Comparison Between Nebulized 0.9% Normal Saline and 3% Hypertonic Saline in the Management of Acute Bronchiolitis in the Emergency Department
Downloads
Background: Acute bronchiolitis is an acute viral infection of the lower respiratory tract that primarily affects infants and young children, usually under two years of age. It is characterized by inflammation, edema, and necrosis of the epithelial cells lining the small airways, resulting in increased mucus production, airway obstruction, wheezing, and respiratory distress. Respiratory syncytial virus is the most common causative agent. Nebulized 3% hypertonic saline is a sterile sodium chloride solution administered as a fine mist directly into the airways. It functions as a mucolytic and airway-hydrating agent by drawing water into the mucus and airway surface, thereby thinning secretions, improving mucus rheology, and enhancing mucociliary clearance through osmotic mechanisms. Nebulized 0.9% normal saline is an isotonic sterile sodium chloride solution commonly used to hydrate the airways, facilitate mucus clearance, and dilute inhaled medications. Although normal saline provides a gentle and soothing effect in respiratory infections, some studies suggest that 3% hypertonic saline may be more effective in reducing the duration of hospitalization among infants with bronchiolitis. Aim of the Study: This study aimed to compare the clinical effectiveness of nebulized 0.9% normal saline and nebulized 3% hypertonic saline in the management of acute bronchiolitis in the emergency department. Patients and Methods: This prospective comparative study was conducted at Babil Teaching Hospital for Maternity and Children, Babil City, Iraq, from November 1, 2025, to March 15, 2026. A total of 200 consecutive infants diagnosed with acute bronchiolitis were included. The participants were divided into two groups. Group H consisted of 100 infants who received 4 mL of nebulized 3% hypertonic saline at each treatment session, whereas Group N consisted of 100 infants who received 4 mL of nebulized 0.9% normal saline. Clinical responses were assessed using the Modified Tal Score. Statistical significance was set at p < 0.05. Results: The mean age was 5.095 ± 4.13 months in Group H and 6.03 ± 3.90 months in Group N, with no statistically significant difference between the groups (p = 0.1181). A statistically significant difference was observed in body weight between Group H (6.16 ± 2.12 kg) and Group N (6.86 ± 2.28 kg; p < 0.001). The initial Modified Tal Score was slightly higher in Group N (5.12 ± 1.49) than in Group H (4.98 ± 1.64), although the difference was not statistically significant (p = 0.110). One hour after nebulization, Group H had a lower mean Modified Tal Score (3.91 ± 0.99) than Group N (4.14 ± 0.99), but the difference remained statistically non-significant (p = 0.149). After the second nebulization session, Group H continued to demonstrate a lower mean score (3.20 ± 1.23) than Group N (3.50 ± 1.26), with no statistically significant difference (p = 0.103). Following the third nebulization session, the mean Modified Tal Score was 2.70 ± 1.09 in Group H and 2.95 ± 1.16 in Group N, with no statistically significant difference between the groups (p = 0.976). Conclusion: Nebulized 3% hypertonic saline produced slightly greater clinical improvement than nebulized 0.9% normal saline in infants with acute bronchiolitis. However, the differences in Modified Tal Scores between the two treatment groups were not statistically significant.
[1] R. M. Kliegman, J. W. St. Geme, N. J. Blum, S. S. Shah, R. C. Tasker, and K. M. Wilson, Eds., “Bronchiolitis,” in Nelson Textbook of Pediatrics, 21st ed. Philadelphia, PA, USA: Elsevier, 2020.
[2] M. S. Zach and E. Eber, “Viral lower respiratory tract infections,” in Textbook of Pediatric Respiratory Medicine, 2nd ed. Philadelphia, PA, USA: Elsevier, 2018.
[3] N. McIntosh, P. J. Helms, and R. L. Smyth, Eds., “Bronchiolitis,” in Forfar and Arneil’s Textbook of Pediatrics, 7th ed. Edinburgh, U.K.: Churchill Livingstone, 2018.
[4] E. L. Kendig, R. W. Wilmott, T. F. Boat, et al., Eds., Kendig and Chernick’s Disorders of the Respiratory Tract in Children, 7th ed. Philadelphia, PA, USA: Elsevier Saunders, 2019.
[5] J. F. Murray and J. A. Nadel, “Lower respiratory tract infections in children,” in Murray and Nadel’s Textbook of Respiratory Medicine, 6th ed. Philadelphia, PA, USA: Elsevier, 2016.
[6] R. M. Kliegman, J. W. St. Geme, N. J. Blum, S. S. Shah, R. C. Tasker, and K. M. Wilson, Eds., “Bronchiolitis,” in Nelson Textbook of Pediatrics, 21st ed. Philadelphia, PA, USA: Elsevier, 2020.
[7] C. D. Rudolph, A. M. Rudolph, G. E. Lister, L. R. First, and A. A. Gershon, Eds., “Lower respiratory tract infections,” in Rudolph’s Pediatrics, 23rd ed. New York, NY, USA: McGraw-Hill Education, 2023.
[8] W. W. Hay, Jr., M. J. Levin, R. R. Deterding, and M. J. Abzug, Eds., “Bronchiolitis,” in Current Diagnosis and Treatment: Pediatrics, 25th ed. New York, NY, USA: McGraw-Hill Education, 2023.
[9] S. L. Ralston, A. S. Lieberthal, H. C. Meissner, et al., “Clinical practice guideline: The diagnosis, management, and prevention of bronchiolitis,” Pediatrics, vol. 134, no. 5, pp. e1474–e1502, 2014.
