Effects of nebulized epinephrine in association with hypertonic saline for infants with acute bronchiolitis: A systematic review and meta-analysis

Background Nebulized epinephrine and hypertonic saline have been extensively studied in infants with acute bronchiolitis, with conflicting results. Aims To evaluate the efficacy on length of stay (LOS), clinical severity scores (CSS), oxygen saturation (SaO(2)), and safety profile of nebulized epinephrine plus hypertonic saline (HS) in infants with acute bronchiolitis. Materials & Methods This is a systematic review and meta-analysis. Outcomes were represented by mean differences (MD) or standard mean differences (SMD) and 95% confidence intervals (CIs) were utilized. Results Eighteen trials were systematically selected and 16 of them contributed to the meta-analysis (1756 patients). Overall, a modest but significant positive impact was observed of the combination therapy on LOS (MD of -0.35 days, 95% CI -0.62 to -0.08, p = 0.01, I-2 = 91%). Stratification by time of CSS assessment unveiled positive results in favor of the combination therapy in CSS assessed 48 and 72 h after the admission (SMD of -0.35, 95% CI -0.62 to -0.09, p = 0.008, I-2 = 41% and SMD of -0.27, 95% CI -0.50 to -0.04, p = 0.02, I-2 = 0%, respectively). No difference in SaO(2) was observed. Additional data showed a consistent safety profile, with a low rate of adverse events (1%), most of them mild and transient. Conclusion Low-quality evidence from this systematic review suggests that nebulized epinephrine plus HS may be considered as a safe and efficient therapy for decreasing LOS and CSS in infants with acute bronchiolitis, especially in those who require hospitalization for more than 48 h.