Name: Taiba Shah
Mini-CAT Final RT4 Wk 3&4
Clinical Question: Brief description of patient problem/setting (summarize the case very briefly)
6-month-old F brought in by mother, with no PMHX presents to the ED for wheezing and cough x 2 days. After being diagnosed with acute bronchiolitis she is given a treatment of nebulized normal saline. She is discharged after 2 hours after two doses of 4 ml of nebulized normal saline.
PICO Question: Clearly state the question (including outcomes or criteria to be tracked)
In infants with bronchiolitis, does nebulized hypertonic saline decrease length of hospital stay compared to nebulized normal saline?
PICO Question:
Identify the PICO elements – this should be a revision of whichever PICO you have already begun in a previous week
| P | I | C | O |
| Infants with Bronchiolitis | Nebulized hypertonic saline | Normal saline nebulizer | Length of hospital stay |
| Infants with RSV | Nebulized HS | Nebulized NS | Hours in emergency department |
| Bronchiolitis | Nebulised hypertonic saline | 0.9% saline nebulizer | Duration of hospital stay |
| 3% saline nebulizer |
Search Strategy:
Outline the terms used, databases or other tools used, how many articles returned, and how you selected the final articles to base your CAT on. This will likewise be a revision and refinement of what you have already done.
PubMed:
- Hypertonic saline for bronchiolitis (best match) – 173
- Hypertonic saline for bronchiolitis (5 years, best match) – 86
- Hypertonic saline for bronchiolitis (5 years, best Match, free full text, review)– 39
- Hypertonic saline nebulizer for bronchiolitis (5 years, Best Match, free full text, review) – 8
Google Scholar:
- Bronchiolitis in infants treatment with hypertonic saline (Any time, sort by relevance) – 7,910
- Bronchiolitis in infants treatment with hypertonic saline (range 2010-2020, sort by relevance) – 4,920
- Bronchiolitis in infants treatment with hypertonic saline and hospital stay (range 2015-2020, sort by relevance) – 3,490
- Bronchiolitis in infants treatment with hypertonic saline and hospital stay (range 2015-2020, sort by relevance) – 2,570
Cochrane
- Bronchiolitis and hypertonic saline (Trials)- 160
- Bronchiolitis and hypertonic saline (Cochrane Reviews)- 2
- The articles I came across were mainly RCTs and I wanted to find systematic reviews and meta-analyses. Some of the RTCs I came across compared different concentrations of hypertonic saline which was different from what I was looking for. Eventually I found a few systematic reviews and meta-analyses that were applicable to my search question. After I found these high levels of evidence articles, I was more opened to RCTs. Therefore, for my Mini-CAT I included a 4th article that is a RCT. I then looked at publication date to make sure it was within the past few years. I also made sure that the systematic reviews and meta-analyses I included had a large number of included studies. This is how I decided on the four studies I included.
Articles Chosen (3-5) for Inclusion (please copy and paste the abstract with link):
Please pay attention to whether the articles actually address your question and whether they are the highest level of evidence available. If you cannot find high quality articles, be prepared to explain the extensiveness of your search and why there aren’t any better sources available.
| CITATION | 1) Chen, Yen-Ju, et al. “Nebulized Hypertonic Saline Treatment Reduces Both Rate and Duration of Hospitalization for Acute Bronchiolitis in Infants: an Updated Meta-Analysis.” Pediatrics and Neonatology, U.S. National Library of Medicine, Dec. 2014, www.ncbi.nlm.nih.gov/pubmed/24461195.
