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Meta-Analysis
. 2011 Apr 6:342:d1714.
doi: 10.1136/bmj.d1714.

Steroids and bronchodilators for acute bronchiolitis in the first two years of life: systematic review and meta-analysis

Lisa Hartling  1 , Ricardo M Fernandes, Liza Bialy, Andrea Milne, David Johnson, Amy Plint, Terry P Klassen, Ben Vandermeer
Affiliations
Meta-Analysis

Steroids and bronchodilators for acute bronchiolitis in the first two years of life: systematic review and meta-analysis

Lisa Hartling et al. BMJ. .

Abstract

Objective: To evaluate and compare the efficacy and safety of bronchodilators and steroids, alone or combined, for the acute management of bronchiolitis in children aged less than 2 years.

Design: Systematic review and meta-analysis.

Data sources: Medline, Embase, Central, Scopus, PubMed, LILACS, IranMedEx, conference proceedings, and trial registers. Inclusion criteria Randomised controlled trials of children aged 24 months or less with a first episode of bronchiolitis with wheezing comparing any bronchodilator or steroid, alone or combined, with placebo or another intervention (other bronchodilator, other steroid, standard care).

Review methods: Two reviewers assessed studies for inclusion and risk of bias and extracted data. Primary outcomes were selected by clinicians a priori based on clinical relevance: rate of admission for outpatients (day 1 and up to day 7) and length of stay for inpatients. Direct meta-analyses were carried out using random effects models. A mixed treatment comparison using a Bayesian network model was used to compare all interventions simultaneously.

Results: 48 trials (4897 patients, 13 comparisons) were included. Risk of bias was low in 17% (n = 8), unclear in 52% (n = 25), and high in 31% (n = 15). Only adrenaline (epinephrine) reduced admissions on day 1 (compared with placebo: pooled risk ratio 0.67, 95% confidence interval 0.50 to 0.89; number needed to treat 15, 95% confidence interval 10 to 45 for a baseline risk of 20%; 920 patients). Unadjusted results from a single large trial with low risk of bias showed that combined dexamethasone and adrenaline reduced admissions on day 7 (risk ratio 0.65, 0.44 to 0.95; number needed to treat 11, 7 to 76 for a baseline risk of 26%; 400 patients). A mixed treatment comparison supported adrenaline alone or combined with steroids as the preferred treatments for outpatients (probability of being the best treatment based on admissions at day 1 were 45% and 39%, respectively). The incidence of reported harms did not differ. None of the interventions examined showed clear efficacy for length of stay among inpatients.

Conclusions: Evidence shows the effectiveness and superiority of adrenaline for outcomes of most clinical relevance among outpatients with acute bronchiolitis, and evidence from a single precise trial for combined adrenaline and dexamethasone.

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Conflict of interest statement

Competing interests: All authors have completed the Unified Competing Interest form at www.icmje.org/coi_disclosure.pdf (available on request from the corresponding author) and declare that (1) LH, DJ, AP, TPK, and BV have support from the Canadian Institutes for Health Research for the submitted work; (2) none of the authors has relationships with Canadian Institutes for Health Research that might have an interest in the submitted work in the previous 3 years; (3) none of their spouses, partners, or children has financial relationships that may be relevant to the submitted work; and (4) the authors have no non-financial interests that may be relevant to the submitted work.

Figures

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Fig 1 Flow diagram for study selection
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Fig 2 Results from meta-analysis of direct comparisons for admission rates from emergency department (day 1 and day 7) in outpatients. Only comparisons with quantitative results are shown
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Fig 3 Comparisons (14 studies) contributing to mixed treatment analysis for admissions at day 1. Numerals within figure are studies at low risk of bias (four in total)
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Fig 4 Results of mixed treatment analysis for admissions at day 1, showing probability ranking and probability of being best statistic
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Fig 5 Results from meta-analysis of direct comparisons for length of stay in inpatients. Only comparisons with quantitative results are shown
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Fig 6 Comparisons (19 studies) contributing to mixed treatment analysis for length of stay. Numerals within figure are studies at low risk of bias (two in total)
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Fig 7 Results of mixed treatment analysis for length of stay, showing probability ranking and probability of being best statistic
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Comment in

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