[10] National Institute for Health and Care Excellence, Bronchiolitis in Children: Diagnosis and Management, NICE Guideline NG9. London, U.K.: NICE, 2021.
[11] National Institute for Health and Care Excellence, Bronchiolitis in Children: Diagnosis and Management, NICE Guideline NG9. London, U.K.: NICE, 2021.
[12] Italian Society of Pediatrics, Italian Guidelines on Bronchiolitis Management. Italy: Italian Society of Pediatrics, 2022–2023.
[13] T. A. Florin, A. C. Plint, and J. J. Zorc, “Viral bronchiolitis,” Lancet, vol. 389, no. 10065, pp. 211–224, 2017.
[14] J. N. Friedman, M. J. Rieder, and J. M. Walton, “Bronchiolitis: Recommendations for diagnosis, monitoring and management,” Paediatr. Child Health, vol. 19, no. 9, pp. 485–498, 2018.
[15] R. M. Kliegman and J. W. St. Geme, “Epidemiology and severity of bronchiolitis,” in Nelson Textbook of Pediatrics, 21st ed. Philadelphia, PA, USA: Elsevier, 2020.
[16] American Academy of Pediatrics, Red Book: 2021–2024 Report of the Committee on Infectious Diseases, 32nd ed. Itasca, IL, USA: American Academy of Pediatrics, 2021.
[17] StatPearls Publishing, “Pediatric bronchiolitis,” in StatPearls. Treasure Island, FL, USA: StatPearls Publishing, 2023.
[18] R. M. Kliegman and J. W. St. Geme, Eds., Nelson Textbook of Pediatrics, 21st ed. Philadelphia, PA, USA: Elsevier, 2020.
[19] C. A. Gleason and S. E. Juul, Eds., Diseases of the Newborn, 10th ed. Philadelphia, PA, USA: Elsevier, 2018.
[20] J. D. Cherry and G. J. Demmler-Harrison, Eds., Feigin and Cherry’s Textbook of Pediatric Infectious Diseases. Philadelphia, PA, USA: Elsevier, 2019.
[21] B. P. Fuhrman and J. J. Zimmerman, Eds., Pediatric Critical Care. Philadelphia, PA, USA: Elsevier, 2017.
[22] M. C. Rogers, Ed., Rogers’ Textbook of Pediatric Intensive Care, 4th ed. Baltimore, MD, USA: Williams & Wilkins, 2020.
[23] R. M. Kliegman and J. W. St. Geme, “Respiratory syncytial virus and bronchiolitis,” in Nelson Textbook of Pediatrics, 21st ed. Philadelphia, PA, USA: Elsevier, 2020.
[24] J. D. Cherry, G. J. Harrison, S. L. Kaplan, W. J. Steinbach, and P. J. Hotez, Eds., Feigin and Cherry’s Textbook of Pediatric Infectious Diseases, 8th ed. Philadelphia, PA, USA: Elsevier, 2019.
[25] C. D. Rudolph, G. E. Lister, L. R. First, and A. A. Gershon, Eds., Rudolph’s Pediatrics, 23rd ed. New York, NY, USA: McGraw-Hill Education, 2023.
[26] G. L. Mandell, J. E. Bennett, and R. Dolin, Eds., Principles and Practice of Infectious Diseases, 9th ed. Philadelphia, PA, USA: Elsevier, 2020.
[27] R. A. Tripp and H. C., “Title not provided,” Viruses, vol. 13, no. 12, Art. no. 2478, 2021.
[28] A. Chatterjee, K. Mavunda, and L. R. Krilov, “Current state of respiratory syncytial virus disease and management,” Infect. Dis. Ther., vol. 10, suppl. 1, pp. 5–16, 2021.
[29] T. Gondwe et al., “Title not provided,” BMC Pediatr., vol. 18, Art. no. 346, 2018.
[30] J. Sandall, R. M. Tribe, L. Avery, et al., “Short-term and long-term effects of caesarean section on the health of women and children,” Lancet, vol. 392, no. 10155, pp. 1349–1357, 2018.
[31] T. J. van Hasselt et al., “Title not provided,” BMC Pediatr., vol. 23, Art. no. 326, 2023.
[32] “Systematic review of risk factors for severe bronchiolitis,” 2025.
[33] A. Teijeiro and R. M. Gómez, “Title not provided,” Front. Allergy, vol. 2, Art. no. 726972, 2021.
[34] L. Zhang, R. A. Mendoza-Sassi, C. Wainwright, and T. P. Klassen, “Nebulised hypertonic saline solution for acute bronchiolitis in infants,” Cochrane Database Syst. Rev., no. 6, Art. no. CD006458, 2023.
[35] J. F. Yu, Y. Zhang, Z. B. Liu, J. Wang, and L. P. Bai, “3% nebulized hypertonic saline versus normal saline for infants with acute bronchiolitis: A systematic review and meta-analysis of randomized controlled trials,” Medicine, vol. 101, no. 43, Art. no. e31270, 2022.
[36] N. A. Awang et al., “Hypertonic saline versus normal saline in bronchiolitis management,” Malays. J. Med. Sci., vol. 27, no. 2, pp. 45–52, 2020.
[37] P. Szupieńko-Bujak et al., “Randomised, multicentre clinical trial found that hypertonic saline did not reduce the length of stay of hospitalised patients with acute bronchiolitis,” Acta Paediatr., 2026.
