The effect of nebulised hypertonic saline on the length of hospitalisation in infantile bronchiolitis

Abstract

Overview: Since 2013 there has been an interest in the use of nebulised hypertonic saline in infantile bronchiolitis. Later conflicting evidence has diminished earlier claims that it significantly reduced length of hospital stay. Research question: "Does the use of nebulised hypertonic saline solution reduce the duration of hospitalisation in infants admitted with bronchiolitis?" PICO elements: Population: Infants who are hospitalised for bronchiolitis; Intervention: Nebulised hypertonic saline with standard care; Comparator: Standard care alone; Outcome: Reduction in duration of hospitalisation; Studies: RCTs, Metaanalyses, Systematic Reviews Inclusion and exclusion criteria: Based on PICO elements, restricting to 'infants 0-24 months of age' and studies published in English, through 1996-2016. Literature search outcome: A finalised list of seven systematic reviews and metaanalyses of RCTs, and five select RCTs out of a series of twenty-four. Appraisal: The CASP tool and the Cochrane Collaboration 'risk of bias' tool indicated valid reviews, and later RCTs with greater bias, though the largest RCT was robust and locally applicable. Results: An updated meta-analysis of 20 RCTs involving 2169 participants was homogenously defined after exclusion of 4 outlier RCTs. It showed that hypertonic saline reduced length of hospital stay by 7 hours. Standard subgroup analysis in published reviews showed a greater effect in those hospitalised beyond 3 days, and when hypertonic saline was combined with nebulised adrenaline. The most locally applicable and largest RCT did not show that hypertonic saline reduced length of hospitalisation. All studies showed that hypertonic saline was safe. Conclusion: Hypertonic saline should be used only in those infants admitted with bronchiolitis not showing satisfactory improvement on standard care alone. Recommendations: The implementation of a pragmatic local protocol together with further specific RCTs, and literature searches not restricted to the English language.