Saline in acute bronchiolitis RCT and economic evaluation: hypertonic saline in acute bronchiolitis - randomised controlled trial and systematic review

Acute bronchiolitis is the most common cause of hospitalisation in infancy. Supportive care and oxygen are the cornerstones of management. A Cochrane review concluded that the use of nebulised 3% hypertonic saline (HS) may significantly reduce the duration of hospitalisation. To test the hypothesis...

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Published in:	Health technology assessment (Winchester, England) Vol. 19; no. 66; pp. 1 - 130
Main Authors:	Everard, Mark L, Hind, Daniel, Ugonna, Kelechi, Freeman, Jennifer, Bradburn, Mike, Dixon, Simon, Maguire, Chin, Cantrill, Hannah, Alexander, John, Lenney, Warren, McNamara, Paul, Elphick, Heather, Chetcuti, Philip Aj, Moya, Eduardo F, Powell, Colin, Garside, Jonathan P, Chadha, Lavleen Kumar, Kurian, Matthew, Lehal, Ravinderjit S, MacFarlane, Peter I, Cooper, Cindy L, Cross, Elizabeth
Format:	Journal Article
Language:	English
Published:	England NIHR Journals Library 01-08-2015
Subjects:	acute bronchiolitis Acute Disease Administration, Inhalation Albuterol - therapeutic use Bronchiolitis - drug therapy Bronchiolitis - therapy Bronchodilator Agents - therapeutic use Combined Modality Therapy Cost-Benefit Analysis Drug Therapy, Combination economic evaluation Female Humans hypertonic saline Infant Length of Stay Male meta-analysis Nebulizers and Vaporizers Oxygen Inhalation Therapy - methods Patient Readmission Quality of Life Quality-Adjusted Life Years randomised controlled trial sabre Saline Solution, Hypertonic - administration & dosage Saline Solution, Hypertonic - economics Saline Solution, Hypertonic - therapeutic use Severity of Illness Index systematic review United Kingdom United Kingdom
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Summary:	Acute bronchiolitis is the most common cause of hospitalisation in infancy. Supportive care and oxygen are the cornerstones of management. A Cochrane review concluded that the use of nebulised 3% hypertonic saline (HS) may significantly reduce the duration of hospitalisation. To test the hypothesis that HS reduces the time to when infants were assessed as being fit for discharge, defined as in air with saturations of > 92% for 6 hours, by 25%. Parallel-group, pragmatic randomised controlled trial, cost-utility analysis and systematic review. Ten UK hospitals. Infants with acute bronchiolitis requiring oxygen therapy were allocated within 4 hours of admission. Supportive care with oxygen as required, minimal handling and fluid administration as appropriate to the severity of the disease, 3% nebulised HS every ± 6 hours. The trial primary outcome was time until the infant met objective discharge criteria. Secondary end points included time to discharge and adverse events. The costs analysed related to length of stay (LoS), readmissions, nebulised saline and other NHS resource use. Quality-adjusted life-years (QALYs) were estimated using an existing utility decrement derived for hospitalisation in children, together with the time spent in hospital in the trial. We searched MEDLINE, EMBASE, the Cochrane Central Register of Controlled Trials and other databases from inception or from 2010 onwards, searched ClinicalTrials.gov and other registries and hand-searched Chest, Paediatrics and Journal of Paediatrics to January 2015. We included randomised/quasi-randomised trials which compared HS versus saline (± adjunct treatment) or no treatment. We used a fixed-effects model to combine mean differences for LoS and assessed statistical heterogeneity using the I (2) statistic. The trial randomised 158 infants to HS (n = 141 analysed) and 159 to standard care (n = 149 analysed). There was no difference between the two arms in the time to being declared fit for discharge [median 76.6 vs. 75.9 hours, hazard ratio (HR) 0.95, 95% confidence interval (CI) 0.75 to 1.20] or to actual discharge (median 88.5 vs. 88.7 hours, HR 0.97, 95% CI 0.76 to 1.23). There was no difference in adverse events. One infant developed bradycardia with desaturation associated with HS. Mean hospital costs were £2595 and £2727 for the control and intervention groups, respectively (p = 0.657). Incremental QALYs were 0.0000175 (p = 0.757). An incremental cost-effectiveness ratio of £7.6M per QALY gained was not appreciably altered by sensitivity analyses. The systematic review comprised 15 trials (n = 1922) including our own. HS reduced the mean LoS by -0.36 days (95% CI -0.50 to -0.22 days). High levels of heterogeneity (I (2) = 78%) indicate that the result should be treated cautiously. In this trial, HS had no clinical benefit on LoS or readiness for discharge and was not a cost-effective treatment for acute bronchiolitis. Claims that HS achieves small reductions in LoS must be treated with scepticism. Well-powered randomised controlled trials of high-flow oxygen are needed. This study is registered as NCT01469845 and CRD42014007569. This project was funded by the NIHR Health Technology Assessment (HTA) programme and will be published in full in Health Technology Assessment; Vol. 19, No. 66. See the HTA programme website for further project information.
ISSN:	1366-5278 2046-4924
DOI:	10.3310/hta19660