A Randomized Trial of Home Oxygen Therapy From the Emergency                   Department for Acute Bronchiolitis         ...
ARTICLEA Randomized Trial of Home Oxygen Therapy Fromthe Emergency Department for Acute BronchiolitisLalit Bajaj, MD, MPHa...
B      RONCHIOLITIS IS THE most common cause of hospital       admission in children Ͻ1 year of age. An estimated80 000 to...
TABLE 2 Inclusion/Exclusion CriteriaInclusion criteria   2–24 mo, minimum of 44 wk after conceptional age   Clinical diagn...
TABLE 3 Demographics/Clinical Characteristics of Randomized                                                               ...
after the 24-hour follow-up appointment. This was a                   1 patient resolved the oxygen requirement before rea...
TABLE 6 Hospitalized Patients (n ‫)33 ؍‬                                                 with supplemental oxygen for bron...
tients were observed for an extended period of time and          Bronchiolitis is the most common cause of lowerwere found...
ygen requirement and those who may worsen and re-                        8. Thilo EH, Comito J, McCulliss D. Home oxygen t...
A Randomized Trial of Home Oxygen Therapy From the Emergency                    Department for Acute Bronchiolitis        ...
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  1. 1. A Randomized Trial of Home Oxygen Therapy From the Emergency Department for Acute Bronchiolitis Lalit Bajaj, Carol G. Turner and Joan Bothner Pediatrics 2006;117;633-640 DOI: 10.1542/peds.2005-1322The online version of this article, along with updated information and services, is located on the World Wide Web at: http://www.pediatrics.org/cgi/content/full/117/3/633PEDIATRICS is the official journal of the American Academy of Pediatrics. A monthlypublication, it has been published continuously since 1948. PEDIATRICS is owned, published,and trademarked by the American Academy of Pediatrics, 141 Northwest Point Boulevard, ElkGrove Village, Illinois, 60007. Copyright © 2006 by the American Academy of Pediatrics. Allrights reserved. Print ISSN: 0031-4005. Online ISSN: 1098-4275. Downloaded from www.pediatrics.org. Provided by Indonesia:AAP Sponsored on September 29, 2010
  2. 2. ARTICLEA Randomized Trial of Home Oxygen Therapy Fromthe Emergency Department for Acute BronchiolitisLalit Bajaj, MD, MPHa, Carol G. Turner, MDb, Joan Bothner, MDaaDepartment of Pediatrics, Section of Emergency Medicine, University of Colorado Health Sciences Center/Children’s Hospital, Denver, Colorado; bAspen Park Pediatrics,Conifer, ColoradoThe authors have indicated they have no financial relationships relevant to this article to disclose.ABSTRACTOBJECTIVE. Hypoxia is a common reason for hospital admission in infants and chil-dren with acute bronchiolitis. No study has evaluated discharge from the emer- www.pediatrics.org/cgi/doi/10.1542/gency department (ED) on home oxygen. This study evaluated the feasibility and peds.2005-1322safety of ED discharge on home oxygen in the treatment of acute bronchiolitis. doi:10.1542/peds.2005-1322METHODS. This was a prospective, randomized trial of infants and children with acute Key Words bronchiolitis, hypoxia, oxygen, homebronchiolitis and hypoxia (room-air saturations of Յ87%) aged 2 to 24 months therapy, observationpresenting to an urban, academic, tertiary care children’s hospital ED from De- Abbreviationscember 1998 to April 2001. Subjects received inpatient admission or home oxygen PCP—primary care providerafter an 8-hour observation period in the ED. We measured the failure to meet ED— emergency department RDSS—respiratory distress severity scoredischarge criteria during the observation period, return for hospital admission, and Accepted for publication Jul 22, 2005incidence of serious complications. Address correspondence to Lalit Bajaj, MD, MPH, Department of Pediatrics/Section ofRESULTS. Ninety-two patients were enrolled. Fifty three (58%) were randomly as- Emergency Medicine, University of Coloradosigned to home and 39 (42%) to inpatient admission. There were no differences Health Sciences Center/Children’s Hospital, 1056 E 19th Ave B251, Denver, CO 80218. E-between the groups in age, initial room-air saturation, and respiratory distress mail: bajaj.lalit@tchden.orgseverity