Nebulized Hypertonic Saline for Bronchiolitis in Infants

Benefits in NNT

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Harms in NNT

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Efficacy Endpoints

Duration of Hospital Stay, Decrease in Clinical Severity Scores, Decrease in Admission Rates

Harm Endpoints

Tachycardia, Hypertension, Pallor, Tremor, Nausea, and Vomiting


Acute bronchiolitis is the one of the most common respiratory infections in infants. It affects the lower respiratory tract and is usually caused by a virus, with respiratory syncytial virus (RSV) being the most common pathogen. It is estimated that nearly all infants are infected with RSV and that between 1 and 2% of these develop symptoms severe enough to warrant admission. While the use of nebulized racemic epinephrine has been shown to cause a temporary and modest improvement of symptoms in the outpatient population, the treatment options for admitted patients are limited. The administration of nebulized 3% saline had been proposed as an intervention that may help improve mucous clearance and therefore clinical outcomes through various mechanisms. The Cochrane Review included four trials, one outpatient (n = 65) and three inpatient (n = 189) of patients who were randomized to receive either nebulized 3% saline or 0.9% saline in addition to bronchodilators (either albuterol or racemic epinephrine) and standard supportive care. We also looked at a recently completed emergency department study (Kuzik et al 2010) that randomized infants to 3% or 0.9% saline and examined whether there was a significant change in the rate of admission (n = 81).

Administration of nebulized 3% saline in the emergency department did not result in a statistically significant decrease in the rate of admission for infants presenting with acute bronchiolitis, though there was a trend towards decreased admissions in both outpatient studies. However, in the studies examining inpatients, infants in the treatment arms had an average decrease in hospital stay of approximately 1 day, with no adverse reactions or harms recorded. Subjects receiving 3% saline were also noted to have improved clinical severity scores, especially on the first day of admission, when compared to the groups receiving 0.9% saline.


The total number of patients involved in both the inpatient (189 total) and outpatient trials (146 total) included in our analysis were quite small. In addition, given the subjectivity of calculating clinical severity scores it is difficult to give much weight to the benefit reported in the children receiving the 3% saline. The patients treated with 3% saline went home an average of one day earlier. Given the prevalence of bronchiolitis, the cost and morbidity associated with hospitalization, and the emotion and stress involved for the admitted infants and their families, we feel this is a meaningful reduction. Furthermore, this intervention is affordable, minimally invasive and does not appear to be associated with any significant potential harms or adverse reactions.


Dan Runde, MD


March 10, 2011