Intern 朱學彥 pager:23356
題目（第三梯~3/15）
一位 1 歲的小男孩到本院門診就診主要原因為最近 1-2 天內有明顯的咳嗽與氣喘，他過
去身體狀況良好，此次主因為咳嗽、氣喘、與輕微的喘鳴聲外，有發燒至 38.3 0C，身體檢查
顯示病人有呼吸急促且合併有呼吸輔佐肌肉使用費力現象，兩側肺葉有高頻的喘鳴聲，實驗
室檢查有輕微的白血球高、胸部 X 光有兩側肺基底部增加浸潤現象，可能性的診斷為細支氣
管發炎 (bronchiolitis)，此時您正在決定是否使用支氣管擴張劑 (bronchodilator) 來改善病患
的支氣管發炎與氣喘，但是住院醫師認為只要使用生理鹽水蒸氣即可，且可減少醫療成本，
請問您就醫療實證醫學為依據，要如何回答此問題？
Critical Appraisal Topics (CAT):
CAT: bronchodilator is effective in treating bronchiolitis
Clinical bottom line:
Bronchodilators produce small short-term improvements in clinical scores.
This small benefit must be weighed against the costs and adverse effects of these agents.
Clinical scenario:
An one-year-old boy came to OPD due to cough and asthmatic attack in recent 1-2 days. Fever up to 38 degrees Celsius
was noted. Physical examination showed dyspnea and accessory muscle assisted breathing. Wheezing was noted over
bilateral lung fields. CXR showed bilateral lung infiltration. Lab result yielded mild leukocytosis. Bronchiolitis was
suspected. Whether the use of bronchodilators or normal saline inhalation was considered. Cost-effective was also taken
into consideration.
Three part question:
Is the bronchodilator more effective than normal saline inhalation in the treatment of bronchiolitis in children?
Searching terms:
Use “bronchodilator” and “bronchiolitis” as search terms in Cochrane library, and PubMed. I found a review article in
Cochrane library appears to be useful in answering the above question.
The study:
Randomized controlled trials (RCTs) comparing bronchodilators (other than epinephrine) with placebo in the treatment
of bronchiolitis.
Searching strategy:
Searching the Cochrane Central Register of Controlled Trials (CENTRAL) and the Database of Abstracts of Reviews of
Effects (DARE) (The Cochrane Library, Issue 1, 2006), MEDLINE (1966 to October 2005), EMBASE (2003 to
September 2005) and the reference lists of articles. The files of one author (AG) were also reviewed
Target disorder and gold standard.
Intern 朱學彥 pager:23356
Bronchiolitis. No gold standard was established. Clinical improvement and manifestation were observed.
Patients.
Participants were infants and young children with bronchiolitis no older than 24 months. All articles used the term
"bronchiolitis" to refer to an acute lower respiratory tract infection with wheezing
Diagnostic test.
Clinical score based on a multi-item clinical scale, oxygen saturation (oximetry) and admission to hospital were
selected to measure the effect of bronchodilators. Because a number of inpatient studies were subsequently published,
duration of hospitalization was added as an outcome measure. These outcomes were thought to be the most clinically
relevant and to have the largest amount of experimental data reported.
The evidence
Twenty-two clinical trials studying 1428 infants with bronchiolitis were included in these analyses.
Bronchodilator versus placebo
No. of No. of
Outcome title
studies participants Statistical method
Effect size
01 Improvement in clinical score (dichotomous)
8
468
Odds Ratio (Random) 95% CI
0.45 [0.15, 1.29]
02 Average clinical score after treatment: by treatment
15
814
Standardised Mean Difference (Fixed) 95% CI -0.48 [-0.62,
setting (continuous)
-0.33]
03 Oximetry by treatment setting
20
990
Weighted Mean Difference (Random) 95% CI -0.57 [-1.17, 0.03]
04 Hospital admission after treatment (outpatients)
5
224
Odds Ratio (Fixed) 95% CI
0.70 [0.36, 1.35]
05 Duration of hospitalization (inpatients)
5
314
Weighted Mean Difference (Fixed) 95% CI
0.02 [-0.32, 0.36]
The level of evidence: Ia
Comments (recommendations):
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Implications for practice
Bronchodilators produce small short-term improvements in clinical scores among infants with bronchiolitis and may
slightly improve oxygenation in those treated as outpatients. However, given the high costs, incidence of adverse
effects and uncertain efficacy based on the findings of this meta-analysis, bronchodilators cannot be recommended
for routine management of first-time wheezers who present with the clinical findings of bronchiolitis.
Bronchodilators should not be used in patients who are hospitalized with bronchiolitis.
Expiry data: 2007
Reference:
[Review] Bronchodilators for bronchiolitis AM Gadomski and AL Bhasale
Cochrane Database of Systematic Reviews 2007 Issue 1