Evaluation of the use of Hypertonic Saline 3% Nebulizer versus Intravenous Hypertonic Saline 3% to Attenuate the Manifestations of Acute Respiratory Distress Syndrome
Authors: Sobhy Amr , Hussiny Abdelkarem , Kamal Mohammed 
Published: September 2020

Background:
A well-known disease, Acute Respiratory Distress Syndrome (ARDS) presents a daunting challenge to the medical community with alarmingly high mortality rates. Initiation of hypertonic saline (HTS) nebulization therapy for patients with early ARDS appears to be tolerable and may be beneficial. However, using a nebulizer is cumbersome and less efficient. This study aims to assess the efficacy of using HTS3% in a nebulizer in comparison with intravenously injecting it to attenuate the manifestation of ARDS. The study analyses factors such as the severity of the disease, need and duration of mechanical ventilation (MV), ICU stay, and mortality rate in the comparative analysis.

Materials and Methods:

The randomized, comparative, and controlled study included patients of both genders from an age bracket of 18-60 years. The patients fulfilled the Berlin definition of ARDS. Additionally, the whole sample was divided into four groups (26 patients each): Group A received standard pharmacotherapy [methylprednisolone 1mg/kg/day intravenously and salbutamol nebulizer 2.5 mg (1 ml) + 3 ml normal saline/8hr] and normal saline 0.9% (5ml) nebulizer /8hr: Group B received standard pharmacotherapy + HTS2.7% (5ml) nebulizer/8hr: Group C also received standard pharmacotherapy and 500ml normal saline intravenously over 24 hours: Group D received standard pharmacotherapy and 500 ml HTS 3% intravenously over 24 hours. The following parameters were recorded: Lung injury score (Murray Score, calculated every 24 hours), the incidence of the need for MV, duration of MV, length of ICU stay, and mortality rate.

Results:
Group B (HTS nebulizer group) and group D (HTS IV group) showed the most rapid improvement in the Murray score with a 50% decrease in the score from its initial value (D50%) by day 4 with P-values of 0.013 and 0.022 respectively. Subjects from Group D (HTS IV) and Group B (HTS Nebulizer) were the least in need of MV as only 38.5% needed MV with a P-value <0.001. In comparison, 69.2% subjects from group A (control) and 73.1% from group C required MV, with a P-value <0.001. The shortest duration of MV care was found in group D (median 3.12 days), followed by group B (median 4.21 days). The results were highly significant, with P-value 0.004 when compared with group A (control group) and group C. In addition, the longest duration of MV care was reported in group A (median 5.37 days). There was significant variation in all groups regarding the length of ICU stay: group D required the least number of days (median 6.76 days), followed by group B (median 7.08 days). The result was statistically significant, with a P-value of 0.004 when compared with the control group (median 9.1 days) and group C(longest duration of MV with a median of 10.13 days). However, no significant difference was found in the mortality rate (P-value >0.05).

Conclusion:
The use of hypertonic saline 3% intravenously has a comparable effect as the use of hypertonic saline 3% via nebulizer to attenuate the manifestations of (ARDS) and even superior in the mechanically ventilated patient.