score. Of 53 patients, 37 (70%) randomly assigned to home oxygen PEDIATRICS (ISSN Numbers: Print, 0031-4005;completed the observation period and were discharged from the hospital. The Online, 1098-4275). Copyright © 2006 by the American Academy of Pediatricsremaining 16 patients were excluded from the study (6), resolved their oxygenrequirement (5), or failed to meet the discharge criteria and were admitted (5).One discharged patient (2.7%) returned to the hospital and was admitted for acyanotic spell at home after the 24-hour follow-up appointment. The patient hadan uncomplicated hospital course with a length of stay of 45 hours. The remaining36 patients (97%) were treated successfully as outpatients with home oxygen.Satisfaction with home oxygen was high from the caregiver and the primary careprovider.CONCLUSIONS. Discharge from the ED on home oxygen after a period of observationis an option for patients with acute bronchiolitis. Secondary to the low incidenceof complications, the safety of this practice will require a larger study. PEDIATRICS Volume 117, Number 3, March 2006 633 Downloaded from www.pediatrics.org. Provided by Indonesia:AAP Sponsored on September 29, 2010
  3. 3. B RONCHIOLITIS IS THE most common cause of hospital admission in children Ͻ1 year of age. An estimated80 000 to 120 000 children Ͻ1 year of age are admitted fined as (1) not requiring transfer to the intensive care unit (ICU), (2) not being readmitted to the hospital after discharge, and (3) not having any serious complications.annually. Hospitalization rates have been increasing dra- Serious complications were defined as respiratory arrest,matically, with estimates of an increase of 239% in apnea, cyanotic spell, and respiratory failure. The successchildren Ͻ6 months from 1980 to 1996.1 One of the rate for hospitalized patients was estimated at 99%. Us-hypotheses for this dramatic increase is the almost uni- ing a minimum success rate of 90% for home oxygen,versal use of pulse-oximetry screening and the imple- we estimated that ϳ160 patients (80 in each group)mentation of an oxygen-saturation cut off that warrants would be needed with an ␣ value of .05 and a ␤ value ofhospital admission for supplemental oxygen. The need .20.for supplemental oxygen therapy in a previously healthy Patients were enrolled over 3 consecutive winter sea-patient is considered by many to require mandatory sons from December 1998 to April 2001 at an urban,admission and is included as one of the therapies defin- academic, tertiary care children’s hospital at an elevationing mandatory admission in studies evaluating a pediat- of 5280 ft (1609 m). All of the patients received deepric risk of admission score.2,3 It has also been demon- nasal suctioning and 2 albuterol treatments (2.5 mg) viastrated that physicians use the oxygen-saturation nebulizer over the first 60 minutes. All of the patientsinformation frequently to determine whether a patient had their respiratory distress severity score (RDSS) (Ta-requires hospital admission.4 A recent study addressed ble 1) documented at the start of the study, after suc-how often patients remain in the hospital only for sup- tioning, and after the nebulizer treatments. The RDSSplemental oxygen after other clinical parameters (oral has 4 categories: respiratory rate, wheezing, aeration,intake and work of breathing) have improved and found and retractions, and each category has a scoring systemthat 26% of patients have a prolonged stay of an average of 0, 1, or 2 points. The total score is obtained by addingof 1.6 days.5 the score from each category. All of the patients then In the years preceding this study, community primary received a chest radiograph, and, if read by the attendingcare providers (PCPs) were faced with a rapidly expand- radiologist as consistent with an acute bacterial pneu-ing population of children and a large burden of patients monia, the patient was not approached for enrollment inwith bronchiolitis requiring oxygen. Hospital beds the study.around the community were becoming very difficult to Caregivers were approached during times at which afind, and the practice of arranging home oxygen from research assistant was available to assess whether theythe office setting began