Nebulised hypertonic saline solution for acute bronchiolitis in infants
Editorial Group: Cochrane Acute Respiratory Infections Group
Published Online: 31 JUL 2013
Assessed as up-to-date: 8 MAY 2013
Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.
How to Cite
Zhang L, Mendoza-Sassi RA, Wainwright C, Klassen TP. Nebulised hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database of Systematic Reviews 2013, Issue 7. Art. No.: CD006458. DOI: 10.1002/14651858.CD006458.pub3.
- Publication Status: New search for studies and content updated (no change to conclusions)
- Published Online: 31 JUL 2013
Airway oedema and mucus plugging are the predominant pathological features in infants with acute viral bronchiolitis. Nebulised hypertonic saline solution may reduce these pathological changes and decrease airway obstruction.
To assess the effects of nebulised hypertonic (≥ 3%) saline solution in infants with acute viral bronchiolitis.
We searched CENTRAL 2013, Issue 4, OLDMEDLINE (1951 to 1965), MEDLINE (1966 to April week 4, 2013), EMBASE (1974 to May 2013), LILACS (1985 to May 2013) and Web of Science (1955 to May 2013).
Randomised controlled trials (RCTs) and quasi-RCTs using nebulised hypertonic saline alone or in conjunction with bronchodilators as an active intervention and nebulised 0.9% saline as a comparator in infants up to 24 months of age with acute bronchiolitis.
Data collection and analysis
Two review authors independently performed study selection, data extraction and assessment of risk of bias in included studies. We conducted meta-analyses using the Cochrane statistical package RevMan 5.2. We used the random-effects model for meta-analyses. We used mean difference (MD) and risk ratio (RR) as effect size metrics.
We included 11 trials involving 1090 infants with mild to moderate acute viral bronchiolitis (500 inpatients, five trials; 65 outpatients, one trial; and 525 emergency department patients, four trials). All but one of the included trials were of high quality with a low risk of bias. A total of 560 patients received hypertonic saline (3% saline n = 503; 5% saline n = 57). Patients treated with nebulised 3% saline had a significantly shorter mean length of hospital stay compared to those treated with nebulised 0.9% saline (MD -1.15 days, 95% confidence interval (CI) -1.49 to -0.82, P < 0.00001). The hypertonic 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 -0.88, 95% CI -1.36 to -0.39, P = 0.0004; day 2: MD -1.32, 95% CI -2.00 to -0.64, P = 0.001; day 3: MD -1.51, 95% CI -1.88 to -1.14, P < 0.00001). The effects of improving clinical score were observed in both outpatients and inpatients. Four emergency department-based trials did not show any significant short-term effects (30 to 120 minutes) of up to three doses of nebulised 3% saline in improving clinical score and oxygen saturation. No significant adverse events related to hypertonic saline inhalation were reported.
Current evidence suggests nebulised 3% saline may significantly reduce the length of hospital stay among infants hospitalised with non-severe acute viral bronchiolitis and improve the clinical severity score in both outpatient and inpatient populations.
Plain language summary
Hypertonic saline solution administered via nebuliser for acute bronchiolitis in infants
Acute viral bronchiolitis is the most common lower respiratory tract infection in infants up to two years old. Currently there is no effective treatment so standard treatment remains supportive care. Airway oedema (abnormal accumulation of fluid) and mucus plugging can cause wheezing and difficulty breathing in these patients. Nebulised hypertonic saline may be a beneficial treatment to manage acute bronchiolitis because it can improve airway hygiene. This review was conducted to assess the effects of hypertonic (≥ 3%) saline solution administered via a nebuliser in infants with acute bronchiolitis, compared with nebulised normal (0.9%) saline. The establishment of a therapeutic role for hypertonic saline solution may provide a cheap and effective therapy for these patients.
We included 11 randomised trials involving 1090 infants with mild to moderate bronchiolitis. All but one of the 11 trials are considered as high-quality studies with low risk of error (i.e. bias) in their conclusions. Meta-analysis suggests that nebulised hypertonic saline could lead to a reduction of 1.2 days in the mean length of hospital stay among infants hospitalised for non-severe acute bronchiolitis and improve the clinical severity score in both outpatient and inpatient populations. No significant short-term effects (at 30 to 120 minutes) of one to three doses of nebulised 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 the use of nebulised hypertonic saline when administered along with bronchodilators.
Given the clinically relevant benefit and good safety profile, nebulised hypertonic saline used in conjunction with bronchodilators should be considered an effective and safe treatment for infants with mild to moderate acute viral bronchiolitis.