Hypertonic (3%) saline vs 0.93% saline nebulization for acute viral bronchiolitis: a randomized controlled trial

Nebulised hypertonic saline solution for acute bronchiolitis in infants

BACKGROUND

Airway oedema (swelling) and mucus plugging are the principal pathological features in infants with acute viral bronchiolitis. Nebulised hypertonic saline solution (≥ 3%) may reduce these pathological changes and decrease airway obstruction. This is an update of a review first published in 2008, and updated in 2010, 2013, and 2017.

OBJECTIVES

To assess the effects of nebulised hypertonic (≥ 3%) saline solution in infants with acute bronchiolitis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily, Embase, CINAHL, LILACS, and Web of Science on 13 January 2022. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov on 13 January 2022.

SELECTION CRITERIA

We included 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 or standard treatment as a comparator in children under 24 months with acute bronchiolitis. The primary outcome for inpatient trials was length of hospital stay, and the primary outcome for outpatients or emergency department (ED) trials was rate of hospitalisation.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, data extraction, and assessment of risk of bias in included studies. We conducted random-effects model meta-analyses using Review Manager 5. We used mean difference (MD), risk ratio (RR), and their 95% confidence intervals (CI) as effect size metrics.

MAIN RESULTS

We included six new trials (N = 1010) in this update, bringing the total number of included trials to 34, involving 5205 infants with acute bronchiolitis, of whom 2727 infants received hypertonic saline. Eleven trials await classification due to insufficient data for eligibility assessment. All included trials were randomised, parallel-group, controlled trials, of which 30 were double-blinded. Twelve trials were conducted in Asia, five in North America, one in South America, seven in Europe, and nine in Mediterranean and Middle East regions. The concentration of hypertonic saline was defined as 3% in all but six trials, in which 5% to 7% saline was used. Nine trials had no funding, and five trials were funded by sources from government or academic agencies. The remaining 20 trials did not provide funding sources. Hospitalised infants treated with nebulised hypertonic saline may have a shorter mean length of hospital stay compared to those treated with nebulised normal (0.9%) saline or standard care (mean difference (MD) -0.40 days, 95% confidence interval (CI) -0.69 to -0.11; 21 trials, 2479 infants; low-certainty evidence). Infants who received hypertonic saline may also have lower postinhalation clinical scores than infants who received normal saline in the first three days of treatment (day 1: MD -0.64, 95% CI -1.08 to -0.21; 10 trials (1 outpatient, 1 ED, 8 inpatient trials), 893 infants; day 2: MD -1.07, 95% CI -1.60 to -0.53; 10 trials (1 outpatient, 1 ED, 8 inpatient trials), 907 infants; day 3: MD -0.89, 95% CI -1.44 to -0.34; 10 trials (1 outpatient, 9 inpatient trials), 785 infants; low-certainty evidence). Nebulised hypertonic saline may reduce the risk of hospitalisation by 13% compared with nebulised normal saline amongst infants who were outpatients and those treated in the ED (risk ratio (RR) 0.87, 95% CI 0.78 to 0.97; 8 trials, 1760 infants; low-certainty evidence). However, hypertonic saline may not reduce the risk of readmission to hospital up to 28 days after discharge (RR 0.83, 95% CI 0.55 to 1.25; 6 trials, 1084 infants; low-certainty evidence). We are uncertain whether infants who received hypertonic saline have a lower number of days to resolution of wheezing compared to those who received normal saline (MD -1.16 days, 95% CI -1.43 to -0.89; 2 trials, 205 infants; very low-certainty evidence), cough (MD -0.87 days, 95% CI -1.31 to -0.44; 3 trials, 363 infants; very low-certainty evidence), and pulmonary moist crackles (MD -1.30 days, 95% CI -2.28 to -0.32; 2 trials, 205 infants; very low-certainty evidence). Twenty-seven trials presented safety data: 14 trials (1624 infants; 767 treated with hypertonic saline, of which 735 (96%) co-administered with bronchodilators) did not report any adverse events, and 13 trials (2792 infants; 1479 treated with hypertonic saline, of which 416 (28%) co-administered with bronchodilators and 1063 (72%) hypertonic saline alone) reported at least one adverse event such as worsening cough, agitation, bronchospasm, bradycardia, desaturation, vomiting and diarrhoea, most of which were mild and resolved spontaneously (low-certainty evidence).

AUTHORS' CONCLUSIONS

Nebulised hypertonic saline may modestly reduce length of stay amongst infants hospitalised with acute bronchiolitis and may slightly improve clinical severity score. Treatment with nebulised hypertonic saline may also reduce the risk of hospitalisation amongst outpatients and ED patients. Nebulised hypertonic saline seems to be a safe treatment in infants with bronchiolitis with only minor and spontaneously resolved adverse events, especially when administered in conjunction with a bronchodilator. The certainty of the evidence was low to very low for all outcomes, mainly due to inconsistency and risk of bias.

3% nebulized hypertonic saline versus normal saline for infants with acute bronchiolitis: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

This study evaluated the efficacy and safety of 3% nebulized hypertonic saline (NHS) in infants with acute bronchiolitis (AB).

METHODS

We systematically searched the PUBMED, EMBASE, Cochrane Library, China National Knowledge Infrastructure Database, WANFANG, and VIP databases from inception to June 1, 2022. We included randomized controlled trials comparing NHS with 0.9% saline. Outcomes included the length of hospital stay (LOS), rate of hospitalization (ROH), clinical severity score (CSS), rate of readmission, respiratory distress assessment instrument, and adverse events. RevMan V5.4 software was used for statistical analysis.

RESULTS

A total of 27 trials involving 3495 infants were included in this study. Compared to normal saline, infants received 3% NHS showed better outcomes in LOS reduction (MD = -0.60, 95% CI [-1.04, -0.17], I2 = 92%, P = .007), ROH decrease (OR = 0.74, 95% CI [0.59, 0.91], I2 = 0%, P = .005), CSS improvement at day 1 (MD = -0.79, 95% CI [-1.23, -0.34], I2 = 74%, P < .001), day 2 (MD = -1.26, 95% CI [-2.02, -0.49], I2 = 91%, P = .001), and day 3 and over (MD = -1.27, 95% CI [-1.92, -0.61], I2 = 79%, P < .001), and respiratory distress assessment instrument enhancement (MD = -0.60, 95% CI [-0.95, -0.26], I2 = 0%, P < .001). No significant adverse events related to 3% NHS were observed.

