Nasal saline as adjunctive treatment

in allergic rhinitis
Nina Irawati
Allergy Immunology Division
Department of Otorhinolaryngology Head and Neck Surgery
Faculty of Medicine Universitas Indonesia - Ciptomangunkusumo Hospital
Introduction
• Allergic Rhinitis : 10-30 % (children & adult) in US &
industrialized countries
• Cardinal symptoms:
o Nasal congestion,sneezing, runny & itchy nose
o Disturbances of sleep and daily functions
• Co-existence allergic disorder : atopic dermatitis, asthma
• Comorbid disorder : CRSwNP/nNP, OME, Adenoid hypertrophy
• Important health threat worldwide

Li CL, Lin HC et all. Effectiveness of Hypertonic Saline Nasal Irrigation for Alleviating Allergic Rhiitis in Children:
A Syetematic Revies and Meta Analysis. J.Clin.Med 2019
 Treatment of Allergic Rhinitis
• Aim → improve QOL by eliminating symptoms
• No or minimal side effects and fast therapeutic effect of AR
treatment
• Avoidance, antihistamine with/without decongestant,
intranasal corticosteroid , LTRA, immunotherapy,
• Non pharmacological therapy (nasal saline irrigation):
alleviate nasal symptoms, reduce patient reported disease
severity
Sinonasal inflammation
• Sinonasal disease: damage of the mucociliary transport
system
• Mucus contains inflammatory mediators → slow
transportation through the nose (poor ciliary function) → ↑
inflammation
• Nasal saline irrigation : beneficial in removing thickened
mucus → ↓inflammation
• Post operative : cleansing treatment to aid in the healing
process
• Salib RJ et al(2013): large volume low pressure irrigation
associated with better post-op nasal cavity cleansing (Lund-
Mackay post op endoscopy score)
Nasal irrigation
• Nasal irrigation as a single or adjunctive treatment : beneficial
in reducing nasal symptoms (AR, NAR or sinonasal infection)

• Nasal irrigation : safe and simple system of washing out the

nose
• Performed in several different ways, optimal volume,
pressure, concentration and delivery device.
History
 Nasal irrigation
• Recommended before applying a corticosteroid nasal
treatment
• Douching → cleansing the mucous membranes to aid in
maximum surface exposure on which to apply INS
(enhance efficacy) → improve symptomatic control.
• Complimentary/adjunctive treatment for INCS →
contribute to its therapeutic effects
• Reducing recourse to antihistamine and INCS

Lohia S, Schlosser RJ, Soler Z. Nasal Saline for Allergic Rhinitis. Cochrane Database of Systematic Reviews. 2013; 9
International Forum of Allergy and Rhinology: Allergic Rhnitis. 2018
 Nasal irrigation
• Anti inflammatory effects
• Reduce inflammatory mediators (histamine, PGD2, LTC4)
→ decrease nasal symptoms (nasal congestion )
• Cleaning nasal secretion, allergens, mucus, and irritants
• Improve mucociliary clearance, reduces the mucus
contact time
• Increase nasal patency
• Well tolerated, effective, inexpensive, decrease
medication requirements
• Isotonic ( 0.9 % sodium chloride) or hypertonic (> 0.9%)
Lohia S, Schlosser RJ, Soler Z. Nasal Saline for Allergic Rhinitis. Cochrane Database of Systematic Reviews. 2013; 9
International Forum of Allergy and Rhinology: Allergic Rhnitis. 2018
 Isotonic solution
• no changes to the mucous membranes when used
regularly.
• isotonic balanced salt solution to aid in osmotic mucus
drainage from the sinuses.
• safely used by all age groups to support daily nasal hygiene.
• base line preparation treatment or alone in mild
symptomatic disease
• an alternative treatment when a person is unwilling or
unable to use intranasal steroid.
 Nasal irrigation Solution
• A solution can be mixed-up at home, or commercial products
• A proprietary product for children < 12 years: nasal douching
more acceptable and safer
• The mixed dry ingredients in sachets added to cooled boiled
water to make a solution.
• Commercial products can support compliance for regular use
 Mechanism of actions
Mechanical
Effect Based
on Clearing
• The exact mechanism of action Mucus
is still unknown.
• It is not clear whether the effect
Salt and
is predominantly mechanical, Trace
based on clearing mucus, or elements
whether salts and trace Effect
elements in seawater solutions
play a significant role.
Mechanical Cleans and humidifies the
Effect Based mucus, deeply but gently
on Clearing
Mucus in vitro findings, saline
reduces the production and
release of interleukin 8 by
the respiratory epithelium
→ reduces Inflammation

