Intermittent Pulse Oximetry Sufficient for Most Hospitalized Children

By Will Boggs MD

July 20, 2020

NEW YORK (Reuters Health) - Intermittent assessment of vital signs, including pulse oximetry, should be sufficient for most hospitalized children, according to an expert panel.

"Current practice for using continuous cardiorespiratory and pulse oximetry monitors for hospitalized children is highly variable between hospitals nationally," Dr. Amanda C. Schondelmeyer from Cincinnati Children's Hospital Medical Center and University of Cincinnati College of Medicine told Reuters Health by email. "We have evidence suggesting that some of this variability is driven by hospital culture, clinician preferences, or habit rather than patient acuity."

Dr. Schondelmeyer and colleagues combined the best available evidence with their own skills and insights to develop recommendations on the indications for continuous monitoring of the most common conditions seen in children's hospitals.

Children receiving supplemental oxygen should have continuous oximetry monitoring, but they should be transitioned from continuous monitoring to intermittent monitoring within 1 hour of achieving stable oxygen saturation levels of at least 90%, according to the online report in Pediatrics.

Intravenous opioid and benzodiazepine therapy requires continuous cardiorespiratory and oximetry monitoring only when there is a new medication or an increased dose of a current medication. Otherwise, intermittent monitoring is sufficient.

For patients with mild or moderate asthma, mild or moderate croup, routine pneumonia, or low-risk bronchiolitis, intermittent monitoring is sufficient.

On the other hand, severe asthma, croup, or pneumonia; high-risk bronchiolitis, pertussis, or brief resolved unexplained event; and severe sepsis require continuous monitoring.

"Physicians, nurses, and families have come to expect monitoring as part of hospitalization, even though we have no evidence in the scientific literature that monitors improve outcomes for most hospitalized children," Dr. Schondelmeyer said. "For that reason, the concept of less monitoring could generally be viewed as controversial."

"These new recommendations can serve as the basis for implementation and effectiveness studies aimed at standardizing the way clinicians use continuous cardiorespiratory and pulse oximetry monitors for hospitalized general pediatric patients," she said.

Two other online reports in Pediatrics address other aspects of pulse oximetry monitoring.

Dr. Kevin W. Chi from Lucile Packard Children's Hospital, Stanford, California and colleagues conducted a survey on parental perspectives on continuous pulse oximetry monitoring of their children hospitalized for bronchiolitis. Half of the participants were randomly assigned to receive an additional statement during the postdischarge interview on the potential harms of continuous pulse oximetry monitoring.

During the in-hospital interview, almost all parents either strongly agreed or agreed that having hospital monitors on their child was helpful (98%) and made them feel secure (94%), but about a quarter of parents strongly agreed or agreed that having the hospital monitors on their child was annoying and made them feel anxious.

During the postdischarge phone interview, 70% of parents reported that they had been told what is considered a low oxygen level for their child, but of those who identified the oxygen saturation level at which additional oxygen support was warranted, the reported range was from 30% to 98% (median, 89%).

The proportions of parents who still preferred continuous monitoring should their child be hospitalized again for bronchiolitis was lower among those who received the educational messaging (20%) than among those who didn't (40%).

Dr. Chi told Reuters Health by email, "If it is true that most parents prefer continuous pulse oximetry monitoring at all times and that clinical guidelines recommend transitioning to intermittent monitoring when a child with bronchiolitis is improving, then inevitably there is a point of conflict. But this study suggests that even a short, one-minute explanation can potentially align agendas between physicians and parents and allow recommendations to flourish under shared-decision making."

"I hope this study may encourage physicians to engage in these challenging conversations, knowing that it is possible for parents to quickly grasp the potential harms of continuous monitoring," he said.

Dr. Lawrence Rhein from University of Massachusetts Memorial Medical Center, Worcester, and colleagues investigated whether recorded home oximetry could reduce the duration of home oxygen therapy in premature infants.

In their randomized trial of 196 infants, the time to discontinue home oxygen therapy was 22% shorter in the recorded home oximetry group (mean, 78.1 days) than in the standard-care group (mean, 100.1 days).

Parental quality of life improved significantly from baseline to 3 months after discontinuation of home oxygen therapy to a similar extent in both groups.

Earlier discontinuation of home oxygen therapy did not result in adverse growth for infants.

Dr. Rhein told Reuters Health by email, "Recorded home oximetry should become the standard for weaning infants home oxygen therapy. Especially now in the COVID-19 era, patients and providers are looking for more, not less, ways to safely manage patients remotely. Recorded home oximetry allows for an objective, data driven management strategy that is safe and effective."

Dr. Paul Seddon from Royal Alexandra Children's Hospital, Brighton, UK, who earlier evaluated the feasibility of infant home respiratory monitoring using pulse oximetry, told Reuters Health by email, "Recorded home oximetry is safe, is already standard of care in many countries outside the U.S., and should be more widely used in the U.S."

"Providing a home oximeter full-time to each infant on home oxygen therapy will be expensive, and I am not sure continuous recording at home is entirely justified or even desirable," he said. "In my experience, some parents become over-obsessed with minor artefactual 'desaturations.' However, it was reassuring that the quality of life during home oxygen therapy was not worse in the intervention group."

"I think further work is needed to compare different patterns of weaning using recorded home oximetry, for example, different intervals between studies/attempts to wean and different algorithms for weaning," Dr. Seddon said.

SOURCE: https://bit.ly/30zLDYL, https://bit.ly/3987eez, https://bit.ly/398qDvH and https://bit.ly/3fPS3cg Pediatrics, online July 17, 16, and 14, 2020.

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