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Original Investigation |

Nebulized Hypertonic Saline for Bronchiolitis:  A Randomized Clinical Trial

Susan Wu, MD1,2; Chris Baker, MD3; Michael E. Lang, MD, MPH4; Sheree M. Schrager, PhD, MS5; Fasha F. Liley, MD6,7; Carmel Papa, MS-HCA3; Valerie Mira, MPH1,2; Ara Balkian, MD, MBA1,2; Wilbert H. Mason, MD, MPH8,9
[+] Author Affiliations
1Division of Hospital Medicine, Children’s Hospital Los Angeles, Los Angeles, California
2Division of Hospital Medicine, University of Southern California Keck School of Medicine, Los Angeles
3Division of Emergency Medicine, Children’s Hospital and Research Center Oakland, Oakland, California
4Division of Pediatrics, Children’s Hospital and Research Center Oakland, Oakland, California
5Division of Adolescent Medicine, Children’s Hospital Los Angeles, Los Angeles, California
6Division of General Pediatrics, Children’s Hospital Los Angeles, Los Angeles, California
7Division of General Pediatrics, University of Southern California Keck School of Medicine, Los Angeles
8Division of Infectious Disease, Children’s Hospital Los Angeles, Los Angeles, California
9Division of Infectious Disease, University of Southern California Keck School of Medicine, Los Angeles
JAMA Pediatr. 2014;168(7):657-663. doi:10.1001/jamapediatrics.2014.301.
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Importance  Bronchiolitis is one of the most common and costly respiratory diseases in infants and young children. Previous studies have shown a potential benefit of nebulized hypertonic saline; however, its effect in the emergency department (ED) setting is unclear.

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.

Design, Setting, and Participants  We conducted a double-blind, randomized clinical trial during 3 consecutive bronchiolitis seasons from March 1, 2008, through April 30, 2011. We recruited a convenience sample of patients younger than 24 months with a primary diagnosis of viral bronchiolitis presenting to the ED of 2 urban free-standing tertiary children’s hospitals. We excluded patients who were premature (gestational age, <34 weeks) or who had chronic pulmonary disease, immune deficiency, cardiac disease, or previous episodes of wheezing or inhaled bronchodilator use. Of eligible patients who were approached, 161 (26.6%) declined to participate.

Interventions  Patients received 4 mL of 3% sodium chloride (hypertonic saline [HS group]) or 0.9% sodium chloride (normal saline [NS group]) inhaled as many as 3 times in the ED. Those admitted received the assigned medication every 8 hours until discharge. All treatment solutions were premedicated with albuterol sulfate.

Main Outcomes and Measures  Hospital admission rate, length of stay for admitted patients, and Respiratory Distress Assessment Instrument score.

Results  A total of 197 patients were enrolled in the NS group and 211 in the HS group. Admission rate in the 3% HS group was 28.9% compared with 42.6% in the NS group (adjusted odds ratio from logistic regression, 0.49 [95% CI, 0.28-0.86]). Mean (SD) length of stay for hospitalized patients was 3.92 (5.24) days for the NS group and 3.16 (2.11) days for the HS group (P = .24). The Respiratory Distress Assessment Instrument score decreased after treatment in both groups; however, we found no significant difference between groups (P = .35).

Conclusions and Relevance  Hypertonic saline given to children with bronchiolitis in the ED decreases hospital admissions. We can detect no significant difference in Respiratory Distress Assessment Instrument score or length of stay between the HS and NS groups.

Trial Registration  clinicaltrials.gov Identifier: NCT00619918

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Figure 1.
Patient Enrollment Flowchart

Thirty-nine patients who were enrolled after admission to the hospital are not included in this figure. ED indicates emergency department; HS, hypertonic saline; ICU, intensive care unit; LOS, length of stay; and NS, normal saline.

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Figure 2.
Forest Plot for Admission Rate

Odds ratios (ORs) (markers) are for the unadjusted model. Whiskers indicate 95% CIs.

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