www.bjorl.org
Brazilian
Journal
of
OTORHINOLARYNGOLOGY
ORIGINAL
ARTICLE
Variations
in
peak
nasal
inspiratory
flow
among
healthy
students
after
using
saline
solutions
夽
Jaime
Olbrich
Neto
a,∗,
Sandra
Regina
Leite
Rosa
Olbrich
b,
Natália
Leite
Rosa
Mori
b,
Ana
Elisa
de
Oliveira
c,
José
Eduardo
Corrente
daDepartmentofPediatrics,FaculdadedeMedicinadeBotucatu,UniversidadeEstadualPaulista(UNESP),Botucatu,SP,Brazil bDepartmentofNursing,FaculdadedeMedicinadeBotucatu,UniversidadeEstadualPaulista(UNESP),Botucatu,SP,Brazil cPublicHealth,FaculdadedeMedicinadeBotucatu,UniversidadeEstadualPaulista(UNESP),Botucatu,SP,Brazil
dDepartmentofBiostatistics,InstitutodeBiociênciasdeBotucatu,UniversidadeEstadualPaulista(UNESP),Botucatu,SP,Brazil
Received22January2015;accepted20March2015 Availableonline10September2015
KEYWORDS
Children;
Peaknasalinspiratory flow;
Nasalhygiene; Saline
Abstract
Introduction:Nasalhygienewithsalinesolutionshasbeenshowntorelievecongestion,reduce thethickeningofthemucusandkeepnasalcavitycleanandmoist.
Objective:Evaluatingwhethersalinesolutionsimprovenasalinspiratoryflowamonghealthy children.
Methods:Studentsbetween8and11yearsofageunderwent6procedureswithsalinesolutions atdifferentconcentrations.Thepeaknasalinspiratoryflowwasmeasuredbeforeand30min aftereachprocedure.Statisticalanalysiswasperformedbymeansofttest,analysisofvariance, andTukey’stest,consideringp<0.05.
Results:Weevaluated124childrenatallstages.Thereweredifferencesonthewayasame concentrationwasused.Therewasnodifferencebetween0.9%salinesolutionand3%saline solutionbyusingasyringe.
Conclusion:The3%salinesolutionhadhigheraveragesofpeaknasalinspiratoryflow,butitwas notsignificantlyhigherthanthe0.9%salinesolution.Itisimportanttooffervariousoptionsto patients.
© 2015 Associac¸ão Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Published by Elsevier Editora Ltda. This is an open access article under the CC BY license (http://creativecommons.org/licenses/by/4.0/).
夽 Pleasecitethisarticleas:OlbrichNetoJ,OlbrichSRLR,MoriNLR,deOliveiraAE,CorrenteJE.Variationsinpeaknasalinspiratoryflow
amonghealthystudentsafterusingsalinesolutions.BrazJOtorhinolaryngol.2016;82:184---90. ∗Correspondingauthor.
E-mail:joilbrich@fmb.unesp.br(J.OlbrichNeto). http://dx.doi.org/10.1016/j.bjorl.2015.03.012
PALAVRAS-CHAVE
Crianc¸as; Picodefluxo inspiratórionasal; Higienenasal; Salina
Variac¸õesdopicodefluxoinspiratórionasalentreescolaressadiosapósouso desoluc¸õessalinas
Resumo
Introduc¸ão: Ahigienenasalcomsoluc¸õessalinastemsidoindicadaparaaliviaracongestão, reduziroespessamentodomucoemanteracavidadenasallimpaeúmida.
Objetivo: Avaliar se as soluc¸ões salinas melhoram o fluxoinspiratório nasal entre crianc¸as sadias.
Método: Escolares comidadesentre8e11 anosforamsubmetidos a6procedimentos com soluc¸ões salinasem diferentesconcentrac¸ões.Opicode fluxoinspiratórionasal foimedido antese30 minutosapóscadaprocedimento.A análiseestatísticafoirealizada pormeiodo testet,análisedevariânciaetestedeTukey,considerandop<0,05.