to emerge. This was especially met the inclusion criteria or had any of the exclusiontrue in practices that had close relationships with their criteria (Table 2). Informed consent was obtained, andpatients and felt comfortable that if any deterioration patients were randomly assigned to traditional inpatientoccurred, the caregivers would quickly notify them and hospitalization or to home oxygen therapy. Randomiza-present to a local emergency department (ED). To date, tion was performed by using a block-randomization ta-there are no publications evaluating the use of home ble created before the start of the study. Research assis-oxygen therapy from the ED or the primary care clinic in tants were blinded to allocation at the time ofpatients with acute bronchiolitis requiring supplemental enrollment. The study packet with the assignment couldoxygen. We undertook a prospective, randomized pilot not be opened until informed consent had been ob-study of home oxygen from the ED compared with tained. Patients randomly assigned to the inpatient armtraditional inpatient hospitalization to assess for the fea- of the study had an RDSS recorded every 2 hours for thesibility and safety of this practice. first 8 hours of hospitalization. Other treatments in the hospital were at the discretion of the inpatient attending,METHODS and the families were contacted at 1 week by telephoneWe conducted a prospective, randomized trial of tradi- and were asked to answer questions from a standardizedtional inpatient hospitalization versus home oxygen questionnaire. A chart review was also performed tofrom the ED in a convenience sample of patients with extract hospital complications and length of stay data.acute bronchiolitis and hypoxia. In preparation for con- Patients randomly assigned to the home oxygen armducting the study, we sent out information letters to allPCPs who refer patients to our ED to let them knowwhat the study would require of them if a patient in TABLE 1 RDSStheir practice was enrolled. Score Respiratory Rate Wheezing Aeration Retractions A sample-size calculation was performed before the 0–1 y 1–2 ystart of the study. The success of the home oxygen 0 20–40 15–30 None All fields Noneprotocol was defined as (1) not requiring hospitalization 1 41–55 31–45 Mild-Exp Ն4 fields Mildafter ED discharge and (2) not having any serious com- 2 Ͼ55 Ͼ45 Insp and Exp Ͻ4 fields Markedplications. Success with hospitalized patients was de- Total score: 0 – 4, mild; 5–7, moderate; Ͼ8, severe.634 BAJAJ, et al Downloaded from www.pediatrics.org. Provided by Indonesia:AAP Sponsored on September 29, 2010
  4. 4. TABLE 2 Inclusion/Exclusion CriteriaInclusion criteria 2–24 mo, minimum of 44 wk after conceptional age Clinical diagnosis of bronchiolitis defined as an acute respiratory illness associated with nasal congestion, cough, diffuse wheezing or crackles, and tachypnea or retractions Chest radiograph consistent with viral bronchiolitis First episode of wheezing Room-air saturation of Յ87% on arrival to the ED Family has transportation to return to PCP or ED 24 and 48 h after discharge from the ED Lives at altitude Յ6000 ft (1829 m) Lives Յ30 min from an emergency medical facility Caregivers must maintain a smoke-free environment defined as no smoking in house or car Caregivers must have a contact telephone numberExclusion criteria Preexisting cardiac, pulmonary (including bronchopulmonary dysplasia), neuromuscular, or nutritional (including failure to thrive) disorders and preexisting congenital or acquired airway anomalies Ͻ44 wk after conceptional age History of apnea Acute bacterial pneumonia as defined as a focal infiltrate on chest radiograph Prior episode of wheezing Room-air saturations Ͼ87% No available transportation for follow-up visits Lives at altitude Ͼ6000 ft (1829 m) Lives Ͼ30 min from health care facility Steroid administration Caregivers unable to stay with patient in observation unitof the study were placed in the ED observation unit foran 8-hour observation period. Standard observationconsisted of continuous pulse oximetry and vital-signchecks every 2 hours. An RDDS was assigned every 2hours. Four separate pulse-oximetry measurementswere recorded while on oxygen (asleep and feedingwere mandatory). At