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Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial
Suzanne Schuh1, Stephen Freedman2, Allan Coates3
1Department of Pediatrics, The Hospital for Sick Children, Toronto, Ontario, Canada2Research Institute, The Hospital for Sick Children, Toronto, Ontario, Canada.
Insights
Artificially elevating pulse oximetry readings in infants with bronchiolitis significantly reduced hospitalization rates. This study suggests reevaluating oxygen saturation
Area of Science:
- Pediatric Emergency Medicine
- Respiratory Illnesses
- Clinical Trial Methodology
Background:
- Routine pulse oximetry use influences bronchiolitis management.
- Potential for lowered hospitalization thresholds due to oximetry.
- Need to investigate the impact of displayed vs. true oxygen saturation.
Purpose of the Study:
- To determine if artificially elevated pulse oximetry readings (3% higher) reduce hospitalization in infants with bronchiolitis.
- To compare hospitalization rates between infants receiving true vs. altered oximetry measurements.
Main Methods:
- Randomized, double-blind, parallel-group trial (2008-2013) in a pediatric emergency department.
- 213 infants (4 weeks to 12 months) with mild to moderate bronchiolitis and true saturation ≥88%.
- Intervention: displayed oximetry readings artificially elevated by 3% vs. true readings.
Main Results:
- Hospitalization within 72 hours occurred in 25% of the altered oximetry group vs. 41% in the true oximetry group (16% difference, P=.005).
- The primary treatment effect remained significant after adjusting for physician effects (aOR, 4.0; P=.009).
- No significant differences in secondary outcomes, including supplemental oxygen use or unscheduled visits.
Conclusions:
- Artificially elevated pulse oximetry readings decreased hospitalization rates in infants with bronchiolitis.
- Findings suggest oxygen saturation alone should not dictate admission decisions.
- Reevaluation of pulse oximetry's role in bronchiolitis management is warranted.
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.
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