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

Expert consensus on the diagnosis, treatment, and prevention of respiratory syncytial virus infections in children

BACKGROUND

Respiratory syncytial virus (RSV) is the leading global cause of respiratory infections and is responsible for about 3 million hospitalizations and more than 100,000 deaths annually in children younger than 5 years, representing a major global healthcare burden. There is a great unmet need for new agents and universal strategies to prevent RSV infections in early life. A multidisciplinary consensus development group comprising experts in epidemiology, infectious diseases, respiratory medicine, and methodology aims to develop the current consensus to address clinical issues of RSV infections in children.

DATA SOURCES

The evidence searches and reviews were conducted using electronic databases, including PubMed, Embase, Web of Science, and the Cochrane Library, using variations in terms for "respiratory syncytial virus", "RSV", "lower respiratory tract infection", "bronchiolitis", "acute", "viral pneumonia", "neonatal", "infant" "children", and "pediatric".

RESULTS

Evidence-based recommendations regarding diagnosis, treatment, and prevention were proposed with a high degree of consensus. Although supportive care remains the cornerstone for the management of RSV infections, new monoclonal antibodies, vaccines, drug therapies, and viral surveillance techniques are being rolled out.

CONCLUSIONS

This consensus, based on international and national scientific evidence, reinforces the current recommendations and integrates the recent advances for optimal care and prevention of RSV infections. Further improvements in the management of RSV infections will require generating the highest quality of evidence through rigorously designed studies that possess little bias and sufficient capacity to identify clinically meaningful end points.

Effects and safety of hypertonic saline combined with airway clearance in non-hospitalized children with recurrent wheezing

Background

The International Study of Wheezing in Infants defines recurrent wheezing as the presence of three or more medically documented episodes of wheezing within one year. To date, there is no evidence on the use of hypertonic saline (HS) combined with airway clearance techniques (ACT) for children with recurrent wheezing treated in an outpatient setting. Therefore, this is the first study to explore the use of such interventions in infants with recurrent wheezing.

Objectives

To evaluate the effects and safety of a three-month protocol including HS and ACT for non-hospitalized infants with recurrent wheezing.

Methods

Randomized, double-blind, controlled trial, including outpatient infants with recurrent wheezing. Children were randomized to either 3% HS or 0.9% saline groups and were treated with bronchodilator and nebulized with the respective solutions before ACT. The primary outcome was the Wang score. Secondary outcomes included the number of hospitalizations and respiratory crisis, need for rescue medication, and school absences. All variables were measured during the three previous months from inclusion and during intervention period. The study protocol was registered at ClinicalTrials.gov (NCT04331496) on March, 31, 2020.

Results

Forty children were included. Regarding immediate effects, significant differences (p < 0 . 001 ) were found for time, but not for group or interaction (group × time), in all outcome variables (increase in SpO2, decrease in heart and respiratory rate, wheezing episodes, retraction, and Wang score). Comparing the previous three months with the study period, there were significant differences in both groups for the severity of crisis (p < 0 . 001 ) and medication steps (p = 0 . 002 ).

Conclusion

A three-month protocol including HS and ACT for outpatient infants with recurrent wheezing was safe and reduced morbidity. No differences were found between the use of HS and 0.9% saline.

Nebulised 3% hypertonic saline versus 0.9% saline for treating patients hospitalised with acute bronchiolitis: protocol for a randomised, double-blind, multicentre trial

INTRODUCTION

Bronchiolitis is an acute viral infection of the lower respiratory tract. It is most commonly caused by respiratory syncytial virus. Being a common reason for hospitalisation, it affects 13-17% of all hospitalised children younger than 2 years. Only supportive therapy, including suctioning nasal secretions, water-electrolyte balance maintenance and oxygen supplementation when needed, is recommended. However, non-evidence-based diagnostic and therapeutic approaches, including the use of inhaled bronchodilators, nebulised epinephrine, and nebulised and systemic steroids, are common. The inhalation of 3% hypertonic saline is not recommended in bronchiolitis management. However, a recently published meta-analysis revealed that the inhalation of hypertonic saline can reduce the risk of hospitalisation for outpatients with bronchiolitis, while resulting in a shorter length of hospital stay and reduced severity of respiratory distress for inpatients, although the evidence is of low certainty. We aim to assess the efficacy of nebulised hypertonic saline for the treatment of children hospitalised with bronchiolitis.

METHODS AND ANALYSIS

This will be a randomised, double-blinded, parallel-group, controlled trial. Children younger than 2 years who are hospitalised due to bronchiolitis will be recruited from at least three paediatric departments in Poland. Bronchiolitis is defined as an apparent viral respiratory tract infection associated with airway obstruction that is manifested by at least one of following symptoms: tachypnoea, increased respiratory effort, crackles and/or wheezing. A total of 140 children will be randomised (1:1) to receive either hypertonic saline nebulisation (5 mL, three times a day) or normal saline at the same dose. The primary outcome measure will be the duration of hospitalisation.

ETHICS AND DISSEMINATION

The Bioethics Committee of the Lower Silesia Medical Chamber in Wroclaw approved the study protocol (4/PNDR/2023). Caregivers will receive oral and written information about the study and written informed consent will be obtained by the study physicians. The findings of the study will be submitted to a peer-reviewed journal, and abstracts will be submitted to relevant national and international conferences.

TRIAL REGISTRATION NUMBER

ClinicalTrials.gov Registry (NCT06069336).

