Salbutamol Should Not Be Used Routinely in Infants with RSV Bronchiolitis
Bronchodilators, including salbutamol (albuterol), should not be used routinely in the management of infants with RSV bronchiolitis, as they do not improve meaningful clinical outcomes such as length of hospital stay, disease resolution, or need for hospitalization. 1
Evidence Against Routine Use
The American Academy of Pediatrics provides clear guidance against routine bronchodilator use in bronchiolitis:
Bronchodilators should not be used routinely in the management of bronchiolitis (Evidence Level B: RCTs with limitations; preponderance of harm over benefit). 1
A Cochrane systematic review of 30 randomized controlled trials involving 1,992 infants found no significant benefit in the clinical course of infants with bronchiolitis who received bronchodilators. 2
At most, only 1 in 4 children treated with bronchodilators might have a transient improvement in clinical score of unclear clinical significance. 1
Studies assessing long-term outcomes found no impact on the overall course of illness, including hospital length of stay or disease resolution. 1
The potential adverse effects (tachycardia and tremors) and cost outweigh any potential benefits. 2, 3
The Pathophysiology Explains Why Bronchodilators Don't Work
The lack of efficacy makes physiological sense:
In viral bronchiolitis, wheezing is caused by airway inflammation, edema, necrosis of epithelial cells, and mucus plugging—not reversible bronchospasm typical of asthma. 1, 4
Bronchodilators target bronchospasm, which is not the primary pathophysiology in bronchiolitis. 4
This is fundamentally different from asthma, where bronchodilators are clearly indicated. 3
When a Carefully Monitored Trial May Be Considered
Despite the recommendation against routine use, the AAP acknowledges that a carefully monitored trial may be an option in select cases:
A trial of bronchodilator medication is an option, but should be continued only if there is documented positive clinical response using objective means of evaluation. 1
For office or clinic settings, salbutamol is more appropriate than epinephrine due to longer duration of action and suitability for home use. 1, 2
Parameters to measure effectiveness should include improvements in wheezing, respiratory rate, respiratory effort, and oxygen saturation. 1, 2
Document pre-therapy and post-therapy changes objectively—if no improvement is observed after the trial dose, treatment must be discontinued. 1, 2
Dosing When a Trial Is Attempted
If clinicians choose to attempt a trial:
Critical Pitfalls to Avoid
Do not confuse viral bronchiolitis with asthma or recurrent wheezing—this is the most common error:
Infants under 2 years with their first episode of viral bronchiolitis do not have asthma. 4
The wheezing in bronchiolitis has a different mechanism than asthmatic wheezing. 4
Continuing bronchodilators without documented objective improvement exposes infants to unnecessary adverse effects (tachycardia, tremors) and costs. 1, 2, 3
Specific Populations That Might Respond
While evidence is limited, some subgroups may theoretically benefit from a trial:
Preterm infants (<37 weeks gestation). 4
Children with bronchopulmonary dysplasia. 4
Those with a family history of atopy or previous wheezing episodes. 4
However, even in these populations, objective documentation of response is mandatory before continuing treatment. 1, 2
The Bottom Line for Clinical Practice
The evidence is clear: salbutamol does not work for typical RSV bronchiolitis. 1, 2 The cornerstone of management remains supportive care with supplemental oxygen, nasal suctioning, and hydration. 5 If you choose to attempt a bronchodilator trial despite guideline recommendations, you must objectively document improvement—otherwise, you are providing ineffective treatment with potential for harm. 1, 2