Case

A previously healthy, fully immunized 8-month-old boy presents to the emergency department (ED) with increased work of breathing. The patient developed rhinorrhea, a non-productive cough, and increased congestion two days before presentation. On the day of the ED visit, the patient’s mother found him to have a fever of 102.6F and thought that he was breathing faster than normal. Although he was still making the same number of wet diapers, he was unable to take his full bottle feed due to his nasal congestion.

Upon arrival to the ED, the patient was noted to be fussy, but consolable. He had mildly increased work of breathing, with intermittent subcostal retractions and moderate rhinorrhea. Lung sounds were significant for bilateral crackles without wheezing or stridor. Vital signs included a heart rate of 165 beats per minute, a respiratory rate of 36 breaths per minute, an oxygen saturation of 96% on room air, temperature of 101.2F, and a blood pressure of 82/56. The patient was suctioned by the nurse and subsequently tolerated a full bottle feed without increased respiratory distress. He received rectal acetaminophen, and his fever resolved. He produced two wet diapers while in the ED. Prior to discharge, the patient’s monitor began to alert for a low oxygen saturation of 88% while the patient was sleeping. This immediately resolved when the patient was woken up and stimulated. Because of the intermittent low oxygen level, the patient’s parents were uncomfortable with the patient going home, and he was admitted to the hospital.

Diagnosis

Nonsevere Bronchiolitis

Discussion

For children under two years of age, the most frequent cause of hospitalization is bronchiolitis [1,2]. Bronchiolitis is a respiratory syndrome that causes rhinorrhea, respiratory tract inflammation, and abnormal lung sounds, such as wheezing or crackles [3]. Infection with a respiratory virus can precipitate bronchiolitis in children [3]. Each year, approximately 130,000 children are admitted to the hospital with bronchiolitis, costing a cumulative $1.7 billion [1,2]. Almost 300,000 annual ED visits are due to bronchiolitis [4]. The percent of infant admissions attributable to bronchiolitis in the US increased from 5.4% in 1980 to 16% in 2009, despite no change in mortality rates in bronchiolitis over this time period [4,5]. Treatment for bronchiolitis is mainly supportive. Interventions such as albuterol, non-invasive positive pressure ventilation, and nebulized hypertonic saline do not demonstrate any proven benefit above standard of care [6]. For patients who are hypoxic, initiation of oxygen therapy, either through standard nasal cannula or high-flow nasal cannula (HFNC), is a common practice [6]. These patients are often admitted to the hospital for observation and titration of their oxygen [6].

While it might be intuitive that patients with low oxygen saturations need extra oxygen, some data suggest that when and how we measure a patient’s oxygen makes a big difference in their care. It is common practice to use continuous pulse oximetry (CPO), the practice of constantly measuring a patient’s oxygen levels, even in patients who do not require oxygen. A study of community and tertiary care pediatric hospitals showed that up to 92% of patients were on CPO despite not needing oxygen [7]. Although widly used, the data show that CPO may be responsible for more harm than benefit in this population. A retrospective study of infants admitted with bronchiolitis found that 26% of admissions were prolonged an average of 1.6 days due to transient low oxygen levels seen with CPO [8]. Data show that transient hypoxemia is common in bronchiolitis and does not have any effect on escalation of care or need to return to the hospital [1,9,10]. CPO has been associated with increased rates of admission, cost, and use of supplemental oxygen [1]. For these reasons, CPO in nonsevere bronchiolitis is opposed by both the American Academy of Pediatrics (AAP) and the Choosing Wisely campaign [2].

Emergency medicine (EM) physicians often drive the decision to admit infants with bronchiolitis, sometimes due to oxygen levels alone. When pediatric EM physicians were presented with clinical vignettes as part of a 2003 study, they were twice as likely to choose to admit an infant with an oxygen saturation of 92% versus 94% without any other differences in vital signs or work of breathing [5]. When patients are kept on CPO in the ED, medical teams are more likely to capture clinically insignificant, transient desaturations, leading to an increase in admissions [1]. It should be the responsibility of EM physicians to reverse this practice and implement an intermittent pulse oximetry check for stable bronchiolitis patients who do not require oxygen. Some hospitals have already had success at doing this through staff and family education, chart auditing, and individualized feedback [2]. By limiting the use of CPO in this population, EM physicians may reduce the rate of unnecessary admissions and cut costs without sacrificing patient safety.

