Nebulized hypertonic saline solution for acute bronchiolitis in infants

Zhang L, Mendoza-Sassi RA, Wainwright C, Klassen TP

Published Online:

March 16, 2011

Acute viral bronchiolitis is the most common lower respiratory tract infection in infants, but the standard treatment remains supportive care. This review was conducted to assess the effects of 3% saline solution administered via nebulizer, which can increase clearance of mucus, in these patients. We included seven randomized trials involving 581 infants with mild to moderate bronchiolitis. Meta-analysis suggests that nebulized 3% saline may significantly reduce the length of hospital stay among infants hospitalized for non-severe acute bronchiolitis and improve the clinical severity score in both outpatient and inpatient populations. No significant short-term effects (30 to 120 minutes) of one to two doses of nebulized hypertonic saline were observed among emergency department patients; however, more trials are needed to address this question. There were no significant adverse effects noted with nebulized hypertonic saline when administered along with bronchodilators.

Abstract (click to read)

Background:

Airway edema and mucus plugging are the predominant pathological features in infants with acute viral bronchiolitis. Nebulized hypertonic saline solution may reduce these pathological changes and decrease airway obstruction.

Objectives:

To assess the effects of nebulized hypertonic saline solution in infants with acute viral bronchiolitis.

Search strategy:

We searched the Cochrane Central Register of Controlled Trials (CENTRAL) (The Cochrane Library 2010, Issue 2), which contains the Cochrane Acute Respiratory Infections Group Specialized Register, OLDMEDLINE (1951 to 1965), MEDLINE (1966 to May Week 4, 2010), EMBASE (1974 to June 2010) and LILACS (1985 to June 2010).

Selection criteria:

Randomized controlled trials (RCTs) and quasi-RCTs using nebulized hypertonic saline alone or in conjunction with bronchodilators as an active intervention in infants up to 24 months of age with acute bronchiolitis.

Data collection and analysis:

Two review authors independently performed data extraction and study quality assessment. We performed meta-analyses using the Cochrane statistical package RevMan 5. We used the random-effects model for meta-analyses. We used mean difference (MD) and risk ratio (RR) as effect size metrics.

Main results:

We included seven trials (581 infants) with mild to moderate acute viral bronchiolitis (282 inpatients, 65 outpatients and 234 emergency department patients). Patients treated with nebulized 3% saline had a significantly shorter mean length of hospital stay compared to those treated with nebulized 0.9% saline (MD -1.16 days, 95% CI -1.55 to -0.77, P < 0.00001). The 3% saline group also had a significantly lower post-inhalation clinical score than the 0.9% saline group in the first three days of treatment (day 1: MD -0.95, 95% CI -1.52 to -0.39, P = 0.0009; day 2: MD -1.31, 95% CI -1.87 to -0.75, P < 0.00001; day 3: MD -1.31, 95% CI -2.01 to -0.61, P = 0.0003). The effects of improving clinical score were observed in both outpatients and inpatients. Two emergency department-based trials failed to show significant short-term effects (30 to 120 minutes) of up to two doses of nebulized hypertonic saline in improving clinical score and oxygen saturation. No significant adverse events related to 3% saline inhalation were reported.

Authors' conclusions:

Current evidence suggests nebulized 3% saline may significantly reduce the length of hospital stay among infants hospitalized with non-severe acute viral bronchiolitis and improve the clinical severity score in both outpatient and inpatient populations.

This record should be cited as:

Zhang L, Mendoza-Sassi RA, Wainwright C, Klassen TP. Nebulized hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database of Systematic Reviews 2008, Issue 4. Art. No.: CD006458. DOI: 10.1002/14651858.CD006458.pub2

Assessed as up to date:

June 7, 2010

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Primary Review Group:

Acute Respiratory Infections Group

PEARLS - Practical Evidence About Real Life Situations (click to read)

Clinical question:

How effective is nebulised hypertonic saline solution in infants with acute viral bronchiolitis?

Bottom line:

Compared to treatment with nebulised 0.9% saline, nebulised 3% saline produced a 25.9% reduction (0.94 days) in the mean length of hospital stay among infants hospitalised with viral bronchiolitis. The 3% saline group also had a significantly lower post-inhalation clinical score than the 0.9% saline group in the first 3 days of treatment. The effect of nebulised hypertonic saline in improving clinical score was greater among outpatients than inpatients. No adverse events related to the 3% saline inhalations were reported.

Caveat:

Three trials did not use analysis on an intention-to-treat basis. The sample size of the review was relatively small, and the statistical power of the studies may have been sufficient for some but not for other outcome measures. The optimal delivery intervals and concentration of saline, and the most effective delivery devices remain to be determined.

Context:

Acute viral bronchiolitis is the most common lower respiratory tract infection in infants. The standard treatment remains supportive care. Nebulised hypertonic saline solution may reduce airway oedema and mucus plugging, the main pathological changes, and decrease airway obstruction.

Cochrane Systematic Review:

Zhang L et al. Nebulised hypertonic saline solution for acute bronchiolitis in infants. Cochrane Reviews 2008, Issue 4. Article No. CD006458. DOI: 10.1002/14651858.CD006458.pub2. This review contains 4 trials involving 254 participants.

Authored by:

Brian R McAvoy

Cochrane Primary Health Care Field

Health topics:

Infectious disease > Respiratory infections > Bronchiolitis

Lungs & airways > Respiratory infections > Bronchiolitis

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

Nebulized hypertonic saline solution for acute bronchiolitis in infants

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