Wednesday, June 10, 2009

Therapy for Bronchiolitis?

You could knock me over with a feather. I've watched bronchiolitis attack vulnerable infants over the last four years. There hasn't been much we could do. Supportive care? Nasal saline, intubate or NIPPV for respiratory failure, some people use oxymetazoline drops for the snotty noses thwarting the respiratory efforts of our little obligate nose breathers. Now it seems that there may actually be something helpful to offer. The literature is rife with randomized trials that fail to show that albuterol, racemic epinephrine, or steroids offer any benefits.

The fine folks at Cochrane published an analysis of 4 trials looking at nebulized hypertonic saline for acute bronchiolitis last fall. I have not been able to access the full text at home, because either I am too dim-witted to figure it out, or OSU doesn't subscribe to the most influential EBM resource available. Hopefully the former.

The bear of bronchiolitis is that it attacks the upper respiratory tract via snotty nose and it attacks the lower respiratory tract with more mucous and sloughed epithelium. This is a tough 1-2 punch for infants with little reserve.

Inhaled hypertonic saline has been used to augment airway clearance in CF over the last few years, so it only made sense to try it in infants. The 4 trials reviewed were small, so the total number of patients analyzed was small (254). They looked at both inpatients and outpatients and showed reduction in Length of Stay (LOS) by one day. They also found improvement in clinical score.

Well, according to the cochrane review and the 2007 paper from the journal of pediatrics, it evidently works. In the 2007 paper they gave it every 2 hours for 3 doses and then every 4 hours for 5 doses and then every 6 hours.

There doesn't seem to be a downside.

Anybody used hypertonic saline nebs for acute bronchiolitis?