ASK DIS: Management of Viral Induced Wheeze

Monday, August 24, 2015

Inhaled bronchodilators

often first-line therapy
effective rescue treatment in symptomatic patients, especially in children with established asthma
have not been shown to improve clinical outcomes, decrease the rate of hospital admission, or decrease the duration of hospitalization in children with bronchiolitis

Inhaled hypertonic saline

Limited data suggest that HS in combination with a short-acting beta2-agonist may be effective
Similar limited findings have been reported for the treatment of bronchiolitis.
The use is based upon the hypothesis that viral infection, particularly with rhinovirus, leads to dehydration of the airway surface liquid and impaired mucus clearance

intermittent high-dose inhaled glucocorticoids

if started at the onset of a URI and continued for up to 10 days, may decrease asthma-type symptoms and rescue oral glucocorticoid use in preschool children
may be particularly effective in patients with asthma risk factors

Systemic glucocorticoids

data are mixed regarding, although overall this approach does not appear to be effective in most patients

Intermittent leukotriene-receptor antagonists

results are mixed, but the majority of studies do not favor the use
PREEMPT study examined intermittent montelukast compared with placebo in 220 children aged 2-14. Treatment was initiated at the onset of symptoms of a respiratory tract infection and continued for a minimum of a week or until symptoms had disappeared for 48 hours. The montelukast group had fewer unscheduled consultations for asthma and fewer days away from school.
A three way comparison between standard treatment, intermittent montelukast, and intermittent nebulised budesonide (the only aerosolised steroid permitted by the FDA in preschool children) in 238 children aged 12-59 months showed minor and equivalent benefits for the two active treatments compared with standard treatment.

Recommendation For treatment

inhaled short-acting beta2-agonist (Grade 2B) such as albuterol via nebulizer (in NS) or metered dose inhaler (MDI) with spacer (table 1).
suggest not using inhaled glucocorticoids (Grade 2B).
suggest not using an oral glucocorticoid (Grade 2B). One exception is patients with severe acute wheezing symptoms and risk factors for persistent asthma (assessed by positive-modified asthma predictive indices)

Recommendation for prevention

intermittent high-dose inhaled glucocorticoids (table 2), begun at the onset of a URI, before wheezing has occurred, and continued for up to 10 days (Grade 2B). Fluticasone propionate 750 mcg inhaled twice daily and budesonide 1 mg nebulized twice daily have both been studied in the prevention of virus-inducing wheezing in preschool children.
suggest not using an oral glucocorticoid at the onset of a URI before wheezing has occurred (Grade 2B). Exceptions include patients with a prior history of a severe virus-induced wheezing exacerbation requiring hospitalization, patients with asthma risk factors who are currently on daily inhaled glucocorticoids for frequent exacerbations, or those who have not responded to high-dose intermittent inhaled glucocorticoids in the past.
recommend daily inhaled glucocorticoids at standard doses in children who continue to experience severe or recurrent episodes of wheezing despite intermittent high-dose inhaled glucocorticoids (Grade 1A).
Intermittent or daily montelukast is an alternative, especially for patients who do not tolerate daily inhaled glucocorticoids.

References;

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