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Evidence summaries

Inhaled Hyperosmolar Agents for Bronchiectasis

Inhalation of dry powder mannitol may increase the time to first exacerbation and reduce the number of days on antibiotics for exacerbations in patients with bronchiectasis as compared with placebo. Nebulised hypertonic saline may not provide any benefit over isotonic saline at least in patients with a milder disease. Level of evidence: "C"

A Cochrane review [Abstract] 1 included 11 studies with 1 021 patients. Five studies (n=883) compared inhaled mannitol with placebo. One of the studies was of cross-over design and the others were parallel group trials. Only one 12-month trial (n=461) provided results for exacerbations and demonstrated an advantage for mannitol in terms of time to first exacerbation (median 165 versus 124 days for mannitol and placebo respectively; HR 0.78, 95% CI 0.63 to 0.96). Number of days on antibiotics for bronchiectasis exacerbations was significantly better with mannitol (RR 0.76, 95% CI 0.58 to 1.00). Exacerbation rate per year was not significantly different between mannitol and placebo (RR 0.92 95% CI 0.78 to 1.08). Inhaled mannitol did not appear to cause many adverse events.

Two small cross-over studies (n=25) compared inhaled mannitol to no treatment. Data from these studies were inconclusive.

Four studies (n=113) compared hypertonic saline versus isotonic saline. Three of the four studies were cross-over design and one was a 12-month parallel group trial. On most outcomes there were conflicting results, and it is not possible to draw robust conclusions for this comparison.

Comment: The quality of evidence is downgraded by imprecise results (few patients for each comparison) and study limitations (selective outcome reporting).

    References

    • Hart A, Sugumar K, Milan SJ et al. Inhaled hyperosmolar agents for bronchiectasis. Cochrane Database Syst Rev 2014;5():CD002996. [PubMed]

Primary/Secondary Keywords