the end of the observation period,the following defined discharge criteria had to be met:saturations of Ն90% on Յ1 L/min nasal cannula oxygenwhile the patient was awake, asleep, and feeding; the FIGURE 1patient must be able to maintain hydration; the patient Treatment protocol.must have no signs of deteriorating respiratory status;the attending physician and caregiver must be comfort-able with discharge; and 24-hour follow-up must be incidence of serious complications. Secondary outcomearranged. Patients were taught the operation of the por- measures were caregiver satisfaction, caregiver prefer-table home oxygen unit and were given the unit before ence, PCP satisfaction, and PCP preference.discharge. Patients were discharged on Յ1 L nasal can- Data were analyzed by using SPSS 12.0 (SPSS Inc,nula oxygen. Chicago, IL). Differences between groups were analyzed Standardized questionnaires were completed by the by the Student’s t test for continuous variables and thePCP at the 24- and 48-hour visit and were faxed back to ␹2 test for categorical variables. This study was approvedthe study coordinator. At 72 hours, a telephone fol- by the Colorado Multiple Institutional Review Boardlow-up questionnaire was administered to both the PCP and the Kaiser Permanente Institutional Review Board.and the caregiver. A 1-week telephone follow-up ques-tionnaire was also administered to the caregiver. Fig 1 RESULTSdisplays the treatment protocol. Ninety-two patients were enrolled over 3 consecutive Primary outcome measures included failure to meet bronchiolitis seasons. A modified consolidated standardsdischarge criteria during the observation period, return of reporting trials diagram is presented in Fig 2. Thesefor hospital admission after successful discharge, and patients had a mean age of 7.8 months, a mean room-air PEDIATRICS Volume 117, Number 3, March 2006 635 Downloaded from www.pediatrics.org. Provided by Indonesia:AAP Sponsored on September 29, 2010
  5. 5. TABLE 3 Demographics/Clinical Characteristics of Randomized Patients (n ‫)29 ؍‬ Characteristic Overall Home Inpatient P (n ϭ 92) (n ϭ53) (n ϭ 39) Age, mo Mean 7.8 7.6 8.2 .606a Range 2–23 2–21.4 2.1–23 Gender, n (%) Male 52 (57) 29 (55) 23 (59) .424b Female 40 (43) 24 (45) 16 (41) Maternal age, y Mean 27.06 26.68 27.59 .541a Range 16–43 18–43 16–43 Initial RDSS Mean 4.23 4.13 4.43 .366a Initial room-air saturation, 85.0 84.3 85.8 .208a mean, % 8-h RDSS, mean 2.28 2.31 2.25 .876a 8-h O2 required, L/min Mean 0.485 0.436 0.560 .037a Range 0.125–1 0.125–1 0.125–1 a Student’s t test. b ␹2 test. TABLE 4 Demographics/Clinical Characteristics of PatientsFIGURE 2 Completing Study (n ‫)07 ؍‬Modified consolidated standards of reporting trials diagram. Characteristic Overall Home Inpatient P (n ϭ70) (n ϭ 37) (n ϭ 33) Age, mosaturation of 85%, a mean RDSS of 4.23, and a mean Mean 7.54 7.09 8.02 .438a Range 2–22.4 2–17.4 2–22.4oxygen requirement of 0.485 L/min. Gender, n (%) Fifty-three patients (58%) were randomly assigned to Male 39 (55.7) 19 (51.4) 20 (60.6) .478bhome, and 39 (42%) were randomly assigned to inpa- Female 31 (44.3) 18 (48.6) 13 (39.4)tient admission. There were no differences between the Initial RDSS, mean 4.04 3.72 4.39 .069agroups in age, initial room-air saturation, and initial Initial room-air saturation, 85.1 84.8 85.4 .659a mean, %RDSS. There was a statistically significant difference in 8-h RDSS, mean 2.04 1.86 2.25 .262athe amount of oxygen required at 8 hours for the pa- 8-h O2 required, L/mintients who had been admitted versus those who were Mean 0.492 0.434 0.563 .013adischarged (Table 3). These relationships remained the Range 0.125–1 0.125–1 0.125–1same when patients completing the study were analyzed a Student’s t test. b ␹2 test.