Pediatric Bronchiolitis: Intermittent Pulse Oximetry OK

Troy Brown, RN

September 01, 2015

For children hospitalized with bronchiolitis, intermittent pulse oximetry did not shorten length of hospital stay (LOS), nor did it result in any difference in the rate of escalation of care or use of diagnostic or therapeutic measures compared with continuous monitoring. These results from a new randomized controlled trial show that clinicians can routinely consider intermittent pulse oximetry monitoring in the management of these children if they are improving clinically.

Russell McCulloh, MD, from the Department of Pediatrics, Children's Mercy Hospital, Kansas City, Missouri, and colleagues report their findings in an article published online August 31 in JAMA Pediatrics.

"Pulse oximetry remains a controversial element of care in pediatrics because there is tension between the assertion that missing, clinically unapparent hypoxia could have a significant negative effect on infants with bronchiolitis and the belief that monitoring may result in unnecessary hospitalizations and a prolonged LOS," the authors explain.

To address those issues, Dr McCulloh and colleagues designed the randomized, parallel-group superiority clinical trial. The study enrolled otherwise healthy infants and children aged 2 years or younger who were hospitalized for bronchiolitis during 2009 to 2014 at one of four children's hospitals in the United States.

The researchers randomly assigned patients to undergo continuous (n = 80) or intermittent (n = 81) pulse oximetry monitoring. For children undergoing intermittent monitoring, staff obtained pulse oximetry measurements at the time of scheduled vital signs checks or when clinicians suspected deterioration; clinicians only initiated the intermittent monitoring once a child had oxygen saturation levels of 90% or greater.

There was no difference in mean LOS, which was the primary endpoint, based on pulse oximetry monitoring strategy (48.9 hours [95% confidence interval (CI), 41.3 - 56.5 hours] for continuous monitoring vs 46.2 hours [95% CI, 39.1 - 53.3 hours] for intermittent monitoring; P = .77).

Nor did the two groups differ by secondary endpoints, including duration of oxygen therapy or rate of transfer to an intensive care unit. Rates of performance of laboratory tests, medical therapies, and treatment procedures also did not differ between the two groups. The authors caution, however, that the study sample size may not have been sufficient to detect differences in intensive care unit transfers.

The American Academy of Pediatrics guidelines recommend that continuous pulse oximetry is not routinely necessary for patients who are improving clinically. The guidelines also recommend intermittent pulse oximetry monitoring for children hospitalized for bronchiolitis who are not receiving supplemental oxygen.

The Choosing Wisely Campaign also recommends avoidance of continuous pulse oximetry for pediatric hospital medicine.

"The rationale for intermittent pulse oximetry use is that continuous pulse oximetry is more likely to detect transient oxygen desaturations of uncertain significance, which in turn drives extended supplemental oxygen use," the authors explain.

"Hypoxia is common in infants with bronchiolitis, but so too is intermittent self-resolving brief desaturation: the former important, the latter probably not," Steve Cunningham, MBChB, PhD, from the Department of Respiratory and Sleep Medicine, Royal Hospital for Sick Children, Edinburgh, Scotland, writes in an accompanying editorial.

That said, one strategy for managing oxygen saturation does not suit all clinical scenarios, even those occurring within the same disease process, Dr Cunningham notes, leaving a clear need for clinical judgement.

"We need to rebuild confidence in the value of clinical acumen for the management of bronchiolitis and, in doing so, limit the medicalization of this self-limiting illness," Dr Cunningham explains. "Intermittent monitoring of pulse oxygen saturation in patients recovering from bronchiolitis is not a game of peekaboo; it is good clinical care."

Support was provided by an Early Career Award from the Thrasher Foundation and by the Rhode Island Hospital. The authors and editorialist have disclosed no relevant financial relationships.

JAMA Pediatrics. Published online August 31, 2015. Article abstract, Editorial full text

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