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| ABSTRACT | Abstract
Nebulized hypertonic saline (HS) treatment reduced the length of hospitalization in infants with acute bronchiolitis in a previous meta-analysis. However, there was no reduction in the admission rate. We hypothesized that nebulized HS treatment might significantly decrease both the duration and the rate of hospitalization if more randomized controlled trials (RCTs) were included. We searched MEDLINE, PubMed, CINAHL, and the Cochrane Central Register of Controlled Trials (CENTRAL) without a language restriction. A meta-analysis was performed based on the efficacy of nebulized HS treatment in infants with acute bronchiolitis. We used weighted mean difference (WMD) and risk ratio as effect size metrics. Eleven studies were identified that enrolled 1070 infants. Nebulized HS treatment significantly decreased the duration and rate of hospitalization compared with nebulized normal saline (NS) [duration of hospitalization: WMD = −0.96, 95% confidence interval (CI) = −1.38 to −0.54, p < 0.001; rate of hospitalization: risk ratio = 0.59, 95% CI = 0.37–0.93, p = 0.02]. Furthermore, nebulized HS treatment had a beneficial effect in reducing the clinical severity (CS) score of acute bronchiolitis infants post-treatment (Day 1: WMD = −0.77, 95% CI = −1.30 to −0.24, p = 0.005; Day 2: WMD = −0.85, 95% CI = −1.30 to −0.39, p < 0.001; Day 3: WMD = −1.14, 95% CI = −1.69 to −0.58, p < 0.001). There was no decrease in the rate of readmission (risk ratio = 1.08, 95% CI = 0.68–1.73, p = 0.74). Nebulized HS treatment significantly decreased both the rate and the duration of hospitalization. Due to the efficacy and cost-effectiveness, HS should be considered for the treatment of acute bronchiolitis in infants.
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| LINK/PDF | Article 1 (1) |
| CITATION | 2) Zhang L, Mendoza‐Sassi RA, Wainwright C, Klassen TP. Nebulised hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database of Systematic Reviews 2017, Issue 12. Art. No.: CD006458. DOI: 10.1002/14651858.CD006458.pub4. |
| ABSTRACT | Abstract:
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. |
| LINK/PDF | Article 2 |
| CITATION | 3) Wang, Zhi-Yong et al. “Efficacy of 3% hypertonic saline in bronchiolitis: A meta-analysis.” Experimental and therapeutic medicine vol. 18,2 (2019): 1338-1344. doi:10.3892/etm.2019.7684
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| ABSTRACT | Abstract
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. |
| LINK/PDF | Article 3 |
| CITATION | 4) Angoulvant F, Bellêttre X, Milcent K, et al. Effect of Nebulized Hypertonic Saline Treatment in Emergency Departments on the Hospitalization Rate for Acute Bronchiolitis: A Randomized Clinical Trial. JAMA Pediatr. 2017;171(8):e171333. doi:10.1001/jamapediatrics.2017.1333 |
| ABSTRACT | Importance Acute bronchiolitis is the leading cause of hospitalization among infants. Previous studies, underpowered to examine hospital admission, have found a limited benefit of nebulized hypertonic saline (HS) treatment in the pediatric emergency department (ED).
Objective To examine whether HS nebulization treatment would decrease the hospital admission rate among infants with a first episode of acute bronchiolitis. Design, Setting, and Participants The Efficacy of 3% Hypertonic Saline in Acute Viral Bronchiolitis (GUERANDE) study was a multicenter, double-blind randomized clinical trial on 2 parallel groups conducted during 2 bronchiolitis seasons (October through March) from October 15, 2012, through April 15, 2014, at 24 French pediatric EDs. Among the 2445 infants (6 weeks to 12 months of age) assessed for inclusion, 777 with a first episode of acute bronchiolitis with respiratory distress and no chronic medical condition were included. Interventions Two 20-minute nebulization treatments of 4 mL of HS, 3%, or 4 mL of normal saline (NS), 0.9%, given 20 minutes apart. Main Outcomes and Measures Hospital admission rate in the 24 hours after enrollment. Results Of the 777 infants included in the study (median age, 3 months; interquartile range, 2-5 months; 468 [60.2%] male), 385 (49.5%) were randomized to the HS group and 387 (49.8%) to the NS group (5 patients did not receive treatment). By 24 hours, 185 of 385 infants (48.1%) in the HS group were admitted compared with 202 of 387 infants (52.2%) in the NS group. The risk difference for hospitalizations was not significant according to the mixed-effects regression model (adjusted risk difference, –3.2%; 95% CI, –8.7% to 2.2%; P = .25). The mean (SD) Respiratory Distress Assessment Instrument score