CONCLUSION

This study showed that 3% NHS was better than 0.9% normal saline in reducing LOS, decreasing ROH, improving CSS, and in enhancing the severity of respiratory distress. Further studies are needed to validate these findings.

Exploring the appropriate dose of nebulized hypertonic saline for bronchiolitis: a dose-response meta-analysis

Nebulized hypertonic saline (HS) has gathered increasing attention in bronchiolitis. This study aims to evaluate the relationship between the dose of nebulized HS and the effects on bronchiolitis. Five electronic databases-PubMed, EMBASE, Cochrane Central Register of Controlled Trials, ClinicalTrials.gov, and ISRCTN-were searched until May 2021. Randomized controlled trials (RCTs) that investigated the effect of HS on bronchiolitis were included. A total of 35 RCTs met the eligibility criteria. HS nebulization may shorten the length of stay (LOS) in hospital (mean difference -0.47, 95% CI -0.71 to -0.23) and improve the 24-hour, 48-hour, and 72-hour Clinical Severe Score (CSS) in children with bronchiolitis. The results showed that there was no significant difference between 3% HS and the higher doses (>3%) of HS in LOS and 24-hour CSS. Although the dose-response meta-analysis found that there may be a linear relationship between different doses and effects, the slope of the linear model changed with different included studies. Besides, HS nebulization could reduce the rate of hospitalization of children with bronchiolitis (risk ratio 0.88, 95% CI 0.78 to 0.98), while the trial sequential analysis indicated the evidence may be insufficient and potentially false positive. This study showed that nebulized HS is an effective and safe therapy for bronchiolitis. More studies are necessary to be conducted to evaluate the effects of different doses of HS on bronchiolitis.

Inhaled hypertonic saline after pediatric lung transplant-Caution required?

Management of pulmonary infection following lung transplant is multifaceted and includes respiratory physiotherapy. Inhaled hypertonic saline (HTS) has been introduced as an adjunct to physiotherapy in pediatric transplant patients. There are no published studies investigating the use of HTS in this population. This study aimed to evaluate the effect of inhaled HTS, in the acute post-operative period, in pediatric lung transplant patients. A retrospective case-note review was completed at a single UK pediatric transplant center. An intervention group who received HTS was compared to a historical control group. Participants were frequency matched for age, gender, and diagnosis (14 per group); median age in years was 13.7(IQR 12.7-15.3) in the controls and 14.8(IQR 12.4-16.1) in the intervention group. Primary outcome was the requirement of invasive and non-invasive ventilation. Secondary outcomes included oxygen use and length of stay. Median days of invasive ventilation were shorter in the control group (1, 95% CI 1-1) compared to the intervention group (2, 95% CI 1-2.5) (P < .05). Days of non-invasive ventilation and oxygen were higher in the HTS group, but this was not statistically significant. The controls displayed shorter median length of stay (23 days, 95% CI 20-24) compared to the intervention group (31 days, 95% CI 24.5-39) (P < .05). The results of this small study provide uncertainty regarding the safety of inhaled hypertonic saline after lung transplant. There was a trend of poorer acute outcomes in patients who received HTS. However, the findings should be interpreted with caution and further investigation using larger samples is required.

Exploring the efficacy of using hypertonic saline for nebulizing treatment in children with bronchiolitis: a meta-analysis of randomized controlled trials

BACKGROUND

Inhaled hypertonic saline (HS) has shown benefit in decreasing airway edema in acute bronchiolitis which is the most common lower respiratory infection resulting in dyspnea among infants under 2 years old. The aim of this systematic review and meta-analysis was to evaluate the efficacy and safety of HS in the implementation of treatment with nebulized HS among children with bronchiolitis.

METHODS

A systematic literature search was conducted using Cochrane Library, PubMed, EMBASE and Airiti Library (Chinese Database) for randomized controlled trials from inception to July 2019. We calculated pooled risk ratios (RR), mean difference (MD) and 95% CI using RevMan 5.3 for meta-analysis.

RESULTS

There were 4186 children from 32 publications included. Compared to the control group, the HS group exhibited significant reduction of severity of respiratory distress, included studies used the Clinical Severity Score (n = 8; MD, - 0.71; 95% CI, - 1.15 to - 0.27; I2 = 73%) and full stop after Respiratory Distress Assessment Instrument (n = 5; MD, - 0.60; 95% CI, - 0.95 to - 0.26; I2 = 0%) for evaluation respectively. Further, the HS group decreased the length of hospital stay 0.54 days (n = 20; MD, - 0.54; 95% CI, - 0.86 to - 0.23; I2 = 81%).

CONCLUSIONS

We conclude that nebulization with 3% saline solution is effective in decreasing the length of hospital stay and the severity of symptoms as compared with 0.9% saline solution among children with acute bronchiolitis. Further rigorous randomized controlled trials with large sample size are needed.

Nebulised normal saline in moderate acute bronchiolitis and pneumonia in a low- to middle-income country: a randomised trial in Papua New Guinea

BACKGROUND

Acute lower respiratory tract infections are the commonest cause of hospitalisation in young children and supportive care remains the cornerstone of management. A randomised open trial was undertaken at the Port Moresby General Hospital Children's Emergency Department (CED) to determine whether nebulised normal saline had beneficial effects.

METHODS

Children <2 years of age presenting with a clinical diagnosis of moderate acute bronchiolitis or moderate pneumonia were randomised to receive standard care alone or with nebulised normal saline administered hourly. The outcomes were the difference in respiratory distress scores (RDS) and oxygen saturation between 0 and 4 hours, and admission rates.

RESULTS

A total of 199 patients participated; 100 patients were randomised to normal saline and 99 to standard care. At 4 hours there was a significant difference in the change of the respiratory distress scores: mean RDS reduced by 3.41 (95% CI 3.0-3.8) in the normal saline group, and for the standard group, the RDS reduced by 1.96 (95% CI 1.5-2.4, p < 0.0001). In those receiving normal saline oxygen saturation measured by pulse oximetry (SpO₂) increased by a mean of 7% (95% CI 6.0-7.9) to 90.7% at 4 hours. For those receiving standard care, the SpO₂ increased by a mean of 4% (95% CI 2.8-5.2) to 87.5% at 4 hours (p < 0.001). Of 100 patients, 58 (58%) in the normal saline group and 24 of 99 (24.2%) in the standard arm were discharged from the Children's Emergency Department (p < 0.001).

CONCLUSIONS

This study supports the use of nebulised normal saline in the treatment of moderate acute bronchiolitis or pneumonia in an emergency department setting in a low- to middle-income country.