Resultados: Foramavaliadas124crianc¸asemtodasasetapas.Houvediferenc¸asquantoàforma deusodeumamesmaconcentrac¸ão.Nãohouvediferenc¸aentresoluc¸ãosalinaa0,9%esoluc¸ão salinaa3%pormeiodeseringa.
Conclusões: Asoluc¸ãosalinaa3%obtevemaioresmédiasdopicodefluxoinspiratórionasal, porémnãofoisignificativamentesuperioràsoluc¸ãosalinaa0,9%.Éimportanteoferecer difer-entesopc¸õesaospacientes.
© 2015 Associac¸ão Brasileira de Otorrinolaringologia e Cirurgia Cérvico-Facial. Publicado por Elsevier Editora Ltda. Este é um artigo Open Access sob a licença de CC BY (http://creativecommons.org/licenses/by/4.0/).
Introduction
Nasalhygienehasbeenshowntorelievecongestion,reduce theviscosityofmucusandkeepnasalcavitycleanandmoist. Nasalbreathingistheonlyphysiologicaltypeofbreathingin humans,andisconsideredmandatory,althoughsubstituting mouthbreathingiscompatiblewithlife.
Themucociliarylayer,whichcoversthenostrils,actively participatesinrespiratoryhomeostasisthroughciliary func-tion, mucus secretion and the release of inflammatory mediators.1---4 The maintenance of integrity of the
respi-ratory mucosa is essential for the airways to fulfill their role; this can justify the use of external media, such as sprays,lavageandirrigationofthenasalcavitytopromote or facilitate nasal hygiene.2---5 The use of saline solutions
seemstofacilitate thetransportof mucus,particles, irri-tantsandmicroorganismstowardnasopharynx,probablyby direct physical action and by increasing ciliary beating, whichisreducedduringinflammatoryprocesses.Inpatients withchronic sinusitis, Uralet al.observed a reductionin mucociliaryclearancewiththe saccharineclearancetest. Minetal.,6conductedanexperimentalstudyinwhich
ani-mals were submitted to staphylococcal toxin in different concentrations, andobserved a reductionin the speedof ciliarybeatingandthedevelopmentofaninflammatory infil-trateinrabbitmaxillarysinusmucosa.
Inchildren,thenoseisnarrowerthaninadults,andcold, pollutionandallergicorinfectiousprocesseseasilyclogthe nostrils.Inchildren,nasalhygienecanandshouldbedone inanaturalandphysiologicalway,atanytimeofday,inthe morningandatbedtime.Greaterfrequencyshouldbe con-sideredwhenthechildstaysinanindoorenvironmentwith airconditioning,inperiodsoflowairhumidity,andduring allergicorinfectiousinflammatoryprocesses.Nasalhygiene complementsbasictherapiesandpromotesnormalmucosal
function.Thebenefitsofnasalapplicationofsalinesolutions havebeendemonstratedfordecadesbyseveralauthors.In areview article, Khianey etal.7 concludedthat the
ben-efit is small but thereare few side effects and it is well tolerated,afactalsoconfirmedbyJeffeetal.,8who
stud-iedthetoleranceanduseofsalinesolutionsin61children. Theuseofsalinesolutionsasacomplementarytherapy or astreatmenthasnotbeenestablishedyet.Fashneretal.9
suggestedtheuse ofthesesolutionsfor 3weeks for com-moncoldcases,andfelttheycouldbeusedfor9weeksas apreventivemeasure.Hermelingmeieretal.,10inareview
article,concludedthatsalinesolutionsshouldbeusedasa complementarytherapy.
