Comparative Efficacy of Hypertonic Versus Normal Saline Nebulization in Acute Bronchiolitis in Infants at a Tertiary Care Hospital: Hypertonic vs Normal Saline Nebulization in Infant Bronchiolitis

Kainaat Emel; Khalil Ahmad; Warda Gul; Muhammad Rafiq Khan; Kainat Pervez; Zakir Ullah

doi:10.54393/pjhs.v7i6.3599

Authors

Kainaat Emel Department of Pediatric Medicine, Gajju Khan Medical College, Swabi, Pakistan
Khalil Ahmad Department of Pediatric Medicine, Bacha Khan Medical College, Mardan, Pakistan
Warda Gul Department of Pediatric Medicine, Mardan Medical Complex, Mardan, Pakistan
Muhammad Rafiq Khan Department of Pediatric Medicine, Bannu Medical College, Bannu, Pakistan
Kainat Pervez Department of Pediatrics, Mardan Medical Complex, Mardan, Pakistan
Zakir Ullah Department of Pediatric Medicine, Mardan Medical Complex, Mardan, Pakistan

DOI:

https://doi.org/10.54393/pjhs.v7i6.3599

Keywords:

Acute Bronchiolitis, Hypertonic Saline Nebulization, Normal Saline Nebulization, Infants, Respiratory Distress Assessment Instrument

Abstract

Acute bronchiolitis is a leading cause of hospitalization in infants and is managed mainly with supportive care. Nebulized 3% hypertonic saline (HS) has been used in some settings, but evidence from routine-care practice remains variable. Objectives: To compare short-term clinical outcomes of nebulized 3% hypertonic saline versus 0.9% normal saline administered as routine care in infants hospitalized with acute bronchiolitis at Mardan Medical Complex. Methods: This was a prospective quasi-experimental comparative cohort study to compare the outcomes between infants receiving 3% hypertonic saline and those receiving 0.9% normal saline. Participants were actively followed for up to 72 hours to assess clinical response, with treatment allocation based on routine clinical decisions made by the treating pediatrician. Efficacy was predefined as a ≥2-point reduction in the Respiratory Distress Assessment Instrument (RDAI) score within 72 hours or discharge without supplemental oxygen. Results: Treatment response occurred in 27/30 (90%) in the 3% HS group versus 15/30 (50%) in the 0.9% NS group (p<0.001). Mean oxygen-therapy duration was shorter (17.3 ± 4.2 vs 26.8 ± 5.6 hours; p<0.001), and hospital stay was shorter (2.6 ± 0.8 vs 3.5 ± 1.0 days; p<0.001) in the 3% HS group. Conclusions: In this routine-care setting, nebulized 3% hypertonic saline was associated with a higher treatment-response rate and shorter oxygen-therapy duration and hospital stay than 0.9% normal saline.

References

Moulia DL. Use of Clesrovimab for Prevention of Severe Respiratory Syncytial Virus–Associated Lower Respiratory Tract Infections in Infants: Recommendations of The Advisory Committee on Immunization Practices—United States. Morbidity and Mortality Weekly Report. 2025 Aug; 74(32): 508–514. doi: 10.15585/mmwr.mm7432a3.

Jo YM, Kim J, Chang J. Vaccine Containing G Protein Fragment and Recombinant Baculovirus Expressing M2 Protein Induces Protective Immunity to Respiratory Syncytial Virus. Clinical and Experimental Vaccine Research. 2019 Jan; 8(1): 43-53. doi: 10.7774/cevr.2019.8.1.43.

Oz-Alcalay L, Ashkenazi S, Glatman-Freedman A, Weisman-Demri S, Lowenthal A, Livni G. Hospitalization for Respiratory Syncytial Virus Bronchiolitis in the Palivizumab Prophylaxis Era: Need for Reconsideration of Preventive Timing and Eligibility. Israel Medical Association Journal. 2019 Feb; 21(2): 110-115.

Soudani N, Caniza MA, Assaf‐Casals A, Shaker R, Lteif M, Su Y et al. Prevalence and Characteristics of Acute Respiratory Virus Infections in Pediatric Cancer Patients. Journal of Medical Virology. 2019 Jul; 91(7): 1191-1201. doi: 10.1002/jmv.25432.

Supino MC, Buonsenso D, Scateni S, Scialanga B, Mesturino MA, Bock C et al. Point-of-Care Lung Ultrasound in Infants with Bronchiolitis in The Pediatric Emergency Department: A Prospective Study. European Journal of Pediatrics. 2019 May; 178(5): 623-632. doi: 10.1007/s00431-019-03335-6.

Lodeserto FJ, Lettich TM, Rezaie SR. High-Flow Nasal Cannula: Mechanisms of Action and Adult and Pediatric Indications. Cureus. 2018 Nov; 10(11): 1-9. doi: 10.7759/cureus.3639.

Stobbelaar K, Kool M, de Kruijf D, Van Hoorenbeeck K, Jorens P, De Dooy J et al. Nebulised Hypertonic Saline in Children with Bronchiolitis Admitted to The Paediatric Intensive Care Unit: A Retrospective Study. Journal of Paediatrics and Child Health. 2019 Sep; 55(9): 1125-1132. doi: 10.1111/jpc.14371.

