Opinion
EDITORIAL
Bronchiolitis and Pulse Oximetry Choosing Wisely With a Technological Pandora’s Box Lalit Bajaj, MD, MPH; Joseph J. Zorc, MD, MSCE
In this issue of JAMA Pediatrics, Principi et al1 report the findings of their study titled, “Effect of Desaturations on Subsequent Medical Visits in Infants Discharged From the Emergency Department With Bronchiolitis.” The investigators prospectively enrolled Related article page 602 infants with bronchiolitis deemed suitable for discharge and monitored them with continuous pulse oximetry at home for the first day. The essential element of this study is that the pulse oximeter had deactivated threshold alarms and did not display saturation values. The monitors, in addition to study diaries, were collected and analyzed, and the patients received follow-up calls at 72 hours. The results of this study call into question the assumptions of current practice around use of pulse oximetry for decision making in bronchiolitis, but they likely are not surprising to experienced clinicians. Principi and colleagues found desaturations to be a common event after discharge from the emergency department, with two-thirds of the infants having at least 1 desaturation episode at home and many having sustained desaturations to 70% or less. The primary outcome of rate of unscheduled visits was the same in both groups, at approximately 25%, which included unscheduled visits to the primary care physician and the emergency department. There was also no difference in hospitalizations between those who had desaturation episodes and those who did not. The study places the issue of transient desaturations and their clinical importance at the forefront of the discussion around management of these patients. In addition, it adds to the dilemma of which patients should receive pulse oximetry in their evaluation and how to interpret the values. Bronchiolitis has been a focus for quality improvement and clinical practice guideline work since Shay et al2 reported in 1999 that bronchiolitis admissions had skyrocketed during the preceding decades. Many have implicated the use of the pulse oximeter and the choice of somewhat arbitrary “hypoxemia” cutoffs as the primary driver of this phenomenon. In 2003, Mallory et al3 tested this hypothesis in a survey of pediatric emergency medicine physicians and found that a 2% difference in oxygen saturation in simulated case scenarios was a large driver in the decision to admit. In a recent issue of JAMA, Schuh et al4 published a trial that randomized patients to either display their true oxygen saturation levels to physicians or to substitute artificially altered saturations (3% higher). The patients with the altered saturations displayed were less likely to be admitted, and there was no effect on the rate of revisits after discharge. These studies add to the hypothesis that phyjamapediatrics.com
sician perceptions about the importance of mild hypoxemia are driving hospitalizations that may not be necessary. This concern is not limited to the admission decision. Unger and Cunningham5 also found that patients stay in the hospital much past the resolution of other issues such as hydration status, solely due to perceived need for supplemental oxygen. Some have used strategies such as home oxygen administration for otherwise healthy infants with bronchiolitis to decrease admission rates and have demonstrated a strong safety profile.6,7 Hospital admission is not a benign intervention, with errors unfortunately being common. Patients hospitalized for hypoxemia may also be subjected to a cascade of unwarranted interventions (ie, the chest radiograph that leads to the diagnosis of “pneumonia” and then leads to antibiotics, etc) as well as the costs associated with constant adjustment of oxygen flow rates as saturations vary. The most recent guidelines from the American Academy of Pediatrics recommend that patients with an oxygen saturation of 90% or greater need not receive oxygen supplementation and that most patients do not require continuous pulse oximetry.8 McCulloh et al9 recently studied this in inpatients and found that there was no effect on length of stay or escalation of care in patients with intermittent monitoring instead of continuous pulse oximetry. There are a number of limitations to the study by Principi and colleagues that are important to consider. This is a relatively small single-center study performed in Canada, where universal health care access likely increases reassurance that patients have reliable clinical follow-up. While clinically meaningful, unscheduled returns at 72 hours after discharge may not be the most important clinical outcome measure to assess the effect of desaturations. Some may raise concerns about the effect of transient hypoxemia on long-term cognitive development, particularly for children with cardiac and other chronic cardiopulmonary conditions. 10 However, chronic hypoxemia is a very different situation from transient desaturations during an acute illness, and those findings should not be generalized to otherwise healthy children with bronchiolitis. As noted in the American Academy of Pediatrics guideline, hypoxemia well below an oxygen saturation of 90% occurs regularly in healthy infants and is also associated with travel to moderate altitude. The results in the bronchiolitis study by Principi and colleagues suggest that it is also common during this infection, which affects more than a third of infants. Given the apparent ubiquity of intermittent hypoxemia during common events of childhood, the longterm impact would be difficult to study and even more challenging to prevent. (Reprinted) JAMA Pediatrics June 2016 Volume 170, Number 6
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