Compared to isotonic solutions, the use of solutions withhigherconcentrationsofsodiumhaspromotedbetter mucociliaryfunctionresponsesinpatientswithchronic rhi-nosinusitis.Süslüetal.,11 usingacousticrhinometryanda
saccharine test in patients undergoing septoplasty, noted improvementinnasalobstructionandmucociliaryclearance withthe use of a hypertonic solution after 20 days. In a randomizedstudy,Satdhabudhaetal.12comparedthe
ben-efits of hypertonic and isotonic solutions with respect to qualityof life,nasalscore andsaccharinetest. They con-cludedthatbothsolutionsproducedimprovement,butthe hypertonicsolutionwassignificantlysuperiorwhenusedin childrenwithallergicrhinitisfor2weeks,buttherewasno differencefromisotonicsolutionafterfourweeksofuse.An invitrostudybyMinetal.6showedthattheciliary
move-ment diminished andstopped after a few minutes of use of 3% and 7% hypertonic solutions, which theyattributed toinjury ofthe nasalepithelium.Onthe otherhand, Kim etal.13 observedthat the exclusive use of isotonicsaline
didnotcausecelldamagecomparedtohyper-orhypotonic saline,andViertleretal.14observedlesstissuedamagewith
The measures ofmucociliaryfunction, improvementof nasalinspiratoryflowanddosageofinflammatorymediators indifferentsalineconcentrations, volumesand conditions havebeenevaluated,withnodefinitiveconsensus.2,3,7,9,15---18
Severalauthorsobservedimprovementoftheseparameters withtheuseofsalinesolutionsasacomplementarytherapy inpatientswithchronicnasosinusaldisease;however,there isnoconsensusontheconcentration,volumeand applica-tionmethod.2,9,10,15,19,20
Indailypractice,salinesolutionsfornasalhygieneusually employsnormalsaline,thatis,0.9%saline,atroom temper-ature,usingapositive-pressuredropperorsyringe.Sprays, drips,aerosolsornebulizersmayalsobeused,dependingon theavailabilityoftheseresources.Allofthemhave advan-tagesanddisadvantages, andcost seemstobea decisive factorin lowerincomepopulations.MelloJr. etal.2draw
attentiontothefactthattheresultsarenotimmediateand theadherencetotheuseofsalinemaybepoor,butthelow costanditsfewreportedadverseeffectsandtheobserved clinicalimprovementjustifytheiruse.Theimprovementin nasalinspiratoryflow aftertheuseof salinesolutionscan beastimulusfor adherencetotheir continueduse,when theseproductsareprescribed.
Among the techniques used to assess improvement in nasalbreathingwiththeuseofsalinesolutions,patient eval-uationandselfreportingscoreshavebeenevaluated.5,11,12,21
Thosemethodsaresubjective,andinmoststudiespatients were instructed to use saline solutions for several days without instructions for controlling time,frequency, tem-peratureandhumidity.18,22,23Rhinomanometryisconsidered
themostreliabletechnique,butwithlimitedapplicationin fieldstudies.21 Anotheralternative is touse simpler,
low-costportableinstrumentsthatmeasurethenasalinspiratory flow;butitshouldbeborneinmindthatthesedevicesare dependent onthe capacityto comprehendthe procedure andonphysicaleffort.Withthismodality,whilethereare noreferencevaluesfor differentpopulations,the patient canbe used ashis/herown control.1,8,24 The methodhas
alimitedroleinyoungchildren,whoseagedoes notallow theuseofinhaleddispensingdevicesthataredependenton effort.1,21,23,25
The aim of this study was to evaluate whether saline solutions at different concentrations and techniques of administrationimprovenasalinspiratoryflow duringnasal hygienepracticesinhealthychildren.
Methods
Thisseriesconsistedofstudentsaged8---11yearsbelonging toaneducationalinstitutioninaruralcityinSãoPaulostate; alegalguardianforeachchildwascontactedandsigneda consentform.ThisstudywasapprovedbythelocalEthics CommitteeunderNo.CEP4226-2012.
