Background: Asthma and bronchiolitis are the most common respiratory ailments affecting pediatric patients worldwide. Management guidelines have been developed in an effort to standardize the treatment of these patients. Nowhere in these guidelines (both the 2007 Expert Panel Report 3 Guidelines for the Management of Asthma and the 2014 American Academy of Pediatrics Guidelines for the management of an Initial Episode of Bronchiolitis) is there mention of the use of nebulized normal saline. The only nebulized medications indicated for the treatment of asthma exacerbations are SABA’s and inhaled ipratropium. As for bronchiolitis, the mainstay of treatment remains supportive care, emphasizing adequate hydration and oxygenation, with little to no role for the use of bronchodilators, steroids, or antibiotics.
Nonetheless, we have seen nebulized normal saline being used in these patient populations. Its use however does not come without risk, with reports documenting bronchospasm in some asthmatics. Furthermore, the use of normal saline in asthmatics delays treatment of the asthma exacerbation with albuterol as a rescue medication.

The goal of this study is to educate providers on the risks of saline administration in these settings and reinforce clinical guidelines. This should decrease hospitalization costs and unnecessary resource utilization, while limiting the time burden for parents and staff.

Methods: A chart review from November 1, 2014 – April 1, 2015 was performed to document the number of times and indications for which normal saline was administered. An in-service was then provided to both pediatric and emergency room residents and attendings, serving as a refresher to current guidelines and management protocols. A follow-up chart review was performed from November 1, 2016 – April 1, 2017. Statistical analysis was performed using REDCap and SAS.

Results: A total of 733 patients were included in the study, 263 of which were diagnosed with bronchiolitis and 470 with asthma. This was further subdivided by year and in patient vs ED presentation. The use of normal saline for bronchiolitis was decreased significantly in the ED and in-patient setting (p-value = 1.790E-09, and 0.0265 respectively). The use of normal saline for asthma exacerbations was decreased significantly in the in-patient setting (p-value = 0.0245). The use of normal saline for asthma exacerbations in the ED were low in number at baseline and remained unchanged.

Conclusions: Nebulized normal saline is not a standard of care treatment modality for bronchial asthma exacerbations or bronchiolitis. When nebulized normal saline is administered in the ED or in the inpatient setting for asthma exacerbations, the practice is continued in the community, resulting in preventable ED visits and admissions for bronchial asthma, where albuterol should be first line therapy.

Although it could be assumed that decreasing the frequency of normal saline use decreased hospitalization costs and resource utilization and limited time burden for both parents and staff, cost and time were not measured. We hope to extend this practice to the community and in turn further present ED visits for asthma exacerbations where normal saline nebulizations were used first hand instead of the recommended albuterol.