improvement was greater in the HS group (–3.1 [3.2]) than in the NS group (–2.4 [3.3]) (adjusted difference, –0.7; 95% CI, –1.2 to –0.2; P = .006) and similarly for the Respiratory Assessment Change Score. Mild adverse events, such as worsening of cough, occurred more frequently among children in the HS group (35 of 392 [8.9%]) than among those in the NS group (15 of 384 [3.9%]) (risk difference, 5.0%; 95% CI, 1.6%-8.4%; P = .005), with no serious adverse events. Conclusions and Relevance Nebulized HS treatment did not significantly reduce the rate of hospital admissions among infants with a first episode of acute moderate to severe bronchiolitis who were admitted to the pediatric ED relative to NS, but mild adverse events were more frequent in the HS group. |
| LINK/PDF | Article 4 |
Summary of the Evidence:
| Author (Date) | Level of Evidence | Sample/Setting
(# of subjects/ studies, cohort definition etc) |
Outcome(s) studied | Key Findings | Limitations and Biases |
| Yen-Ju Chen, Wen-Li Lee, Chuang-Ming Wang, Hsin-Hsu Chou (2014) | Systematic Review and Meta-Analysis | – 11 Randomized Control trials with a total sample of 1070 pts
-552 patients who received nebulized HS (either 3% or 5% saline) were assigned to the treatment group – -518 patients who received nebulized NS were assigned to the control group – All 11 studies were double-blind RCTs. Six trials recruited outpatient or emergency department participants, and five trials recruited inpatients. Patients with previous wheezing episodes were excluded in all trials, except one study reported viral bronchiolitis patients either with or without wheezing history – Articles investigated were from 2002 until June 2011
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– Effects on duration of hospitalization
– Effects on rate of hospitalization – Effects on rate of admission – Effects on clinical severity score |
-The authors concluded that nebulized HS significantly decreased the duration of hospital stay by approximately 1 day compared with nebulized NS in infants hospitalized with acute bronchiolitis.
-The HS groups also had significantly reduced rate of hospitalizations among outpatients and the CS score among outpatient sand inpatients with mild-moderate acute bronchiolitis. Risk of readmission was not different between the NS and HS groups
-Eight trials used clinical severity score as an outcome. Six of the trials compare the post-inhalation CS score between infants treated with nebulized HS and infants with nebulized NS during the first 3 days of treatment. -First post-treatment day, infants treated with nebulized HS had a significantly lower CS score compared with infants treated with NS. Day 2 of treatment a significant difference between the treatment and the control groups was observed.
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– Limitation of the study is mainly due to the quality of available RCTs.
– Intention to treat analysis was not used in 6 trials. -The sample size of the included trials was generally small |
| Zhang L, Mendoza-Sassi RA, Wainwright C, Klassen TP (2017) | Systematic Review and Meta-Analysis | – 28 trials involving 4195 infants with acute bronchiolitis, of whom 2222 infants received hypertonic saline.
– Randomized controlled trials and quasi-randomized controlled trials were included in this review. – excluded studies including participants who had recurrent wheezing or who were intubated and ventilated, and studies that assessed pulmonary function alone. – Children up to 24 months of age diagnosed with acute bronchiolitis. Acute bronchiolitis was defined as the first episode of acute wheezing associated with clinical evidence of a viral infection
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Primary outcomes
– Length of hospital stay or time taken to be ready for discharge (inpatients). – Rate of hospitalization (outpatients or emergency department patients).
Secondary Outcomes: – Clinical severity score. Rate of re-admission to hospital. – Hemoglobin saturation(oximetry). Respiratory rate. – Heart rate. Time to resolution of symptoms or signs. – Duration of in-hospital oxygen supplementation. – Need for add-on treatment (bronchodilator, systemic corticosteroids, antibiotics, and oxygen supplementation). – Results of PFTs – Results of radiographic findings – Adverse effects
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– The pooled results of 17 trials with a total of 1867 inpatients showed that infants treated with nebulized hypertonic saline had a statistically significant shorter mean length of hospital stay compared to those treated with nebulized 0.9% saline.