(Table 4). Based on the actual number of patients en-rolled and a success rate of 99% in the hospitalizedpatients, we would detect an 80% success rate in thehome oxygen patients as a statistically significant differ- tion period and were discharged with no supplementalence. oxygen. These 5 patients did not return to the study Of the 53 patients, 37 (70%) randomly assigned to institution in the following week for any additional care.home oxygen completed the observation period and The remaining 5 patients did not meet discharge criteriawere discharged from the hospital. Six patients (11.3%) and were subsequently admitted to the hospital for fur-failed to complete the observation period: 2 patients ther care: 2 patients had concerns from the nursing staffwere diagnosed with pneumonia from their chest radio- and attending physician for inadequate oral intake, 2graph that was obtained after enrollment instead of be- patients had concerns for increased work of breathing,fore randomization, 3 withdrew secondary to caregiver and 1 patient was given a change in diagnosis to reactiveanxiety, and 1 was excluded secondary to transfer from airways disease and was given oral corticosteroids. Thir-another facility, which did not allow for the ascertain- ty-seven patients were successfully sent home withment of initial data. home oxygen. Ten patients completed the observation period but One patient (2.7%; 95% confidence interval: 0.6 –were unable to complete the remainder of the study: 5 13.8%) of the 37 discharged from the ED returned to theresolved their oxygen requirement during the observa- hospital and was admitted for a cyanotic spell at home636 BAJAJ, et al Downloaded from www.pediatrics.org. Provided by Indonesia:AAP Sponsored on September 29, 2010
  6. 6. after the 24-hour follow-up appointment. This was a 1 patient resolved the oxygen requirement before reach-4-month-old who was sent to the ED from the 24-hour ing the inpatient bed, 1 family became uncomfortablefollow-up visit with a history of a possible cyanotic spell with being in a research study, and 2 patients had in-at home. The patient had an uncomplicated hospital complete medical charts for review. The patient dis-course with a length of stay of 45 hours. This is the only charged who no longer required supplemental oxygenpatient who had a serious complication in the study. The did not return in the following week for additional careremaining 36 patients (97%; 95% confidence interval: to the study institution. The remaining 33 patients were86 –99%) were treated successfully as outpatients with available for analysis.home oxygen therapy. The hospitalized patients had a mean length of stay of Of the 37 patients, 33 (89%) had a 24- or 48-hour 1.8 days, with a range of 0.58 to 6.3 days. Five of thesurvey completed by their PCP; 33 (89%) had a com- patients (15.2%) had a hospital stay of Ͼ3 days (Tablepleted 72-hour telephone follow-up; and 35 (95%) had 6). Of these 5 patients, 2 were diagnosed with pneumo-a completed 1-week telephone follow-up. All 37 (100%) nia on subsequent chest radiograph, and 1 was diag-of the patients had at least 1 of the 3 follow-up surveys nosed with pneumonia and required intravenous fluids.completed (Table 5). One patient was a former 29-week infant who had no At the 24/48-hour follow-up, 97% of the caregivers complications noted, and the remaining patient had nowere satisfied with their child at home, and 94% of the complications noted. Twenty six of the patients (79%)PCPs were satisfied with the patient being at home. At were discharged from the inpatient medical service onthe 72-hour telephone follow-up we asked about pref- home oxygen. There were no patients who requirederence, and 79% of the caregivers stated that they pre- transfer to the ICU, and there were no readmissionsferred to be at home, and 15% of the caregivers would within 1 week after discharge. All 33 of the patient’shave preferred to be in the hospital. Sixty-four percent caregivers were successfully contacted at the 1-weekof the PCPs stated they preferred their patients to be at telephone follow-up; 36% of the caregivers would havehome, whereas 27% of them would have preferred the preferred home care, 49% preferred hospital care, andhospital. At the 72-hour survey, 100% of the caretakers 15% had no opinion (Table 7).felt they had received adequate instruction on the use of Analysis of self-reported data on missed days fromhome oxygen. Ninety-seven percent (34 of 35) of the work showed a trend in less missed days from work inpatients at the 7-day follow-up were satisfied with home the home oxygen group versus the hospitalized groupoxygen for their child. Four patients (11%) were still on (mean: 1.72 vs 2.69, respectively). This