We first interviewed 20 family members, guardians of childrenenrolledinaneducationalinstitutioninaruralcity inSão Paulo state, inorder tolearnwhatmeasures were usedroutinely for children toimprove nasal breathing in periodsoflowhumidityandheat,orinthepresenceof rhi-nosinusaldiseases.Basedontheirresponses,wecraftedsix procedures,asfollows:
• Procedure A: no stimulation whatsoever; the child performedonlythemeasurementparameter(nasal inspi-ratoryflow);
• ProcedureB:0.9%salineintranasal---1mLineachnostril usingadisposablesyringe;
• ProcedureC: 0.9% saline --- 5mL inhaled by nasalmask throughaportablecompressed-airdevicefor5min;
• ProcedureD:3%saline intranasal---1mLin eachnostril usingadisposablesyringe;
• ProcedureE:filteredwater---200mLorallyindisposable cup;
• ProcedureF: 0.9% saline --- 5mL inhaled by nasal mask throughanultrasonicportabledevicefor5min.
Thechildrenincludedinthisstudyweredividedrandomly intosixgroupsaccordingtothetypeofinitialprocedureand inasequencedmanner,withanintervalof48---72haccording totheschemebelow.
Group Proceduresequence
1 A B C D E F
2 B C D E F A
3 C D E F A B
4 D E F A B C
5 E F A B C D
6 F A B C D E
Salinesolutionsanddeviceswerethosecommonlyused by people examined in health services or found in their homes;therefore,thesolutionsusedwerenotbuffered.
Forapplicationofinclusionandexclusioncriteria, chil-dren’s parents were questioned about the presence of allergic diseases such as: rhinitis, asthma or atopic der-matitis, previous treatment of rhinitis, nocturnal snoring, supplementaryoralbreathing,sneezingforaperiodlonger thantwodaysinarow,nasalsalinesolutionuse,andhowthe productwasobtained.Childrenwithhistoryofallergy, rhini-tis,obstruction,nasalitchingorsneezingwereclassifiedas rhinitisI.Ontheotherhand,thosewithahistoryof rhini-tis,sneezing,itchynose,mouth breathingor snoring,and thathadundergonetreatmentforrhinitiswereclassifiedas rhinitisII.
Exclusioncriteria
• Childrenbelongingtoagegroupsunder8years,inviewof thepossibledifficultiesin understandingtheinspiratory maneuvers,andchildren over11 years,considering the variabilityinphysicaldevelopment;
• Children with airway infection in the preceding three weeks;
• Childrenusingdrugsforallergicrespiratorydiseaseinthe preceding6months;
• Childrenwithhistoryofnasalsurgery;
• Childrenwithneuromusculardisease;
• Childrenwithchestdeformity.
Table1 Comparisonofallproceduresaccordingtothepercentagechangeinpre-andpost-procedurenasalinspiratoryflow peak.
Procedure Mean±SD Median(minimumandmaximum)
A 5.33±17.09b 3.94(−30.43;75.00)
B 8.44±17.44ab 5.94(−28.57;73.33)
C 6.22±19.06ab 5.04(−28.57;119.35)
D 12.33±21.42a 7.28(−26.09;146.67)
E 5.04±15.16b 4.81(−22.22;52.94)
F 7.26±15.23ab 5.13(−29.51;58.35)
ComparisonsmadeusingANOVA(p=0.0133).Meansfollowedbythesameletterdonotdifferata5%levelbyTukeytest.
afternoon,according totheir classschedule.Thechildren werecalledintheirclassrooms,outoftheirtestperiod.
For randomizationof groups, children’s names in each period---morningorafternoon---werelistedalphabetically and randomly assigned to one of the six groups. At the beginningofeachprocedure,theassessmentsequencewas thoroughlypresentedtoeachchild.
Theefficacyofthevariousproceduresusedinthisstudy was evaluated by measuring nasal inspiratory flow, per-formedbyusinganIn-CheckTMnasalinspiratoryflowmeter
device(ClementClarkeInternational)withanair-cushioned face mask. Peak nasal inspiratory flow was averaged for threedeterminations,withaone-minuteintervalbetween them,andtheoperatorwasblindedateachstep.