– The effect size of hypertonic saline on reduction of risk of hospitalization appeared to be greater in the subgroups of trials in which virological testing was available and multiple doses (≥ two) of saline solutions were administered. – On the first day of treatment, (N = 65 outpatients) showed that the 3% saline group had a statistically significant lower clinical severity score compared to the 0.9% saline group – The pooled results of these trials did not demonstrate significant benefits of nebulized hypertonic saline in reducing the risk of re‐admission.
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– The articles chosen were from various different countries, causing a lack of consistency between studies.
-Concentration if hypertonic saline used varied among studies – Downgraded quality of the evidence to low for length of hospital stay due to high levels of statistical heterogeneity and potential risk of selection bias in one‐third of the included trials -some of the studies included used NS as a placebo, which can minimize the effects of HS, since NS is not a placebo and is a form of treatment.
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| Zhu-Yong Wang, Xiao-Dong Li, Ai-Ling Sun and Xue-Qin Fu (2019) | Systematic Review and Meta-analysis | – Inclusion criteria: i) randomized controlled trials (RCTs); ii) the studies investigated the efficacy of 3% HS in bronchiolitis; iii) they included a comparison in efficacy between 3% HS and normal saline (NS; 0.9% saline) was performed; and iv) they examined length of stay, CSS score, or re-admission rates.
– 23 studies were included -14 of those included the analysis of hospital stay -8 provided information on clinical severity score -5 RCTs measured outcomes of re-admission rates |
– Length of stay
– Clinical severity score – Re-admission rates |
– The data reveled that infants treated with HS nebulizers exhibited shorter periods of hospitalization compared with those treated by NS nebulizers
– Subgroup analysis of additional medications demonstrated that HS nebulizer with epinephrine may significantly decrease the length of hospital stay – Compared with the NS nebulizer, HS nebulizers significantly decreased CSS scores on the first day of treatment – The results demonstrated that there was statistically significant difference in CSS scores between HS and NS nebulizers on the second day – Statistically significant difference in CSS scores between HS and NS nebulizers on the second day
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– Significant heterogenicity was observed in the analysis of length of stay
– Only 3% HS was analyzed, and other concentrations of HS were not considered. -Some studies included beta-2 agonists in the treatment group
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| François Angoulvant, MD, PhD; Xavier Bellêttre, MD; Karen Milcent, MD, PhD; Jean-Paul Teglas, PhD; Isabelle Claudet, MD
(2017) |
Randomized control trial | -Double-blind randomized clinical trial conducted in 24 French pediatric EDs during 2 bronchiolitis seasons.
-Patients were randomized into two parallel groups: 3% HD or 0.9% NS nebulization treatment -Eligibility- 6 weeks to 12 months old with a first episode of moderate to severe bronchiolitis -777 infants were included in the study
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Primary outcome: Hospital admission up to 24 hours after enrollment in the study
Secondary outcomes were: – Admission within 28 days – Duration of symptoms – Length of hospital stay for hospitalized infants – Adverse effects |
– This study concluded no significant difference between the study groups with respect to hospitalization. By 24 hours, 185 of the 385 infants (48.1%) in the HS group were admitted compared with 202 of the 387 infants (52.2%) in the NS group. The difference was insignificant.
Subgroup analyses comparing the admission rates among infants younger than 3 months revealed no significant difference between the HS and NS groups. with admission rates of 54.8% (121 of 221 infants) in the HS group and 57.4% (132 of 230 infants) in the NS group (P = .58) -Mild adverse effects were more frequent in the HS group – HS group had better respiratory distress assessment and respiratory change compared to NS group
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– More severe bronchiolitis cases were not included and therefore no conclusion about the efficacy of HS can be made in this population
– Same goes for preterm infants – the use of thresholds for respiratory rate and oxygen saturation to define respiratory distress as an inclusion criterion is a limitation since these factors vary across conditions – only infants with a first episode of bronchiolitis were included; infants with recurrent wheezing were not included
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Conclusion(s):
Chen et al concluded that nebulized hypertonic saline significantly decreased the duration of hospital stay by approximately 1 day compared with normal saline in infants hospitalized with acute bronchiolitis. There was also significant reduction in the rate of hospitalization among outpatients and in the clinical severity score in the hypertonic saline group. Risk of readmission was did not have any statistically significant difference.
