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 Table of Contents  
ORIGINAL ARTICLE
Year : 2016  |  Volume : 3  |  Issue : 3  |  Page : 98-101

The priority of using hypertonic saline over ventolin in the treatment of bronchiolitis


1 Department of Pediatric, Mosavi Hospital, Zanjan University of Medical Science, Zanjan, Iran
2 Department of Social Medicine, Faculty of Medicine, Zanjan University of Medical Science, Zanjan, Iran

Date of Submission03-Oct-2015
Date of Acceptance20-May-2016
Date of Web Publication2-Nov-2016

Correspondence Address:
Asadi Fardin
No: 786 Shahrak Karmandan, Apartment 1, Faz-e-yek, Zanjan 4513985495
Iran
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/2394-2010.193180

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  Abstract 

Introduction: Bronchiolitis is one of the important causes of hospitalizing infants in the hospital. Nebulized saline and/or ventolin are usually used in the treatment of this disease. This study aims to compare the effects of these two methods on the treatment of this disease. Materials and Methods: This cohort study was conducted on 67 hospitalized children ranging in age from 2 to 7 months with the diagnosis of bronchiolitis in Ayatollah Mousavi hospital in Zanjan City, from 2013 to 2014. In Group A; 33 patients received nebulized ventolin, and in Group B; 34 patients received nebulized 5% hypertonic saline. The two groups were compared in terms of the length of hospitalization and respiratory status, in the 3rd day of hospitalization. The data were described using SPSS software, according to the independent t-test. Results: In this study, the length of hospitalization was 4.2 days, on average, in the patients treated with ventolin, and 3.8 days in the patients treated with hypertonic saline. The patients treated with hypertonic saline had a lower respiratory rate and retraction, on the 3rd day, than the patients treated with ventolin. These differences are not statistically significant either. Conclusion: In this study, the patients in the hypertonic saline group have benefited a little more, in terms of the improvement of clinical symptoms and reduction in the length of hospitalization. Although these differences are not statistically significant, but considering the fact that hypertonic saline is cheaper and more accessible than ventolin, and unlike ventolin, the remaining of the hypertonic saline vial can be re-used, thus the use of hypertonic saline has priority over ventolin.

Keywords: Bronchiolitis, hypertonic saline, ventolin


How to cite this article:
Mojtaba KA, Fardin A, Ali Naghi KS, Koorosh K, Elham E. The priority of using hypertonic saline over ventolin in the treatment of bronchiolitis. J Health Res Rev 2016;3:98-101

How to cite this URL:
Mojtaba KA, Fardin A, Ali Naghi KS, Koorosh K, Elham E. The priority of using hypertonic saline over ventolin in the treatment of bronchiolitis. J Health Res Rev [serial online] 2016 [cited 2019 Dec 8];3:98-101. Available from: http://www.jhrr.org/text.asp?2016/3/3/98/193180