ABBREVIATIONS

ALRI, acute lower respiratory infection; CED, Children's Emergency Department; NaCl, sodium chloride; PMGH, Port Moresby General Hospital; PNG, Papua New Guinea; RDS, respiratory distress score; SpO₂, oxygen saturation by pulse oximetry.

Efficacy of 3% hypertonic saline in bronchiolitis: A meta-analysis

A meta-analysis was performed to analyze the efficacy of 3% hypertonic saline (HS) in bronchiolitis. Pubmed and MEDLINE databases were searched for relevant articles. A total of 2 authors selected the articles according to the inclusion criteria and then data were carefully extracted. Weighted mean difference (WMD) with 95% confidence interval (95% CI) values were used to pool continuous data, including length of stay and clinical severity score (CSS). Relative risk (RR) with 95% CI was calculated to determine the association between 3% HS and re-admission. The pooled data revealed that infants treated with 3% HS exhibited shorter durations of hospitalization compared with those treated with normal saline (NS; WMD=-0.43; 95% CI=-0.70, -0.15). Subgroup analysis examining the combination of HS or NS with additional medication demonstrated that 3% HS with epinephrine significantly decreased the length of hospital stay, with a WMD=-0.62 (95% CI=-0.90, -0.33). The results indicated a lower CSS score in the 3% HS group compared with the NS group (SMD=-0.80; 95% CI=-1.06, -0.54). The pooled outcome indicated a beneficial effect of 3% HS on decreasing re-admission rates compared with NS (RR=0.93; 95% CI=0.70, 1.23). No potential publication bias was observed (Begg's, P=0.133; Egger's, P=0.576). In conclusion, 3% HS was demonstrated to be a more successful therapy compared with NS for infants with bronchiolitis.

Australasian bronchiolitis guideline

AIM

Bronchiolitis is the most common lower respiratory tract disorder in infants aged less than 12 months, and research has demonstrated that there is substantial variation in practice patterns despite treatment being well defined. In order to align and improve the consistency of the management of bronchiolitis, an evidence-based guideline was developed for the Australasian population.

METHODS

The guideline development committee included representation from emergency and paediatric specialty medical and nursing personnel in addition to geographical representation across Australia and New Zealand - rural, remote and metropolitan. Formulation of the guideline included identification of population, intervention, comparator, outcomes and time questions and was associated with an extensive literature search from 2000 to 2015. Evidence was summarised and graded using the National Health and Medical Research Council and Grading of Recommendations Assessment, Development and Evaluation methodology, and consensus within the guideline group was sought using nominal group technique principles to formulate the clinical practice recommendations. The guideline was reviewed and endorsed by key paediatric health bodies.

RESULTS

The guideline consists of a usable clinical interface for bedside functionality supported by evidence summary and tables. The Grading of Recommendations Assessment, Development and Evaluation and National Health and Medical Research Council processes provided a systematic and transparent process to review and assess the literature, resulting in a guideline that is relevant to the management of bronchiolitis in the Australasian setting.

CONCLUSION

This is the first robust Australasian acute paediatric guideline and provides clear guidance for the management of the vast majority of patients seen in Australasian emergency departments and general paediatric wards with bronchiolitis.

Hypertonic Saline in Bronchiolitis and Type I Error: A Trial Sequential Analysis

: media-1vid110.1542/5799873875001PEDS-VA_2018-1144Video Abstract BACKGROUND AND OBJECTIVES: Meta-analyses of nebulized hypertonic saline (HS) for acute viral bronchiolitis have yielded disparate conclusions. Trial sequential analysis (TSA) is a novel method designed to account for potential sources of error in conventional meta-analysis. We sought to use TSA to determine if the existing literature base is sufficient to draw firm conclusions about the effectiveness of HS in bronchiolitis.

METHODS

We used the cohort of studies identified in previously published conventional meta-analyses. Included studies were those in which authors compared treatment with HS versus normal saline (or supportive care) in children with bronchiolitis to reduce hospital length of stay (LOS) or hospitalizations. TSA results are used to provide a required information size and monitoring boundaries for statistical significance.

RESULTS

For the LOS outcome, 17 studies including 1866 patients analyzed in which authors used conventional meta-analysis reveal a statistically significant benefit (mean difference = -0.41 days; 95% confidence interval = -0.07 to -0.75); however, TSA suggests that those conclusions are premature because of failure to reach the adequate information size of 2665 individuals. For the risk of hospitalization outcome, 8 studies including 1728 patients analyzed in which authors used conventional meta-analysis reveal a reduction in the relative risk of hospitalization (relative risk = 0.86; 95% confidence interval = 0.76 to 0.98); however, TSA suggests these conclusions are premature because of failure to reach the adequate information size of 4770. Both LOS and hospitalization results from conventional meta-analysis would be considered potentially false-positives by TSA.

CONCLUSIONS

TSA reveals that concluding benefit from HS for children with bronchiolitis potentially represents type I error.

Impact of hypertonic saline on hospitalization rate in infants with acute bronchiolitis: A meta-analysis

AIM

This meta-analysis aimed to assess the efficacy of nebulized hypertonic saline (HS) on the rate of hospitalization in infants with acute bronchiolitis in the Emergency Department (ED) setting.

METHOD

We searched PubMed, Virtual Health Library-BVS and Cochrane CENTRAL from inception until January 31, 2018. We selected randomized trials that compared nebulized HS with normal saline (NS) or standard care in children up to 24 months of age with acute bronchiolitis in the ED setting. We conducted random-effects meta-analyses to estimate the risk ratio (RR) and 95% confidence interval (CI).

RESULTS

A total of 293 records were screened and 8 trials involving 1708 patients were included. The meta-analysis showed a 16% reduction in the risk of hospitalization among patients treated with HS compared to NS (risk ratio [RR]: 0.84, 95% confidence interval [CI]: 0.71-0.98, P = 0.03). A significant effect of HS in reducing the risk of hospitalization was found only in the subgroup analyses of trials in which HS was mixed with bronchodilators, multiple doses (≥3) were given, and risk of bias was low.

CONCLUSIONS

Nebulized hypertonic saline may potentially reduce the risk of hospitalization in infants with acute bronchiolitis in the ED setting. Quality of evidence is moderate due to substantial clinical heterogeneity between studies and large multicenter trials are still warranted.

