Original Articles
 

By Dr. Ambrish D Mishra , Dr. Sampada Tambolkar , Dr. Nitin Yelikar , Dr. Sharad Agarkhedkar
Corresponding Author Dr. Sampada Tambolkar
Pediatrics,Dr. D.Y Patil Medical College,Pune, plot no 10 C Ram indu park baner pune 411045 - India 411045
Submitting Author Dr. Sampada A Tambolkar
Other Authors Dr. Ambrish D Mishra
Pediatrics,Dr. D.Y Patil Medical College,Pune, A 702 Runwal Regency Sadhu Vaswani Chowk Camp Pune - India 411001

Dr. Nitin Yelikar
Pediatrics,Dr. D.Y Patil Medical College,Pune, Pediatrics Dept Dr.D Y Patil Medical College Pimpri Pune 411018 - India 411018

Dr. Sharad Agarkhedkar
Pediatrics,Dr. D.Y Patil Medical College,Pune, Flat no D 101 Hill View Residency Baner Pune - India 411045

PAEDIATRICS

Bronhiolitis,hypertonic saline,pressure driven nebuliser, ultrasonic nebuliser,improved efficacy,aerosol size

Mishra AD, Tambolkar S, Yelikar N, Agarkhedkar S. To compare efficacy of 3% saline administered by pressure driven nebuliser Vs ultrasonic nebuliser in patients of Bronchiolitis. WebmedCentral PAEDIATRICS 2015;6(8):WMC004966

This is an open-access article distributed under the terms of the Creative Commons Attribution License(CC-BY), which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.
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Submitted on: 23 Aug 2015 09:59:11 AM GMT
Published on: 24 Aug 2015 07:52:10 AM GMT

Abstract


OBJECTIVE:
To compare efficacy of pressure driven nebuliser vs ultrasonic nebuliser in management of Bronchiolitis using 3% saline as nebulising solution .
DESIGN:
Prospective randomised control trial .
SETTING:
Tertiary care teaching hospital in Pune .
PARTICIPANTS:
75 children with clinical diagnosis of Bronchiolitis .
PROCEDURE:
Children were randomly administered 3%saline nebulisation through either pressure driven nebuliser or ultrasonic nebuliser . RDAI score ,RR,HR ,SPo2 , were recorded before and one hour after nebulisation . Parameters were statistically analysed.
RESULTS:
Baseline characteristics of both were comparable ( P > 0.05 ) . 3% saline administered with either of the two nebulisers was effective in management of Bronchiolitis ( P < 0.001 ) . When efficacy of both nebulisers was compared ,it was found that observed parameters showed significant more improvement with ultrasonic nebuliser than pressure driven nebuliser ( P < 0.001 ) .
CONCLUSION:
Ultrasonic nebuliser is better than pressure driven nebuliser in management of Bronchiolitis when 3% saline is used as nebulisation solution.

Introduction


Bronchiolitis is the most common acute lower respiratory tract infection during first 2 years of life (1) . Bronchiolitis is a clinical diagnosis, based on typical history and examination (2) . Clinical manifestations occur due to airway inflammation and air trapping. It is a self-limiting disease and less than 1% progress to severe disease. There is lack of evidence based management and supportive treatment remains the mainstay therapy in Bronchiolitis . Inhalation therapy with nebuliser is widely used and effective therapy.
 The principle of nebulisation is generation of aerosol particles. The lung deposition and efficacy of an aerosol depends on particle size .Particles larger than 10 micron get deposited in the mouth and nasal cavity .  5 to10 micron particles reach peripheral bronchi. Particles  less than 5 micron reach distal most bronchioles but may be exhaled out without deposition (3).
Two types of nebulisers are available 1 :- pressure driven   2 :- ultrasonic.
The pressure driven nebuliser generates aerosol with smaller mass ( diameter  of 5 micron ) as compared to 6 micron diameter aerosol generated by ultra-sonic nebuliser ( 4) .Particle size around 5 micron have better deposition at bronchioles while those less than 5 micron are exhaled out without deposition  (4) .  But   pressure driven nebuliser is cheap and hence widely used.
Purpose of this study is to compare efficacy of both nebulisers in treatment of Bronchiolitis. Very few such comparative studies are available.

