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Bronchiolitis and Pulse Oximetry: Choosing Wisely With a Technological Pandora’s Box

Bronchiolitis and Pulse Oximetry: Choosing Wisely With a Technological Pandora’s Box 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 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 physician 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 long-term impact would be difficult to study and even more challenging to prevent. Pulse oximetry has undoubtedly contributed to improved quality and safety of pediatric care, as these boxes have become a fixture at virtually every hospital bedside during recent decades. For bronchiolitis, however, some may view the oximeter as a Pandora’s box that was opened before the research had been done to appropriately interpret this stream of data. This has led to arbitrary thresholds for oxygen implementation and widespread use of continuous pulse oximetry. As with many areas where data are unclear, use of pulse oximetry may reinforce tendencies of clinicians. For those looking for a reason to admit, continuous pulse oximetry can provide an excuse when an inevitable desaturation occurs. For others, oximetry can be used as an indication for outpatient interventions such as home oxygen use. With this study, we now have a clearer view that the transient hypoxemia events these interventions are intended to prevent are likely occurring in many infants with bronchiolitis and are not associated with apparent negative outcomes. Incorporating this information into clinical practice will require health care professionals to take a more judicious approach to the use of pulse oximetry in the evaluation of the patient. The American Academy of Pediatrics guidelines serve as a good start, but more work is needed to rationalize the use of this important but overemphasized technology. Health care professionals and parents are obviously frustrated in caring for patients with bronchiolitis. The sheer volume strains the system, and there are no proven therapies, no helpful predictive models, and no easy objective measures of severity. The evidence points to a clinical evaluation that incorporates oxygen saturation into the decision making but does not absolutely determine disposition. The time has come to stop focusing on the numbers on Pandora’s box and to develop strategies to thoughtfully use the data it provides us in the overall clinical care of the patient. Back to top Article Information Corresponding Author: Lalit Bajaj, MD, MPH, Department of Pediatrics, Section of Emergency Medicine, University of Colorado/Children’s Hospital Colorado, 13123 E 16th Ave, B 251, Aurora, CO 80045 (lalit.bajaj@childrenscolorado.org). Published Online: February 29, 2016. doi:10.1001/jamapediatrics.2016.0090. Conflict of Interest Disclosures: None reported. References 1. Principi T, Coates AL, Parkin PC, Stephens D, DaSilva Z, Schuh S. Effect of oxygen desaturations on subsequent medical visits in infants discharged from the emergency department with bronchiolitis [published online February 29, 2016]. JAMA Pediatr. doi:10.1001/jamapediatrics.2016.0114.Google Scholar 2. Shay DK, Holman RC, Newman RD, Liu LL, Stout JW, Anderson LJ. Bronchiolitis-associated hospitalizations among US children, 1980-1996. JAMA. 1999;282(15):1440-1446.PubMedGoogle ScholarCrossref 3. Mallory MD, Shay DK, Garrett J, Bordley WC. Bronchiolitis management preferences and the influence of pulse oximetry and respiratory rate on the decision to admit. Pediatrics. 2003;111(1):e45-e51.PubMedGoogle ScholarCrossref 4. Schuh S, Freedman S, Coates A, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014;312(7):712-718.PubMedGoogle ScholarCrossref 5. Unger S, Cunningham S. Effect of oxygen supplementation on length of stay for infants hospitalized with acute viral bronchiolitis. Pediatrics. 2008;121(3):470-475.PubMedGoogle ScholarCrossref 6. Bajaj L, Turner CG, Bothner J. A randomized trial of home oxygen therapy from the emergency department for acute bronchiolitis. Pediatrics. 2006;117(3):633-640.PubMedGoogle ScholarCrossref 7. Halstead S, Roosevelt G, Deakyne S, Bajaj L. Discharged on supplemental oxygen from an emergency department in patients with bronchiolitis. Pediatrics. 2012;129(3):e605-e610.PubMedGoogle ScholarCrossref 8. Ralston SL, Lieberthal AS, Meissner HC, et al; American Academy of Pediatrics. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-e1502.PubMedGoogle ScholarCrossref 9. McCulloh R, Koster M, Ralston S, et al. Use of intermittent vs continuous pulse oximetry for nonhypoxemic infants and young children hospitalized for bronchiolitis: a randomized clinical trial. JAMA Pediatr. 2015;169(10):898-904.PubMedGoogle ScholarCrossref 10. Bass JL, Corwin M, Gozal D, et al. The effect of chronic or intermittent hypoxia on cognition in childhood: a review of the evidence. Pediatrics. 2004;114(3):805-816.PubMedGoogle ScholarCrossref http://www.deepdyve.com/assets/images/DeepDyve-Logo-lg.png JAMA Pediatrics American Medical Association

Bronchiolitis and Pulse Oximetry: Choosing Wisely With a Technological Pandora’s Box