The change in management of bronchiolitis in the intensive care unit between 2000 and 2015

This case-control study evaluated interventions for bronchiolitis in relation to time in the pediatric intensive care unit (PICU) during a 16-year surveillance period. Together, 105 infants aged < 12 months were treated for bronchiolitis in the PICU, and for them, we selected 210 controls admitted for bronchiolitis closest to cases. We collected data on treatments in the PICU, at the ward and in the emergency department for three periods: years 2000-2005, 2006-2010, and 2011-2015. Median hospital length of stay for PICU patients were 7 days (interquartile range 5-12), 5 days (4-8) and 8 days (4-12.5, p = 0.127), respectively. By time, the use of inhaled beta-agonist (68 vs. 44 vs. 38%, p = 0.019) and systemic corticosteroids (29 vs. 15 vs. 5%, p = 0.019) decreased, but that of racemic adrenaline (59 vs. 78 vs. 84%, p = 0.035) and hypertonic saline (0 vs. 0 vs. 54%, p < 0.001) inhalations increased in the PICU. Similar changes were seen at the ward. In the PICU, non-invasive ventilation therapies increased significantly, but intubation rates did not decline.Conclusion: Beta-agonists and systemic corticosteroids were used less by time in intensive care for infant bronchiolitis, but the use of hypertonic saline and racemic adrenaline increased, though their effectiveness has been questioned. What is Known: • Until now, studies have shown which treatments do not work in bronchiolitis, and so, there is no consensus how infants with bronchiolitis should be treated. In particular, there is no consensus on different interventions in intensive care for bronchiolitis. What is New: • During 2000-2015, treatments with inhaled beta-agonists and systemic corticosteroids decreased but treatments with racemic adrenaline and hypertonic saline inhalations increased in intensive care for bronchiolitis. Similar changes were seen at the ward. Though non-invasive ventilation therapies increased, the intubation rate did not decline.

Saline as a vehicle control does not alter ventilation in male CD-1 mice

Saline (0.9% NaCl) is used in clinical and research settings as a vehicle for intravenous drug administration. While saline is a standard control in mouse studies, there are reports of hyperchloremic metabolic acidosis in high doses. It remains unknown if metabolic acidosis occurs in mice and/or if compensatory increases in breathing frequency and tidal volume accompany saline administration. It was hypothesized that saline administration alters blood pH and the pattern of breathing in conscious CD-1 male mice exposed to air or hypoxia (10% O2 , balanced N2 ). Unrestrained barometric plethysmography was used to quantify breathing frequency (breaths/min; bpm), tidal volume (VT; mL/breath/10 g body weight (BW)), and minute ventilation (VE; mL/min/10 g BW) in two designs: (1) 11-week-old mice with no saline exposure (n = 11) compared to mice with 7 days of 0.9% saline administration (intraperitoneal, i.p.; 10 mL/kg body mass; n = 6). and (2) 17-week-old mice tested before (PRE) and after 1 day (POST1, n = 6) or 7 days (POST7, n = 5) of saline (i.p.; 10 mL/kg body mass). There were no differences when comparing frequency, VT, or VE between groups for either design with room air or hypoxia exposures. Hypoxia increased frequency, VT, and VE compared to room air. Moreover, conscious blood sampling showed no differences in pH, paCO2 , paO2 , or HCO3- in mice without or with 7 days of saline. These findings reveal no differences in ventilation following 1 and/or 7 days of saline administration in mice. Therefore, the use of 0.9% saline as a control is supported for studies evaluating the control of breathing in mice.

Nebulized hypertonic saline in infants hospitalized with moderately severe bronchiolitis due to RSV infection: A multicenter randomized controlled trial

INTRODUCTION

The efficacy of nebulized hypertonic saline (HS) therapy for shortening hospital length of stay (LOS) or improving bronchiolitic symptoms remains controversial. Most studies enrolled small numbers of subjects and did not consider the role of respiratory syncytial virus (RSV), the most common cause of acute bronchiolitis. Our aim was to evaluate the efficacy and safety of nebulized HS therapy for acute bronchiolitis due to RSV in moderately ill hospitalized infants.

MATERIALS AND METHODS

This was an open-label, multicenter, randomized controlled trial comparing a nebulized HS treatment group with a normal saline (NS) group. The subjects, 128 infants with bronchiolitis due to RSV, were admitted to five hospitals in Tokyo, Japan. Three-percent HS or NS was administered via bronchodilator four times daily post-admission. The primary outcome was LOS, defined as the time until the patients fulfilled the discharge criteria, namely, absence of fever, no need for supplemental oxygen, and adequate feeding. Survival analysis was conducted in accordance with the intention-to-treat principle.

RESULTS

The baseline characteristics were similar between the two groups. There was no significant overall difference in LOS between the groups (4.81 ± 2.14 days in HS vs 4.61 ± 2.18 days in NS; P = 0.60). Survival analysis by log-rank test also showed no significance (P = 0.62). Multivariate adjustment did not significantly alter the results. The treatment was well-tolerated, with no adverse effects attributable to the use of HS.

CONCLUSIONS

Nebulized HS therapy did not significantly reduce LOS among infants with bronchiolitis due to RSV.

Hypertonic saline inhalations in bronchiolitis-A cumulative meta-analysis

We undertook a cumulative meta-analysis for the efficacy of hypertonic saline (HS) compared to normal saline (NS) inhalations or no inhalations as controls in bronchiolitis. We performed literature searches from PubMed, Scopus, and by hand search until 20 June 2017. We accepted published randomized controlled trials of HS inhalations in children with bronchiolitis aged <24 months. We evaluated the differences between treatment group with HS and control group without HS inhalations for the length-of-stay in hospital (LOS) by cumulative mean difference (MD) and in hospitalization rate by cumulative risk ratio (RR). We identified 18 studies including 2102 children treated in hospital, and the cumulative MD in LOS was -0.471 days (95% confidence interval [CI] -0.765 to -0.177, Higgins heterogeneity test [I² ] 72.9%). The cumulative MD reduced in more recently published papers. In studies with the upper age limit of 12 months, the cumulative MD was -0.408 days (95%CI -0.733 to -0.083) without any important heterogeneity (I²  = 0%). If only studies with a very low risk of bias were included, the cumulative MD was 0.034 (95%CI -0.361 to 0.293) without any important heterogeneity (I²  = 0%). We identified eight studies including 1834 children in the outpatient setting, and the cumulative risk ratio for hospitalization was 0.771 (95%CI 0.619-0.959, I² 55.8%). In conclusion, HS inhalations offered only limited clinical benefits, though the differences between HS and control groups were statistically significant. The heterogeneity between the studies was substantial. Further studies are warranted with consistent definitions of bronchiolitis and comparable research frames.

