Manejo de Bronquiolitis Aguda: según Medicina Basada Evidencia

Transcripción

1 Manejo de Bronquiolitis Aguda: según Medicina Basada Evidencia Jose A. Castro-Rodriguez, MD, PhD Escuela de Medicina Pontificia Universidad Católica de Chile

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3 Levels of evidence 1 ++ High quality meta-analyses analyses,, systematic reviews, or randomised controlled trials (RCTs) with a very low risk of bias 1 + Well-conducted meta-analyses, analyses, systematic reviews, or RCTs with a low risk of bias 1 Meta-analyses, analyses, systematic ti reviews, or RCTs with a high h risk of bias Grades of recommendation Relate to strength of evidence, not clinical importance Low grade recommendations in important clinical areas should stimulate research Recommendation Evidence A At least one 1 ++ directly applicable to target population; ; or Many studies 1 + directly applicable to target population and demonstrating consistency Introduction. Thorax 2003; 58 (Suppl I): i1-i92

4 Manejo Bronquiolitis en Urgencia 1. Hidratación 2. Oxigenoterapia 3. Broncodilatadores (salbutamol, epinefrina) 4. Corticoides 5. Suero Hipertónico 6. Terapia respiratoria (kinesioterapia)

5 Salbutamol by nebulizer vs. placebo Gadomski & Scribani Cochrane 2014

6 Gadomski & Scribani Cochrane 2014 Salbutamol by nebulizer vs. placebo

7 Gadomski & Scribani Cochrane 2014 Salbutamol by nebulizer vs. placebo

8 Hartling et al, Cochrane 2011 Epinephrine by nebulized vs. placebo

9 Hartling et al, Cochrane 2011

10 Epinephrine nebulized & oral dexamethasone vs. placebo Hartling et al, Cochrane 2011

11 Fernandes et al. Cochrane 2013

12 Fernandes et al. Cochrane 2013

13 Nebulized Hypertonic Saline (3%) vs. Normal Saline Risk of hospitalization ti among outpatients ti t Zhang et al. Pediatrics 2015

14 Chest therapy (slow & long expiration flow techniques) in infants: RCT n=48 Santiago, Chile Castro-Rodriguez et al. Acta Paeditric 2014

15 Manejo Bronquiolitis en Hospital 1. Hidratación 2. Oxigenoterapia 3. Broncodilatadores d (Salbutamol, l Epinefrina) i 4. Corticoides 5. Suero Hipertónico 6. Heliox, DNAasa, Surfactante, Rivabirina, Inmunoglobulina 7. Terapia respiratoria (kinesioterapia)

16 Sp<90% Sp<94% Cunningham et al. Lancet 2015

17 1 RCT (n=19), pilot study. HFNC therapy vs. oxygen via a head box. SpO2 was higher in HFNC: at 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, time to discharge or total length of stay. 5 ongoing g RCTs Beggs S. et al, Cochrane 2014

18 Umoren et al. Cochrane Collab Pub 2011 Umoren et al. Cochrane 2011

19 Umoren et al. Cochrane Collab Pub 2011 Umoren et al. Cochrane 2011

20 Salbutamol by nebulizer vs. placebo Gadomski & Scribiani Cochrane 2014

21 Salbutamol by nebulizer vs. placebo Gadomski & Scribiani Cochrane 2014

22 Salbutamol by nebulizer vs. placebo Gadomski & Scribiani Cochrane 2014

23 Hartling et al, Cochrane 2011 Epinephrine vs. Salbutamol

24 Hartling et al, Cochrane 2011

25 Hartling et al, Cochrane 2011

26 Fernandes et al. Cochrane 2013

27 Fernandes et al. Cochrane 2013

28 Blom. et al, Cochrane 2006 RCTs=4, n=84

29 Blom. et al, Cochrane 2006 RCTs=4, n=84

30 Blom. et al, Cochrane 2006 RCTs=4, n=84

31 Zhang et al. Cochrane 2013

32 Zhang et al. Cochrane 2013

33 Zhang et al. Cochrane 2013

34 Zhang et al. Cochrane 2013

35 Nebulized Hypertonic Saline vs. Normal Saline Reduction of long of stay among inpatients Zhang et al. Pediatrics 2015

36 Liet et al, Cochrane 2010 RCTs=4, n=84

37 Enriquez et al. Cochrane 2012

38 3 small RCTs, n=79 Jat & Chawla, Cochrane 2012

39 3 small RCTs, n=79 Jat & Chawla, Cochrane 2012

40 In 12 RCTs (n=158) Ribavirin vs. placebo Mortality 5.8% vs 9.7% (OR: 0.58 [0.18 to 1.85]) In 3 RCTs (n=116) Ribavirini i vs. placebo Respiratory deterioration: 7.1% vs. 18.3% (OR: 0.37 [0.12 to 1.18]) 18]) In 3 RCTs (n=104 ventilated) Ribavirin vs. placebo Fewer 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

41 4 RCTs. No significant benefit of intravenous immunoglobulin (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 studies Fuller et al, Cochrane Collab Pub 2006

42 9 RCTs (n=891) physiotherapy vs. no intervention. 5 RCTs (n=246) vibration & percussion techniques 4 RCTs (n=645) passive expiratory techniques. No differences between groups in: Respiratory Parameters (2 RCTs, n=118), Oxygen Requirements (1 RCTs, n=50), 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 (1 RCT, 496 participants). Roque i Figuls et al, Cochrane 2012

43 Conclusiones: Manejo de Bronquiolitis Urgencia Hospitalizados -Epinephrine vs. placebo: -Epinephrine vs. salbutamol nebuliz: Mejora Score Clínico primeras 2 hr Reduce Admisiones en el 1er. día Mejora Saturometría primeras 2 hr Reduce días de Hospitalización -Suero hipertónico 3% vs. sol. 9%: -Suero hipertónico 3% vs. sol. 9%: Reduce Admisiones -Salbutamol nebulizado vs. placebo: Mejora Score Clínico (?) Mejora Score clínico primeras 3 hr Reduce días de Hospitalización -Surfactante: Mejora gasometría primeras 24hr Reduce Duración Vent. Mecánica Reduce días en UCI

44 v.s. Pediatrics 2014:134; e1474-e1502

45 Pediatrics 2014:134; e1474-e1502 by nebulizer Zhang et al. Pediatrics 2015

46 Thanks for your attention!! jcs