Rationale and evidence
Rationale
Chest X-rays
Chest X-rays for patients with acute lower respiratory tract infections rarely affect clinical treatments and outcomes. Chest X-ray films do not discriminate well between bronchiolitis and other forms of lower respiratory tract infection and in mild cases do not offer information that is likely to affect treatment. It is estimated that 133 children with typical bronchiolitis would have to undergo radiography to identify 1 radiograph that is suggestive of an alternate diagnosis.
Salbutamol
With the exception of improving clinical scores in infants treated as outpatients, the evidence overwhelmingly shows that bronchodilators, including salbutamol, do not improve oxygen saturation, reduce hospital admissions or shorten the duration of hospitalisation and time to resolution of illness in children with bronchiolitis. Compared with these minimal benefits, salbutamol is associated with adverse impacts such as tachycardia, oxygen desaturation and tremors. If a bronchodilator is required, epinephrine appears to be a superior alternative to salbutamol in reducing the severity of bronchiolitis.
Steroids
The majority of randomised controlled trials have not found a clinically relevant, sustained impact of systemic or inhaled glucocorticoids on admissions or length of hospitalisation in children with bronchiolitis or other forms of lower respiratory tract infection.
Evidence
Beigelman A, King TS, Mauger D, et al. Do oral corticosteroids reduce the severity of acute lower respiratory tract illnesses in preschool children with recurrent wheezing? Journal of Allergy and Clinical Immunology. 2013; 131(6): 1518-25.
Bordley WC, Viswanathan M, King VJ, et al. Diagnosis and testing in bronchiolitis: a systematic review. Archives of Pediatric Adolescent Medicine. 2004; 158(2): 119-26.
Cao AY, Choy JP, Mohanakrishnan L, et al. Chest radiographs for acute lower respiratory tract infections. Cochrane Database of Systematic Reviews. 2013; 12: CD009119.
Fernandes RM, Bialy LM, Vandermeer B, et al. Glucocorticoids for acute viral bronchiolitis in infants and young children. Cochrane Database of Systematic Reviews. 2013; 6: CD004878.
Gadomski AM, Scribani MB. Bronchodilators for bronchiolitis. Cochrane Database of Systematic Reviews. 2014; 6: CD001266.
Hartling L, Fernandes RM, Bialy L, et al. Steroids and bronchodilators for acute bronchiolitis in the first two years of life: systematic review and meta-analysis. British Medical Journal. 2011; 342: d171.
Modaressi MR, Asadian A, Faghihinia J, et al. Comparison of epinephrine to salbutamol in acute bronchiolitis. Iranian Journal of Pediatrics. 2012; 22(2): 241-4.
Schuh S, Lalani A, Allen U, et al. Evaluation of the utility of radiography in acute bronchiolitis. Journal of Pediatrics. 2007; 150(4): 429-33.
Yong JH, Schuh S, Rashidi R et al. A cost effectiveness analysis of omitting radiography in diagnosis of acute bronchiolitis. Pediatric Pulmonology. 2009; 44(2): 122-7.