The cost-effectiveness of hypertonic saline inhalations for infant bronchiolitis: a decision analysis

BACKGROUND

This study evaluated the cost-effectiveness of hypertonic saline (HS) inhalations for infant bronchiolitis, compared to normal saline inhalations or standard treatment without inhalations as controls.

METHODS

The decision tree in the decision analysis was used to calculate the expected costs. Actual cost data were obtained from our retrospective case-control study on bronchiolitis treatment. The effectiveness of treatment, based on the hospitalization rate of those admitted to the emergency department and the length of stay (LOS) of those who were hospitalized, was collected from previous studies. For the effectiveness estimations, we made a meta-analysis summarizing the results of the meta-analysis of the Cochrane review in 2013 and the results of 10 studies published after it.

RESULTS

The mean hospitalization rate was 24.7% in the HS inhalation group and 32.6% in the control group [risk ratio: 0.80, 95% confidence interval (CI) 0.67-0.96] and the mean LOS was 3.736 (HS group) and 4.292 (controls) days (mean difference: - 0.55 days, 95% CI - 0.96 to - 0.15), respectively. The expected costs per patient, when both inpatients and outpatients were included, were €816 ($1111) in the HS inhalation group and €962 ($1310) in the control group. The expected costs per hospitalization, when only inpatients were included, were €2600 ($3540) in the HS inhalation group and €2890 ($3935) in the control group.

CONCLUSIONS

HS inhalations slightly reduced the expected hospitalization costs of infant bronchiolitis. However, the low effectiveness, rather than the cost, is the factor that will limit the use of HS inhalations in infant bronchiolitis.

Does nebulized hypertonic saline shorten hospitalization in young children with acute viral wheezing?

BACKGROUND

Although previous studies have shown benefits of nebulized hypertonic saline (HS) for improving airway clearance and shortening hospitalization in infants with bronchiolitis, prospective blinded studies in preschool children with acute viral wheezing are limited.

OBJECTIVES

To determine nebulized 3% HS efficacy in young children admitted with acute viral wheezing.

METHODS

This double-blind, randomized controlled trial was conducted in children aged 6 months to 5 years admitted with acute viral wheezing from July 1st to December 31st 2016. Patients were randomized to receive inhalation of 2.5 mg salbutamol dissolved in either 3% HS or normal saline (NS). Clinical data, asthma clinical severity score, and length of hospital stay (LOS) were recorded.

RESULTS

A total of 47 patients were enrolled (22 in HS and 25 in NS) without significant differences in demographic data and baseline clinical scores. Median LOS and median time of oxygen therapy were significantly shorter in HS than NS group: 48 versus 72 h, P = 0.021 and 36 versus 72 h, P = 0.025, respectively. HS patients had significantly improved asthma clinical severity scores, respiratory rates and oxygen saturation at 12 h compared to NS group (P-value 0.042, 0.032, and 0.043). There were no adverse events.

CONCLUSION

In children under 5 years admitted with acute viral wheezing, nebulized hypertonic saline/salbutamol significantly shortened hospital stay length, time of oxygen therapy, and improved asthma clinical severity score faster than normal saline/salbutamol.

Nebulised hypertonic saline solution for acute bronchiolitis in infants

BACKGROUND

Airway oedema (swelling) and mucus plugging are the principal pathological features in infants with acute viral bronchiolitis. Nebulised hypertonic saline solution (≥ 3%) may reduce these pathological changes and decrease airway obstruction. This is an update of a review first published in 2008, and previously updated in 2010 and 2013.

OBJECTIVES

To assess the effects of nebulised hypertonic (≥ 3%) saline solution in infants with acute bronchiolitis.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, MEDLINE Epub Ahead of Print, In-Process & Other Non-Indexed Citations, Ovid MEDLINE Daily, Embase, CINAHL, LILACS, and Web of Science on 11 August 2017. We also searched the World Health Organization International Clinical Trials Registry Platform (WHO ICTRP) and ClinicalTrials.gov on 8 April 2017.

SELECTION CRITERIA

We included randomised controlled trials and quasi-randomised controlled trials using nebulised hypertonic saline alone or in conjunction with bronchodilators as an active intervention and nebulised 0.9% saline, or standard treatment as a comparator in children under 24 months with acute bronchiolitis. The primary outcome for inpatient trials was length of hospital stay, and the primary outcome for outpatients or emergency department trials was rate of hospitalisation.

DATA COLLECTION AND ANALYSIS

Two review authors independently performed study selection, data extraction, and assessment of risk of bias in included studies. We conducted random-effects model meta-analyses using Review Manager 5. We used mean difference (MD), risk ratio (RR), and their 95% confidence intervals (CI) as effect size metrics.

MAIN RESULTS

We identified 26 new trials in this update, of which 9 await classification due to insufficient data for eligibility assessment, and 17 trials (N = 3105) met the inclusion criteria. We included a total of 28 trials involving 4195 infants with acute bronchiolitis, of whom 2222 infants received hypertonic saline.Hospitalised infants treated with nebulised hypertonic saline had a statistically significant shorter mean length of hospital stay compared to those treated with nebulised 0.9% saline (MD -0.41 days, 95% CI -0.75 to -0.07; P = 0.02, I² = 79%; 17 trials; 1867 infants) (GRADE quality of evidence: low). Infants who received hypertonic saline also had statistically significant lower post-inhalation clinical scores than infants who received 0.9% saline in the first three days of treatment (day 1: MD -0.77, 95% CI -1.18 to -0.36, P < 0.001; day 2: MD -1.28, 95% CI -1.91 to -0.65, P < 0.001; day 3: MD -1.43, 95% CI -1.82 to -1.04, P < 0.001) (GRADE quality of evidence: low).Nebulised hypertonic saline reduced the risk of hospitalisation by 14% compared with nebulised 0.9% saline among infants who were outpatients and those treated in the emergency department (RR 0.86, 95% CI 0.76 to 0.98; P = 0.02, I² = 7%; 8 trials; 1723 infants) (GRADE quality of evidence: moderate).Twenty-four trials presented safety data: 13 trials (1363 infants, 703 treated with hypertonic saline) did not report any adverse events, and 11 trials (2360 infants, 1265 treated with hypertonic saline) reported at least one adverse event, most of which were mild and resolved spontaneously.

AUTHORS' CONCLUSIONS

Nebulised hypertonic saline may modestly reduce length of stay among infants hospitalised with acute bronchiolitis and improve clinical severity score. Treatment with nebulised hypertonic saline may also reduce the risk of hospitalisation among outpatients and emergency department patients. However, we assessed the quality of the evidence as low to moderate.

