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AAP Grand Rounds 18:63-64 (2007)
© 2007 American Academy of Pediatrics
Researchers from Canada and the United Arab Emirates collaborated in a prospective, randomized, double-blind, controlled, multicenter investigation to determine whether nebulized 3% hypertonic saline (HS) therapy of infants hospitalized with moderately severe bronchiolitis would result in shorter length of stay (LOS) compared with a control group receiving standard therapy without HS.
Infants were eligible for enrollment if they were admitted to the hospital for treatment of moderately severe bronchiolitis, defined as a history of a preceding viral upper respiratory infection, the presence of wheezing or crackles, plus either SaO2 <94% on room air or significant respiratory distress as measured by the Respiratory Distress Assessment Instrument (RDAI).1 Exclusion criteria included a history of wheezing, chronic cardiopulmonary disease or immunodeficiency, presentation requiring admission to intensive care, gestational age 
34 weeks at birth, or the use of nebulized HS within the previous 12 hours.
Over three bronchiolitis seasons, a total of 96 infants (mean age 4.7 months; range 0.3–18 months) admitted to three regional tertiary care centers were randomized to receive 4 mL of either nebulized 3% HS (n=47) or 0.9% normal saline (NS) (n=49) in addition to standard therapy as ordered by their attending physicians. The nebulized solutions were administered every two hours for three doses, followed by every four hours for five doses, followed by every six hours until discharge. If the attending ordered additional nebulized treatments, the medication was provided in 4 mL of the assigned study solution. The two study groups were comparable at baseline with regard to duration of illness, respiratory distress score, and preadmission treatment received. Adjunctive therapies ordered by the attending physicians were similar in the two groups.
Infants who received HS had a shorter mean LOS (2.6 ± 1.9 days) as compared with infants who received NS (3.5 ± 2.9 days, P=.05). All participants tolerated therapy without apparent adverse effects. The authors conclude that inhaled 3% HS is an effective treatment for decreasing LOS in previously well infants hospitalized with moderately severe viral bronchiolitis.
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Commentary by
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| Pediatrics, Naval Medical Center, San Diego, CA |
HS has long been used to induce sputum production.2 Legend is that surfers with cystic fibrosis (CF) cough up thick mucous more easily after hitting the waves. That observation inspired Australian researchers to try hypertonic saline therapy in CF patients. A recent large, controlled clinical trial showed that HS use improved FVC and FEV1 in CF patients while reducing the number and duration of flare-ups of their disease, and improved their overall quality of life.3 The mechanism of action is not entirely clear but the rehydration of inspissated secretions and induction of cough and mucus clearance are among the proposed theories. Perhaps it is reasonable to expect that another disease process involving plugging with sloughed epithelium, increased mucus production, and mucosal edema might benefit from HS therapy. Prior studies have shown HS in conjunction with epinephrine4 or terbutaline5 to be helpful in treating bronchiolitis.
It should be noted that HS may cause bronchoconstriction in asthmatics,6 and coadministration with a bronchodilator is often recommended.7 The only side effects recorded in this study were crying and agitation.
The encouraging results of this study of HS, coupled with the recent spate of contradictory data regarding corticosteroid therapy of bronchiolitis (see
AAP Grand Rounds, October 2007;18:38–39
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