Restores the filter and barrier abilities

(cilia more mobile)

Salt and
Trace
elements Helps in cellular renewal
Effect
 Component & Trace elements
• Sodium ions : inhibit hair cell calcium flow → ↓ ciliary beat freq
(in vitro)
• Magnesium : ↓ mediator local inflammation & degranulation, ↑
IL8 nasal epithelial cell
• Mg and Zinc : ↓ apoptosis respiratory epithelial cell
• Calcium : regulating cilary beat frequency and synchronization
• Airflow : stimulates cell Ca intake and ciliary beat via shear-stress-
induced mechanotransduction
• Potassium : promotes respiratory repair via EGF/EFGR pathway
• Bicarbonates : acting as buffer, ↓ mucus viscosity
• Slightly alkaline pH (electrolyzed seawater): optimizes trophic and
functional recovery of respiratory epithelium
Bastier PL Lechot A, Bordenave L Durand M, Gabory L. Nasal Irrigation: From Empiricism to Evidence-Based
Medicine. A Review . European Ann Otolaryngol Head and Neck Dis 2015;132:281-5
 Physical and chemical characteristics of various
isotonic saline solutions vs seawater
100% 2 6
12
90% 8
26
80%
23
70% 61
Main elements (calcium,
60% 56 potassium, magnesium)
40 Buffers (bicarbonate, nitrate,
50%
sulfate)
46
40% Chloride
30%
Sodium
20% 39
32 32
10% 19

0%
Physiological Ringer's Seawater(pH=8) Electrolyzed
saline(pH=5) Lactate(pH=6.5) seawater(pH=8)
Bastier PL Lechot A, Bordenave L Durand M, Gabory L. Nasal Irrigation: From Empiricism to Evidence-Based
Medicine. A Review . European Ann Otolaryngol Head and Neck Dis 2015;132:281-5
Composition (mg/L) of physiological saline,
electrodialyzed seawater, and Ringer’s lactate
Physiological saline Seawater Ringer’s Lactate
Sodium 3500 2400-2600 3000
Chloride 5500 5400-6300 3900
Magnesium 1100-1500
Calcium 280-390 120
Potassium 44-62 150
Sulfates 2755
Lactates 2500
Irons 6
Zinc 27-90
Selenium 38
Copper 13-40
pH 4.5-7 8 6-7.5
 Why sea water?
• Pure sea water is rich in the different salts, minerals
and trace elements important for overall health and
wellbeing
• Our body cells are physiologically close to sea water
Clinical Trial
“SNI using isotonic solution can be recommended as complementary therapy in AR. It is
well tolerated, inexpensive, easy to use, and there is no evidence showing that regular,
daily SNI adversely affects the patient’s health or causes unexpected side effects.”
 META-ANALISIS NASAL SALINE (1)

• Result: All study ( except 1):improvement of TNSS 3,15% - 70,49%

after using Nasal Saline

Hermelingmeier, et al. Nasal irrigation as an adjunctive treatment in allergic rhinitis. 2012.

 META-ANALISIS NASAL SALINE (2)

• Result: improvement of MCT 2.67 %-31.60%

Hermelingmeier, et al. Nasal irrigation as an adjunctive treatment in allergic rhinitis. 2012.

