knew how to use it correctly. In the same study, 36% of pediatric residents showed they could use an auto-injector correctly and only 18% of attendings could do so.
To address these issues, sit with your patients/families and give them the facts:
Be on the watch if you have had anaphylaxis before. If you encounter the same trigger again, use your auto-injector if you develop symptoms
In anaphylaxis, not everyone has skin manifestations (itching, urticaria, angioedema, flushing)
If you have a history of asthma and are having an allergic reaction, strongly consider treating with autoinjector early when having respiratory symptoms, as there is a strong correlation with severe and fatal anaphylaxis in this group
If you have experienced generalized acute urticaria due to a nut allergy or an insect sting, your risk of a more serious reaction from a future exposure is higher
When using the auto-injector (see below) make sure to hold it firmly against the thigh to ensure it produces an intramuscular injection. Peak concentrations of epinephrine differ between by approximately 8 minutes (intramuscular) to approximately 34 minutes (subcutaneous) for injections
Always have an auto-injector available and on your person. Check the expiration date and train with it frequently
When in doubt, err on the side of using the auto-injector rather than waiting too long, because adverse effects from epinephrine use are generally not a concern for healthy children
Know Your Device
Whether you decide to prescribe the time tested and recognizable EpiPen, or the sleek, phone sized, talking Auviq as your autoinjector of choice, you must understand one thing: You probably don’t know how to teach patients how to use these devices. Multiple studies clearly show that physicians consistently teach improper technique and omit steps, even after reading the inserts in some cases. There is even a statistic as to the likelihood of a physician injecting his or her own thumb in the process of teaching or administering (16% — which I have witnessed first hand). If you’re thinking that a pharmacist can do it better, think again. In one study about one-third of patients would not have received their epinephrine dose had they followed the pharmacist’s instructions.
So How to Proceed
While it never hurts to carefully review the manufacturer’s instructions included in the package insert, there are some common themes:
Remove the auto-injector from its protective case
Remove the safety release mechanism to arm the device, making sure that the appropriate end is perpendicular to the middle of the outer thigh
Firmly push the auto-injector against the middle of the outer thigh until you hear a clicking sound. This can be done through clothing, if needed
Hold firmly against the thigh for 5-10 seconds (depending on the manufacturer) to deliver the medication
Remove the device from the thigh and discard it
One final word of advice
Some patients may require more than one dose. It is also possible that despite your best efforts at teaching, the patient may inject their thumb or otherwise fail to use the device correctly. For that reason, it is a good idea to prescribe two auto-injectors.
Multiple studies clearly show that when physicians prescribe an EpiPen, they consistently teach improper technique and omit steps, even after reading the inserts in some cases. Here’s what your patient needs to know.
Epinephrine (adrenaline) given before hospital arrival for cardiac arrest was associated with poorer chances of survival without substantial mental disability, an observational study showed.
Among those who initially recovered spontaneous circulation, survival to hospital discharge with a Cerebral Performance Category 1 or 2 occurred in 17% of those given prehospital epinephrine compared with 60% not given the drug (P<0.001), Florence Dumas, MD, PhD, of the Parisian Cardiovascular Research Center, and colleagues found.
In a propensity score-matched subanalysis, survival with good neurologic outcome remained substantially less common in the epinephrine group (30% versus 61%,P<0.001), the researchers reported in the Dec. 9 issue of the Journal of the American College of Cardiology.
That association in the large, single-center registry persisted regardless of length of resuscitation or in-hospital interventions performed.
The adjusted odds ratio also showed a dose-dependent risk compared with no epinephrine:
0.48 for 1 mg of epinephrine (95% confidence interval 0.27-0.84)
0.30 for 2 to 5 mg of epinephrine (95% CI 0.20-0.47)
0.23 for more than 5 mg of epinephrine (95% CI 0.14-0.37)
These findings come amid growing evidence questioning the role of this guideline-recommended vasopressor for out-of-hospital cardiac arrest, Gordon A. Ewy, MD, of the University of Arizona’s Sarver Heart Center in Tucson, noted in an accompanying editorial.
The reason might have to do with timing, or it could be that adrenaline isn’t the best vasopressor for the job, he suggested.
