The effect of oximetry on hospital admission for bronchiolitis

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Bronchiolitis is a very common presentation to paediatric emergency departments. In the absence of any effective treatments, most of care focuses around supportive measures e.g. oxygen or feeding supplementation.

There is no clear cut-off for the requirement for supplemental oxygen, but this generally varies between 90 and 95% saturation. These cut-offs are often used for deciding about admission to hospital, but in actual fact they are not predictive of progression of the illness.

This randomised, double-blind, parallel-group trial aims to investigate the role of pulse oximetry in making decisions around hospital admissions. It essentially tries to determine whether as doctors, we over-rely on these measurements.

Schuh S, Freedman S, Coates A, Allen U, Parkin PC, Stephens D, Ungar W, DaSilva Z, Willan AR. Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial. JAMA. 2014 Aug 20;312(7):712-8. doi: 10.1001/jama.2014.8637.

Who were the study participants?

These were infants presenting with bronchiolitis to a tertiary paediatric emergency department over a five year period. They had to have saturations of 88% or higher to be included.

Those with cardiopulmonary, neuromuscular, haematologic, or congenital airway anomalies were excluded. They also excluded those with severe respiratory distress.

There were 108 infants in the control group, and 105 infants in the intervention group.

What was the intervention?

Recruited infant were randomised to either the true saturation group, or the altered saturation group.

Those in the altered saturation group had their saturations displayed three points higher than the true reading (i.e. if the true reading was 89% the sats monitor displayed 92%).

Doctors in the department knew that 50% of the infants would have their saturations altered in some way, but they didn’t know how much or in which direction.

What were the outcomes measured?

The primary outcome was admission to hospital within 72 hours – this included either admission to the ward, or active care for respiratory symptoms for at least six hours. Active care was: oxygen, IV fluids, or bronchodilators.

Secondary outcomes included: supplemental oxygen in ED, timing of agreement for discharge home, length of stay, representations within the 72 hours.

What were the hospitalisation rates?

In the true saturations group, 41% were admitted. In the altered saturations group, only 25% were admitted (p=0.005)

There were no differences in the the secondary outcomes (p=0.16).

What does this all mean for us?

By falsely elevating the oxygen saturations by just three points, there was a significant reduction in hospital admission rates for bronchiolitis in infants.

Oxygen saturations are just one of the factors we should take into account when deciding on the need for admission in bronchiolitis. We must be careful not to over-depend on arbitrary cut-offs.

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Tessa Davis is a paediatric emergency registrar from Glasgow and Sydney, but currently living in London. Tessa tries to spend time with her 3 kids in between shifts. @tessardavis | + Tessa Davis | Tessa's DFTB posts