  Introduction Top


Bronchiolitis is one of the common causes of hospitalizing infants in the hospital. About 50% of children are affected by bronchiolitis during the first 2 years of their lives, the peak age of the disease is between 2 and 7 months of age. Four percent of the children affected by bronchiolitis are hospitalized in the hospital.[1] Boys are more affected by this disease than girls. Many factors affect the peaks of incidence of this disease. The peak of prevalence of bronchiolitis occurs 3–4 months in winter in a climate such as in Europe and the United States, but it usually occurs in the warmest and the most pluvial seasons of the year in tropical areas.[1] The incubation period of bronchiolitis is usually 4–6 days. The routine laboratory tests lack the necessary features for the diagnosis of bronchiolitis, and they are not required for the confirmation of the diagnosis.[2] The chest radiography often shows the symptoms of hyperexpansion of the chest with normal pulmonary spaces, which suggests viral pneumonia or local atelectasis.[3] The diagnosis of bronchiolitis is clinical. Due to the fear of misdiagnosis between allergic airway disease and bronchiolitis, some physicians use beta-adrenergics in the treatment, but the use of beta-adrenergic drugs is not routinely recommended as a first-line treatment for bronchiolitis.[3] Review studies have emphasized the transitory and nontherapeutic effects of beta-adrenergics. However, they are still used variably with different impacts at 75–80% of the centers.[4] Ventolin, which is widely prescribed, has complications such as nervousness, restlessness, insomnia, anxiety, fear, irritability, dizziness, mild tremor, headache, heart palpitations, changes in blood pressure, angina, nausea and vomiting, heartburn, dry mouth, difficulty in urinating, and potential interaction with other drugs. There are also different reports about the effect of using inhaler hypertonic saline, and some studies have reported a decrease in the length of hospitalization through the use of this treatment.[5] However, in case of using sodium chloride without bronchodilator in the treatment, much less complications can be seen.[6] Therapeutic measures for bronchiolitis in hospitalized patients are very different. In different examinations, statistically significant differences have been reported about the type of treatment in the United States [7] and Europe.[8] Given the differences of opinion existing in the treatment of bronchiolitis, it seems that further research has to be conducted in the field of treatment. This project aims to compare the effects of nebulized ventolin and hypertonic saline on the treatment of moderate bronchiolitis in the children hospitalized in Ayatollah Mousavi hospital in Zanjan from 2013 to 2014.


  Materials and Methods Top


After explaining to the patient about the safeness and getting consent of both methods, this study had been conducted in the form of a cohort study, the study period (duration) was 6 months, in which all the 2–7 months patients hospitalized in the pediatric wards of Ayatollah Mousavi Hospital, with a diagnosis of moderate bronchiolitis, 60< respiratory rate (RR) <75, and the existence of suprasternal and intercostal retractions and nasal flaring, without underlying disease (inclusion criteria), were visited by a pediatric infectious diseases specialist on the 1st day of hospitalization, and were included in the study in case of the confirmation of the diagnosis. According to the type of treatment, the patients were divided into two groups; A and B. Group A received a nebulized ventolin treatment at a dose of fifteen-hundredth of milligram per kilogram in normal saline. Group B received nebulized 5% hypertonic saline. We have used a Jet nebulizer in our research. Both groups received standard supportive measures (Hydration – oxygenation - suctioning of secretions) normally. In the 1st and 3rd days of hospitalization as well as the day of discharge, all the patients were examined to be assessed in terms of respiratory status (RR, and distress symptoms, such as retraction and nasal flaring) as well as the length of hospitalization. Exclusion criteria were patients with secondary bacterial infection and those who are needed mechanical ventilation in course of treatment, patients with underlying disease such as congenital heart disease, metabolic disorder, immunodeficiency disease.

It is a prospective study. The patients were divided into two groups (A and B) without physician interfering in type of therapy based on admission sequence just every other day. During the study period, all patients (who have inclusion criteria) were enrolled for study (total sampling was carried).

According to the information obtained, the therapeutic effect of nebulized hypertonic saline was compared with ventolin. The gathered information was described using SPSS software (SPSS statistics V0 11.5 for windows Chicago, IL, USA), and according to the independent t-test. The number of patients had been anticipated about 30 individuals in each group, and a total of 60 individuals. So that with a Type I error of 0.05 and the statistical power of 0.8, it will show a difference of 0.35 in efficacy between the two groups (efficacy is assumed to be 0.5 at the desired time). This research project was approved by the Deputy of Research of Zanjan University of Medical Sciences on May 17, 2014, and has received the license of the University's Ethics Committee under the number ZUMS. Rec. 1393.29.


  Results Top


In this cohort study, 74 cases with the primary diagnosis of moderate bronchiolitis were identified from among the total patients hospitalized in the pediatric ward of Mousavi Hospital, during a time period of 6 months. Seven patients were excluded from the study, due to the associated underlying diseases and immunodeficiency, Bronchopulmonary dysplasia, excessive aspiration resulting from failure to observe NPO, and congenital heart disease. Among the 67 children examined, 39 were boys and 28 were girls. From among the 33 cases of the ventolin group; 20 cases were boys and 13 cases were girls, and from among the 34 cases of the hypertonic saline group; 20 cases were boys and 14 cases were girls. This difference between the two groups was not statistically significant (P = 0.918).

