Is nebulized hypertonic saline effective in preventing hospitalizations of infants with moderate to severe bronchiolitis?

Hypertonic saline is no more effective than normal saline in preventing hospitalizations of otherwise healthy infants with acute moderate to severe bronchiolitis. Infants treated with hypertonic saline are more likely to have adverse events. This study is a good example of how evidence evolves. Early studies resulted in the enthusiastic use of hypertonic saline, yet the mounting evidence now questions its usefulness in these children. (LOE = 1b)

Angoulvant F, Bellettre X, Milcent K, et al, for the Efficacy of 3% Hypertonic Saline in Acute Viral Bronchiolitis (GUERANDE) Study Group. Effect of nebulized hypertonic saline treatment in emergency departments on the hospitalization rate for acute bronchiolitis: a randomized clinical trial. JAMA Pediatr 2017;171(8):e171333.  [PMID:28586918]

Randomized controlled trial (double-blinded)

Government

Concealed

Emergency department

This study included otherwise healthy infants, 6 weeks to 12 months of age, presenting to emergency departments in France with a first episode of moderate to severe bronchiolitis. The researchers randomized consecutive infants to receive hypertonic (3%) saline (n = 387) or normal (0.9%) saline (n = 390). The agents were administered via nebulizer for 20 minutes and repeated 20 minutes later. The authors diagnosed bronchiolitis when the infants had a viral upper respiratory tract infection, plus wheezing and/or crackles on chest auscultation, accompanied by 2 signs of respiratory distress (decreased oral intake, respiratory rate > 50 per minute, oxygen saturation < 95%, or retractions). They used intention to treat to analyze the rate of hospitalizations. Although approximately half the children in each group were hospitalized, those treated with hypertonic saline had slight improvements in respiratory distress. However, the infants treated with hypertonic saline were more likely to have adverse events, including worsening of cough (9% vs 4%; number needed to treat to harm = 20; 95% CI 12-64). The authors estimated they would need 349 infants in each group to detect a 10% difference in the hospitalization rate.