Downloaded from emj.bmj.

com on 3 July 2009

Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infirmary
Kevin Mackway-Jones Emerg. Med. J. 2008;25;839-840 doi:10.1136/emj.2008.066886

Updated information and services can be found at:

http://emj.bmj.com/cgi/content/full/25/12/839-a

These include:

Rapid responses Email alerting service

You can respond to this article at:

http://emj.bmj.com/cgi/eletter-submit/25/12/839-a

Receive free email alerts when new articles cite this article - sign up in the box at the top right corner of the article

Topic collections

Articles on similar topics can be found in the following collections

Bronchiolitis (161 articles) TB and other respiratory infections Bronchitis (366 articles)

(1093 articles)

Notes

To order reprints of this article go to:

http://journals.bmj.com/cgi/reprintform

To subscribe to Emergency Medicine Journal go to:

http://journals.bmj.com/subscriptions/

Downloaded from emj.bmj.com on 3 July 2009

Best evidence topic reports

Towards evidence based emergency medicine: Best BETs from the Manchester Royal Infirmary
Edited by Kevin Mackway-Jones
BET 1
ORAL STEROIDS ARE NOT INDICATED IN BRONCHIOLITIS Report by: Jayachandran Panickar, Consultant Respiratory Paediatrician Search checked by: Michael Eisenhut, Consultant Paediatrician Institution: Central Manchester and Manchester Childrens University Hospital and Luton and Dunstable Hospital A short-cut review was carried out to establish whether steroids are indicated in the management of bronchiolitis. Six Table 1 Relevant papers
Author, date and country Klassen et al, 1997, Canada Patient group Study type (level of evidence) Outcomes Key results No significant difference No significant difference Study weaknesses Short duration (3 days) of treatment. Application of mean and t test to ordinal scale data inappropriate. No microbiological confirmation in 12% of controls and 14% of cases. No justification of choice of primary outcome. Treatment given for 2 days beyond time of primary outcome assessment. Microbiological confirmation of diagnosis in only 50% of cases. Inappropriate use of the mean as measure of distributions in small samples. No power calculation regarding chronic symptoms. No power calculation for ventilated patients. Small number of ventilated patients.

Best Evidence Topic reports (BETs) summarise the evidence pertaining to particular clinical questions. They are not systematic reviews, but rather contain the best (highest level) evidence that can be practically obtained by busy practising clinicians. The search strategies used to find the best evidence are reported in detail in order to allow clinicians to update searches whenever necessary. Each BET is based on a clinical scenario and ends with a clinical bottom line which indicates, in the light of the evidence found, what the reporting clinician would do if faced with the same scenario again. The BETs published below were first reported at the Critical Appraisal Journal Club at the Manchester Royal Infirmary1 or placed on the BestBETs website. Each BET has been constructed in the four stages that have been described elsewhere.2 The BETs shown here together with those published previously and those currently under construction can be seen at http://www.bestbets.org.3
1. Carley SD, Mackway-Jones K, Jones A, et al. Moving towards evidence based emergency medicine: use of a structured critical appraisal journal club. J Accid Emerg Med 1998;15:220222. Mackway-Jones K, Carley SD, Morton RJ, et al. The best evidence topic report: a modified CAT for summarising the available evidence in emergency medicine. J Accid Emerg Med 1998;15:222226. Mackway-Jones K, Carley SD. bestbets.org: Odds on favourite for evidence in emergency medicine reaches the worldwide web. J Accid Emerg Med 2000;17:2356.

2.

3.

Length of hospital stay Randomised double 67 patients (6 weeks blind placebo controlled Respiratory distress 15 months). Oral dexamethasone (0.5 mg/kg per trial assessment instrument day, day 1, 0.3 mg/kg per day, score days 2 and 3) vs placebo Oxygen saturation Respiratory rate

No significant difference No significant difference

Berger et al, 1998, Israel

Van Woensel et al, 1997, The Netherlands

Development of chronic 38 Patients (118 months). Oral Randomised double prednisolone (2 mg/kg per day) blind placebo controlled respiratory symptoms (at 2-year follow-up) trial for 3 days vs placebo. All patients received nebulised Oxygen saturation salbutamol Clinical score Length of hospital stay Randomised double 54 Patients aged less than blind placebo controlled (ventilated patients) 2 years. Oral prednisolone (1 mg/kg per day) for 7 days vs trial Length of hospital stay placebo (non-ventilated patients) Duration of mechanical ventilation (ventilated patients) Symptom score (nonventilated patients)