Animal research has shown that during the circulatory phase of ventricular fibrillation arrest (after the first 10 minutes), adding a beta-adrenergic blocker helped, although adding a pure alpha-adrenergic drug, such as phenylephrine or methoxamine, didn’t.
“Further research, first in animal models and later in humans, can continue to assess whether a pure alpha agent or combination of agents may be superior to epinephrine during the circulatory phase of resuscitation,” Ewy noted.
Timing of Epinephrine
Delayed administration of epinephrine was associated with worse outcome in Dumas’ study of patients admitted to a single large cardiac arrest-receiving hospital in Paris after out-of-hospital cardiac arrest and who achieved successful return of spontaneous circulation from January 2000 through August 2012.
Among the 1,556 such patients in the study, 73% had received epinephrine.
Outcomes weren’t as bad versus no epinephrine when the drug was given sooner after arrest, as reflected in adjusted odds ratios of
0.54 when given within the first 9 min after cardiac arrest (95% CI 0.32-0.91)
0.23 when given between 10 and 15 min after onset of arrest (95% CI 0.20-0.56)
0.23 when given between 16 and 22 min after onset of arrest (95% CI 0.12-0.43)
0.17 when given more than 22 min after cardiac arrest (95% CI 0.09-0.34)
The reason could be double-edged effects, Dumas’ group suggested.
“The alpha-adrenergic effects of epinephrine can increase coronary and cerebral perfusion pressure during the resuscitation period and subsequently help achieve return of spontaneous circulation,” they wrote. “However, epinephrine may exert adverse effects during the post-resuscitation phase and contribute to myocardial dysfunction, increased oxygen requirements, and microcirculatory abnormalities.”
The only randomized trial of epinephrine versus placebo in out-of-hospital cardiac arrest showed better rates of spontaneous circulatory recovery but no difference in survival to hospital discharge with the vasopressor, which did not support the overwhelmingly negative effect of epinephrine reported by Dumas’ group, Ewy noted.
“Unfortunately, in this important study, time to administration of adrenaline was not reported,” he wrote. “Future human investigation of vasopressor agents for out-of-hospital cardiac arrest, whether prospective or retrospective, must separate time courses for vasopressor administration.”
Limitations
One limitation was the lack of information about why one-quarter of patients didn’t receive epinephrine, Ewy said.
Another was the less favorable prognostic characteristics of those who did get epinephrine, he noted, writing that “they were older, less likely to have a witnessed event, and less likely to present with a shockable rhythm, and they had a longer duration of resuscitation (P<0.001).”
Those differences could be at the core of the findings, commented Karl B. Kern, MD, also of the Sarver Heart Center, where he is co-director.”It may really be as simple as these were a sicker group of people,” he told MedPage Today. “Even though the whole paper is really based on a number of statistical efforts to equalize those groups, it still leaves you wondering, Is it just a population study?”
“Really, all these studies have been cohorts, before and after, and the drug has been given really quite late, usually 20 to 25 minutes after onset of cardiac arrest,” he cautioned. “We need a randomized trial to really get that bias out of the way and understand does this drug really make a difference in the long-term outcome?”
Altogether, the message may be “if you’re going to use epinephrine, use it early,” Kern suggested, though he predicted that the level of evidence to date likely wouldn’t be enough to change the resuscitation guidelines that are being revised for 2015.
Action Points
In cardiac arrest patients who achieved return of spontaneous circulation, pre-hospital use of epinephrine was associated with a lower chance of survival.
The association showed a dose effect and persisted despite post-resuscitation interventions.
Importance Among patients with cardiac arrest, preliminary data have shown improved return of spontaneous circulation and survival to hospital discharge with the vasopressin-steroids-epinephrine (VSE) combination.
Objective To determine whether combined vasopressin-epinephrine during cardiopulmonary resuscitation (CPR) and corticosteroid supplementation during and after CPR improve survival to hospital discharge with a Cerebral Performance Category (CPC) score of 1 or 2 in vasopressor-requiring, in-hospital cardiac arrest.
Design, Setting, and Participants Randomized, double-blind, placebo-controlled, parallel-group trial performed from September 1, 2008, to October 1, 2010, in 3 Greek tertiary care centers (2400 beds) with 268 consecutive patients with cardiac arrest requiring epinephrine according to resuscitation guidelines (from 364 patients assessed for eligibility).