Petrarca L, Jacinto T, Nenna R. The Treatment of Acute Bronchiolitis: Past, Present and Future. Breathe. 2017 May; 13(1): 24-26. doi: 10.1183/20734735.000717.

Zhang L, Mendoza‐Sassi RA, Wainwright C, Klassen TP. Nebulised Hypertonic Saline Solution for Acute Bronchiolitis in Infants. Cochrane Database of Systematic Reviews. 2013; 7: 1-41. doi: 10.1002/14651858.CD006458.pub3.

Máiz Carro L and Martínez-García MA. Nebulized Hypertonic Saline in Noncystic Fibrosis Bronchiectasis: A Comprehensive Review. Therapeutic Advances in Respiratory Disease. 2019 Aug; 13: 1-15. doi: 10.1177/1753466619866102.

Islam KT, Mollah AH, Matin A, Begum M. Comparative Efficacy of Nebulized 3% Hypertonic Saline Versus 0.9% Normal Saline in Children with Acute Bronchiolitis. Bangladesh Journal of Child Health. 2018 Dec; 42(3): 130-137. doi: 10.3329/bjch.v42i3.39264.

Sanghavi B and Sugapradha GR. Clinical Profile and Outcome of Bronchiolitis in Children With 1-24 Months of Age. Cureus. 2024 Sep; 16(9): 1-6.

Erickson EN, Bhakta RT, Tristram D, Mendez MD. Pediatric bronchiolitis. StatPearls Publishing. 2025 Jan.

Almansoor BA. Epidemiology of Hospitalization for Acute Bronchiolitis in Children: A Systematic Review. International Journal of Medicine in Developing Countries. 2023 Apr; 7(7): 1046. doi: 10.24911/IJMDC.51-1677868429.

Omparkash AL, Laghari TM, Sirichand MA, Aslam M. Compare the Clinical Severity and Length of Hospital Stay in Children with Bronchiolitis Treated with the 3% Hypertonic Saline Nebulization Versus Normal Saline and Salbutamol. 2023; 17(3): 448-451. doi: 10.53350/pjmhs2023173448.

Louman S, van Stralen KJ, Pijnenburg MW, Koppelman GH, Boehmer AL. Oxygen Saturation Targets for Children with Respiratory Distress: A Systematic Review. European Respiratory Society open research. 2023 Oct; 9(5). doi: 10.1183/23120541.00256-2023.

Jhaveri S, Patel B, Kariya PV. A Prospective Study on the Efficacy of Hypertonic Saline Nebulization in Infants with Acute Bronchiolitis. European Journal of Cardiovascular Medicine. 2025 Apr; 15: 593-595.

Alamer HS, Asiri AJ, Aalhassan A, Tahaeibashir SE. A retrospective study on the effect of nebulized hypertonic saline (3%) vs. epinephrine on admission rates among infants with acute moderate to severe bronchiolitis at AFHSR. International Journal of Advanced Research. 2025; 13(1): 1360-1368. doi: 10.21474/IJAR01/20326.

Mahjoub E, Suliman O, Alhussain Z, Alsubhi H, Altom S. Clinical Practice Guidelines for the Diagnosis and Management of Bronchiolitis in Infants and Young Children: A Systematic Review. Vascular and Endovascular Review. 2025 Oct; 8(5): 43-54.

Parveen A, Naureen S, Waseem R, Noor T, Malik T, Shaheen B. Comparison Between 0.9% Normal Saline and 0.3% Hypertonic Saline Nebulization in Acute Bronchiolitis in Terms of Mean Length of Hospital Stay. Pakistan Pediatric Journal. 2025 Aug; 49(2): 1-5.

Brown CS, Rabinstein AA, Zhao Y, Wieruszewski ED. Safety of Peripheral 3% Hypertonic Saline Bolus Administration for Neurologic Emergency. The American Journal of Emergency Medicine. 2023 Jul; 69: 83-86. doi: 10.1016/j.ajem.2023.04.007.

Khan Z, Naeem MO, Amin A, Amin L, Shah A, Khaliq SU et al. Effectiveness of Hypertonic Saline with or without Hyaluronic Acid Among Patients with Cystic Fibrosis: A Systematic Review and Meta-Analysis. Annals of Medicine and Surgery. 2024 Oct; 86(10): 6091-6096. doi: 10.1097/MS9.0000000000002450.

Kelly S, Valentine M, Chua WH, Tatkov S. Impact of High-And Low-Flow Nebulised Saline on Airway Hydration and Mucociliary Transport. ERJ Open Research. 2023 Jun; 9(3): 1-10. doi: 10.1183/23120541.00724-2022.

Roe T, Talbot T, Terrington I, Johal J, Kemp I, Saeed K et al. Physiology and Pathophysiology of Mucus and Mucolytic Use in Critically Ill Patients. Critical Care. 2025 Feb; 29(1): 68. doi: 10.1186/s13054-025-05286-x.

Ahmadi Z, Smallwood NE, Russell AM, Saggu R, Romero L, Holland AE et al. Supplemental Oxygen for Symptomatic Relief in People with Serious Respiratory Illness: A Systematic Review and Meta-Analysis. European Respiratory Review. 2025 Mar; 34(175): 1-19. doi: 10.1183/16000617.0025-2024.