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Bronchiolitis Updates

Susan Wu MD, Solomon Behar, MD, and Mel Herbert, MD
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We review the current AAP recommendations on bronchiolitis management and discuss two seemingly contradictory papers on inhaled hypertonic saline both published in the same month in JAMA.

Background

What is Bronchiolitis?

  • Snotty, wheezy babies, less then 24 months of age.
  • Standard therapy is lots of suction.
  • Although only a subset of patients with bronchiolitis respond to beta 2 agents, these agents are used by many practitioners in patients with suspected bronchiolitis.
  • Alpha blockers are used by some.
  • Prior to these two articles a Cochrane Collaboration review said the preponderance of the evidence is in favor of using hypertonic saline (HS)
  • 2014 AAP bronchiolitis guidelines recommend against use of HS in the Emergency Department; however, the guidelines suggest that clinicians may administer HS to hospitalized infants and children with bronchiolitis and this may be efficacious.

Below is a summary of a discussion regarding two articles published in the same issue of JAMA Pediatrics July 2014 addressing the use of hypertonic saline in bronchiolitis; the studies have led to conflicting results.

A few thoughts up front on the studies:

 

  • They are treating different populations.
  • The Philadelphia study excluded non-English speaking patients, while the LA study included many non-English speaking patients.
  • An editorial in the same issue suggests that we just add this information to what we already know and do another meta-analysis .
  • Given the previous meta-analysis from Cochrane and the relative size of these two well-designed studies it is likely another meta-analysis will support efficacy of HS. 

 

Interview with Susan Wu - first author of Los Angeles study

What is the current understanding of mechanism of action of hypertonic saline in bronchiolitis

  • Reduces airway edema due to an osmotic effect.
  • Pulling interstitial fluid out may improve airway clearance.
  • Improves ciliary motility.

Background

What is the background on hypertonic saline literature prior to these two studies?

  • Hypertonic saline has been used for induction of bronchospasm in pulmonary function tests. Because of this effect, its use in bronchiolitis has been studied using pre-treatment or combined administration with a bronchodilator.
  • It is used in patients with cystic fibrosis at a higher concentration (7%).
  • Cochrane Collaboration review showed a one day reduction in length of stay [LOS] for patients with bronchiolitis.
  • Previous studies on length of stay had limitations, including a couple that had length of stays over 5 days; this is not the case in the US where the average length of stay is between 2 and 3 days.  
  • No prior studies were powered to detect admission rates.

Study Design

What was the purpose and design of your study?

  • We wanted to do a study that was practical, following what the current standards of care were (2006 AAP Bronchiolitis guidelines) and utilize HS to see if it would have an impact on both length of stay and readmissions.
  • 408 patients enrolled from the Emergency Department.
  • These patients received a dose of albuterol followed by 4 mL of either 3% Hypertonic saline or 4 mL of normal saline.
  • “Respiratory distress assessment” instrument scoring was done immediately prior to, as well as 30 to 60 minutes after the treatments.

Findings

What were the results?

  • The odds of admission for the hypertonic saline group was 0.55
  • 42.6% of the patients who received normal saline required admission compared to 28.9% of patients who received hypertonic saline.

Why does your study have such different results then the other study published in the same issue of JAMA Pediatrics?

  • The outcome they were looking at was a change in respiratory score and a survey of the parents assessing for their perception of the child’s ability to feed and ease of breathing
  • They used the same Respiratory Distress Scoring system that we used and they did not find the hypertonic saline to be superior. Our study did not find any difference between groups in terms of our respiratory distress scores or vital signs, which is the same as what they found.  It’s not too discrepant.
  • Further study has shown that this score is not predictive of clinical outcomes like admission.
  • Their study only included 31 patients in each group which isn’t really sufficient to address the issue of admission rate

Opinion 

What is your take on the new AAP guidelines in regards to the recommendations NOT to use bronchodilators?

  • From a population standpoint, it makes sense that most patients will not benefit.
  • Some patients will, but with the current evidence we have, we have no way of identifying which of those patients will and which will not .
  • What the guidelines don’t address are those patients who have a strong history of atopy or history of wheezing. In this case, I think it is up to your clinical judgment.

What do you send kids home with?

  • If you need to send someone home with something, I use nasal saline or the NoseFrida.
  • The NoseFrida looks like a test tube with a hole on the end. There is a little foam stopper to keep you from sucking up the boogers and on the other end of the tube is where you place your mouth to suck.

What should the pediatrician take home from your study and what should we make sure we are not doing?

  • Hypertonic saline is cheap and easy and it is worth a try
  • Outpatient studies and studies of home use are still needed

Anything we should not be doing for sure?

  • There is good evidence that steroids are not effective and that they can be harmful.

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Wheezing, Wee Wee and Weed Full episode audio for MD edition 221:54 min - 104 MB - M4APeds RAP March 2015 Summary 1 MB - PDF