finding was notoxygen at a week follow-up (Table 5). statistically significant. Thirty-nine patients (42%) were randomly assignedto traditional inpatient hospitalization. Six patients were DISCUSSIONexcluded from the study: 2 patients were diagnosed with This study describes the discharge on home oxygen frompneumonia from their chest radiograph that was ob- the ED after an 8-hour period of observation of infantstained after enrollment instead of before randomization, with uncomplicated bronchiolitis. This practice is be- TABLE 5 Caregiver/PCP Satisfaction With Home O2 (n ‫)73 ؍‬ Variable 24/48-h Visit 72-h Telephone 7-d Telephone Questionnaire at Questionnaire Questionnaire PCP Office (33 of 37), n (%) (33 of 37), n (%) (35 of 37), n (%) Caregiver satisfied at home 32/33 (97) 31/33 (94) 34/35 (97) Caregiver preference Home 26 (79) Hospital 5 (15) No preference 2 (6) PCP preference Home 21 (64) Hospital 9 (27) No preference 3 (9) PCP satisfaction 31/33 (94) Adequate instruction 33/33 (100) Parent observation length Too short 1 (3) Right 13 (40) Too long 15 (45) No opinion 4 (12) Still on O2 at 1 wk 4/35 (11.4) PEDIATRICS Volume 117, Number 3, March 2006 637 Downloaded from www.pediatrics.org. Provided by Indonesia:AAP Sponsored on September 29, 2010
  7. 7. TABLE 6 Hospitalized Patients (n ‫)33 ؍‬ with supplemental oxygen for bronchiolitis. Other au- Variable Hospitalized Patients thors have indicated that the management of bronchi- (n ϭ 33) olitis varies widely in both the ED setting, as well as theLength of stay, d inpatient setting, and is not based on clear evidence of Mean 1.83 efficacy of treatment options.12–14 Range 0.58–6.33 The implementation of clinical care pathways haveϾ3 d of hospitalization, n/N (%) 5/33 (15.2) been shown to decrease ancillary testing and overall costDischarged on home O2, n/N (%) 26/33 (79)Telephone questionnaire at 7 d, n/N (%) 33/33 (100) and length of stay; however, use of home oxygen afterCaregiver preference ED evaluation and observation have not been part of Home, n (%) 12 (36) published guidelines to date.15–18 Hospitalization rates for Hospital, n (%) 16 (49) bronchiolitis have increased 239% over the past 2 de- No opinion, n (%) 5 (15) cades for children Ͻ6 months of age.1 During that time period, mortality rates remained relatively constant.19 This increase in admission frequency has been postu- TABLE 7 Days Missed From Work: Home Versus Hospital lated to relate to perhaps an increased reliance on pulse- Days Home Hospital P oximetry measurements.4 In a retrospective analysis ofMissed (n ϭ 37) (n ϭ 33) 62 patients admitted for bronchiolitis, Schroeder et al5Mean 1.72 2.69 .145a showed that hospitalization was prolonged by an aver-a Student’s t test. age of 1.6 days in 16 patients (26%) because of oxygen- ation concerns based on pulse-oximetry readings after all of the other discharge criteria were met. These pro-coming more common in many sectors of the medical longed hospitalizations are not without potential addi-community and in PCP offices without benefit of mea- tional costs and the risk of adverse events.20surement of return rates, subsequent ED visit for wors- To enroll patients with uncomplicated cases of bron-ening disease, or hospital admission. The reasons for this chiolitis, we chose to obtain a chest radiograph on all ofchange in clinical practice are not known but could the patients to exclude possible bacterial pneumonia,reflect a perceived overcrowding of EDs, the belief that foreign bodies, pulmonary edema, and other cardiac orbronchiolitis is a mild disease in most infants, that the respiratory tract abnormalities. Standard care at the timeneed for oxygen is often the only reason for hospital of our study included deep nasal suction and a trial ofadmission, ease of care of patients on home oxygen, and beta agonists. We realize that these aspects of bronchi-the fact that home oxygen has become easily accessible olitis care, with the exception of nasal suctioning, mayfrom home health care companies in recent years. no longer be necessary. We used a respiratory distress The use of home oxygen therapy and subsequent score modeled from a previously published respiratoryearly nursery discharge has been evaluated in the man- distress