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Manejo de Bronquiolitis Aguda: según Medicina Basada Evidencia Jose A. Castro-Rodriguez, MD, PhD Escuela de Medicina Pontificia Universidad Católica de Chile
Manejo de Bronquiolitis Aguda: j q gsegún Medicina Basada Evidencia
Jose A. Castro-Rodriguez, MD, PhDEscuela de Medicina
Pontificia Universidad Católica de Chile
Levels of evidenceLevels of evidenceLevels of evidenceLevels of evidence11++++ High quality metaHigh quality meta--analysesanalyses, systematic reviews, or randomised , systematic reviews, or randomised
controlled trials (RCTs) with a very low risk of biascontrolled trials (RCTs) with a very low risk of biascontrolled trials (RCTs) with a very low risk of biascontrolled trials (RCTs) with a very low risk of bias11++ WellWell--conducted metaconducted meta--analyses, systematic reviews, or RCTs with a low analyses, systematic reviews, or RCTs with a low
risk of biasrisk of bias11 M tM t l t ti i RCT ith hi h i k f bil t ti i RCT ith hi h i k f bi11 MetaMeta--analyses, systematic reviews, or RCTs with a high risk of biasanalyses, systematic reviews, or RCTs with a high risk of bias
Grades of recommendationGrades of recommendation• Relate to strength of evidence, not clinical importance• Low grade recommendations in important clinical areas should stimulate research
R d tiR d ti E idE idRecommendationRecommendation EvidenceEvidence
AAAt least one 1At least one 1++++ directly applicable to target populationdirectly applicable to target population; or; orMany studies 1Many studies 1++ directly applicable to target population and directly applicable to target population and demonstrating consistencydemonstrating consistency
Introduction. Thorax 2003; 58 (Suppl I): i1-i92
g yg y
Manejo Bronquiolitis en Urgencia
1. Hidratación
2. Oxigenoterapia
3. Broncodilatadores (salbutamol, epinefrina)
4. Corticoides
5 Suero Hipertónico5. Suero Hipertónico
6. Terapia respiratoria (kinesioterapia)p p ( p )
Salbutamol by nebulizer vs. placebo
Gadomski & Scribani Cochrane 2014
Salbutamol by nebulizer vs. placebo
Gadomski & Scribani Cochrane 2014
Salbutamol by nebulizer vs. placebo
Gadomski & Scribani Cochrane 2014
Epinephrine by nebulized vs. placebo
Hartling et al, Cochrane 2011
Hartling et al, Cochrane 2011
Epinephrine nebulized & oral dexamethasone vs. placebo
Hartling et al, Cochrane 2011
Fernandes et al. Cochrane 2013
Fernandes et al. Cochrane 2013
Nebulized Hypertonic Saline (3%) vs. Normal Saline
Ri k f h it li ti t ti tRisk of hospitalization among outpatients
Zhang et al. Pediatrics 2015
Chest therapy (slow & long expiration flow techniques) in infants: RCT
n=48Santiago, Chile
Castro-Rodriguez et al. Acta Paeditric 2014
Manejo Bronquiolitis en Hospital
1. Hidratación
2. Oxigenoterapia
3 B dil t d (S lb t l E i f i )3. Broncodilatadores (Salbutamol, Epinefrina)
4. Corticoides
5. Suero Hipertónico
6 Heliox DNAasa Surfactante Rivabirina Inmunoglobulina6. Heliox, DNAasa, Surfactante, Rivabirina, Inmunoglobulina
7. Terapia respiratoria (kinesioterapia)
Sp<90%Sp<94%
Cunningham et al. Lancet 2015
• 1 RCT (n=19), pilot study.
• HFNC therapy vs. oxygen via a head box.
• SpO2 was higher in HFNC: p gat 8hrs (100% vs. 96%, p= 0.04) at 12 hrs (99% vs. 96%, p = 0.04), but similar at 24 hrs.
• No clear evidence: total duration oxygen therapy, yg pytime to discharge or total length of stay.