JAMA Pediatrics , Volume 170 (6) – Jun 1, 2016

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American Medical Association
Copyright
Copyright © 2016 American Medical Association. All Rights Reserved.
ISSN
2168-6203
eISSN
2168-6211
DOI
10.1001/jamapediatrics.2016.0090
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Abstract

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 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 physician 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 long-term impact would be difficult to study and even more challenging to prevent. Pulse oximetry has undoubtedly contributed to improved quality and safety of pediatric care, as these boxes have become a fixture at virtually every hospital bedside during recent decades. For bronchiolitis, however, some may view the oximeter as a Pandora’s box that was opened before the research had been done to appropriately interpret this stream of data. This has led to arbitrary thresholds for oxygen implementation and widespread use of continuous pulse oximetry. As with many areas where data are unclear, use of pulse oximetry may reinforce tendencies of clinicians. For those looking for a reason to admit, continuous pulse oximetry can provide an excuse when an inevitable desaturation occurs. For others, oximetry can be used as an indication for outpatient interventions such as home oxygen use. With this study, we now have a clearer view that the transient hypoxemia events these interventions are intended to prevent are likely occurring in many infants with bronchiolitis and are not associated with apparent negative outcomes. Incorporating this information into clinical practice will require health care professionals to take a more judicious approach to the use of pulse oximetry in the evaluation of the patient. The American Academy of Pediatrics guidelines serve as a good start, but more work is needed to rationalize the use of this important but overemphasized technology. Health care professionals and parents are obviously frustrated in caring for patients with bronchiolitis. The sheer volume strains the system, and there are no proven therapies, no helpful predictive models, and no easy objective measures of severity. The evidence points to a clinical evaluation that incorporates oxygen saturation into the decision making but does not absolutely determine disposition. The time has come to stop focusing on the numbers on Pandora’s box and to develop strategies to thoughtfully use the data it provides us in the overall clinical care of the patient. Back to top Article Information Corresponding Author: Lalit Bajaj, MD, MPH, Department of Pediatrics, Section of Emergency Medicine, University of Colorado/Children’s Hospital Colorado, 13123 E 16th Ave, B 251, Aurora, CO 80045 (lalit.bajaj@childrenscolorado.org). Published Online: February 29, 2016. doi:10.1001/jamapediatrics.2016.0090. Conflict of Interest Disclosures: None reported. References 1. Principi T, Coates AL, Parkin PC, Stephens D, DaSilva Z, Schuh S. Effect of oxygen desaturations on subsequent medical visits in infants discharged from the emergency department with bronchiolitis [published online February 29, 2016]. JAMA Pediatr. doi:10.1001/jamapediatrics.2016.0114.Google Scholar 2. Shay DK, Holman RC, Newman RD, Liu LL, Stout JW, Anderson LJ. Bronchiolitis-associated hospitalizations among US children, 1980-1996. JAMA. 1999;282(15):1440-1446.PubMedGoogle ScholarCrossref 3. Mallory MD, Shay DK, Garrett J, Bordley WC. Bronchiolitis management preferences and the influence of pulse oximetry and respiratory rate on the decision to admit. Pediatrics. 2003;111(1):e45-e51.PubMedGoogle ScholarCrossref 4. Schuh S, Freedman S, Coates A, et al. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014;312(7):712-718.PubMedGoogle ScholarCrossref 5. Unger S, Cunningham S. Effect of oxygen supplementation on length of stay for infants hospitalized with acute viral bronchiolitis. Pediatrics. 2008;121(3):470-475.PubMedGoogle ScholarCrossref 6. Bajaj L, Turner CG, Bothner J. A randomized trial of home oxygen therapy from the emergency department for acute bronchiolitis. Pediatrics. 2006;117(3):633-640.PubMedGoogle ScholarCrossref 7. Halstead S, Roosevelt G, Deakyne S, Bajaj L. Discharged on supplemental oxygen from an emergency department in patients with bronchiolitis. Pediatrics. 2012;129(3):e605-e610.PubMedGoogle ScholarCrossref 8. Ralston SL, Lieberthal AS, Meissner HC, et al; American Academy of Pediatrics. Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis. Pediatrics. 2014;134(5):e1474-e1502.PubMedGoogle ScholarCrossref 9. McCulloh R, Koster M, Ralston S, et al. Use of intermittent vs continuous pulse oximetry for nonhypoxemic infants and young children hospitalized for bronchiolitis: a randomized clinical trial. JAMA Pediatr. 2015;169(10):898-904.PubMedGoogle ScholarCrossref 10. Bass JL, Corwin M, Gozal D, et al. The effect of chronic or intermittent hypoxia on cognition in childhood: a review of the evidence. Pediatrics. 2004;114(3):805-816.PubMedGoogle ScholarCrossref

Journal

JAMA PediatricsAmerican Medical Association

Published: Jun 1, 2016

Keywords: hypoxemia,bronchiolitis,emergency service, hospital,infant,oximetry, pulse,health care decision making,oxygen saturation measurement,emergency medical services for children

References