UPDATE - 2022 Italian guidelines on the management of bronchiolitis in infants

Bronchiolitis is an acute respiratory illness that is the leading cause of hospitalization in young children. This document aims to update the consensus document published in 2014 to provide guidance on the current best practices for managing bronchiolitis in infants. The document addresses care in both hospitals and primary care. The diagnosis of bronchiolitis is based on the clinical history and physical examination. The mainstays of management are largely supportive, consisting of fluid management and respiratory support. Evidence suggests no benefit with the use of salbutamol, glucocorticosteroids and antibiotics with potential risk of harm. Because of the lack of effective treatment, the reduction of morbidity must rely on preventive measures. De-implementation of non-evidence-based interventions is a major goal, and educational interventions for clinicians should be carried out to promote high-value care of infants with bronchiolitis. Well-prepared implementation strategies to standardize care and improve the quality of care are needed to promote adherence to guidelines and discourage non-evidence-based attitudes. In parallel, parents' education will help reduce patient pressure and contribute to inappropriate prescriptions. Infants with pre-existing risk factors (i.e., prematurity, bronchopulmonary dysplasia, congenital heart diseases, immunodeficiency, neuromuscular diseases, cystic fibrosis, Down syndrome) present a significant risk of severe bronchiolitis and should be carefully assessed. This revised document, based on international and national scientific evidence, reinforces the current recommendations and integrates the recent advances for optimal care and prevention of acute bronchiolitis.

Chest physiotherapy for mechanically ventilated children: a survey of current UK practice

OBJECTIVES

Chest physiotherapy is a treatment option for mechanically ventilated children. However, there is a lack of consensus regarding its value and informal discussions suggest variation in practice. This study describes chest physiotherapy practices for mechanically ventilated children in the UK and explores clinical decision making related to its delivery.

DESIGN

Cross-sectional study, using an anonymous, electronic survey.

PARTICIPANTS

Qualified physiotherapists working in UK NHS paediatric intensive care units (PICUs).

RESULTS

The response rate was 61% (72/118), this included physiotherapists from 26/27 (96%) PICUs. All participants reported using manual hyperinflations and position changes 'always' or 'often'. Variation in practice was evident for some techniques, including Metaneb® and percussion. DNase (99%, 71/72) and hypertonic saline (90%, 65/72) were the most frequently used mucoactives: 91% (59/65) of physiotherapists reported only nebulising hypertonic saline and 69% (49/71) use both nebulised and instilled DNase. Use and delivery of N-acetylcysteine was inconsistent (nebulised only 55%, 26/47; instilled only 15%, 7/47; both 30%, 14/47). Chest physiotherapy was most commonly delivered with a nurse (67%, 48/72). Clinical decision making processes were comparable between physiotherapists and encompassed three main elements: individual patient assessment, involvement of the multidisciplinary team, and risk versus benefit analysis.

CONCLUSIONS

A range of chest physiotherapy treatments and adjuncts were used with ventilated children. Variation was apparent and may be due to individual preferences of those training staff or local policies. Pragmatic, interventional studies are required to determine best practice. Further exploration is necessary to understand the variation in practice and intricacies of decision making.

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.

Bronchiolitis

Viral bronchiolitis is the most common cause of admission to hospital for infants in high-income countries. Respiratory syncytial virus accounts for 60-80% of bronchiolitis presentations. Bronchiolitis is diagnosed clinically without the need for viral testing. Management recommendations, based predominantly on high-quality evidence, advise clinicians to support hydration and oxygenation only. Evidence suggests no benefit with use of glucocorticoids or bronchodilators, with further evidence required to support use of hypertonic saline in bronchiolitis. Evidence is scarce in the intensive care unit. Evidence suggests use of high-flow therapy in bronchiolitis is limited to rescue therapy after failure of standard subnasal oxygen only in infants who are hypoxic and does not decrease rates of intensive care unit admission or intubation. Despite systematic reviews and international clinical practice guidelines promoting supportive rather than interventional therapy, universal de-implementation of interventional care in bronchiolitis has not occurred and remains a major challenge.

Bronchodilator response to albuterol nebulized with hypertonic saline in asthmatic children

INTRODUCTION

Asthma is distinguished by bronchial obstruction reversible by bronchodilators. The first-line treatment for asthmatic exacerbations is the use of inhaled beta-agonists, by pressurized metered-dose inhalers or nebulized with normal saline solution (NSS). There are no reports of nebulized beta agonists' efficacy in asthmatic children when administered with hypertonic saline solution (HSS).

OBJECTIVE

To evaluate bronchodilator responses (BDR) to albuterol nebulized with 3%-HSS in asthmatic children, compared to albuterol nebulized with NSS.

POPULATION AND METHODS

In a prospective, experimental, double-blind, randomized clinical study, children with a confirmed diagnosis of asthma with mild or moderate bronchial obstruction (FEV₁ 40%-79% of predicted) were randomized to receive a nebulization with 2.5 mg of albuterol diluted in 3 cc of 3%-HSS or NSS (0.9%), by means of a jet nebulizer. After 30 min, the BDR was assessed.

RESULTS

Fifty patients (mean age 12.0 ± 3 years, 29 males) were enrolled; 25 were randomized to the 3%-HSS group (FEV₁ 65.2% ± 10) and 25 to the NSS group (FEV₁ 69.1% ± 7.1). The BDR of FEV₁ was 41.2% (SD: ±20.1; 95% confidence interval [CI]: 35.1-50.4) and 17.3% (SD: ±19.4; 95% CI: 9.7-24.9) (p < .0001) and of maximum mid-expiratory flow was 130% (SD: ±90.8; 95% CI: 94.6-166) and 69.8% (SD: ±72.5; 95% CI: 41.4-98.2) (p < .01), for the 3%-HSS and NSS groups, respectively.

CONCLUSION

Albuterol produces a greater BDR when nebulized with 3%-HSS compared to NSS in asthmatic children with mild or moderate bronchial obstruction.