In total, 33 patients were treated with ventolin and 34 patients were treated with hypertonic 5% saline. The length of hospitalization was (standard deviation [SD] =1.4) 4.2 days, on average, in the patients treated with ventolin, and (SD = 2.2) 3.8 days in the patients treated with hypertonic saline. This difference was not statistically significant between the two groups (P = 0.426).

Because the mean and SD of the number of hospitalization days in the ventolin group was greater than that of the number of hospitalization days in the saline group, but this difference was statistically significant (P = 0.420). For this test, a statistical power was calculated which was 12.3%; thus, with the current power value, the effects of the two drugs cannot be considered equal based on the number of hospitalization days, and suffice it to say that there is no statistically significant difference.

As shown in [Table 1], the average age of the group which received ventolin was 3.9 months, and for the hypertonic saline group, it was 4.1 months, and there was no statistically significant difference in terms of age between the two groups (P = 0.619). And also, the difference between the average RR at the beginning of the study, birth weight, and average weight during hospitalization in the two groups was not statistically significant.
Table 1: The initial characteristics of the patients at the beginning of the study in the recipients of ventolin and hypertonic saline

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The intercostal retractions in the patients in the saline and ventolin groups were 44.1% and 48.5 on the 1st day of hospitalization, respectively. As can be seen in [Table 2], different types of retractions between the two groups do not differ significantly (P = 0.523).
Table 2: Respiratory retraction on the 1st day of hospitalization of the patients in the two groups

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There is no statistically significant difference between the patients' respiratory retractions in the saline group and ventolin group on the 3rd day of treatment, either (P = 0.091). The patients had no intercostal retraction on the day of discharge. To evaluate the effectiveness of the drugs, we calculated the difference between the RR on the 1st day of hospitalization and that on the day of discharge, and examined this difference with the aid of independent t-test; the mean (and SD) of the difference between the RR on the day of discharge and that on the day of hospitalization were 22.7 and (12.9) in Group B, and 17.8 and (11.9) in Group A, and this difference between the two groups was not statistically significant either (P = 0.244). For this test, a statistical power was also calculated which was 27.8%; thus, with the current power value, the effects of the two drugs cannot be considered equal based on the difference between the RRs, and suffice it to say that there is no statistically significant difference.


