Clinical Exam Poor for Albuterol Response in Bronchiolitis

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Albuterol responders...or not
It seems like patients with wheezing and bronchiolitis would be easy to assess for responsiveness to albuterol, but they aren't.  These were critically ill, ventilated children.  Nurses, respiratory therapists (RTs), and physicians performed 75 clinical assessments on 25 patients before and after for response to albuterol, compared with paired assessments of objective measures of pulmonary mechanics on the ventilator.  Nine children (36%) had 20% improvement in pulmonary mechanics and were albuterol responders.  Overall diagnostic accuracy for clinical assessment for nurses, RTs, and physicians was terrible, all < 50%.  Inter-rater agreement for wheezing, aeration, and expiratory time was equally bad.  Flipping a coin to decide would have been more accurate.

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It was hard to tell which critically ill, ventilated patients were responders to albuterol.  Nurses, RTs, and physicians were all equally bad.  Objective measures of pulmonary mechanics are a better means to assess this.


Abstract

Pediatr Crit Care Med. 2017 Jan;18(1):e18-e23. doi: 10.1097/PCC.0000000000000999.

Clinical Examination Does Not Predict Response to Albuterol in Ventilated Infants With Bronchiolitis.

Schramm CM1, Sala KACarroll CL.

Author information:

1All authors: Department of Pediatrics, Connecticut Children's Medical Center, Hartford, CT.

Abstract

OBJECTIVE:

Bronchiolitis is a common respiratory infection in infants that is sometimes treated with albuterol. Response to albuterol is determined by clinical assessment, but this subjective determination is potentially unreliable. In this study, we compared providers' clinical assessment of response to albuterol with the measurement of response by pulmonary mechanics in intubated, sedated, and ventilated infants.

DESIGN:

Before and 20 minutes following racemic albuterol therapy, a nurse, respiratory therapist, and physician performed simultaneous examinations and assessed response to albuterol in a population of intubated infants with bronchiolitis. Measurements of ventilator-derived pulmonary mechanics were obtained at these same times.

SETTING:

This study was conducted in a PICU of a children's hospital.

PATIENTS:

Seventy-five paired clinical assessments were made in 25 infants who were intubated and mechanically ventilated for severe bronchiolitis.

INTERVENTIONS:

Pulmonary function measurements and clinical assessments before and after administration of albuterol.

MEASUREMENTS AND MAIN RESULTS:

Response to albuterol was defined using a threshold of improvement in respiratory system resistance from baseline. Nine children (36%) had greater than 20% change and were deemed responders. Providers' discrimination of response was poor. The positive predictive values of nurses, respiratory therapists, and physicians were 38%, 25%, and 25%, respectively, and the negative predictive values were 67%, 54%, and 59%, respectively. Overall accuracy was 44% for nurses, 40% for respiratory therapists, and 48% for physicians. When comparing separate assessments of wheezing, aeration, and expiratory time, there was poor agreement between groups of providers in all variables (κ < 0.4 for each).

CONCLUSIONS:

A provider's clinical assessment was not a reliable method for determining response to albuterol in children with bronchiolitis. Without assessment of pulmonary mechanics, caution should be used in classifying children with bronchiolitis as responders to albuterol.

PMID: 27811530 [PubMed - in process]