Afterhavingundergoneoneoftheproceduresandafter thethreemeasuresofnasalinspiratoryflowwereaveraged, thechildwassentbacktotheclassroom,witha recommen-dationtonotrunortakewater.Thetimeintervalbetween pre-andpost-measurementwas30min.
Allproceduresandmeasuresofnasalinspiratoryairflow were performed by the same professionals. The quanti-tative results were recorded in an Excel spreadsheet and interpreted the end of the study. Other parameters ana-lyzedwereage(inmonths),weight,heightandbodymass index.These measurementsweretransformed toz-scores usingtheEpi-InfoTM version2002 program(nutrition).The
environmenttemperature andrelativehumiditywerealso measured. As to the use of saline solutions, the follow-ingquestionswereasked:Ifthechildalreadymadeuseof these solutions,if this use wasrestricted tosituations of upperrespiratorytractinfections(URTI), ifwithexclusive useaccording tomedicalprescription. The originof nasal salinewasalsoinvestigated:homemade solution,solution providedbythehealthservice(UBS),purchaseof pharma-ceutical0.9%saline,andwhetherthechildhasalreadyused apharmaceutical0.3%hypertonicsolution.
The study was conducted in two periods: morning (8:00---10:00 am) and afternoon (1:00---3.00 pm), with simultaneous measurements of temperature and relative humidity,obtainedinalocalagriculturalweatherstation.
Statisticalanalysis
For analysis of the parameters age, gender, weight and height,thettestwasusedfortwocategories,andANOVA followedbyTukeytestformorethantwocategories,always consideringassignificantaresultwithp<0.05.
Results
Amongthe202childreninthe8---11yearagerangeenrolled inthe school,129(56.58%), metthe inclusioncriteria, of which5(3.87%)wereexcludedduringthestudy.Thus,124 (96.12%)childrencompletedallsteps.
Therewasnosignificantdifferencein age(inmonths), height,weight,orbodymassindex.
In the comparison between each procedure, the peak nasal inspiratory flow was significantly increased with 3%
versus0.9%salineinhalationwithacompressor(p=0.0185) andwith an ultrasonic inhaler (p=0.0330). There was no differencebetween 0.9% versus 3% saline by nasal route (p=0.1186).The setofprocedureswhichusedsaline solu-tionshadasignificantlyhigherpeaknasalinspiratoryflow, when comparedwith the use of water, or nostimulation (p=0.0133)(Table1).
Therewasnosignificantdifferencebetweengendersas to overall mean peak inspiratory flow among all proce-dures (p=0.65331), and individually for each procedure: A (p=0.754); B (p=0.936); C (p=0.328); D (p=0.368); E (p=0.186);andF(p=0.391)(Table2).
Values of temperature andrelative humidityshowed a significantdifference,p<0.05,withlowerhumiditylevelsin theafternoonandhighertemperaturesinthesameperiod, forthesameprocedures.Therewasnosignificantdifference betweenmeanvaluesforpercentagechangeinpeaknasal inspiratoryflowaccordingtotheproceduresequence.
Mostchildren(54%) showedpeaknasalinspiratoryflow above the mean for procedure A --- no stimulation, with respect to at least one of the dispensing modes and/or concentrations of salinesolutions, withno significant dif-ference in gender, period of the day or initial sequence.
Table 2 Distribution of mean values of the percentage changeinnasalinspiratoryflowpeakbeforeandafter stim-ulation applied in 124 children, according to the time of day.
Procedure Morning Afternoon p-Value
A 2.68 7.73 0.100
B 5.51 11.10 0.074
C 4.52 7.76 0.346
D 9.54 14.85 0.168
E 3.05 6.84 0.165
Astothequestionnaireonhabitualuse ofsalinesolutions bythestudied population,itwasobservedthat 80.65%of this population makes use of saline, 50% only in case of flu;35.49%onlywhenprescribedbyaphysician;43.55%buy theproduct, andthe remainingchildren obtain the prod-uctfreeofchargeinhealthservices.Theuseofhypertonic saline was reportedby 4.84% of the participants. 13.71% wereclassifiedasrhinitisI,and7.26%asrhinitis II.There wasnosignificant differencein percentagemeans of pro-cedures,whencomparingtheinformationprovidedbythe questionnaire.