Interventions Patients received either vasopressin (20 IU/CPR cycle) plus epinephrine (1 mg/CPR cycle; cycle duration approximately 3 minutes) (VSE group, n = 130) or saline placebo plus epinephrine (1 mg/CPR cycle; cycle duration approximately 3 minutes) (control group, n = 138) for the first 5 CPR cycles after randomization, followed by additional epinephrine if needed. During the first CPR cycle after randomization, patients in the VSE group received methylprednisolone (40 mg) and patients in the control group received saline placebo. Shock after resuscitation was treated with stress-dose hydrocortisone (300 mg daily for 7 days maximum and gradual taper) (VSE group, n = 76) or saline placebo (control group, n = 73).
Main Outcomes and MeasuresReturn of spontaneous circulation (ROSC) for 20 minutes or longer and survival to hospital discharge with a CPC score of 1 or 2.
Results Follow-up was completed in all resuscitated patients. Patients in the VSE group vs patients in the control group had higher probability for ROSC of 20 minutes or longer (109/130 [83.9%] vs 91/138 [65.9%]; odds ratio [OR], 2.98; 95% CI, 1.39-6.40; P = .005) and survival to hospital discharge with CPC score of 1 or 2 (18/130 [13.9%] vs 7/138 [5.1%]; OR, 3.28; 95% CI, 1.17-9.20; P = .02). Patients in the VSE group with postresuscitation shock vs corresponding patients in the control group had higher probability for survival to hospital discharge with CPC scores of 1 or 2 (16/76 [21.1%] vs 6/73 [8.2%]; OR, 3.74; 95% CI, 1.20-11.62; P = .02), improved hemodynamics and central venous oxygen saturation, and less organ dysfunction. Adverse event rates were similar in the 2 groups.
Conclusion and Relevance Among patients with cardiac arrest requiring vasopressors, combined vasopressin-epinephrine and methylprednisolone during CPR and stress-dose hydrocortisone in postresuscitation shock, compared with epinephrine/saline placebo, resulted in improved survival to hospital discharge with favorable neurological status.
Acute bronchiolitis in infants frequently results in hospitalization, but there is no established consensus on inhalation therapy — either the type of medication or the frequency of administration — that may be of value. We aimed to assess the effectiveness of inhaledracemicadrenaline as compared with inhaled saline and the strategy for frequency of inhalation (on demand vs. fixed schedule) in infants hospitalized with acute bronchiolitis.
METHODS
In this eight-center, randomized, double-blind trial with a 2-by-2 factorial design, we compared inhaled racemic adrenaline with inhaled saline and on-demand inhalation with fixed-schedule inhalation (up to every 2 hours) in infants (<12 months of age) with moderate-to-severe acute bronchiolitis. An overall clinical score of 4 or higher (on a scale of 0 to 10, with higher scores indicating more severe illness) was required for study inclusion. Any use of oxygen therapy, nasogastric-tube feeding, or ventilatory support was recorded. The primary outcome was the length of the hospital stay, with analyses conducted according to the intention-to-treat principle.
RESULTS
The mean age of the 404 infants included in the study was 4.2 months, and 59.4% were boys. Length of stay, use of oxygen supplementation, nasogastric-tube feeding, ventilatory support, and relative improvement in the clinical score from baseline (preinhalation) were similar in the infants treated with inhaled racemic adrenaline and those treated with inhaled saline (P>0.1 for all comparisons). On-demand inhalation, as compared with fixed-schedule inhalation, was associated with a significantly shorter estimated mean length of stay — 47.6 hours (95% confidence interval [CI], 30.6 to 64.6) versus 61.3 hours (95% CI, 45.4 to 77.2; P=0.01) — as well as less use of oxygen supplementation (in 38.3% of infants vs. 48.7%, P=0.04), less use of ventilatory support (in 4.0% vs. 10.8%, P=0.01), and fewer inhalation treatments (12.0 vs. 17.0, P<0.001).
CONCLUSIONS
In the treatment of acute bronchiolitis in infants, inhaled racemic adrenaline is not more effective than inhaled saline. However, the strategy of inhalation on demand appears to be superior to that of inhalation on a fixed schedule.
ARYAN'S BLOG 