7% hypertonic saline does not improve clinical outcomes for acute bronchiolitis
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1. 7% hypertonic saline with epinephrine did not improve bronchiolitis severity assessments, hospitalization rate, or length of stay compared to normal saline with epinephrine in acute bronchiolitis.
2. Further studies are needed the evaluate the safety and efficacy of 7% saline in this clinical setting.
Evidence rating level: 1 (Excellent)
Study Rundown: Acute viral bronchiolitis represents a significant amount of disease burden in infants and young children, being the most common cause of lower respiratory infection. Management typically focuses on supportive care with supplemental oxygen and hydration. Previous studies have suggested that 3% and 5% nebulized saline can reduce the length of hospital stay and improve the clinical severity scores in these patients. The authors of this study investigated whether 7% saline may also offer additional benefit in terms decreases in bronchiolitis severity score (BSS), hospitalization rate and length of stay.
At the conclusion of this randomized, controlled trial, the authors found that inhaled 7% saline with epinephrine had no statistically significant difference in  the primary or secondary outcomes measured when compared to normal saline with epinephrine in patients with moderate to severe bronchiolitis. The discrepancy between these results and those of previous studies may relate to differences in treatment administration, study design or in respiratory assessment tools. The authors concluded that, while no additional clinical benefit was shown here, future larger studies may determine 7% saline efficacy in more severely ill patients or when administered alone versus when combined with epinephrine.
These results benefit from the randomized, controlled design of this investigation. Nevertheless, there are several caveats. First, this study was underpowered to determine a statistically significant difference in the secondary outcomes measured. It was also performed in a single tertiary care center. Discharge criteria for each patient was also not standardized, and the BSS, while standard in the authors’ home institution, lacks external validation. The use of epinephrine may also have masked any significant associations.
Click to read the article in Pediatrics
Relevant reading: Nebulized 3% hypertonic saline solution treatment in ambulatory children with viral bronchiolitis decreases symptoms
In-Depth [randomized controlled trial]: The investigators behind this double-blind, randomized, controlled trial enrolled patients age 6 weeks to 18 months old presenting to the ED of an urban tertiary care center with bronchiolitis between 2010 and 2012. To be included, they had to have presented with bronchiolitis, defined as viral respiratory illness and first episode of wheeze, and a BSS of 4 or greater. Exclusion criteria were a previous history of wheezing, any use of bronchodilators within 2 hours of presentation, prematurity, history or congenital heart disease or chronic pulmonary/renal disease, oxygen saturation <85%, or ICU admissions. A total of 101 infants were enrolled and randomized to either 7% hypertonic saline or 0.9% saline, both with epinephrine. The primary outcome measured was a change in bronchiolitis severity score (BSS) obtained before and after treatment and at the time of disposition. Secondary outcomes included hospitalization rate, proportion of those admitted discharged at 23 hours, and ED and inpatient length of stay. Interobserver variability was assessed between two groups of nurses and respiratory therapists. There was no loss to follow-up.
Both treatment arms experienced a decrease in BSS from baseline to ED disposition, but the difference between the two groups was not statistically significant. There was also no difference in proportion of patients hospitalized from the ED, discharged at 23 hours after admission, or inpatient length of stay. Neither group had any adverse effects.
By Monica Parks and Andrew Bishara
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