Viral Lower Respiratory Tract Infections

Lower respiratory tract infections in children are often viral in origin. Unfortunately in this time of significant antimicrobial resistance of infectious organisms, especially bacteria, there is still a tendency for clinicians to manage a child who coughs with antibiotics. In addition, the World Health Organization (WHO) has defined “pneumonia” as a condition that only occurs in children who have “fast breathing or chest wall indrawing”. That would delineate upper respiratory tract infections from those in the lower airway. However, in addition to pneumonia another important entity exists in the lower respiratory tract that is almost always viral in origin. This condition is acute viral bronchiolitis. The concept of “acute lower respiratory tract infection” (ALRTI) has emerged and it is becoming increasing evident from a number of studies that the infectious base of both acute pneumonia (AP) and acute bronchiolitis in children has a mixed etiology of microorganisms. Therefore, whilst certain clinical phenotypes do not require antibiotics the actual microbial etiology is much less distinct.

Hypertonic Saline for the Treatment of Bronchiolitis in Infants and Young Children: A Critical Review of the Literature

Bronchiolitis, an infection of the lower respiratory tract, is the leading cause of infant and child hospitalization in the United States. Therapeutic options for management of bronchiolitis are limited. Hypertonic saline inhalation therapy has been studied in numerous clinical trials with mixed results. In 2014, the American Academy of Pediatrics (AAP) published updated guidelines on the diagnosis and management of bronchiolitis, which include new recommendations on the use of hypertonic saline. We reviewed all published clinical trials mentioned in the 2014 AAP guidelines, as well as additional trials published since the guidelines, and critically evaluated each trial to determine efficacy, safety, and expectations of hypertonic saline inhalation therapy. A total of 2682 infants were studied over the course of 22 clinical trials. Nine trials were carried out in the outpatient/clinic/emergency department and 13 in the inpatient setting. We agree with the AAP guidelines regarding the recommendation to use nebulized hypertonic saline for infants hospitalized with bronchiolitis, with the expectation of reducing bronchiolitis scores and length of stay when it is expected to last more than 72 hours. However, we also believe there might be an advantage for hypertonic saline in reducing admission rates from the emergency department, based on close examination of the results of recent trials. This review also highlights important gaps in the available literature that need to be addressed in order to define the role of inhaled hypertonic saline therapy.

3% Hypertonic Saline Versus Normal Saline in Inpatient Bronchiolitis: A Randomized Controlled Trial

BACKGROUND AND OBJECTIVES

Bronchiolitis, the most common reason for hospitalization in children younger than 1 year in the United States, has no proven therapies effective beyond supportive care. We aimed to investigate the effect of nebulized 3% hypertonic saline (HS) compared with nebulized normal saline (NS) on length of stay (LOS) in infants hospitalized with bronchiolitis.

METHODS

We conducted a prospective, randomized, double-blind, controlled trial in an urban tertiary care children's hospital in 227 infants younger than 12 months old admitted with a diagnosis of bronchiolitis (190 completed the study); 113 infants were randomized to HS (93 completed the study), and 114 to NS (97 completed the study). Subjects received 4 mL nebulized 3% HS or 4 mL 0.9% NS every 4 hours from enrollment until hospital discharge. The primary outcome was median LOS. Secondary outcomes were total adverse events, subdivided as clinical worsening and readmissions.

RESULTS

Patient characteristics were similar in groups. In intention-to-treat analysis, median LOS (interquartile range) of HS and NS groups was 2.1 (1.2-4.6) vs 2.1 days (1.2-3.8), respectively, P = .73. We confirmed findings with per-protocol analysis, HS and NS groups with 2.0 (1.3-3.3) and 2.0 days (1.2-3.0), respectively, P = .96. Seven-day readmission rate for HS and NS groups were 4.3% and 3.1%, respectively, P = .77. Clinical worsening events were similar between groups (9% vs 8%, P = .97).

CONCLUSIONS

Among infants admitted to the hospital with bronchiolitis, treatment with nebulized 3% HS compared with NS had no difference in LOS or 7-day readmission rates.

Hypertonic saline (HS) for acute bronchiolitis: Systematic review and meta-analysis

BACKGROUND

Acute bronchiolitis is the commonest cause of hospitalisation in infancy. Currently management consists of supportive care and oxygen. A Cochrane review concluded that, "nebulised 3 % saline may significantly reduce the length of hospital stay". We conducted a systematic review of controlled trials of nebulised hypertonic saline (HS) for infants hospitalised with primary acute bronchiolitis.

METHODS

Searches to January 2015 involved: Cochrane Central Register of Controlled Trials; Ovid MEDLINE; Embase; Google Scholar; Web of Science; and, a variety of trials registers. We hand searched Chest, Paediatrics and Journal of Paediatrics on 14 January 2015. Reference lists of eligible trial publications were checked. Randomised or quasi-randomised trials which compared HS versus either normal saline (+/- adjunct treatment) or no treatment were included. Eligible studies involved children less than 2 years old hospitalised due to the first episode of acute bronchiolitis. Two reviewers extracted data to calculate mean differences (MD) and 95 % Confidence Intervals (CIs) for length of hospital stay (LoS-primary outcome), Clinical Severity Score (CSS) and Serious Adverse Events (SAEs). Meta-analysis was undertaken using a fixed effect model, supplemented with additional sensitivity analyses. We investigated statistical heterogeneity using I(2). Risk of bias, within and between studies, was assessed using the Cochrane tool, an outcome reporting bias checklist and a funnel plot.

RESULTS

Fifteen trials were included in the systematic review (n = 1922), HS reduced mean LoS by 0.36, (95 % CI 0.50 to 0.22) days, but with considerable heterogeneity (I(2) = 78 %) and sensitivity to alternative analysis methods. A reduction in CSS was observed where assessed [n = 516; MD -1.36, CI -1.52, -1.20]. One trial reported one possible intervention related SAE, no other studies described intervention related SAEs.

CONCLUSIONS

There is disparity between the overall combined effect on LoS as compared with the negative results from the largest and most precise trials. Together with high levels of heterogeneity, this means that neither individual trials nor pooled estimates provide a firm evidence-base for routine use of HS in inpatient acute bronchiolitis.

Nebulized Hypertonic Saline for Acute Bronchiolitis: A Systematic Review

BACKGROUND AND OBJECTIVE

The mainstay of treatment for acute bronchiolitis remains supportive care. The objective of this study was to assess the efficacy and safety of nebulized hypertonic saline (HS) in infants with acute bronchiolitis.