Zheng et al provided an update of his review from 2013. He concluded that the effect size of nebulized hypertonic saline on reducing length of hospital stay in hospitalized infants was 1/3 of what was found in the 2013 review. There were mild adverse effects in hypertonic saline group which resolved spontaneously. They found a reduction of 10 hours in length of hospital stay which is clinically significant taken into account the short duration of the disease
Wang et al demonstrated that 3% hypertonic saline was more effective compared with 0.9% normal saline in decreasing the length of hospitalizations, clinical severity score and rate of re-admission.
Angoulvant et al conclude that in the pediatric ED there was no significant difference in hospital admission rates after 24 hours whether the infants received nebulized HS or NS. They also did not find any difference between the two groups in PICU admission, admission by day 28, or admission among infants younger than 3 months.
My overall conclusion based on these 4 studies is that there is a moderate statistically significant decrease in length of hospital stay in infants with bronchiolitis treated with nebulized hypertonic saline compared to infants treated with normal saline. Three out of the 4 studies that were also the highest levels of evidence showed a statistically significant difference between the groups. The one randomized control trial I included showed that there was a small decrease in the hypertonic saline group, but it was not statistically significant. Two out of the 4 studies reported mild adverse effects in the hypertonic saline group. The most common adverse effects were cough without respiratory distress, which may also be an indication of treatment working since the airway is being rehydrated and the infant has an urge to clear mucus secretions. All 4 studies did show a decrease in hospital say however they differed in the level of significance they reported. Therefore, it can be concluded that nebulized hypertonic saline does moderately decrease the length of hospital stay compared to nebulized normal saline in infants with bronchiolitis.
Clinical Bottom Line:
I weigh my studies in the following order: Wang et al. > Zheng et al. > Cheng et al. > Angoulvant et al.
The three studies above support the conclusion that in infants with bronchiolitis who are given nebulized hypertonic saline have shorter hospital stays compared to treatment with nebulized normal saline. All three studies had 3% saline as a part of the intervention group, and two studies included 5% saline as well.. The second article states that most of the RCTs reported no adverse effects in the HS group and the RCTs that had reported adverse effects, stated that they were mild. This additional information on adverse effects supports the use of hypertonic saline as the mainstay of treatment. The third article which is the strongest in this PICO, included only RCTs that used 3% hypertonic saline as an intervention group. The specificity in concentration in this article shows that 3% concentration is sufficient for treatment in acute bronchiolitis. All three articles also demonstrated lower clinical severity scores in the nebulized HS within 3 days of treatment.
Wang et al study was the highest level of evidence since it was a systematic review as well as a meta-analysis and it was published in 2019. It also included 23 RCTs in the analysis. An advantage to this article was it separated the effects of nebulized HS from the effects of nebulized HS saline with epinephrine and additional bronchodilators. It also focused on 3% hypertonic saline which provides sufficient evidence to make a strong conclusion for recommendations. It showed a decrease in-hospital stay and admission rates in the nebulized HS group. Sub-group analysis showed a decrease in clinical severity score and hospital re-admission rates. They also note the additional medications added to hypertonic saline may also significantly decrease hospital stay. Their statistical analysis showed that the pooled evidence from the articles was robust.
