Bronchiolitis—Reply

In reply

We appreciate Dr DiTraglia's observation that there appeared to be a conflict between the conclusions of our systematic reviews on the diagnosis and treatment of bronchiolitis^1- 2 and the study by Mull et al³ comparing nebulized epinephrine and albuterol for the treatment of bronchiolitis in infants. We would agree with Dr DiTraglia that there is, in his words, a "... disconnect between the evidence and the practice of pediatrics in America." Our review included 9 randomized controlled trials of epinephrine vs a placebo and/or a β2-agonist. The weight of evidence from these studies does not support the routine use of either nebulized epinephrine nor β2-agonists for bronchiolitis. The study by Mull and colleagues was obviously not published prior to the completion of our review, but its inclusion would not have altered our conclusions. The ARCHIVES recently published a meta-analysis by Hartling et al⁴ of randomized controlled trials evaluating the efficacy of epinephrine for bronchiolitis. Hartling and colleagues determined that there was insufficient support for using epinephrine among inpatients but that epinephrine might offer some short-term benefit among outpatients. However, they found no significant differences between epinephrine, albuterol, and a placebo in terms of length of stay in the outpatient setting or rates of admission. Mull and colleagues also found no significant difference in rates of hospitalization. We agree with Hartling et al and concur with the need for large, multicentered trials of epinephrine among outpatients with bronchiolitis before its use is recommended. Our review called for investigators to use outcome measures that mattered most to patients, their parents, and their physicians. Differences in short-term and surrogate outcomes that do not correspond to children who are actually well enough to breathe and feed without assistance and return home are essentially not useful. The continued "disconnect" between best (albeit imperfect) current evidence and the practice of medicine wastes resources and needlessly exposes patients to adverse medication effects.