manejjq go de bronquiolitis a guda: según medicina basada ... · terapia respiratoria...
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Manejo de Bronquiolitis Aguda: j q gsegún Medicina Basada Evidencia
Jose A. Castro-Rodriguez, MD, PhDEscuela de Medicina
Pontificia Universidad Católica de Chile
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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
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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 )
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Salbutamol by nebulizer vs. placebo
Gadomski & Scribani Cochrane 2014
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Salbutamol by nebulizer vs. placebo
Gadomski & Scribani Cochrane 2014
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Salbutamol by nebulizer vs. placebo
Gadomski & Scribani Cochrane 2014
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Epinephrine by nebulized vs. placebo
Hartling et al, Cochrane 2011
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Hartling et al, Cochrane 2011
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Epinephrine nebulized & oral dexamethasone vs. placebo
Hartling et al, Cochrane 2011
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Fernandes et al. Cochrane 2013
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Fernandes et al. Cochrane 2013
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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
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Chest therapy (slow & long expiration flow techniques) in infants: RCT
n=48Santiago, Chile
Castro-Rodriguez et al. Acta Paeditric 2014
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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)
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Sp<90%Sp<94%
Cunningham et al. Lancet 2015
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• 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
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Umoren et al. Cochrane Collab Pub 2011Umoren et al. Cochrane 2011
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Umoren et al. Cochrane Collab Pub 2011Umoren et al. Cochrane 2011
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Salbutamol by nebulizer vs. placebo
Gadomski & Scribiani Cochrane 2014
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Salbutamol by nebulizer vs. placebo
Gadomski & Scribiani Cochrane 2014
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Salbutamol by nebulizer vs. placebo
Gadomski & Scribiani Cochrane 2014
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Epinephrine vs. Salbutamol
Hartling et al, Cochrane 2011
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Hartling et al, Cochrane 2011
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Hartling et al, Cochrane 2011
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Fernandes et al. Cochrane 2013
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Fernandes et al. Cochrane 2013
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RCTs=4, n=84
Blom. et al, Cochrane 2006
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RCTs=4, n=84
Blom. et al, Cochrane 2006
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RCTs=4, n=84
Blom. et al, Cochrane 2006
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Zhang et al. Cochrane 2013
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Zhang et al. Cochrane 2013
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Zhang et al. Cochrane 2013
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Zhang et al. Cochrane 2013
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Nebulized Hypertonic Saline vs. Normal SalineReduction of long of stay among inpatients
Zhang et al. Pediatrics 2015
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RCTs=4, n=84
Liet et al, Cochrane 2010
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Enriquez et al. Cochrane 2012
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3 small RCTs n=793 small RCTs, n=79
Jat & Chawla, Cochrane 2012
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3 small RCTs n=793 small RCTs, n=79
Jat & Chawla, Cochrane 2012
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• 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
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• 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
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• 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).
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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
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v.s.v.s.
Pediatrics 2014:134; e1474-e1502
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Pediatrics 2014:134; e1474-e1502
by nebulizer
Zhang et al. Pediatrics 2015