Nebulized Hypertonic Saline for Bronchiolitis: A Randomized Clinical Trial

An article by Susan Wu and colleagues.

Article link available:
http://archpedi.jamanetwork.com/article.aspx?articleid=1874078

Please see companion pieces in the same issue:
http://archpedi.jamanetwork.com/article.aspx?articleid=1874075
http://archpedi.jamanetwork.com/article.aspx?articleid=1874076

Transcript

1. Copyright restrictions may apply Nebulized Hypertonic Saline for Bronchiolitis: A Randomized Clinical Trial Wu S, Baker C, Lang ME, Schrager SM, Liley FF, Papa C, Mira V, Balkian A, Mason WH. Nebulized Hypertonic Saline for Bronchiolitis. A Randomized Clinical Trial. JAMA Pediatr. [Remaining citation information will be entered later.]
2. Copyright restrictions may apply •  Background –  Bronchiolitis is one of the leading reasons for hospitalization among infants and young children –  Previous studies have shown that hypertonic saline may decrease respiratory distress and shorten length of stay for infants with bronchiolitis –  No studies have been designed to evaluate effect on admission from the ED •  Study Objective –  To compare the effect of nebulized 3% hypertonic saline vs 0.9% normal saline on admission rate and length of stay in infants with bronchiolitis –  Secondary outcomes: RDAI and RACS score, utilization of adjunct therapies (oxygen, inhaled medications, steroids, diuretics) Introduction
3. Copyright restrictions may apply •  Study Design –  Double-blind, randomized trial –  Infants received 4 mL of nebulized 0.9% normal saline (NS) or 3% hypertonic saline (HS) –  Up to 3 doses given in the ED, and Q8h after admission until discharge –  All study medication doses pre-treated with albuterol •  Setting –  Emergency departments of 2 tertiary free-standing urban children’s hospitals in California –  November 2008 - April 2011, during bronchiolitis season (Nov-Apr) •  Patients –  Infants less than 24 months old with primary diagnosis of bronchiolitis –  Excluded: premature < 34 weeks, chronic lung disease, cyanotic heart disease, previous episode of wheezing or bronchodilator use, tracheostomy Methods
4. Copyright restrictions may apply Methods •  Outcomes –  Admission rate/ Odds of admission –  Length of stay (in days) –  Change in RDAI score and RACS score pre- vs post-treatment •  Limitations –  All doses pre-treated with albuterol –  Majority of patients Hispanic/Latino (65.4% in NS group, 63.3% in HS) –  Patients with previous wheezing excluded –  Admission and discharge disposition was left to the discretion of the treating physician –  No minimum severity required for study entry
5. Copyright restrictions may apply Results
6. Copyright restrictions may apply Results •  Admission rate –  84 patients (42.6%) in the NS group required admission, compared with 61 (28.9%) in the HS group (OR, 0.45 [95% CI, 0.28-0.71]. –  Number needed to treat to prevent 1 hospitalization = 8 patients. •  Length of stay –  Mean (SD) length of stay 3.92 (5.24) days in the NS group and 3.16 (2.11) days for the HS group (p=0.24) •  Respiratory score –  Mean (SD) pre-treatment RDAI score 6.16 (2.91) in the NS group and 5.96 (3.08) in the HS group. Post-treatment RDAI 5.32 (3.14) in the NS group and 4.88 (2.95) in the HS group (p=0.35) –  Mean (SD) RACS score -0.35 (2.98) for NS group and -0.85 (3.14) for HS group (p=0.12) •  No difference in hours of oxygen use, additional albuterol or epinephrine use, systemic corticosteroid use, or diuretic use
7. Copyright restrictions may apply
8. Copyright restrictions may apply
9. Copyright restrictions may apply Comment •  Hypertonic saline given in the ED setting decreases odds of admission •  No difference seen in length of stay in this study, which is contrary to previously published studies –  Patients who responded to the treatment may have been discharged from the ED, thus biasing the inpatient sample to include primarily non- responders –  The study did not reach planned sample size, and was thus underpowered to detect length of stay differences of less than 1 day –  Discharge was at the discretion of the treating physician, therefore many other non-clinical factors may have affected discharge time
10. Copyright restrictions may apply Comment •  Additional limitations –  Differences in admission rate and length of stay by study site signifies practice variation which may affect results –  Most patients discharged from the ED only received one dose of study medication –  RDAI and RACS scores may not be good predictors of disease severity •  Future directions –  Other studies suggest that higher concentrations of saline or more frequent dosing may have greater effect –  Pre-treatment with albuterol may not be necessary
11. Copyright restrictions may apply •  If you have questions, please contact the corresponding author: –  Susan Wu, MD (suwu@chla.usc.edu) Funding/Support •  This work was supported by the Thrasher Research Fund and by the University of Southern California Keck School of Medicine Department of Pediatrics Mentored Junior Faculty Career Development Award (Dr. Wu) Conflict of Interest Disclosures •  None of the authors report any conflicts of interest. Contact Information