Discussion
The use of saline solutions has been assessed more fre-quentlyinrhinosinusaldiseaseasameasureofhygieneand humidificationand asanadjuvant procedure inthe main-tenance of nasalhomeostasis. In thisstudy, astothe set ofprocedures,therewasnosignificantdifferencebetween 0.9%and3%saline,regardlessoftheformofadministration; however,intheindividualcomparisonamongprocedures,3% salinenotonlywassignificantlysuperiorversus0.9%saline administered with a syringe; we also observed that 0.9% salinewasnotsuperiortootherprocedures.The concentra-tionsandwaysofadministeringtheproductmakeitdifficult toassigntooneoranothermethodanabsolutesuperiority overallremainingmethods,sincetheresponsesare individ-ualandthereforemaybesubjecttoalargevariation.
Topical use of saline solutionhas been commonin the treatment of rhinosinusal disease.7,15,26 This is considered
anadjuvanttherapy,althoughanimprovementinsignsand symptoms has been demonstrated with the use of saline aloneinlessserioussituations.Inourstudy,wefoundthat themeansofpercentagechangeshowsignificant improve-mentofpeaknasalinspiratoryflow withthe useofsaline solutions.Satdhabudhaetal.,12inarandomizedandblinded
study,comparedmucociliaryclearanceandthetotalscore ofnasalsymptomsbeforeand10minaftertheuseof hyper-tonicversus0.9%salinein81childrenwithallergicrhinitis, and concluded that hypertonic saline produced superior results; but both treatments resulted in improvement in qualityof life andsymptom scores after 2 weeks of use. Hermelingmeieretal.10 ina systematicreview,concluded
thatincasesofallergicrhinitis,theuseofsalineresultedin improvementinnasalsymptomsin27.6%,reducedtheuse ofdrugs in62.1% andimproved qualityoflife in 27.8%of theirpatients;however,Achillesetal.20concluded,alsoin
areviewarticle, thatitisnotpossible tostandardizethis practiceforacuterhinosinusitis.
The negativepercentagechange observedin thisstudy meansthatpatientsmayexperienceworseningofnasalflow afterthe procedure, includingthe use of saline solutions and,therefore,itdoesnotallowforanuniversalindication in favor of a given concentration or form of administra-tion.Theuseofvariationofpeaknasalinspiratoryflowto evaluatean initial obstruction and response totreatment is a practical, simple, and inexpensive method to use in clinicalpractice,andallowsfor theselection of themost appropriatesalinesolutionswithrespecttoconcentrations and delivery method appropriate for each patient (Teix-eiraetal.27).Uraletal.5concludedthattheuseofsaline
solutions shouldbeselective,andnotbasedonanecdotal evidence.
Thereiscontroversyabouttheexactmechanismofaction of saline solutions on nasal mucosa. The use of a saline solutionhelpsreducenasalsymptoms,perhapsbyreducing theinflammation ofmucosa,butlittleis knownabout the effects on human nasal mucosa.Saline solutions are usu-allywelltoleratedandpresentfewsideeffects;additionally theseproductsresultinanimmediatecleaningupof secret-ions.
