The same researchers evaluated nebulized 3% hypertonic saline without bronchodilators, and reported a similar reduction in LOS from an average of 6.4 days with normal saline to a full 4.8 days with hypertonic saline (Clin. Microbiol. Infect. 2010 July 15 [doi:10.1111/j.1469-0691.2010.03304.x]).

Dr. Susan Wu and her colleagues at Children’s Hospital Los Angeles presented data, however, at the recent Pediatric Hospital Medicine 2011 meeting that contradicts these findings. Although the preliminary analysis includes subjects from only the first 2 years of the study and was not fully powered for the LOS outcome, hypertonic saline was no better than normal saline for respira­tory distress, and actually resulted in a longer LOS of 3.46 days, compared with 2.74 days with normal saline (Pediatric Hospital Medicine 2011;1 [poster session B, July 29] abstract 4).

One also has to question whether the cost of respiratory therapy labor to provide such a potentially ineffective ther­apy can be justified in the current health care environment, when hypertonic saline hasn’t been established as being superior to the guideline recommendation of supportive care only.

Some may argue that the cost of hypertonic saline is free, but a quick back-of-the-envelope calculation would suggest otherwise. If you practice in a 90-bed hospital, see 500 bronchiolitis patients per year, and have a 3-day LOS using hypertonic saline every 4 hours, that works out to 12,000 nebulizations and 400 hours of respiratory time, which ends up costing $300,000 per year. At that price tag, you could hire a full-time employee for your team.

Many administrations may also insist that hypertonic saline be given with albuterol, which one could argue may in some cases actually extend LOS because of the potential for patients to desaturate.

Finally, if you’re a fee-for-service hospital, there’s a financial disincentive for your administration to spend $300,000 for a therapy that could actually reduce profits by shortening LOS. Hospitals adopt measures that shorten LOS, but few would be willing to implement such a strategy until a large, randomized, controlled trial conducted in the United States has proved that hypertonic saline, likely without albuterol, is both clinically and cost effective.

Dr. Alverson is director of pediatric hospital medicine at Hasbro Children’s Hospital in Providence, R.I. He said that he had no relevant financial disclosures.