I weighed the Zheng et al article 2nd as it was a Cochrane review from 2017. It is also the most recent and the largest systematic review (28 studies) and meta-analysis that focused on my question. The advantages of this article are that it is the highest level of evidence with a large sample size and has the primary outcome as duration of hospital stay. I appreciated how the authors went into the pathophysiology of how hypertonic saline will work in treating acute bronchiolitis. This study also looked at various types of interventions. They did a really great job of going beyond the outcomes measured and looking at overall cost of the intervention. The article also measures many outcomes such as clinical severity score and hospital re-admission rates. This analysis does have limitations while it is not from the US it includes a few RCTs from the US. Furthermore, the quality of evidence was low to moderate. I still included this article despite its limitations because it focused my population, intervention, outcome of interest and it was a recent meta-analysis.
Next was Cheng study which I ranked 3rd since it was from 2014 and included 11 studies. While still a high level of evidence, it ranks lower compared to the two articles above. Advantaged to this article was how the control group and intervention group had almost an even number of subjects, the hypertonic saline group 522 participants and the normal saline group had 518. Some of RCTs did include bronchodilators added to the intervention of nebulized HS. While this may affect the conclusion on the sole effects of nebulized HS, the discussion stated with supported evidence, that epinephrine and bronchodilators provided little benefit in the treatment for acute bronchiolitis and they have not shown to decrease hospital stay. Therefore, the difference in hospital stay was due to the use of nebulized hypertonic saline or normal saline. I liked that all of the trails included in the review had 3% HS as an intervention. This allows consistency and a basis for clinical practice. An advantage was all the studies included had high methodological quality and a low risk bias. A drawback to this article was that it is not from the US but I still included it due to its large sample size, high level of evidence and it is within the last six years.
Last is the Angoulvant et al article, I weighed this study last since it is a randomized control trial. This was the only article that had a different conclusion compared to my other articles. The article does show that there was a decrease in length of stay in hospital in the nebulized hypertonic saline group. However, after analysis they conclude that the decrease was statistically insignificant. I liked that this article focused on cases in the Emergency department since it related to my clinical scenario. Although they did not find a statistically significant decrease in length of hospital stay they notes that there was a greater improvement in respiratory change scores and respiratory distress assessments. This suggests that nebulized HS can alleviate symptoms in a short time. These tools were not used in the other articles. While this study is not from the US I included it because of its large sample size, inclusion criteria, and measurement of variables that were not considered in my other articles.
Magnitude of any effects
I do believe the effect of nebulized hypertonic saline is moderately greater than the effect of nebulized normal saline in decreasing length of hospital stay in infants with bronchiolitis.
Clinical significance (not just statistical significance)
Based off of the findings in these articles, I would say that weighing the risk and benefits and to decrease hospitalization rates in infants I would recommend nebulized hypertonic saline for infants with bronchiolitis. The highest levels of evidence conclude that there was a statistical significance in decreasing length if hospital stay and with the mild adverse effects, I believe it should be the mainstay of treatment. Bronchiolitis has a short disease course, high prevalence and a large burden on healthcare systems. Along with the decrease in clinical severity score and possible decrease in readmission rates some of the studies reported I believe it should be the main stay of treatment. Furthermore, it is not more invasive compare to normal saline, the method of administration is the same. Implementing this change to nebulized hypertonic saline would be simple, with no additional training. Uptodate supported hypertonic saline for acute bronchiolitis however, it also states that it has been not incorporated into guidelines. Treatment for bronchiolitis has been supportive care, and managing bronchiolitis is difficult since it often does not respond to treatment. Since there is high prevalence and morbidity of acute bronchiolitis in infants and economic burden, nebulized hypertonic saline should be considered as mainstay in the treatment in this common disease.
Any other considerations important in weighing this evidence to guide practice
Future studies could focus on readmission rates. This was not a primary outcome in any of the three above studies however, 2 of the 3 articles stated no difference between the intervention and control group, and the 3rd article stated there was a decreased in re-admission in the nebulized HS group. The evidence is therefore contradictory on this matter. Furthermore, there were mild adverse effects in the stated in two of the articles. While they state that the effects resolved spontaneously, further studies are warranted where adverse effects are the primary outcome. This information is essential to guide practice and can be a deciding factor between hypertonic and normal saline.
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