• 5 ongoing RCTsg g
Beggs S. et al, Cochrane 2014
Umoren et al. Cochrane Collab Pub 2011Umoren et al. Cochrane 2011
Umoren et al. Cochrane Collab Pub 2011Umoren et al. Cochrane 2011
Salbutamol by nebulizer vs. placebo
Gadomski & Scribiani Cochrane 2014
Salbutamol by nebulizer vs. placebo
Gadomski & Scribiani Cochrane 2014
Salbutamol by nebulizer vs. placebo
Gadomski & Scribiani Cochrane 2014
Epinephrine vs. Salbutamol
Hartling et al, Cochrane 2011
Hartling et al, Cochrane 2011
Hartling et al, Cochrane 2011
Fernandes et al. Cochrane 2013
Fernandes et al. Cochrane 2013
RCTs=4, n=84
Blom. et al, Cochrane 2006
RCTs=4, n=84
Blom. et al, Cochrane 2006
RCTs=4, n=84
Blom. et al, Cochrane 2006
Zhang et al. Cochrane 2013
Zhang et al. Cochrane 2013
Zhang et al. Cochrane 2013
Zhang et al. Cochrane 2013
Nebulized Hypertonic Saline vs. Normal SalineReduction of long of stay among inpatients
Zhang et al. Pediatrics 2015
RCTs=4, n=84
Liet et al, Cochrane 2010
Enriquez et al. Cochrane 2012
3 small RCTs n=793 small RCTs, n=79
Jat & Chawla, Cochrane 2012
3 small RCTs n=793 small RCTs, n=79
Jat & Chawla, Cochrane 2012
• In 12 RCTs (n=158) Ribavirin vs. placebo( ) pMortality 5.8% vs 9.7% (OR: 0.58 [0.18 to 1.85])
I 3 RCT ( 116) Rib i i l b• In 3 RCTs (n=116) Ribavirin vs. placeboRespiratory deterioration: 7.1% vs. 18.3%
(OR: 0 37 [0 12 to 1 18])(OR: 0.37 [0.12 to 1.18])
• In 3 RCTs (n=104 ventilated) Ribavirin vs. placeboFewer days of hospitalization: 1.9 [-4.6 to +0.9] Fewer days of ventilation:1.8 [-3.4 to -0.2] √
Ventre & Randolph Cocharne 2007
• 4 RCTs.
• No significant benefit of intravenousgimmunoglobulin (IVIG) treatment added to supportive care vs. supportive care alone.
• No support a role for RSVIG in such a setting, with the doses used in the studieswith the doses used in the studies
Fuller et al, Cochrane Collab Pub 2006
• 9 RCTs (n=891) physiotherapy vs. no intervention. 5 RCTs (n=246) vibration & percussion techniques4 RCTs (n=645) passive expiratory techniques4 RCTs (n 645) passive expiratory techniques.
• No differences between groups in:Respiratory Parameters (2 RCTs, n=118), Oxygen Requirements (1 RCTs, n=50), L th f St (5 RCT 222)Length of Stay (5 RCTs, n=222) Severe Side Effects (2 RCTs, n=595).
• Significant mild transient adverse effects (vomiting & respiratory instability) among chest physiotherapy
Roque i Figuls et al, Cochrane 2012
(1 RCT, 496 participants).
Conclusiones: Manejo de Bronquiolitis Urgencia Hospitalizados
-Epinephrine vs. salbutamol nebuliz:-Epinephrine vs. placebo:
Mejora Saturometría primeras 2 hrReduce días de Hospitalización
Mejora Score Clínico primeras 2 hr Reduce Admisiones en el 1er. día
-Suero hipertónico 3% vs. sol. 9%:-Suero hipertónico 3% vs. sol. 9%:
Mejora Score clínico primeras 3 hr Reduce días de Hospitalización
Reduce Admisiones
-Salbutamol nebulizado vs. placebo: -Surfactante:
Mejora gasometría primeras 24hr Mejora Score Clínico (?)
Reduce Duración Vent. Mecánica Reduce días en UCI
v.s.v.s.
Pediatrics 2014:134; e1474-e1502
Pediatrics 2014:134; e1474-e1502
by nebulizer
Zhang et al. Pediatrics 2015
