Efficacy of nebulised L-Adrenaline with 3 % hypertonic saline versus normal saline in bronchiolitis

Background: Bronchiolitis is one of the most common respiratory diseases requiring hospitalizalion. Nebulized epinephrine and salbutamol therapy has been used in different centres with varying results. Objective: The objective of the study was to compare the efficacy of nebulised adrenaline diluted vu.t+h3% hypertonic saline with nebulised adrenaline diluted with normal saline in bronchiolitis. Methods: Fifty three infants and young children with bronchiolitis, age ranging from 2 months to 2 years, presenting in the emergency department of Manikganj Sadar Hospital were enrolled in the study. After initial evaluation, patients were randomized,to receive either nebulized adrenaline 1.5 ml (1.5 mg) diluted with 2 ml of 3% hypertonic saline (group I) or nebulised adrenaline 1.5 ml (1.5 mg) diluted with 2 ml of normal saline (group II ). Patients were evaluated again 30 minutes after nebulization. Results: Twenty eight patients in the group I (hypertonic saline) and twenty five in groupll (normal saline) were included in the study. After nebulization, mean respiratory rate decreased from {3.7 to 48.1 (p<.01), mean clinical severity score decreased from 8.5 to 3.5 (p<.01) and mean oxygen saturation increased 94.7Yo to 96.9% G,<.01) in group L In group II , mean respiratory rate decreased from 62.4 to 47.4 (p<.01), mean clinical severity score decreased from 7.2to 4.1(p<.01) and mean oxygen saturation increased from94.7%o to 96.70/o (p<.01). Mean respiratory rate decreased by 16 in group I versus 14.8 O>.05) in group II, mean clinical severity score decreased by 4.6 in group versus 3 (p<.05) in group, and mean oxygen saturation increased by 2.2% and. l.9o/o n group and group respectively. Difference in reduction in clinical severity score was statistically significant , though the changes in respiratory rate and oxygen saturation were not statistically significant. Conclusion: The study concluded that both nebulised adrenaline diluted with3Yohypertonic saline and nebulised adrenaline with nomral saline are effective in improving respiratory rate, clinical severity score and oxygen saturation in infants with bronchiolitis; and nebulised adrenaline with hypertonic saline is more effective than nebulised adrenaline with normal saline in improving clinical severity score in bronchiolitis.

IBSMMU J 2014 ; 7 (t) : I5-I9J respiratory diseases.2There is no effective and universally accepted treatment of bronchiolitis.3Treatment of bronchiolitis is still mainly supportive.Children with mild bronchiolitis , which form the large majortty of cases, are treated at home.Children with moderate and severe distress are hospitahzed.3 Bronchodilator therapy is not recommended for routine use in-the maruagement of bronchiolitis.Review of a few studies shows that nebu- lised epinephrine has some potential for being efficacious.aHypertonic saline because of physiologic properties cal reverse the pathophysiologic effects of bronchiolitis.The pathophysiology of bronchiolitis is an infection of the bronchiolar epithelium with subsequent profound submu- cosal and adventitial edema, increased secretion of mucus with peribronchiolar mononuclear cell infiltration and epithelial cell necrosis.5Adrenaline,because of its sympa- thomimetic effect, can decrease the edema of bronchiolar wall and reduce bronchial secretion.6Thus adrenaline may have positive effect in reducing the symptoms of bronchiolitis.
Hypertonic saline may have additive effect in reducing the symptoms of bronchiolitis if combined with adrenaline.If 3% hypertonic saline is substituted to noffnal saline in diluting adrenaline for inhalation in patients with bronchi- olitis, rt may attenuate the bronchial obstruction and thus can decrease the symptoms of bronchiolitis.T We hypoth- esized simply substituting nornal saline solution with hypertonic saline solution in the inhalation mixture for delivering L-adrenaline to infants with bronchiolitis may improve respiratory status and clinical serverity score after inhalation.The study was conducted to evaluate the efficacy of nebulised adrenaline with 3% hypertonic saline in infants with bronchiolitis so that we can use nebulised 3 o/o hypertonic saline to get better response.