No significant difference

No significant difference No significant difference Significantly less in prednisolone group No significant difference No significant difference

Goebel et al, 2000, USA

Clinical trial 48 Children (less than 23 months). Oral prednisolone (2 mg/kg per day) for 5 days vs placebo. All patients received nebulised salbutamol

Length of hospital stay Bronchiolitis score

Significantly faster improvement in prednisolone group (day 3) No significant difference Significant improvement in prednisolone group by day 2 but no difference later on No significant difference No significant difference No significant difference No significant difference No significant difference No significant difference No significant difference

Zhang et al, 2003, Brazil

Corneli et al, 2007, USA

Length of hospital stay Time to clinical resolution Duration of oxygen therapy Prevalence of postbronchiolitis wheezing Hospital admission Randomised double 600 Patients aged 2 12 months. Oral dexamethasone blind placebo controlled Later medical visits trail (1 mg/kg) 1 dose versus Respiratory assessment placebo change score 52 Patients, aged less than 12 months. Oral prednisolone (1 mg/kg per day) for 5 days plus standard care versus standard care

Randomised controlled trial

Exclusion of mild and severe cases of bronchiolitis. Selection bias: only patients with wheeze not responding to nebulised salbutamol were included. 54% of cases and 37% of controls without microbiological confirmation of diagnosis. No microbiological confirmation of diagnosis. Small study.

No microbiological confirmation of diagnosis.

Emerg Med J December 2008 Vol 25 No 12

839

Downloaded from emj.bmj.com on 3 July 2009

Best evidence topic reports

c

Clinical bottom line

Current evidence does not support bronchiolitis as an indication for oral steroids.

papers presented evidence addressing the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that oral steroids are not indicated in bronchiolitis.

Berger I, Argaman Z, Schwartz SB, et al. Efficacy of corticosteroids in acute bronchiolitis: short term and long term follow up. Pediatr Pulmonol 1998;26: 1626. Goebel J, Estrada B, Quinonez J, et al. Prednisolone plus albuterol versus albuterol alone in mild to moderate bronchiolitis. Clin Pediatr 2000;39:21320. Klassen TP, Sutcliffe T, Watters LK, et al. Dexamethasone in salbutamol-treated inpatients with acute bronchiolitis: a randomised controlled trial. J Pediatrics 1997;130:1916. van Woensel JB, Wolfs TF, van Aalderen WM, et al. Randomised double blind placebo controlled trial of prednisolone in children admitted to hospital with respiratory syncytial virus bronchiolitis. Thorax 1997;52:6347.

Clinical bottom line

Current evidence does not support the use of nebulised salbutamol in patients with bronchiolitis.

(bronchiolitis or rsv bronchiolitis). Limit to human, English and randomised controlled trials.

SEARCH OUTCOME
There was a total of 68 hits, nine relevant papers were found.

THREE-PART QUESTION
In [infants with bronchiolitis] do [oral steroids] reduce [clinical severity or length of hospital stay].

COMMENTS
Emerg Med J 2008;25:839840. doi:10.1136/emj.2008.066886

BET 2
IS NEBULISED SALBUTAMOL INDICATED IN BRONCHIOLITIS? Report by: Jayachandran Panickar, Consultant Respiratory Paediatrician Search checked by: Michael Eisenhut, Consultant Paediatrician Institution: Central Manchester and Manchester Childrens University Hospital Luton and Dunstable Hospital A short-cut review was carried out to establish whether nebulised salbutamol is indicated in the management of bronchiolitis. From a search of 68 papers only nine presented trials addressing the clinical question. The author, date and country of publication, patient group studied, study type, relevant outcomes, results and study weaknesses of these papers are tabulated. The clinical bottom line is that on current evidence nebulised salbutamol is not indicated in patients with bronchiolitis.

CLINICAL SCENARIO
A 6-month-old baby is admitted to hospital with a 4-day history of coryzal symptoms, cough, wheeze and decrease in feeds. Respiratory syncytial virus is detected in nasopharyngeal secretions. She is needing oxygen and is on a nasogastric feed. You wonder whether starting oral steroids will improve her clinical condition.

