Efficacy of inhaled salbutamol with and without prednisolone for first acute rhinovirus‐induced wheezing episode

Abstract

Background Acute rhinovirus‐induced wheezing is common in young children and may respond to systemic corticosteroid. There are no trials on the efficacy of inhaled beta2‐agonist in this clinical scenario. Objective To study post hoc the short‐term (up to 2 months) efficacy of inhaled beta2‐agonist with and without oral corticosteroid in the first acute rhinovirus‐induced severe wheezing episode in young hospitalized children. Methods The study population came from two randomized controlled trials comparing oral prednisolone (2 mg/kg/d for 3 days) to placebo: Vinku (n = 35, NCT00494624) used high‐dose regular nebulized salbutamol (0.15 mg/kg 2–4 h intervals) and Vinku2 (n = 60, NCT00731575, EudraCT 2006‐007100‐42) used inhaled salbutamol on‐demand. Both studies used identical detailed follow‐up assessments. The primary outcome of the former was the duration of hospitalization and of the latter the occurrence of and the time to a new physician‐confirmed wheezing episode within 2 months after discharge. Treatment groups included salbutamol high‐dose vs. salbutamol on‐demand while adjusting for prednisolone status and acknowledging for interactions with exception of the duration of hospitalization in which prednisolone groups could not be fully used due to protocol differences. Results Median age of subjects was 13 months, 32% were sensitized and 22% had doctor‐diagnosed eczema. In the duration of hospitalization, salbutamol high‐dose/placebo versus salbutamol on‐demand/placebo groups did not differ (p = .12). In the occurrence of and time to relapse within 2 months, a significant group × treatment interaction was observed (both p = .02), such that high‐dose group had less and longer time to relapses than on‐demand group in prednisolone arm (both p < .05), but no difference was detected in placebo arm (both p > .26). Conclusions In young, hospitalized children with first episode of rhinovirus‐induced wheezing, high‐dose inhaled salbutamol may interact with oral prednisolone. However, further trials are warranted.

Reply to: Medical algorithm: Diagnosis and treatment of preschool asthma

“…However, early treatment of rhinovirus-induced severe wheezing episode with systemic corticosteroid has been shown to reduce subsequent asthma inception within the next 6-7 years by 30% (shown in secondary outcomes and in post hoc analyses). 5,6 Altogether, these findings show that children with early asthma-like inflammation in the airways are more susceptible to rhinovirus infections, which may serve as a good clinical marker. What is more, data support the use of short course of systemic corticosteroid and at least a therapeutic trial with short-acting beta 2 -agonists in selected cases of bronchiolitis, in particular those with the rhinovirus-induced severe wheezing episode.…”

“…Fourth, asthma is considered an incurable disease without any primary or secondary prevention strategies. However, early treatment of rhinovirus‐induced severe wheezing episode with systemic corticosteroid has been shown to reduce subsequent asthma inception within the next 6‐7 years by 30% (shown in secondary outcomes and in post hoc analyses) 5,6 . Altogether, these findings show that children with early asthma‐like inflammation in the airways are more susceptible to rhinovirus infections, which may serve as a good clinical marker.…”

“…Third, there is evidence from at least two trials that young children suffering from severe, first rhinovirus-induced wheezing episode may benefit from traditional asthma medication, including systemic corticosteroid and beta 2 -agonists. 4,5 The efficacy was demonstrated as a shorter duration of hospitalization, shorter duration of cough after discharge and fewer recurrences. Importantly, clear synergy in efficacy between salbutamol and prednisolone was observed.…”

Something Is Changing in Viral Infant Bronchiolitis Approach

“…Similarly to bronchodilators, the use of corticosteroid is not recommended in the management of infant bronchiolitis ( 1 ), but is part of the treatment of viral wheezing or asthma, so we agree that a course of corticosteroid could be indicated in moderate to severe clinical pictures, when the bronchodilators trial gave a positive result ( 42 , 53 – 56 ).…”

Immune modulation and the role of innate immune cells in allergy and asthma

“…Viral respiratory infections, particularly rhinoviruses, are the most prominent trigger of asthma exacerbations 4 . Rhinoviruses were shown to induce airway inflammation and worsen clinical symptoms, with increased exacerbation risk for viral infection concurring with allergen exposure for asthmatic patients 5 . Although the role of DCs is well established in both viral infections and allergens, 6 little is known about their role in viral asthma exacerbations.…”