Methods:
It was a comp arative sfudy.The sfudy was carried out in Moderate: tachypnea,moderate chest indrawirg, wheeze.nasalflaring,frzy appear short of breath when feeding.
Severe: unable to feed,severe respiratory distress with marked chest indrawirg, cyanosis may be present.
On arrival of suspected cases of bronchiolitis, history was taken carefully and thorough physical examination was done.Selected patients were monitored for oxygen saturation; x-ray chest was done to exclude pneumonia or fuberculosis.Clinical severity of bronchiolitis and clinical bronchiolitis score was determined.Demographic characteristics and baseline clinical characteristics such as general condition, respiratory rate, wheeze, chest indrawirg, oxygen safuration, clinical severity and clinical bronchiolitis score were recorded in the pre-tested questionnaire.The patients were then randomly allocated into group I and group II.Rando mtzation was done by lottery method.Informed consent was taken from the parents.Patients in grotrp I were treated with single dose of nebulised adrettaline (1:1000) 1.5 ml (1.5mg) diluted examination (Table I).Results: Fifty three previously healthy infants with bronchiolitis were enrolled in the study-28 in the group I (adrenaline with hypertonic saline) and 25 rn the group II (adrenaline with nonnal saline).Seventeen were male and 11 female in group I, and 16 male and 9 female in group II.Mean age was 4.5 t I.9 and 5.1 + 2.0 months in group I and II respectively.Mean weight was 5.8 + l.2kg in group I and 6.0 + 1.3 kg in group II (Table II).Oxygen saturation (%)94.7+2.0 96.7*1.4 <.01 Respiratory rate and clinical score decreased and oxygen saturation increased signific antly with nebulisation.
After nebulisation, mean respiratory rate decreased by 16.0*9.8 in group I in comparison to 14.8+10.2 in group II (P.05).Mean clinical severtty score decreased by 4.6*2.4 in group I against 3.0*2.1 in group II(p<.05).
Mean oxygen saturation increased by 2.2+1.4% in group I compared with 2.0+1.7% in group II (p>.05) t hypertonicl salinewas more effective than terbutaline with norrnal saline in decreasing the clinical severity score in ho spitahzed infants with bronchiolitis. 8 Tal et al evaluated the efficacy of nebulised adrenaline with hypertonic saline in ambulatory patients with bronchiolitis and found hypertonic saline produced better response than noffinal saline particularly in decreasing hospital admission and decreasing the symptoms of bronchiolitis.12 This study demonstrated better efficacy of nebulised adrenaline with 3%hypertonic saline than adrenaline with noffinal saline in improving the symptoms, particularly in decreasing the clinical severity score of bronchiolitis.The sfudy was conducted in patients presenting in the emer- gency and oul-patient department.Diagnosis of bronchi- olitis was made on clinical grounds only; RSV detection was not possible because of economic constraints.Role of nebulised adrenaline with hypertonic saline in reducing the duration of illness and its role in reducing the duration of hos prtal stay was beyond the scope of the study.No adverse effect was noted in the study.Heart rate did not change significantly after nebulisation with adrenaline.
Arrhythmia was noted in none of the patients.

Conclusion:
The study concludes that both nebulised adrenaline diluted with 3% hypertonic saline and nebulised adrena- line diluted with noffnal saline are effective as a short term therapy in decreasing the respiratory rate, clinical severity score, and improving the oxygen saturation in infants with bronchiolitis.Nebulised adrenaline diluted with 3% hypertonic saline is more effective than nebulised adrena- line diluted with noffnal saline particularly in improving There was no significant difference in age,sex and weight in two groups.A11 the parameters improved signific antly in both the groups after nebulisation therapy with either form of adrenaline.After nebulisation with adrenaline with 3% hypertonic saline, mean respiratory rate and mean clinical severity score decreased and mean oxygen safuration increased ; all respiratory parameter improved signific antly after nebulisation with hypertonic saline, but there was no difference in heart rute before and after nebu- lisation.Similar results were observed in patients of group II after nebulisation of adrenaline with nonnal saline.
Mean respirator mean clinical severity score deceased and mean oxygen saturation increased .A11 the respiratory parameters improved significantly after nebulisation of adrenaline with nofinal saline.'6'7 Mandelberg et aI conducted a study in hospttalized infants with bronchiolitis and observed that nebulised adrenaline

Table - I
Adrenaline with 3o/o h ic saline versus normal saline in bronchiolitis.Shabnam Sharmin et al with 2mL of 3oA hypertonic saline whereas patients in group II were treated with single dose of nebulised adrenaline (1:1000) 1.5 ml(1.5mg)diluted with Zml of norrnal saline.Nebulisation was done by jet nebuliser and was administered by using face mask.Humidified oxygen 2 Llmrn was provided to all patients in both groups when oxygen saturation was less than 93%.A11 the patients were evaluated 30 minutes after nebulisa- tion.Changes in the clinical characteristics, clinical severity score and oxygen saturation 1;vere noted.The decision for further mafiagement was taken on the basis of this evaluation.Patients who improved (decrease in respiratory rute and wheezirg, noffnal feeding, improvement in general condition) were discharged with advice of fuither nebulisation for 3-5 days).Patients who did not improve were admitted in the hospital under supervision of consultant of pediatrrc unit.Data were expressed as mean + SD.Statisti cal analysis was done by paired t-test.

Table - II
Demographic characteristics of group I and group II Baseline clinic al pararreters were respiratory rate (mean * SD) 63.7 +7.4 versus 62.4 + 8.0, clinical severity score saturation increased signific antly with nebulisation.

Table - V
Comparison of response between group I and group II (adrenaline with Hypertonic saline versus adrenaline with normal saline) 3% hypertonic saline produced better responses than adrenaline with nonnal saline in improving the clinical severity score than adrenaline with norunal saline.11Inanother study, Sarrel et al found terbutaline with 3% with