  Discussion Top


In this cohort study, the gender distribution was proportional, and there was no significant difference in the average age, RR at the beginning of hospitalization, birth weight, and the weight during hospitalization between the two groups [Table 1]. There was no statistically significant difference in the different types of respiratory retractions between the two groups at the beginning of the study, either [Table 2]. Except for restlessness in some patients in the group receiving ventolin, we have not seen other major side effects. The absence of complications is consistent with the studies conducted by Tinsa et al. 2009[9] and Anil et al. 2010.[10] The patients treated with hypertonic saline (Group B) had a lower RR and retraction on the 3rd day, compared with the patients treated with ventolin (Group A). Although this difference was not statistically significant, feeding began faster and easier in Group B. In our study, the use of hypertonic saline had better results than the use of ventolin. This finding is consistent with the studies conducted by Zhang et al.[11] and the report of the American Academy of Pediatrics (AAP).[4] In a study by Schweich,[12] ventolin reduced oxygen saturation, but in our study, the changes in oxygen were not among the study objectives, thus we cannot comment on this issue. The mean and (SD) of the number of hospitalization days in Group A “4.2 days (SD = 1.4)” were more than the number of hospitalization days in Group B “3.8 days (SD = 2.1).” This difference with a statistical power of 12.3%, is not significant. With this statistical power, the effects of the two drugs cannot be considered equal based on the number of hospitalization days, and suffice it to say that there is no statistically significant difference. The length of hospitalization in the recipients of bronchodilator was not short in the study by Tinsa et al. 2009,[9] either. And the length of hospitalization in the recipients of bronchodilator, was not less in two other studies.[5],[13] In a study by Tal et al.,[14] the patients' response rate to hypertonic saline has been significantly better than that in normal saline group, taking into account the clinical score in the 1st and 2nd days of nebulization as well as the length of hospital stay. In a study by Ipek et al.,[15] there was little difference in the use of nebulized salbutamol, hypertonic saline, and the combination of salbutamol and hypertonic saline in moderate bronchiolitis between the three groups. Moreover, in a review study by Zhang et al.,[11] the positive effect of using hypertonic saline, compared with normal saline, on clinical symptoms, such as: Cough, wheeze, crackles, and even the number of hospitalization days, was confirmed. In addition, in a study by Anil et al.,[10] the difference between the effect of nebulizing salbutamol, epinephrine, 3% hypertonic saline, and normal saline on the treatment of moderate acute bronchiolitis were investigated, but no difference has been observed, in terms of the effectiveness of different treatments on the variables of interest. In a recent meta-analysis, the available treatments for bronchiolitis have been reported to be low-impact.[16] The results of the recent large study in the United States, which have been obtained from 41 hospitals with 130261 patients suffering from bronchiolitis, from 2004 to 2012, have shown that in recent years, the use of bronchodilators in the treatment of bronchiolitis has decreased.[17] Lack of difference between the use of hypertonic saline and ordinary cares in the treatment of bronchiolitis have also been reported.[18],[19] Another report stated that no kind of treatment can help in the treatment of bronchiolitis, even hypertonic saline.[20] In our study, the difference between the patients' respiratory retractions in Group A and Group B is not statistically significant on the 3rd day of treatment, either. The mean difference between the RR on the day of discharge and that on the day of hospitalization is not statistically significant either. The statistical power for this finding was 27.8%; thus, with the current power value, the effects of the two drugs cannot be considered equal based on the difference between the RRs. The report of the AAP [4] has rejected the use of ventolin in bronchiolitis. This report has mentioned the positive effects of nebulized hypertonic saline on improving the symptoms and reducing the duration of illness, and it is recommended that ventolin should only be prescribed in cases suspected of reactive airway disease, and in case of achieving a result, the treatment with ventolin will be continued. The important limitation of this study was the diagnosis of bronchiolitis. In order to overcome this limitation, the patients were visited by a pediatric infectious diseases specialist on the 1st day of hospitalization, and the suspected cases were excluded from the study.


  Conclusion Top


In this study, the patients in the hypertonic saline group have benefited a little more, in terms of the improvement of symptoms and reduction in the length of hospitalization. Although this difference is not statistically significant, hypertonic saline is cheaper and more accessible than ventolin, and unlike ventolin, the remaining of the hypertonic saline vial can be re-used, thus the use of hypertonic saline has priority over ventolin. Therefore, it is recommended that in certain cases of bronchiolitis, in addition to supportive measures, nebulized hypertonic saline is used in the treatment, instead of ventolin.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

 
  References Top

1.
Mojtaba KA. Wheezing in infant, bronchiolitis. In: Kligman RM, Stanton BF, St. Geme JW, Schor NF, Behrman RE, editors. Nelson Text Book of Pediatrics. 19th ed. Philadelphia: Elsevier Saunders Co.; 2011. p. 1456-60.  Back to cited text no. 1
    
2.
Edward R. The respiratory system. In: Markdante K, Kliegman RM, editors. Nelson Essential of Pediatrics. 7th ed. Philadelphia: Elsevier Saunders Co.; 2015. p. 510-2.  Back to cited text no. 2
    
3.
Kimberlin DW, Brady MT, Jackson MA, Long SS. Bronchiolitis. In: Red Book. 30th ed. Elk Grove Village, IL: American Academy of Pediatrics; 2015. p. 667-76.  Back to cited text no. 3
    