Take Aways

·       Bronchiolitis is the main cause of hospitalization in children <2 years of age.

·       Bronchiolitis causes rhinorrhea, lower airway inflammation, and wheezing or crackles. It is often associated with transient hypoxemia that has no clinical consequence.

·       Continuous pulse oximetry is a common practice in patients with bronchiolitis. CPO has been shown to increase length of stay, use of supplemental oxygen, and cost in stable infants with bronchiolitis.

·       The EM physician must take into account more than just oxygen saturation, such as work of breathing and hydration status, when deciding whether to admit an infant with bronchiolitis.

·       Staff and family education on the drawbacks of continuous pulse oximetry is an effective tool to reduce its use.

Author: Jeffrey Savarino, MD, is 2nd year Emergency Medicine Resident at Brown University/Rhode Island Hospital

Faculty Reviewer: Meghan Beucher, MD, is an attending physician at Hasboro Children’s Hospital and faculty with Brown Pediatric Emergency Medicine

References

1.     Rasooly IR, Beidas RS, Wolk CB, Barg F, Landrigan CP, Schondelmeyer A, Brady PW, McLeod LM, Bonafide CP. Measuring overuse of continuous pulse oximetry in bronchiolitis and developing strategies for large-scale deimplementation. Pilot and Feasibility Studies. 2019;5(68):1-8.

2.     Cheston CC, Vinci RJ. Overuse of Continuous Pulse Oximetry for Bronchiolitis. JAMA. 2020;323(15):1449-1450.

3.     Piedra PA, Stark AR. Bronchiolitis in infants and children: Clinical features and diagnosis. In: UpToDate. Edwards MS, Torchia MM, ed. UpToDate, Waltham, MA. Accessed on Mar 26, 2023.

4.     Luo G, Stone BL, Nkoy FL, He Shan, Johnson MD. Predicting Appropriate Hospital Admission of Emergency Department Patients with Bronchiolitis: Secondary Analysis. JMIR Med Inform. 2019;7(1).

5.     Mallory MD, Shay DK, Garrett J, Bordley WC. Bronchiolitis Management Preferences and the Influence of Pulse Oximetry and Respiratory Rate on the Decision to Admit. Pediatrics. 2003;111(1):45-51.

6.     Piedra PA, Stark AR. Bronchiolitis in infants and children: Treatment, outcome, and prevention. In: UpToDate. Edwards MS, Torchia MM, ed. UpToDate, Waltham, MA. Accessed on Mar 26, 2023.

7.     Bonafide CP, Xiao R, Brady PW, Landrigan CP, Brent C, Wolk CB, Bettencourt AP, McLeod L, Barg F, Beidas RS, Schondelmeyer A. Prevalence of Continuous Pulse Oximetry Monitoring in Hospitalized Children With Bronchiolitis Not Requiring Supplemental Oxygen. JAMA. 2020;323(15):1467-1477.

8.     Schroeder AR, Marmor AK, Pantell RH, Newman TB. Impact of Pulse Oximetry and Oxygen Therapy on Length of Stay in Bronchiolitis Hospitalizations. Arch Pediatr Adolesc Med. 2004;158:527-530.

9.     Principi T, Coates AL, Parkin PC, Stephens D, DaSilva Z, Schuh S. Effect of Oxygen Desaturations on Subsequent Medical Visits in Infants Discharged From the Emergency Department With Bronchiolitis. JAMA Pediatr. 2016;170(6):602-608.

10.  Mahant S, Wahl G, Bayliss A, Giglia L, Kanani R, Pound CM, Sakran M, Kozlowski N, Breen-Reid K, Arafeh D, Moretti ME, Agarwal A, Barrowman N, Willan AR, Schuh S, Parkin PC. Intermittent vs Continuous Pulse Oximetry in Hospitalized Infants With Stabilized Bronchiolitis. JAMA Pediatr. 2021;175(5):466-474.