Methods


The study was conducted at D. Y. Patil medical college Pune from July 2011 to September 2013. After ethical committee approval 70 children between 6 weeks and 2 years with clinical diagnosis of Bronchiolitis were enrolled. Bronchiolitis was defined as first episode of wheezing along with prodromal  symptoms of URI which may progress to dyspnea (5)
It was a randomised controlled single blind study.
Children with recurrent wheezing, associated systemic diseases, and already on bronchodilator were excluded from the study.
Patients were allotted two groups randomly.
Group A -children who received hypertonic 3 % saline with pressure driven nebuliser.
Group. B -children who received hypertonic 3 % saline with ultrasonic nebuliser.
Heart rate, Respiratory rate, Respiratory distress assessment index score, SPo2, were recorded before and one hour after nebulisation.
RDAI score was used in this study ,it scores wheeze and retraction and maximum score is 17 . Children with higher score have severe disease , score above 15 indicates very severe disease (6).
Statistical analysis was done by EPI info.

Results


OBSERVATION AND RESULTS:During study period 75 patients fulfilling eligibility criteria were enrolled .5 patients were    excluded. Out of 70 patients studied 47 were male 23 were female. Both groups were comparable with similar base line characteristics P > 0.05.All patients receiving hypertonic saline nebulisation showed significant improvement after nebulisation over baseline parameters . Both nebulisers, pressure driven and ultrasonic nebuliser , were effective in management of patients with Bronchiolitis . Analysis of patients in group A and group B was done and it was observed that patients who received hypertonic saline through ultrasonic nebuliser had significantly more improvement in RR, RDAI, HR , than those who received it through pressure driven nebuliser P < 0.001 . Change in SpO2 was similar in both groups P> 0.05 . 

 

Discussion


Bronchiolitis is the commonest cause of LRTI in  children less than two years .1 to3 percent of  infants are hospitalised with Bronchiolitis annually. Treatment of Bronchiolitis is largely supportive. Nebulised drugs as aerosol are effective in its treatment. Hypertonic saline (3%) is the currently investigated effective therapy for Bronchiolitis. Nebulised hypertonic saline is also widely used in management of cystic fibrosis . It hydrates mucus ,mucosa ,sub mucosa and releases the obstruction .Studies done to demonstrate efficacy of 3% saline have not mentioned the type of nebuliser used . None of the studies have compared the efficacy of Pressure driven nebulisers and ultrasonic nebuliser  in patients receiving 3% saline nebulisation . In this study comparing efficacy of both type of nebulisers , 65% of admitted were less than 1 years age . Mean age of children in this study was 9.8 +6 months which is  similar to other studies by Neeraj Gupta et al  (7.1+ 6.58 ) months (7) . Both nebulisers were effective in  management of Bronchiolitis.In this study it is observed that patients receiving 3%saline through ultrasonic nebuliser had significantly more improvement in all parameters studied at the end of one hour than patients receiving same drug through pressure driven nebuliser. Difference in RDAI score  p < 0.007,respiratory rate  p. < 0.004 , heart  rate p. <   0.05 , were statistically significant ,while differences  in SpO2 between both groups was statistically not significant  p >0.06 . Serious children were not included in study and hence initial SpO2 was not grossly abnormal  and change in Spo2 was insignificant .

Conclusion


Ultrasonic nebuliser is better than pressure driven nebuliser in management of Bronchiolitis when 3% saline is used as nebulisation solution .

References


1) Wright A L ,Taussing L M , Ray C G : The Tucson Children's respiratory study II . Lower respiratory tract illness in first year of life . Am J Epidemiology 1989;129: Page 1232-46 .
2)Owens DK, Lohr KN ,Atkins D,et al . Grading the strength of a body of evidence when comparing medical interventions : Agency for healthcare research and quality and  the effective  health care program . J Clin Epidemilogy ;63: Page 513-23 .
3)Tal G, Cesar K, Oron A et al . Hypertonic saline / adrenaline treatment in hospilised infants with viral Bronchiolitis reduses hospitalisation stay : 2 years experience . Israel Med Assoc J 2006;8: page 169-73 .
4) O Callaghan C, Barry PW . The science of nebulised  drug delivery . Thorax 1997;2 supp : page S31-44 .
5) Bhagwan S Sharma , Mukesh K Gupta et al . Hypertonic saline vs 0.9% saline nebulisation for acute viral Bronchiolitis : A randomised controlled trial . Indian Paediatrics , Vol 50;15, August 2013: page 743-7 .
6) Lowell D I , Lister G , et al . Wheezing in infants: the response to adrenaline . Pediatrics 1987 ; 87: page 939-45 .
7) Neeraj  Gupta ,Ashis Puliyel , Ayush Manchanda ,et al . Nebulised hypertonic saline vs Adrenaline for Bronchiolitis : Proof of concept study of cumulative sum ( CUSUM  )analysis
Indian Paediatrics vol : 49 ;  July , 16, 2012

Source(s) of Funding


No funding

Competing Interests


No competing interests

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