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Cody Meissner H, Hall CB. Respiratory syncytial virus. In: Feigin and Cherrys Text Book of Pediatric Infectious Disease. Philadelphia, PA: Saunders Co.; 2015. p. 2407-34.  Back to cited text no. 4
    
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Kuzik BA, Al-Qadhi SA, Kent S, Flavin MP, Hopman W, Hotte S, et al. Nebulized hypertonic saline in the treatment of viral bronchiolitis in infants. J Pediatr 2007;151:266-70.e1.  Back to cited text no. 5
    
6.
Ralston S, Hill V, Martinez M. Nebulized hypertonic saline without adjunctive bronchodilators for children with bronchiolitis. Pediatrics 2010;126:e520-5.  Back to cited text no. 6
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7.
Wilson KM, Blumkin AK, Rauch DA, Szilagyi PG. Trends in Cost and Length of Stay for Children Hospitalized for Bronchiolitis: 2000-2006. Pediatric Academic Societies Meeting, May 2, 2010, Vancouver, Canada; 2010. [Abstract].  Back to cited text no. 7
    
8.
Barben J, Hammer J. Current management of acute bronchiolitis in Switzerland. Swiss Med Wkly 2003;133:9-15.  Back to cited text no. 8
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9.
Tinsa F, Ben Rhouma A, Ghaffari H, Boussetta K, Zouari B, Brini I, et al. A randomized, controlled trial of nebulized terbutaline for the first acute bronchiolitis in infants less than 12-months-old. Tunis Med 2009;87:200-3.  Back to cited text no. 9
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Anil AB, Anil M, Saglam AB, Cetin N, Bal A, Aksu N. High volume normal saline alone is as effective as nebulized salbutamol-normal saline, epinephrine-normal saline, and 3% saline in mild bronchiolitis. Pediatr Pulmonol 2010;45:41-7.  Back to cited text no. 10
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11.
Zhang L, Mendoza-Sassi RA, Wainwright C, Klassen TP. Nebulised hypertonic saline solution for acute bronchiolitis in infants. Cochrane Database Syst Rev 2013;7:CD006458.  Back to cited text no. 11
    
12.
Schweich PJ, Hurt TL, Walkley EI, Mullen N, Archibald LF. The use of nebulized albuterol in wheezing infants. Pediatr Emerg Care 1992;8:184-8.  Back to cited text no. 12
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Patel H, Gouin S, Platt RW. Randomized, double-blind, placebo-controlled trial of oral albuterol in infants with mild-to-moderate acute viral bronchiolitis. J Pediatr 2003;142:509-14.  Back to cited text no. 13
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14.
Tal G, Cesar K, Oron A, Houri S, Ballin A, Mandelberg A. Hypertonic saline/epinephrine treatment in hospitalized infants with viral bronchiolitis reduces hospitalization stay: 2 years experience. Isr Med Assoc J 2006;8:169-73.  Back to cited text no. 14
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Ipek IO, Yalcin EU, Sezer RG, Bozaykut A. The efficacy of nebulized salbutamol, hypertonic saline and salbutamol/hypertonic saline combination in moderate bronchiolitis. Pulm Pharmacol Ther 2011;24:633-7.  Back to cited text no. 15
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Ralston S, Comick A, Nichols E, Parker D, Lanter P. Effectiveness of quality improvement in hospitalization for bronchiolitis: A systematic review. Pediatrics 2014;134:571-81.  Back to cited text no. 16
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Kavita P, Matthew H, Stephen J. Management before and after the AAP guidelines. Pediatrics 2014;133:e1-7.  Back to cited text no. 17
    
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Everard ML, Hind D, Ugonna K, Freeman J, Bradburn M, Cooper CL, et al. SABRE: A multicentre randomised control trial of nebulised hypertonic saline in infants hospitalised with acute bronchiolitis. Thorax 2014;69:1105-12.  Back to cited text no. 18
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Cunningham S, Unger SA. Nebulised hypertonic saline in bronchiolitis: Take it with a pinch of salt. Thorax 2014;69:1065-6.  Back to cited text no. 19
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