1. Copyright restrictions may apply A Randomized Trial of Nebulized 3% Hypertonic Saline With Epinephrine in the Treatment of Acute Bronchiolitis in the Emergency Department Grewal S, Ali S, McConnell DW, Vandermeer B, Klassen TP. A randomized trial of nebulized 3% hypertonic saline with epinephrine in the treatment of acute bronchiolitis in the emergency department. Arch Pediatr Adolesc Med. 2009;163(11):1007-1012.

2. Copyright restrictions may apply Introduction Bronchiolitis in infants creates great burden of disease Four trials have investigated use of nebulized 3% hypertonic saline for bronchiolitis –Two showed improvement in clinical severity scores –Two showed reduction in length of hospital stay No studies had been done in the emergency department (ED), which is often the entry point for medical care Objective: To determine whether nebulized 3% hypertonic saline with epinephrine is more effective than nebulized 0.9% saline with epinephrine in the treatment of bronchiolitis in the ED

3. Copyright restrictions may apply Methods Randomized, double-blind, controlled trial N = 46 infants (aged <1 year) with mild to moderate bronchiolitis Randomized to receive nebulized racemic epinephrine in either hypertonic or normal saline Primary outcome was change in respiratory distress, as measured by the Respiratory Assessment Change Score (RACS) from baseline to 120 minutes Secondary outcomes: change in oxygen saturation, rate of hospital admission, and rate of return to the ED Study was supported by the Department of Pediatrics, University of Alberta, and the Alberta Research Centre for Child Health Evidence

4. Copyright restrictions may apply Methods Intention-to-treat principle was used in all analyses Linear multivariable regression analysis was performed to determine whether RACS was influenced by type of solution, second dose of the study drug, family history of asthma, sex, smoke exposure, age in days, and how well the infant fed Limitations: No 24/7 coverage during study period; no placebo group; maximum of only 2 doses of the study drug were given; study period was only 120 minutes

5. Copyright restrictions may apply Results Forty-six patients enrolled and evaluated No improvement in respiratory distress (RACS) from baseline to 120 minutes in the hypertonic saline group compared with the normal saline control group Change in oxygen saturation in the hypertonic saline group was not significantly different from that in the control group Rates of admission and return to the ED were not significantly different between the 2 groups

6. Copyright restrictions may apply Results Clinical Outcomes of the 2 Groups Variable Mean (95% CI) Hypertonic SalineNormal SalineDifference Change in RACS4.39 (2.64 to 6.13)5.13 (3.71 to 6.55)0.74 (−1.45 to 2.93) Change in O 2 saturation−0.44 (−2.11 to 1.23)1.34 (−0.29 to 2.99)1.78 (−0.50 to 4.06) Abbreviations: CI, confidence interval; RACS, Respiratory Assessment Change Score.

7. Copyright restrictions may apply Results Secondary Outcomes Variable No./Total RR (95% CI) Hypertonic SalineNormal Saline Admissions to hospital8/2313/230.61 (0.22-1.19) Returns to ED3/234/230.74 (0.11-2.91) Abbreviations: CI, confidence interval; ED, emergency department; RR, risk ratio.

8. Copyright restrictions may apply Discussion Although not statistically significant, there was a trend toward a decreased rate of hospitalization in the hypertonic saline group While hypertonic saline may not show immediate ED benefits, there is a suggestion that perhaps it should be initiated in the ED for later (inpatient) benefit This is the first study of hypertonic saline for bronchiolitis in the ED This is the first negative study of epinephrine and hypertonic saline in bronchiolitis

9. Copyright restrictions may apply Discussion Need for further research to determine whether hypertonic saline does have a role in the treatment of bronchiolitis in the ED and in subsequent hospitalization Future studies should extend the period of time in which treated patients are observed, as the effects of hypertonic saline may be seen outside the immediate treatment time (ie, 120 minutes)

10. Copyright restrictions may apply Contact Information If you have questions, you may contact the corresponding author, Simran Grewal, MD: –Email: simran@ualberta.casimran@ualberta.ca