Epinephrine and bromhexine in the ambulatory treatment of bronchiolitis

The aim of the study was to investigate the utility of combining inhaled epinephrine with bromhexine, a mucolytic agent, for the management of viral bronchiolitis in an outpatient setting. A randomized double blind, placebo-controlled parallel-group design was used. Three hundred thirty patients aged 1-14 months with respiratory syncytial virus bronchiolitis attending two primary pediatric community clinics were randomly assigned to receive treatment (wet nebulized aerosol) with single-isomer epinephrine diluted (1:1000) in either 2 mL or 2.5 mL (by age) 0.9% saline (control group) or 2 mL or 2.5 mL bromhexine (study group), or 2 mL or 2.5 mL 0.9% saline only (placebo group) (n=110 each). Treatment was administered three times daily for 7 days. Primary outcome measures were changes in bronchiolitis caregiver diary score and pulse oximetry results; secondary outcome measures were emergency department visits/hospitalization and illness-related loss of daycare (patient) or work (parent) days. Baseline background and clinical characteristics were similar in all groups. The study group had significantly lower bronchiolitis caregiver diary scores than the control and placebo groups at all time points (P< 0.0001), significantly greater improvement in pulse oximetry results on days 2 and 4 (P=0.034 and 0.003 respectively), and fewer days missed from daycare/ work. There were no significant differences in hospital admissions, but the risk reduction was lowest in the study group. In children with bronchiolitis, treatment with nebulized epinephrine and bromhexine appears to lead to more rapid clinical improvement than epinephrine alone, thereby reducing the burden of care.