 Standard medication

401 children (6-10 y.o)

With uncomplicated flu & cold Modified Seawater
Solution + standard
medication

Outcome Measures: 12 weeks observation

- nasal symptoms resolution

during acute illness (visits 1
and 2).
- Reappearance of cold or flu,
- consumption of medication,
- Complications,
- Days off school (visits 3 and 4)
Visit 1 - 2 = as acute illness = up to 3 weeks
Visit 3 - 4 = as prevention = up to 12 weeks
Visit 3 at weeks 8
Acute illness = 6 times a day
Prevention = 3 times a day
 Isotonic nasal saline in Children
Nasal Symptom Score (after 12 weeks) %Patients Consuming Drugs (after 12 weeks)
1.8 45.0%

1.6 40.0% *
1.4
* * 35.0%
*
1.2 30.0%
Severity Score

% Patients
1 25.0%

0.8 20.0% *
15.0%
*
0.6

0.4 10.0%

0.2 5.0%

0 0.0%
Nasal secretion Secretion type Breathing score Antipyretics Nasal decongestants Mucolytics

Control Saline * p <0.05 (significant) Control Saline

Mucus secretion types: 1. Absent; 2. Serosal; 3. Seropurulent; and 4. Purulent.
Breathing scores: 1. Without any difficulty; 2. Minor difficulties; 3. Difficult; and 4. Impossible.

• ↓ rhinitis symptoms (mucus secretion, mucus type, difficulty in

breathing) compared to control
• ↓ percentage in usage of antipyretic, nasal decongestant, and
mucolytic compared to control
Slapak I, et al. Efficacy of isotonic nasal wash (seawater) in the treatment and prevention of rhinitis in children. Arch Otolaryngol Head Neck Surg 2008;134(1):67-74.
Mean Rhinoconjunctivitis Quality of Life Questionnaire (RQLQ) scores—baseline versus 4 weeks versus 8 weeks. One-way ANOVA
(F(2,116) = 48.478; p < 0.001) post hoc Duncan's = baseline of >4 and 8 weeks (p < 0.05).

Addition of nasal irrigation with isotonic saline to intranasal

corticosteroid spray improves the quality of life in patients
with allergic rhinitis without any adverse effects.
Isotonic Vs Hypertonic
 Nasal saline concentration
Isotonic Sea water
Purified water

hypotonic hypertonic
NaCl
0% 0,9% 2,2 % 3,5%

ISOTONIK:
Solution with sodium concentration similar with human blood and
cell
0,9% NaCl
 Isotonic VS Hypertonic
Hypertonic Isotonic
Hyper = higher; Tonic = Iso = equal; Tonic =
Definition Tonicity Tonicity
Osmotic shift No osmotic shift
Impact when
No swelling of tissue/cells
contact with
Shrinkage of tissue/cells No shrinkage of
tissue/cells
tissue/cells
Reduce swelling of nasal Reduce inflammation by
Anti
cavity due to shrinkage of decrease IL 8 production in
inflammation cells respiratory epithelium
Possibility of cilia paralyze, Increase
Effect on cilia when use more than few mobility/movement of
days cilia
Induce improvements in
MCT Mild worsening in MCT
MCT
Burning or stinging
Side Effect No side effect
sensation
CARA PAKAI YANG OPTIMAL

1&2 4&5

3
1. Letakkan nozzle pada lubang hidung
2. Miringkan (dan tundukkan) kepala
3. Semprotkan Nasalin pada lubang hidung bagian atas, ulangi untuk lubang hidung yang lain
4. Luruskan kepala kembali
5. Untuk bayi, bersihkan sisa larutan yang keluar. Untuk anak dan dewasa, hembuskan hidung
 Take home messages
• Nasal irrigation as a single or adjunctive treatment : beneficial
in reducing nasal symptoms
• Nasal irrigation : safe and simple and can be performed in
several different ways, optimal volume, pressure,
concentration and delivery device
• Nasal irrigation cleans nasal secretion, allergens, mucus, and
irritants
• Nasal irrigation : anti-inflammatory effects, improves
mucociliary clearance, ↓ the mucus contact time, and ↑ nasal
patency
• Trace elements: role in increasing the action of the
mechanisms
• Nasal irrigation : Complimentary/adjunctive treatment for
INCS → contribute to its therapeutic effects