Nebulized Saline for Bronchiolitis
Nebulized Saline for Bronchiolitis
Editor's Note: Two trials evaluating efficacy of nebulized hypertonic and normal saline in the treatment of infants with bronchiolitis come to different conclusions. How can we make sense of these disparate results?
Wu S, Baker C, Lang ME, et al
JAMA Pediatr. 2014;168:657-663
Wu and colleagues lament the general difficulty researchers have experienced in identifying a therapeutic option to reduce hospitalization or length of stay in children with bronchiolitis. Following up on other studies that showed some potential benefit in reducing admission by using hypertonic saline via nebulizer, this study randomly assigned patients to either hypertonic saline or normal saline and assessed the differences in the frequency of hospital admission, the duration of hospitalization if hospitalized, as well as objective measures of respiratory distress.
All children were younger than 2 years of age. Intervention children received hypertonic (3%) saline, and control children received 0.9% normal saline by nebulizer. The study was conducted at two medical centers on the west coast during three respiratory seasons from 2008 through 2011. Exclusion criteria included a history of wheezing, bronchodilator use, prematurity, or chronic heart or lung disease. At enrollment in the emergency department (ED), the children received an initial treatment with 2.5 mg of nebulized albuterol, followed by 4 mL of the active or control solution, receiving up to three treatments in the first hour in the ED.
Children who had an oxygen saturation level lower than 92%, who exhibited increased work of breathing, or who exhibited ineffective oral intake were admitted to the hospital, but this decision was ultimately at the discretion of the attending physician. After admission, the children received nebulized hypertonic or normal saline (4 mL) every 8 hours. Each hypertonic saline or normal saline administration was preceded by albuterol to ward against bronchospasm.
A total of 408 children were randomly assigned (197 to the normal saline group and 211 to the hypertonic saline group). The mean age of the children was 6.5 months, with 60% of both groups being younger than 6 months old. There was a slight predominance of boys in the sample. The sample was 7% white, 15% black, and almost two thirds of Latino or Hispanic ethnicity. Environmental tobacco exposure was experienced by 10% of the children, 7% had atopic symptoms, and 60% were infected with respiratory syncytial virus.
Looking at admission frequency, the children in the hypertonic saline group were less likely to be admitted (28.9%) compared with children receiving normal saline (42.6%). After controlling for other factors, the odds ratio for admission among the hypertonic saline group was 0.49 (95% confidence interval [CI], 0.28-0.86). The number needed to treat was 8, meaning that for every 8 patients treated, 1 child avoided hospitalization. The mean length of stay was slightly longer in the normal saline group (3.92 days) than in the hypertonic saline group (3.16 days), but this difference did not reach statistical significance after controlling for other factors.
The objective measures of work of breathing were not different between the two groups, nor were the frequency of or duration of oxygen supplementation, with each group requiring oxygen for an average of 28 hours. Wu and colleagues concluded that nebulized hypertonic saline in the ED setting appears to reduce the frequency of hospitalization, but it does not influence length of stay or respiratory work scores after the children have been admitted.
Whether therapeutic modalities influence the course of bronchiolitis has been a long and still-ongoing story. This very-high-quality study suggests that using hypertonic saline in the ED is beneficial, and the investigators help clarify the situation by using bronchodilators before the saline treatments, overcoming some limitations of previous studies that demonstrated worsening children who received nebulized saline products. The investigators did not reach the sample size required to show a length-of-stay difference of less than 1 day, so no firm conclusions can be drawn about the length-of-stay outcome. Furthermore, the preponderance of Latino/Hispanic children makes generalizing to all populations a little more difficult. Nonetheless, this study provides a roadmap of how to study the question going forward and will likely help standardize future trials so that we can compare one therapy with another more effectively.
Abstract
Nebulize or Not?
Editor's Note: Two trials evaluating efficacy of nebulized hypertonic and normal saline in the treatment of infants with bronchiolitis come to different conclusions. How can we make sense of these disparate results?
Nebulized Hypertonic Saline for Bronchiolitis: A Randomized Clinical Trial
Wu S, Baker C, Lang ME, et al
JAMA Pediatr. 2014;168:657-663
Study Summary
Wu and colleagues lament the general difficulty researchers have experienced in identifying a therapeutic option to reduce hospitalization or length of stay in children with bronchiolitis. Following up on other studies that showed some potential benefit in reducing admission by using hypertonic saline via nebulizer, this study randomly assigned patients to either hypertonic saline or normal saline and assessed the differences in the frequency of hospital admission, the duration of hospitalization if hospitalized, as well as objective measures of respiratory distress.
All children were younger than 2 years of age. Intervention children received hypertonic (3%) saline, and control children received 0.9% normal saline by nebulizer. The study was conducted at two medical centers on the west coast during three respiratory seasons from 2008 through 2011. Exclusion criteria included a history of wheezing, bronchodilator use, prematurity, or chronic heart or lung disease. At enrollment in the emergency department (ED), the children received an initial treatment with 2.5 mg of nebulized albuterol, followed by 4 mL of the active or control solution, receiving up to three treatments in the first hour in the ED.
Children who had an oxygen saturation level lower than 92%, who exhibited increased work of breathing, or who exhibited ineffective oral intake were admitted to the hospital, but this decision was ultimately at the discretion of the attending physician. After admission, the children received nebulized hypertonic or normal saline (4 mL) every 8 hours. Each hypertonic saline or normal saline administration was preceded by albuterol to ward against bronchospasm.
A total of 408 children were randomly assigned (197 to the normal saline group and 211 to the hypertonic saline group). The mean age of the children was 6.5 months, with 60% of both groups being younger than 6 months old. There was a slight predominance of boys in the sample. The sample was 7% white, 15% black, and almost two thirds of Latino or Hispanic ethnicity. Environmental tobacco exposure was experienced by 10% of the children, 7% had atopic symptoms, and 60% were infected with respiratory syncytial virus.
Findings
Looking at admission frequency, the children in the hypertonic saline group were less likely to be admitted (28.9%) compared with children receiving normal saline (42.6%). After controlling for other factors, the odds ratio for admission among the hypertonic saline group was 0.49 (95% confidence interval [CI], 0.28-0.86). The number needed to treat was 8, meaning that for every 8 patients treated, 1 child avoided hospitalization. The mean length of stay was slightly longer in the normal saline group (3.92 days) than in the hypertonic saline group (3.16 days), but this difference did not reach statistical significance after controlling for other factors.
The objective measures of work of breathing were not different between the two groups, nor were the frequency of or duration of oxygen supplementation, with each group requiring oxygen for an average of 28 hours. Wu and colleagues concluded that nebulized hypertonic saline in the ED setting appears to reduce the frequency of hospitalization, but it does not influence length of stay or respiratory work scores after the children have been admitted.
Viewpoint
Whether therapeutic modalities influence the course of bronchiolitis has been a long and still-ongoing story. This very-high-quality study suggests that using hypertonic saline in the ED is beneficial, and the investigators help clarify the situation by using bronchodilators before the saline treatments, overcoming some limitations of previous studies that demonstrated worsening children who received nebulized saline products. The investigators did not reach the sample size required to show a length-of-stay difference of less than 1 day, so no firm conclusions can be drawn about the length-of-stay outcome. Furthermore, the preponderance of Latino/Hispanic children makes generalizing to all populations a little more difficult. Nonetheless, this study provides a roadmap of how to study the question going forward and will likely help standardize future trials so that we can compare one therapy with another more effectively.
Abstract
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