No significant improvement in bronchiolitis seen with hypertonic saline plus epinephrine

Article Outline

• Question
• Design
• Setting
• Participants
• Intervention
• Outcomes
• Main Results
• Conclusions
• Commentary
• Copyright

Grewal S, Ali S, McConnell DW, Vandermeer B, Klassen TP. A randomized trial of nebulized 3% hypertonic saline with epinephrine in the treatment of acute bronchiolitis in the emergency department. Arch Pediatr Adolesc Med 2009;163:1007-12.

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Question 

Among infants with bronchiolitis seen in the emergency department, does nebulized 3% hypertonic saline solution with epinephrine improve the respiratory status more effectively than nebulized 0.9% saline solution with epinephrine?

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Design 

Randomized, double-blind, controlled trial.

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Setting 

Urban tertiary care pediatric emergency department in Canada.

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Participants 

Forty-six infants (<12 months) with mild to moderate bronchiolitis.

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Intervention 

Nebulized racemic epinephrine in either hypertonic or normal saline solution.

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Outcomes 

The primary outcome measure was the change in respiratory distress, as measured by the Respiratory Assessment Change Score (RACS) from baseline to 120 minutes. The change in oxygen saturation was also determined. Secondary outcome measures included the rates of hospital admission and return to the emergency department.

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Main Results 

The 2 study groups had similar baseline characteristics. The RACS from baseline to 120 minutes demonstrated no improvement in respiratory distress in the hypertonic saline group compared with the normal saline control group. The change in oxygen saturation in the hypertonic saline group was not significant when compared with the control group. Rates of admission and return to the emergency department were not different between the 2 groups.

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Conclusions 

In the treatment of acute bronchiolitis, hypertonic saline solution and epinephrine did not improve clinical outcome any more than normal saline solution and epinephrine in the emergency setting. This differs from previously published results of outpatient and inpatient populations and merits further evaluation.

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Commentary 

The authors of this study are to be praised for investigating potential treatment options for a common illness that is difficult to treat beyond supportive care and is associated with high resource utilization. Four previous studies have shown the efficacy of nebulized hypertonic saline in bronchiolitis treatment. However, these studies were not conducted in the emergency department (ED) setting, and their cornerstones included treatments several times each day over multiple days. This study looks at appropriate primary outcomes for an ED setting, and demonstrates good improvement in the Respiratory Assessment Change Score (RACS) in both the hypertonic and normal saline groups (improvement of 4.39 and 5.13 points, respectively). Although this supports the use of epinephrine, there is no significant difference when epinephrine is mixed with hypertonic versus normal saline solution. There was also not a significant change in oxygen saturation within or between the 2 groups. Perhaps the most important findings in this study are a decrease in hospital admission with hypertonic saline solution use (8/23 children, vs 13/23 in the normal saline group) and a decrease in return visits to the ED (3/23 vs 4/23, respectively). Even though neither difference was statistically significant, these secondary outcome measures may warrant further evaluation in a study designed with the power to assess them more fully. Finally, the adverse effects of vomiting and diarrhea seen in 17% (4/23) of children treated with hypertonic saline solution in this study may warrant further exploration before its continued use in younger populations.