Someauthorssuggestthat,withrespecttonasalmucus, 0.9% saline solution would be hypotonic (mucosal osmo-lality,390mOsm/Landsolutionosmolality,300mOsm/L).14
Thedifferenceoftonicitywouldcauseadeleteriouseffect to the cells, functioning as a stimulus for proliferation of glands and decrease of ciliary beating. Clinical stud-iesonthebenefitsofdifferentsalineconcentrationshave conflicting results.28,29 In this study, we observed higher
meansofpeaknasalinspiratoryflowwiththeuseofsaline applied through positive pressure withsyringe, but there wasnosignificant differenceastoconcentration.Heatley et al.19 evaluated 150 patients withchronic rhinosinusitis
whowereaskedtouse3%salineandreflexologymassage, and concluded that there wasimprovement of symptoms withbothsalineandmassage.Keojampaetal.30evaluated
mucociliaryclearanceandnasalpatencyin22healthy vol-unteers,eachofthemservingasself-control,withtheuse of 3%or 0.9%saline;andconcludedthatboth saline solu-tions improved nasal clearance; but with the use of 3% saline the clearance was faster, with no change in nasal patency as measured by acoustic rhinometry. In animal studies,thereisalsocontroversy abouttheeffectsof dif-ferent concentrations of saline solutions on the mucosa andciliarybeating.13,14,31 Alzérrecaetal.,15 reviewingthe
use of antifungal medications, shampoos and solutions in the treatment of rhinosinusal disease, concludedthat, to date,thereisnodefinitionforidealpHs,concentrationsor temperatures.
Theoptimal durationofuse ofthesesolutions, aswell astheirdaily frequencyand formofadministration, were not established.2,3,15 Wei et al.17 found that the use of a
salinesolutiononceadayproducedanimprovementin qual-ityoflifeaftersixweeksofuse,with90%ofadherenceto treatment in34 childrenwithchronic rhinosinusitis.Jeffe etal.8 evaluatedtheuse of0.9%saline twicea dayin 61
childrenwithrhinopathy,andconcludedthat86%could tol-eratetheuseof theproduct,buttheadherencewas77%. Althoughitisnotpossibletostatethatpatientswith wors-eningnasalinspiratoryflowafteragivenstimulus,asnoted in our study,may be less compliant with treatment with thesamestimulus,someauthors2arguethattheadherence
may be compromised, considering that the effect on the symptomsmaynotbeimmediate.
thatcontrastdepositionindifferentsinonasalregionswas higherwithpositivepressure.
We observed that the application of 3% saline with a syringehadameanpeaknasalinspiratoryflowsuperiorto 0.9%salineappliedbynebulizer,indicatingthatthe concen-tration and form of administration should be considered together when these products are prescribed, since the concentrationandsalinedepositionmaycontributetothis result.23 There was no statistically significant difference
comparing the use of 0.9% and 0.3% saline solutions; but itisworthtoconsider,intheempiricalinitialindication(in thosecasesinwhichthereisnopossibilityforevaluatingthe answerstotwodifferentconcentrations),that0.3% saline achievedbettermeans.Comparingtheuseofpositive pres-sure withsyringeversusnebulization, the temperatureof thesolutionintocontactwithmucosacouldreducethe effi-cacyofoneofthesemethods.Meantemperaturesofsaline solutions at room temperature were 5---8◦C higher than
those in the compressor nebulizer, and 0.8---1.5◦C higher
thanthoseintheultrasonicnebulizer.Theoptimal temper-aturewould bethatclosest tothetemperaturemeasured atmucosallevel,therebyavoidingresponsesofvesselsand nerveendingstoexposuretoalowertemperaturethanthat intheenvironment.
