Continuing onward with the next in the top ten articles presented at the recent AAP NCE in San Diego is a study of the use of hypertonic saline (HTS) in bronchiolitis. I’ll stray a bit form the usual format in that this paper was presented in a point counterpoint fashion. I’ve also posted on this topic previously as a part of my Bronchiolitis! series (yes, the exclamation point is intentional).
Nebulized hypertonic saline for bronchiolitis: a randomized clinical trial
Nebulized hypertonic saline for bronchiolitis in the emergency department: a randomized clinical trial
The bottom line
Hypertonic saline might help reduce the risk of admission in bronchiolitis, but then again it might not.
What they did
Wu and colleagues performed a RCT over 3 consecutive bronchiolitis seasons and recruited a convenience sample of patients <24 months old with bronchiolitis. from March 1, 2008, through April 30, 2011. 211 patients were randomized to HTS and 197 to saline. They received each treatment up to 3 times. All patients were premedicated with albuterol. The main outcome was hospital admission. Additional outcomes included length of stay for admitted patients, and Respiratory Distress Assessment Instrument score.
- The authors reported that the HTS group had lower odds of admission. HTS was 28.9% compared with 42.6% in the NS group (aOR=0.49 [95% CI, 0.28-0.86])
- There was no significant difference in the respiratory distress score in either group
- Length of stay was marginally shorter for HTS but not significant
Meanwhile Florin et al performed a RCT comparing HTS versus normal saline. 62 patients between 2 and 24 months of age (31 in each arm) with their first episode of bronchiolitis were randomized to placebo or HTS, with the primary outcome being respiratory distress at 1 hour after administration. The included patients were enrolled after they had been suctioned and received albuterol and were determined to still have respiratory distress. They also assessed vital signs, oxygen saturation, hospitalization, physician clinical impression, parental assessment, and adverse events.
- They noted that 1 hour after treatment the HTS improved less versus placebo (HTS, −1 [interquartile range, −5 to 1] vs saline placebo, −5 [interquartile range, −6 to −2]; P = .01)
- They saw no significant differences in heart rate, oxygen saturation, hospitalization rate, or other outcomes
- This study was limited by small numbers and a single trial of HTS
- It is also uncertain as to what effect (if any) the albuterol had on these patients
What you can do
- Read this editorial “A Tale of 2 Trials: disentangling contradictory evidence on hypertonic saline in bronchiolitis“
- Recognize that the evidence for HTS is far from ironclad
- Know that in both studies patients initially received albuterol before HTS. Given that a trial of albuterol is no longer recommended the effect of HTS without other interventions first is understudied
- Consider HTS in the patient at risk for admission – but know that if you send a patient home they can’t use HTS there, and that there is no substitute for solid discharge education and anticipatory guidance.