METHODS

Data sources included PubMed and the Virtual Health Library of the Latin American and Caribbean Center on Health Sciences Information up to May 2015. Studies selected were randomized or quasi-randomized controlled trials comparing nebulized HS with 0.9% saline or standard treatment.

RESULTS

We included 24 trials involving 3209 patients, 1706 of whom received HS. Hospitalized patients treated with nebulized HS had a significantly shorter length of stay compared with those receiving 0.9% saline or standard care (15 trials involving 1956 patients; mean difference [MD] -0.45 days, 95% confidence interval [CI] -0.82 to -0.08). The HS group also had a significantly lower posttreatment clinical score in the first 3 days of admission (5 trials involving 404 inpatients; day 1: MD -0.99, 95% CI -1.48 to -0.50; day 2: MD -1.45, 95% CI -2.06 to -0.85; day 3: MD -1.44, 95% CI -1.78 to -1.11). Nebulized HS reduced the risk of hospitalization by 20% compared with 0.9% saline among outpatients (7 trials involving 951 patients; risk ratio 0.80, 95% CI 0.67-0.96). No significant adverse events related to HS inhalation were reported. The quality of evidence is moderate due to inconsistency in results between trials and study limitations (risk of bias).

CONCLUSIONS

Nebulized HS is a safe and potentially effective treatment of infants with acute bronchiolitis.

Lower respiratory tract infection caused by respiratory syncytial virus: current management and new therapeutics

Respiratory syncytial virus (RSV) is a major worldwide cause of morbidity and mortality in children under five years of age. Evidence-based management guidelines suggest that there is no effective treatment for RSV lower respiratory tract infection (LRTI) and that supportive care, ie, hydration and oxygenation, remains the cornerstone of clinical management. However, RSV treatments in development in the past decade include 10 vaccines and 11 therapeutic agents in active clinical trials. Maternal vaccination is particularly relevant because the most severe disease occurs within the first 6 months of life, when children are unlikely to benefit from active immunisation. We must optimise the implementation of novel RSV therapeutics by understanding the target populations, showing safety, and striving for acceptable pricing in the context of this worldwide health problem. In this Review, we outline the limitations of RSV LRTI management, the drugs in development, and the remaining challenges related to study design, regulatory approval, and implementation.

From bronchiolitis guideline to practice: A critical care perspective

Acute viral bronchiolitis is a leading cause of admission to pediatric intensive care units, but research on the care of these critically ill infants has been limited. Pathology of viral bronchiolitis revealed respiratory obstruction due to intraluminal debris and edema of the airways and vasculature. This and clinical evidence suggest that airway clearance interventions such as hypertonic saline nebulizers and pulmonary toilet devices may be of benefit, particularly in situations of atelectasis associated with bronchiolitis. Research to distinguish an underlying asthma predisposition in wheezing infants with viral bronchiolitis may one day lead to guidance on when to trial bronchodilator therapy. Considering the paucity of critical care research in pediatric viral bronchiolitis, intensive care practitioners must substantially rely on individualization of therapies based on bedside clinical assessments. However, with the introduction of new diagnostic and respiratory technologies, our ability to support critically ill infants with acute viral bronchiolitis will continue to advance.

Saline in acute bronchiolitis RCT and economic evaluation: hypertonic saline in acute bronchiolitis - randomised controlled trial and systematic review

BACKGROUND

Acute bronchiolitis is the most common cause of hospitalisation in infancy. Supportive care and oxygen are the cornerstones of management. A Cochrane review concluded that the use of nebulised 3% hypertonic saline (HS) may significantly reduce the duration of hospitalisation.

OBJECTIVE

To test the hypothesis that HS reduces the time to when infants were assessed as being fit for discharge, defined as in air with saturations of > 92% for 6 hours, by 25%.

DESIGN

Parallel-group, pragmatic randomised controlled trial, cost-utility analysis and systematic review.

SETTING

Ten UK hospitals.

PARTICIPANTS

Infants with acute bronchiolitis requiring oxygen therapy were allocated within 4 hours of admission.

INTERVENTIONS

Supportive care with oxygen as required, minimal handling and fluid administration as appropriate to the severity of the disease, 3% nebulised HS every ± 6 hours.

MAIN OUTCOME MEASURES

The trial primary outcome was time until the infant met objective discharge criteria. Secondary end points included time to discharge and adverse events. The costs analysed related to length of stay (LoS), readmissions, nebulised saline and other NHS resource use. Quality-adjusted life-years (QALYs) were estimated using an existing utility decrement derived for hospitalisation in children, together with the time spent in hospital in the trial.

DATA SOURCES

We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and other databases from inception or from 2010 onwards, searched ClinicalTrials.gov and other registries and hand-searched Chest, Paediatrics and Journal of Paediatrics to January 2015.

REVIEW METHODS

We included randomised/quasi-randomised trials which compared HS versus saline (± adjunct treatment) or no treatment. We used a fixed-effects model to combine mean differences for LoS and assessed statistical heterogeneity using the I (2) statistic.

RESULTS

The trial randomised 158 infants to HS (n = 141 analysed) and 159 to standard care (n = 149 analysed). There was no difference between the two arms in the time to being declared fit for discharge [median 76.6 vs. 75.9 hours, hazard ratio (HR) 0.95, 95% confidence interval (CI) 0.75 to 1.20] or to actual discharge (median 88.5 vs. 88.7 hours, HR 0.97, 95% CI 0.76 to 1.23). There was no difference in adverse events. One infant developed bradycardia with desaturation associated with HS. Mean hospital costs were £2595 and £2727 for the control and intervention groups, respectively (p = 0.657). Incremental QALYs were 0.0000175 (p = 0.757). An incremental cost-effectiveness ratio of £7.6M per QALY gained was not appreciably altered by sensitivity analyses. The systematic review comprised 15 trials (n = 1922) including our own. HS reduced the mean LoS by -0.36 days (95% CI -0.50 to -0.22 days). High levels of heterogeneity (I (2) = 78%) indicate that the result should be treated cautiously.

CONCLUSIONS

In this trial, HS had no clinical benefit on LoS or readiness for discharge and was not a cost-effective treatment for acute bronchiolitis. Claims that HS achieves small reductions in LoS must be treated with scepticism.

FUTURE WORK

Well-powered randomised controlled trials of high-flow oxygen are needed.

STUDY REGISTRATION

This study is registered as NCT01469845 and CRD42014007569.

FUNDING DETAILS

This project was funded by the NIHR Health Technology Assessment (HTA) programme and will be published in full in Health Technology Assessment; Vol. 19, No. 66. See the HTA programme website for further project information.