Apparently, the use of saline solutions, even in dif-ferent concentrations, helps reduce inflammation and inflammatory mediators, cleaning crusts and secretions, softening mucus in patients with rhinopathy, or in daily nasal hygiene.2,5,16,25 The use of saline solutions is also
used to relieve symptoms in conditions of low relative humidity.2,16,32 Krajnik et al.33 observed that high
humid-itycaninfluencethedistributionof theaerosolsproduced by saline nebulization, increasing the particle size. Thus, we must consider the relative humidity and the form of deliveryofsaline.Inourstudy,weobservedthatthe tem-peratureandhumidityweresignificantlydifferentbetween morningandafternoonperiods,buttherewasnosignificant differenceinmeanpeaknasalinspiratoryflowinresponse toprocedures,withrespecttothetimeofday.Inthisstudy, thechildrenstudiedliveinthesameareaandwereexposed tothesameenvironmentalandclimaticfactors.Atahigher humiditycondition,itwouldbeexpectedthatthe environ-mentwater-solubleparticlescouldbedepositedonthenasal mucuscausingirritation,andthatacleaningprocedurewith saline could emphasize the improvement of nasal perfor-mance,byremovingmucusandparticles;butnosignificant differencewasnoted.Usingsensitizedmice,Larsenetal.22
reportedworseningofinflammatoryresponsetoexposureto formaldehydeinalow-humidityenvironment,butnotina high-humidityscenario,suggesting thatwater-soluble par-ticlesaredepositedintheupperairways,beingimprisoned in mucus.In 18patients sensitizedtopollen and exposed toanatmosphereof 37◦Candarelativehumiditygreater
than90%beforetheirprovocationwiththeantigen,Baroody etal.34 observed reduction of acuteinflammatory, neural
andvascularresponsesinpatients’nostrils---afactthatwas attributedtotheactionandlocaleffectonthemucosa.
Theuseofthepercentagechangeinpeaknasal inspira-toryflowbeforeandaftereachprocedurereducedpotential biases, which would not occur in the household environ-ment, since there would be no way to control whether the child actually used the suggested volume, frequency,
andconcentration. It alsowould not bepossible to know whetherconditionsof temperature, humidityand timeof daywouldbethesamefor everyone.Thepositive change inmeasures of not-stimulated flow peak--- procedure A ---indicatesthepossibilityof improvementinchildren’s per-formance,perhaps byimproving the technique;but allof themweresubjecttothesameconditions(whichreduces theriskofinterference)andtherewasnosignificant differ-enceastobeginninginoneoranothergroupofsequenceof procedures.
No significant difference in means of procedures was noted when children classified as rhinitis I versus those asymptomaticoneswerecompared.Thesamewastruefor thoseclassified asrhinitis II. Inchildren with ahistory of rhinitisIorII,nosignificantworseningofresponseoccurred withthe useof 3% saline solution, thanks perhaps tothe absenceofacuteorpersistentinflammatoryprocesses,since thesewereexclusioncriteria.Alzérrecaetal.15foundthat,
formostpatients,thebenefitsoutweighthedrawbacks,for instance,aburningsensationobservedbothwith0.9%and hypertonicsolutions.Adappaetal.35 arguethathypertonic
salinewas not superior to0.9% saline, perhaps by stimu-latinganeural response,causingvasodilation andarunny nose. Jeffeet al.8 notedthat 0.9% saline waswell
toler-atedby83%ofchildrenaged6---12years,andthattheirside effects,suchas earpain,local pain,coughing or nausea, werenotsoimportantastostopthestudy.
Inthecaseof0.9%salinesolutions,therewasno differ-enceaccordingtothedispensingmethodand,therefore,it wouldbeunreasonablethatfamiliesinvesttheirresources innebulizerapparatusesforthepurposeofcleaningup.The 0.9%salinesolutionischeaper,anditislikelythatitsuse, inassociationwiththeuseofwaterbymouth tomaintain bodyhydration, is a simple andinexpensivestrategy that producessatisfactoryeffects.
Beforethisstudy,fewofthechildrenhadusedsalinein higherconcentrations, indicating that, in this population, themethodsofapplicationandthe0.9%concentrationare moretraditional.Thecostofsalinesolutionsinspraymakes itdifficulttheaccesstothisformofadministration.
In thisstudy,sodium absorbedby children usingsaline solutionsrangedfrom4%to15%oftheirdailyneeds.
Conclusion
Theresultssuggestthatsalinesolutionsimprovethepeakof nasalinspiratoryflowofmostusers,andthatwaterintake doesnotreplacetheuseofthesesolutions.Themeanvalues obtained suggest that, by nasal route, 3% saline provides betterresultsthan0.9%salineandissignificantlysuperior to0.9%salinebyinhalation.
Conflicts
of
interest
Theauthorsdeclarenoconflictsofinterest.
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