Effect of Oxygen Desaturations on Subsequent Medical Visits in Infants Discharged From the Emergency Department With Bronchiolitis.

IMPORTANCE: Reliance on pulse oximetry has been associated with increased hospitalizations, prolonged hospital stay, and escalation of care. OBJECTIVE: To examine whether there is a difference in the proportion of unscheduled medical visits within 72 hours of emergency department discharge in infants with bronchiolitis who have oxygen desaturations to lower than 90% for at least 1 minute during home oximetry monitoring vs those without desaturations. DESIGN, SETTING, AND PARTICIPANTS: Prospective cohort study conducted from February 6, 2008, to April 30, 2013, at a tertiary care pediatric emergency department in Toronto, Ontario, Canada, among 118 otherwise healthy infants aged 6 weeks to 12 months discharged home from the emergency department with a diagnosis of acute bronchiolitis. MAIN OUTCOMES AND MEASURES: The primary outcome was unscheduled medical visits for bronchiolitis, including a visit to any health care professional due to concerns about respiratory symptoms, within 72 hours of discharge in infants with and without desaturations. Secondary outcomes included examination of the severity and duration of the desaturations, delayed hospitalizations within 72 hours of discharge, and the effect of activity on desaturations. RESULTS: A total of 118 infants were included (mean [SD] age, 4.5 [2.1] months; 69 male [58%]). During a mean (SD) monitoring period of 19 hours 57 minutes (10 hours 37 minutes), 75 of 118 infants (64%) had at least 1 desaturation event (median continuous duration, 3 minutes 22 seconds; interquartile range, 1 minute 54 seconds to 8 minutes 50 seconds). Among the 118 infants, 59 (50%) had at least 3 desaturations, 12 (10%) had desaturation for more than 10% of the monitored time, and 51 (43%) had desaturations lasting 3 or more minutes continuously. Of the 75 infants who had desaturations, 59 (79%) had desaturation to 80% or less for at least 1 minute and 29 (39%) had desaturation to 70% or less for at least 1 minute. Of the 75 infants with desaturations, 18 (24%) had an unscheduled visit for bronchiolitis as compared with 11 of the 43 infants without desaturation (26%) (difference, -1.6%; 95% CI, -0.15 to ∞; P = .66). One of the 75 infants with desaturations (1%) and 2 of the 43 infants without desaturations (5%) were hospitalized within 72 hours (difference, -3.3%; 95% CI, -0.04 to 0.10; P = .27). Among the 62 infants with desaturations who had diary information, 48 (77%) experienced them during sleep or while feeding. CONCLUSIONS AND RELEVANCE: The majority of infants with mild bronchiolitis experienced recurrent or sustained desaturations after discharge home. Children with and without desaturations had comparable rates of return for care, with no difference in unscheduled return medical visits and delayed hospitalizations.

Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial.

IMPORTANCE: Routine use of pulse oximetry has been associated with changes in bronchiolitis management and may have lowered the hospitalization threshold for patients with bronchiolitis. OBJECTIVE: To examine if infants with bronchiolitis whose displayed oximetry measurements have been artificially elevated 3 percentage points above true values experience hospitalization rates at least 15% lower compared with infants with true values displayed. DESIGN, SETTING, AND PARTICIPANTS: Randomized, double-blind, parallel-group trial conducted from 2008 to 2013 in a tertiary-care pediatric emergency department in Toronto, Ontario, Canada. Participants were 213 otherwise healthy infants aged 4 weeks to 12 months with mild to moderate bronchiolitis and true oxygen saturations of 88% or higher. INTERVENTIONS: Pulse oximetry measurements with true saturation values displayed or with altered saturation values displayed that have been increased 3 percentage points above true values. MAIN OUTCOMES AND MEASURES: The primary outcome was hospitalization within 72 hours, defined as inpatient admission within this interval or active hospital care for greater than 6 hours. Secondary outcomes included the use of supplemental oxygen in the emergency department, level of physician agreement with discharge from the emergency department, length of emergency department stay, and unscheduled visits for bronchiolitis within 72 hours. RESULTS: Forty-four of 108 patients (41%) in the true oximetry group and 26 of 105 (25%) in the altered oximetry group were hospitalized within 72 hours (difference, 16% [95% CI for the difference, 3.6% to 28.4%]; P = .005). Using the emergency department physician as a random effect, the primary treatment effect remained significant (adjusted odds ratio, 4.0 [95% CI, 1.6 to 10.5]; P = .009). None of the secondary outcomes were significantly different between the groups. There were 23 of 108 (21.3%) subsequent unscheduled medical visits for bronchiolitis in the true oximetry group and 15 of 105 (14.3%) in the altered oximetry group (difference, 7% [95% CI, -0.3% to 0.2%]; P = .18). CONCLUSIONS AND RELEVANCE: Among infants presenting to an emergency department with mild to moderate bronchiolitis, those with an artificially elevated pulse oximetry reading were less likely to be hospitalized within 72 hours or to receive active hospital care for more than 6 hours than those with unaltered oximetry readings. This suggests that oxygen saturation should not be the only factor in the decision to admit, and its use may need to be reevaluated. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT00673946.