Nebulized Saline for Stridor

[EpiEMS]

While doing some reading on pediatric respiratory distress, I found that there was some suggestion of using nebulized normal saline (and, in some places, hypertonic saline?) for croup and bronchiolitis. The national model clinical guidelines, interestingly, state "Insufficient data exist to recommend the use of inhaled steam or nebulized saline" (pg. 152), and there some literature out there (e.g., a meta-analysis looking at bronchiolitis), but not a lot by any means.

Have folks here used or considered nebulized saline for croup or anything of that nature in the prehospital setting? (Anecdotally, I know there is some use of the standard whole room nebulizers for croup.) I fully recognize that traditionally ALS modalities like nebulized racemic epinephrine and dexamethasone (for longer-term benefits).

 

[mgr22]

Here's my very unscientific experience: When I worked at the Opry, I treated maybe five vocalists with nebulized saline for non-emergent upper-airway complaints. (None of them presented with lower-airway symptoms that indicated bronchodilators.) They all claimed some degree of improvement after a single dose, including less irritation, better lubrication, better range, and better tone.

 

[E tank]

just sounds like cool mist treatment for croup, the goal being reduction of swelling. Only reason to do that in the PH setting, to my mind, is if racemic epi would not be available, and then just cold air would be just as effective (or not).

 

[Aprz]

The protocol for my ground job is nebulized saline for croup. We don't have carry racemic epi or decadron. I actually just used this protocol a couple of weeks ago and it seemed like it worked great. When we got to the hospital, the doctor then told the parents about how nebulized saline doesn't really work and that it was probably just the cold air from being outside when we were moving the kid. That was the first time I heard about nebulized saline not really working.

My flight job carries racemic epi. We had a shortage at one time, but I never noticed it. I always had racemic epi at all the bases I worked at and never had a case where I felt like I had to give any sort of nebulized epi. Per our protocol, if we didn't have racemic epi, we would use epi ampules instead. Racemic epi contains 11.25 mg epi (both the l and d isomer, the d isomer is considered inactive I think). So only 5.625 mg is active l isomer. You can get close to that by adding 5 mg of l-epi (like epi ampule, cardiac arrest epi) to the nebulizer. Obvious choice is to use epi ampule 1 mg/ml since it would take 50 ml of preload epi 1 mg/10 ml to make 5 mg, lol. Although I've been doing flight for 3 years, I have never used racemic epi or nebulized epi. I've used decadron, but never for croup. I don't recall ever getting a croup call for flight and I don't get them often on ground either.

 

[NomadicMedic]

Why would anyone buy racemic epi when the regular isomer of epi is exactly the same in terms of outcome?

 

[DesertMedic66]

Why would anyone buy racemic epi when the regular isomer of epi is exactly the same in terms of outcome?

Because twisting the top off of Racemic Epi brings back thoughts of childhood

 

[EpiEMS]

The protocol for my ground job is nebulized saline for croup. We don't have carry racemic epi or decadron. I actually just used this protocol a couple of weeks ago and it seemed like it worked great. When we got to the hospital, the doctor then told the parents about how nebulized saline doesn't really work and that it was probably just the cold air from being outside when we were moving the kid. That was the first time I heard about nebulized saline not really working.

Interesting to see it in more protocols, I've only (now that I started looking) in a few states & systems. No protocol at your ground role for nebulized L-epinephrine (like as your backup)?

just sounds like cool mist treatment for croup, the goal being reduction of swelling. Only reason to do that in the PH setting, to my mind, is if racemic epi would not be available, and then just cold air would be just as effective (or not).

That was my thought as well. Hard to test for non-inferiority vs. cold air though!

 

[Aprz]

Interesting to see it in more protocols, I've only (now that I started looking) in a few states & systems. No protocol at your ground role for nebulized L-epinephrine (like as your backup)?

That was my thought as well. Hard to test for non-inferiority vs. cold air though!

No protocol for nebulized l-epi at my ground job. Only to consider nebulized saline for croup. You guys are already aware of which state I live and work in, lol.

 

[Tigger]

I find racemic epi much easier to use than scrounging up five single dose vials. We already have fridges so can keep them at that right temp.

 

[E tank]

Why would anyone buy racemic epi when the regular isomer of epi is exactly the same in terms of outcome?

...so the HR doesn't wind up so much.

 

[DrParasite]

When my son had croup attacks (always in the middle of the night, and 95% of the time pretty severe), we drove him to the ER (and once to urgent care, that was a disaster, and they called 911 on us, and called for an ambulance). He would get them about once a month, so after the 3rd time, the RTs knew us, and we typically would bypass the triage nurse and and have a doc waiting for us bedside with an RT setting up the neb.

He would get back to back racemic epi treatments, followed by a shot of Dexamethasone IM. a few hours later, we would all go home and go back to sleep.

I could see nebulized saline for a sore or irritated throat, to make a person feel better... maybe even very mild croup... but I can't see it doing anything on a really sick patient.

 

[EpiEMS]

I could see nebulized saline for a sore or irritated throat, to make a person feel better... maybe even very mild croup... but I can't see it doing anything on a really sick patient.

Agreed, makes perfect sense. It’s definitely not a substitute for racemic epi, more a comfort measure — mild cases were my target population.