Decreasing Use of Bronchodilators in Bronchiolitis

Abstract

Source: Shanahan KH, Monuteaux MC, Nagler J, et al. Early use of bronchodilators and outcomes in bronchiolitis. Pediatrics. 2021;148(2):e2020040394; doi.10.1542/peds.2020-040394Investigators from Boston Children’s Hospital, Boston, MA, conducted a retrospective analysis to assess US trends in care provided to infants presenting to emergency departments (EDs) and diagnosed with bronchiolitis and evaluate the effect of bronchodilator use on patient outcomes. For the study, they reviewed data from the Pediatric Health Information System (PHIS), an administrative database that includes encounter, demographic, diagnosis, procedure, and medication data on children seen at tertiary care pediatric hospitals in the US. Participants were infants <12 months old seen in the ED of 1 of 49 hospitals between 2010 and 2018 with an ICD-9 or ICD-10 diagnosis of bronchiolitis.Data on the identified patients were abstracted from the PHIS database and used to determine patient- and hospital-level outcomes, including bronchodilator use (albuterol, nebulized epinephrine, ipratropium, and levalbuterol), hospitalization rates, admission to an ICU, ED return visits within 3 days of index visit, and noninvasive and mechanical ventilation. Patient-level temporal trends in these outcomes were assessed with logistic regression models. For the hospital-level analyses, data from 2015 to 2018 were included and limited to hospitals in highest and lowest quartiles of “early” bronchodilator use, defined as administration of bronchodilators to study patients on the day of the index ED encounter. Multivariate logistic regression was used to assess the association between high or low bronchodilator use on outcomes after controlling for patient age and All Patient Refined Diagnosis Related Group (APR-DRG) severity scores.Data on 466,696 ED visits for infants with bronchiolitis were analyzed. The median age of study patients was 5 months, 59.9% were male, and 71.5% were publicly insured. Overall, 32.0% of patients were treated with bronchodilators. During the period 2010 to 2018, there were statistically significant decreases in bronchodilator use (51.5% to 22.8%), hospital admission rate (34.3% to 33.1%), and ED return visits (5.9% to 5.2%), and increases in ICU admission rates (2.4% to 4.3%) and use of noninvasive (1.0% to 2.9%) and mechanical (0.7% to 1.5%) ventilation. Hospital-level analyses included data on 56,852 patients treated at hospitals with high early use of bronchodilators and 54,458 treated at low early use hospitals. After controlling for age and APR-DRG score, there were no differences in outcomes between high and low bronchodilator use hospitals for hospital admission (odds ratio [OR], 0.93; 95% CI, 0.7, 1.3), ICU admissions (OR, 1.5; 95% CI, 0.7, 3.1), ED return visits (OR, 1.2; 95% CI, 0.99, 1.4), noninvasive ventilation (OR, 3.5; 95% CI, 0.7, 19.1) or mechanical ventilation (OR, 8.2; 95% CI, 0.99, 67.5).The authors conclude that use of bronchodilator therapy for infants seen at ED with bronchiolitis decreased between 2010 and 2018, and hospital-level use of bronchodilators was not associated with outcomes.Dr Winer has disclosed no financial relationship relevant to this commentary. This commentary does not contain a discussion of an unapproved/investigative use of a commercial product/device.The history of bronchiolitis management includes multiple instances of a seemingly beneficial intervention later being found to have little or no effect on patient outcomes. Corticosteroids (See AAP Grand Rounds. 2017;38:41), bronchodilators, hypertonic nebulized saline (See AAP Grand Rounds. 2016;35:39), and high-flow nasal cannula therapies all have been used for bronchiolitis and been targets for de-implementation when found not be effective.1Bronchodilators had been found in large meta-analysis not to reduce hospital admission, length of stay, or the time to resolution of symptoms.2 Trial sequential analysis, a methodology for meta-analysis that uses the order of studies to account for error including publication bias, has been used to analyze hypertonic saline3 and may help to explain the reason that early publications are more likely to show positive results even when there are none.The current researchers found that bronchodilator use decreased over time, although there were contemporaneous increases in ICU admission and use of noninvasive and mechanical ventilation. These increases, in the words of the current authors, “are similar to published increases … from 2000–2016” and likely are not caused by decreased bronchodilator usage. Hospital variation of early bronchodilator use still exists, without significant difference in outcomes between high- and low-utilization hospitals.Bronchodilator usage in bronchiolitis decreased substantially from 2010 to 2018, without any increases in hospital admissions, ED return visits, or differences in outcomes.The results of the current study support AAP guidelines that recommend limited use of bronchodilator therapy.4