Should Steroids Be Used in Treating Bronchiolitis?

640 SHOULD STEROIDS BE USED IN TREATING BRONCHIOLITIS? S INCE their introduction into clinical use, corticosteroids have been employed as therapeutic agents in virtually every known disease state, ranging from minor dermatologic disorders to major and serious diseases. These agents have undoubtedly altered the clinical picture and prognosis of certain diseases. However, the use of corticosteroids is always potentially associated with a variety of untoward effects, some of which may be life threatening, i.e., decreased resistance to infection, growth retardation, neurological reactions, hypertension, peptic ulcerations, and many others.’ The time honored principle-first do no harm-should always be the guideline of therapy, especially when a definite indication for a particular therapeutic agent has not been established. In recent years corticosteroids have been employed in the treatment of bronchiolitis on the hypothesis that their anti-inflammatory action would decrease swelling, inflammation, and the consequent respiratory obstruction. The opinions of different investigators on the efficacy of corticosteroids in this disorder have varied greatly; some have regarded their use as ineffective and others as lifesaving. It is the purpose of this report to review the findings from various studies and to oufline the current status of the use of corticosteroids in this common disorder of infants and children. Bronchiolitis is a common, acute respiratory syndrome characterized by infection of the bronchioles and respiratory distress of varying degrees due to obstructive emphysema. It is common in the first year of life and is rare in the child over 2 years of age. It frequently occurs in outbreaks. The great majority of cases are due to viruses, especially the respiratory syncitial, influenza B, and parainfluenza viruses, but it may be due to bacteria and other respiratory pathogens. The walls of the bronchioles and small bronchi are infiltrated with inflammatory cells and the lumina may be markedly reduced by the presence of inflammatory debris and edema; this occlusion leading to widespread areas of obstructive emphysema and patchy ateleetasis expressed clinically by expiratory wheezing. The clinical severity is dependent on the degree of respiratory obstruction and varies from mild to severe. The chief aim of treatment is the relief of respiratory obstruction and the management of secondary complications. The mortality rate has been reported in different series to range from 1 to 5.5%. Heycock and Noble2 reported a mortality rate of 5.5% in 1,230 cases, with the highest fatality rate in infants less than 6 months of age. If patients with milder cases of bronchioiitis are included, the overall death rate probably does not exceed 1%. ’ A number of reports have appeared in the literature relating to the therapeutic use of corticosteroids in bronchiolitis. Many of the studies reporting favorable results with these agents were uncontrolled ones.#{176}’#{176} In general, controlled studies have failed to identify significant favorable effects. One of the earliest and better controlled studies was that by Dennis,7 which showed significant benefits from corticosteroids in a double-blind study of 98 patients with bronchiolitis. Sussman and co-workers8 found no difference in the mean time required for improvement or recovery among 26 infants given dexamethasone in a dose of 0.2 mg/lb for 9 days as compared to 23 patients receiving a placebo. Likewise, Dabbous, et al.,#{176} using a “bronchiolitis score” to quantitate severity ( similar to the Silverman retraction score of the respiratory distress syndrome) and determining blood gases and pH, did not find any therapeutic difference attributable to eorticosteroids in a controlled stlidy of 22 matched pairs of children with bronehiolitis. Damus,1#{176} in a placebo-controlled study, noted no beneficial effect in 30 infants receiving prednisone 1 mg daily for 4 days. Oski and coworkers1’ in 1961 reported a therapeutic effect from corticosteroids in a group of patients as compared to controls. Subse-