SEARCH STRATEGY
Medline 19662008 Embase 19802008 Cochrane database of systematic reviews and Cochrane central register of controlled trials (Oral steroids or prednisolone) AND (bronchiolitis or RSV bronchiolitis) limit to human, english and randomised controlled trials.

All the studies compared the clinical severity score. Seven of these studies showed no significant difference between the salbutamol and placebo group. Three studies looked at the length of hospital stay and showed no significant difference between the salbutamol group and the placebo group. The study by Ling Ho et al showed significant desaturation after nebulised salbutamol compared with placebo. They also showed that the patients in the salbutamol group took longer to normalise their oxygen saturation levels after a desaturation. The only study showing a clinical benefit of salbutamol was the study of Schuh et al. That study showed that there was a significantly greater improvement in respiratory rate and accessory muscle score after nebulised salbutamol compared with placebo. Gadomski et al found a significant increase in heart rate in patients treated with nebulised salbutamol compared with oral placebo.
c

SEARCH OUTCOME
There was a total of 35 hits, with six relevant papers.

COMMENTS
The largest of the studies (Corneli et al) was conducted in the emergency department. Neither the primary outcome measure (hospital admission) nor the secondary outcomes (length of hospital stay and clinical score) showed any significant improvement with steroids. In the first 2 days of treatment prednisolone seems to accelerate the improvement of clinical scores transiently without impact on overall outcomes, such as duration of hospitalisation or chronic symptoms.
c

THREE-PART QUESTION
In [infants with bronchiolitis] will a [treatment with nebulised salbutamol] reduce [the length of hospitalisation and clinical severity].

CLINICAL SCENARIO
A 6-month-old baby is admitted to hospital with a 4-day history of coryzal symptoms, cough, wheeze and poor feeding. Your clinical diagnosis is bronchiolitis. You wonder whether treatment with nebulised salbutamol would improve the clinical condition.
c

Zhang L, Ferruzzi E, Bonfanti T, et al. Long and short-term effect of prednisolone in hospitalized infants with acute bronchiolitis J Paediatr Child Health 2003;39:54851. Corneli HM, Zorc JJ, Majahan P, et al. of the Bronchiolitis Study Group of the Pediatric Emergency Care Applied Reserach Network (PECARN). A multicenter, randomized, controlled trial of dexamethasone for bronchiolitis. N Engl J Med 2007;357:3319.

SEARCH STRATEGY
Medline 19662008, Embase 19802008, Cochrane database of systematic reviews and Cochrane central register of controlled trials. (Nebulised salbutamol or salbutamol or bronchodilators) AND
c

Schuh S, Canny G, Reismann JJ, et al. Nebulised albuterol in acute bronchiolitis. J Pediatr 1990;117: 6337. Klassen TP, Rowe PC, Sutcliffe T, et al. Randomised trial of salbutamol in acute bronchiolitis. J Pediatr 1991;118:80711. Gadomski AM, Aref GH, El Din OB, et al. Oral versus nebulised albuterol in the management of bronchiolitis in Egypt. J Pediatr 1994;124:1318. Gadomski AM, Lichenstein R, Horton L, et al. Efficacy of albuterol in the management of bronchiolitis. Pediatrics 1994;93:90712. Chowdhury D, Al Howasi M, Khalil M, et al. The role of bronchodilators in the management of bronchiolitis: a clinical trial. Ann Trop Paediatr 1995;15:7784. Goh A, Chay OM, Foo AL, et al. Efficacy of bronchodilators in the treatment of bronchiolitis. Singapore Med J 1997;38:3268. Dobson JV, Stephen-Groff SM, McMahon SR, et al. The use of albuterol in hospitalised infants with bronchiolitis. Pediatrics 1998;101:3618. Ho L, Collis G, Landau LI, et al. Effect of salbutamol on oxygen saturation in bronchiolitis. Arch Dis Child 1991;66:10614. Wang EE, Milner R, Allen U, et al. Bronchodilators for treatment of mild bronchiolitis: a factorial randomised trial. Arch Dis Child 1992;67:28993.

Emerg Med J 2008;25:840841. doi:10.1136/emj.2008.066894 Emerg Med J December 2008 Vol 25 No 12

840