Hypertonic saline

Vraag

Hello, for how long can hypertonic saline (HS) be used? My daughter has inhaled it for more than one year, before she was on Amiloride. She expectorates better using HS. One of adverse effects is irritation of respiratory tract. Would not it be better to sometimes change HS with Amiloride? Thank You.

Antwoord

Dear Questioner
Hypertonic saline (HS) is one of several “mucoactive agents” used in CF to increase sputum clearance- others commonly used include DNase and mannitol. You should discuss with your CF doctors which is the best or the best combination of treatment/s for your daughter. You have specifically asked if it would be better to sometimes change HS with Amiloride? Although you need to discuss this fully with your CF doctor research indicates that Amiloride is of limited benefit in CF. It would therefore not usually be advisable to use amiloride in preference to other mucoactive agents including HS.
There are a number of high quality studies that have shown that long term use of hypertonic saline is beneficial in CF in patients 6 years old and over. Your daughter should therefore continue to use it especially if she feels that she expectorates better using hypertonic saline. Studies have looked at the benefit of different concentrations of HS and have shown that the optimum for HS is 7%. However, in people who cannot tolerate this dose a lower dose can also be beneficial.
There are no guidelines to direct timing of HS or the number of times it should be used per day. It is commonly used just prior to airway clearance physiotherapy to facilitate sputum clearance. There are studies showing that HS can be used up to 4 times daily however it is more often used twice daily. The frequency of use is often influenced by the number of other inhaled medications prescribed and should be guided by the CF team.
You correctly report that one of the main adverse effects of hypertonic saline is irritation of respiratory tract. Irritation of respiratory tract often results in bronchospasm which can be reduced by using a bronchodilator before hypertonic saline. If bronchospasm persists despite using a bronchodilator you should discuss this with your CF care team as they may be able to prescribe a lower dose of hypertonic saline.

Related literature:
1. Willis P, Greenstone M. inhaled hyperosmolar agents for bronchiectasis (Review). Cochrane Database Syst Rev. 2006;2:CD002996
2. Elkins MR, Robinson M, Rose BR, Harbour C, Moriarty CP, Marks GB et al. A controlled trial of long-term inhaled hypertonic saline in patients with cystic fibrosis. N Engl J Med. 2006:254(3):229-240
3. Donaldson S, Bennett WD, Zeman KL, Knowles MR, Tarran R, Boucher R. Mucus clearance and lung function in cystic fibrosis with hypertonic saline. N Engl J Med. 2006;354:241-50
4. Wark PAB, McDonald V, Jones AP Nebulised hypertonic saline for cystic fibrosis. Cochrane Database Syst Rev. 2005 Jul;20(3):CD001506
5. Royal Brompton and Harefield NHS Trust. For healthcare professionals: Use of hypertonic saline. Available from: www.rbht.nhs.uk/healthprofessionals/clinical-depts/paediatrics/childrencf/

6. Stanford CF Center. Inhaled medications and nebulisers.
Available from: cfcenter.stanford.edu/Meds-Nebs.html


Best regards, Jitka Brazova
(This question was discussed during ECORN-CF meeting with other European CF specialists)

10.06.2008