SABRE: a multicentre randomised control trial of nebulised hypertonic saline in infants hospitalised with acute bronchiolitis

Aim

Acute bronchiolitis is the commonest cause for hospitalisation in infancy. Supportive care remains the cornerstone of current management and no other therapy has been shown to influence the course of the disease. It has been suggested that adding nebulised hypertonic saline to usual care may shorten the duration of hospitalisation. To determine whether hypertonic saline does have beneficial effects we undertook an open, multi-centre parallel-group, pragmatic RCT in ten UK hospitals.

Methods

Infants admitted to hospital with a clinical diagnosis of acute bronchiolitis and requiring oxygen therapy were randomised to receive usual care alone or nebulised 3% hypertonic saline (HS) administered 6-hourly. Randomisation was within 4 h of admission. The primary outcome was time to being assessed as ‘fit’ for discharge with secondary outcomes including time to discharge, incidence of adverse events together with follow up to 28 days assessing patient centred health related outcomes.

Results

A total of 317 infants were recruited to the study. 158 infants were randomised to HS (141 analysed) and 159 to standard care (149 analysed). There was no difference between the two arms in time to being declared fit for discharge (hazard ratio: 0−95, 95% CI: 0.75−1.20) nor to actual discharge (hazard ratio: 0.97, 95% CI: 0.76−1.23). There was no difference in adverse events. One infant in the HS group developed bradycardia with desaturation.

Conclusion

This study does not support the use of nebulised HS in the treatment of acute bronchiolitis over usual care with minimal handlings.

ClinicalTrials.gov registration number

NCT01469845.

Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis

This guideline is a revision of the clinical practice guideline, "Diagnosis and Management of Bronchiolitis," published by the American Academy of Pediatrics in 2006. The guideline applies to children from 1 through 23 months of age. Other exclusions are noted. Each key action statement indicates level of evidence, benefit-harm relationship, and level of recommendation. Key action statements are as follows:

Bronchodilators for bronchiolitis

BACKGROUND

Bronchiolitis is an acute, viral lower respiratory tract infection affecting infants and is sometimes treated with bronchodilators.

OBJECTIVES

To assess the effects of bronchodilators on clinical outcomes in infants (0 to 12 months) with acute bronchiolitis.

SEARCH METHODS

We searched CENTRAL 2013, Issue 12, MEDLINE (1966 to January Week 2, 2014) and EMBASE (1998 to January 2014).

SELECTION CRITERIA

Randomized controlled trials (RCTs) comparing bronchodilators (other than epinephrine) with placebo for bronchiolitis.

DATA COLLECTION AND ANALYSIS

Two authors assessed trial quality and extracted data. We obtained unpublished data from trial authors.

MAIN RESULTS

We included 30 trials (35 data sets) representing 1992 infants with bronchiolitis. In 11 inpatient and 10 outpatient studies, oxygen saturation did not improve with bronchodilators (mean difference (MD) -0.43, 95% confidence interval (CI) -0.92 to 0.06, n = 1242). Outpatient bronchodilator treatment did not reduce the rate of hospitalization (11.9% in bronchodilator group versus 15.9% in placebo group, odds ratio (OR) 0.75, 95% CI 0.46 to 1.21, n = 710). Inpatient bronchodilator treatment did not reduce the duration of hospitalization (MD 0.06, 95% CI -0.27 to 0.39, n = 349).Effect estimates for inpatients (MD -0.62, 95% CI -1.40 to 0.16) were slightly larger than for outpatients (MD -0.25, 95% CI -0.61 to 0.11) for oximetry. Oximetry outcomes showed significant heterogeneity (I(2) statistic = 81%). Including only studies with low risk of bias had little impact on the overall effect size of oximetry (MD -0.38, 95% CI -0.75 to 0.00) but results were close to statistical significance.In eight inpatient studies, there was no change in average clinical score (standardized MD (SMD) -0.14, 95% CI -0.41 to 0.12) with bronchodilators. In nine outpatient studies, the average clinical score decreased slightly with bronchodilators (SMD -0.42, 95% CI -0.79 to -0.06), a statistically significant finding of questionable clinical importance. The clinical score outcome showed significant heterogeneity (I(2) statistic = 73%). Including only studies with low risk of bias reduced the heterogeneity but had little impact on the overall effect size of average clinical score (SMD -0.22, 95% CI -0.41 to -0.03).Sub-analyses limited to nebulized albuterol or salbutamol among outpatients (nine studies) showed no effect on oxygen saturation (MD -0.19, 95% CI -0.59 to 0.21, n = 572), average clinical score (SMD -0.36, 95% CI -0.83 to 0.11, n = 532) or hospital admission after treatment (OR 0.77, 95% CI 0.44 to 1.33, n = 404).Adverse effects included tachycardia, oxygen desaturation and tremors.

AUTHORS' CONCLUSIONS

Bronchodilators such as albuterol or salbutamol do not improve oxygen saturation, do not reduce hospital admission after outpatient treatment, do not shorten the duration of hospitalization and do not reduce the time to resolution of illness at home. Given the adverse side effects and the expense associated with these treatments, bronchodilators are not effective in the routine management of bronchiolitis. This meta-analysis continues to be limited by the small sample sizes and the lack of standardized study design and validated outcomes across the studies. Future trials with large sample sizes, standardized methodology across clinical sites and consistent assessment methods are needed to answer completely the question of efficacy.

Recent evidence on the management of bronchiolitis

PURPOSE OF REVIEW

Bronchiolitis is a common condition in children less than 2  years of age and is a leading cause of infant hospitalization. Although there is significant variability in testing and treatment of children with bronchiolitis, diagnostic testing rarely improves care, and no currently available pharmacologic options have been proven to provide meaningful benefits or improve outcomes.

RECENT FINDINGS

Beta-agonists continue to be used frequently despite evidence that they do not reduce hospital admissions or length of stay. In general, therapies initially considered promising were subsequently proven ineffective, a pattern seen in studies on corticosteroids, and more recently with nebulized racemic epinephrine and hypertonic saline. Recent research has improved our understanding of the viral epidemiology of bronchiolitis, with increasing recognition of viruses other than respiratory syncytial virus and better awareness of the role of viral coinfections. How these findings will translate into improved outcomes remains uncertain.

SUMMARY

Much of the emphasis of the last few decades of bronchiolitis clinical care and research has centered on the identification and testing of novel therapies. Future quality improvement efforts should focus more on the limitation of unnecessary testing and treatments. Future research should include identification of subgroups of children with bronchiolitis that may benefit from focused clinical interventions.