Is Nebulized Hypertonic Saline More Effective for Bronchiolitis?

William T. Basco, Jr., MD, MS


October 10, 2017

Hypertonic Versus Normal Saline Nebulizer Treatments

The goal of a recent study[1] was to evaluate whether nebulized hypertonic saline (3%) was more beneficial than nebulized normal saline (0.9%) in the treatment of infants presenting to the emergency department (ED) with bronchiolitis. This randomized, double-blind clinical trial was conducted in 24 pediatric EDs in France from October 2012 through April 2014, covering two bronchiolitis seasons.

The infants were 6 weeks to 12 months old, and all were experiencing their first episode of bronchiolitis. Infants were excluded for prematurity or any other chronic medical condition as well as if they were admitted to the intensive care unit from the ED. Both groups received two nebulization treatments after presentation, with each treatment lasting 20 minutes. The treatments were given 20 minutes apart. The nebulizer treatments were delivered by facemask and with oxygen flow. The treatment teams were masked to the intervention being provided.

I admit, it's crazy to think that we've made little improvement in the treatment of bronchiolitis, at least from a true therapeutic standpoint, over 25 years of practice.

The primary outcome of interest was whether the child was admitted to the hospital within 24 hours after enrollment. The treating sites also recorded symptom severity before and after treatment. Finally, telephone follow-up at multiple points up to 28 days after the ED visit obtained information on symptoms after the original visit.

The analyses included 777 infants, enrolled at a median age of 3 months, approximately equally enrolled in the two groups. Respiratory syncytial virus infection accounted for more than 80% of the viral isolates from both groups. The groups were otherwise similar upon admission. Approximately 60% were boys. The average respiratory rate (breaths/min) was in the mid-50s, and the average oxygen saturation was approximately 97%. There was no statistically significant difference in the primary outcome, with 48.1% of the hypertonic saline group admitted to the hospital within 24 hours compared with 52.2% of the normal saline group.

The symptom scores improved slightly in both groups, but the improvement was significantly better among the hypertonic saline group by about 0.7 points. Mild adverse events occurred in 8.9% of the hypertonic saline group compared with 3.9% of the normal saline group, a statistically significant difference. There were no differences in the rate of severe adverse events.

The authors concluded that this randomized, double-blind clinical trial did not demonstrate a benefit of hypertonic saline over normal saline nebulized treatments in preventing hospitalization, intensive care admission, or admission within 28 days of enrollment.


In an excellent accompanying editorial,[2] Ralston commented that the investigation of the use of hypertonic saline in the treatment of bronchiolitis has followed a well-described pattern of early small trials showing benefit and rapid uptake by the medical community, only to have later, larger, and more comprehensive trials fail to establish a clear benefit of the therapy. Practitioners must then abandon approaches that perhaps should never have been adopted in the first place.[3]

Unfortunately, I've been able to experience this phenomenon with at least four different approaches to bronchiolitis: albuterol, systemic steroids, racemic epinephrine, and, more recently, hypertonic saline. I admit, it's crazy to think that we've made little improvement in the treatment of bronchiolitis, at least from a true therapeutic standpoint, over 25 years of practice, but that's the reality of where we stand. That doesn't mean that there isn't anything we can do to make children and families comfortable, but a large body of evidence suggests that doing more for bronchiolitis is not necessarily going to help.


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