score to have an objective measure of respiratoryagement of premature infants with bronchopulmonary distress to allow for comparison between the 2 groups atdysplasia and chronic lung disease and has been shown enrollment and discharge home.21 However, we did notto be safe and effective, with an associated decrease in incorporate this score as either inclusion or exclusioncost and no increase in morbidity or readmission rates.6,7 criteria or as discharge criteria. The study investigatorFamilies, when surveyed, responded 94% of the time team felt that incorporating an absolute cut-off score forthat they would again take an infant home on oxygen, discharge home would be difficult and that the clinicaland this practice is now routine.8,9 This approach has not measures listed in the discharge criteria would be moreyet become the standard of care for older infants and clinically relevant.children with acute respiratory tract illness. In 2001, Our methodology also included a mandatory 8-hourWilson et al10 evaluated care for patients Ͻ1 year of age observation period to allow for varying stages of diseaseadmitted with bronchiolitis in 10 children’s medical cen- at the time of enrollment. This observation periodters and found that care varied widely, that variations proved to be of significant benefit and affected care in 10could not be explained by difference in disease severity, (21%) of 47 patients. Five patients were found to noand that there was no evidence that a greater intensity of longer require supplemental oxygen and were dis-care affected morbidity or mortality. The use of home charged from the hospital. These patients were an un-oxygen was not measured. In a letter to the editor of expected finding. We removed the patients from thePediatrics concerning this publication, Weiss and Anna- study at that time, because it did not seem reasonable tomalai11 queried the issue of standardized discharge cri- require these families to adhere to the stringent fol-teria from the hospital for patients with bronchiolitis. low-up requirements. They did receive standard bron-They report on a survey of chief residents at 30 chil- chiolitis discharge instructions to return immediately fordren’s hospitals, and, of the 17 responses, only 2 hospi- any concern of increased work of breathing, cyanosis,tals reported that they routinely send patients home poor feeding, or any other concerns. Because these pa-638 BAJAJ, et al Downloaded from www.pediatrics.org. Provided by Indonesia:AAP Sponsored on September 29, 2010
  8. 8. tients were observed for an extended period of time and Bronchiolitis is the most common cause of lowerwere found to be hypoxic at the start of their evaluation, respiratory disease that requires hospital admission andwe performed chart review on these patients, and none contributes significantly to health care costs.22 Homeof them returned to the study institution in the follow- management may decrease these costs, as has been dem-ing week for additional care. The remaining 5 patients onstrated with infants discharged on home oxygen fromwere subsequently admitted to the hospital. None of the newborn nursery. Although it did not reach signifi-these patients were transferred to the ICU. Only 1 pa- cance, we also demonstrated a trend toward less missedtient was readmitted for a questionable cyanotic episode days of work for families who were randomly assigned toat home and experienced no additional episodes during home therapy. Family economic impact, ability to com-the subsequent 45-hour inpatient admission. ply with prescribed care plans, and overall acceptance of Our sample size is too small to evaluate the ideal home oxygen therapy for acute respiratory disease inperiod of observation, although the 8-hour time period infants and children has not been fully evaluated andwe chose allowed some patients to improve and identi- warrants further study.fied some patients that failed. Our results do support the Our study has several limitations. This is a conve-use of an observation period rather than immediate nience sample of patients who presented with bronchi-discharge after evaluation and diagnosis. olitis, and we have no information on patients who were Our study showed high rates of caregiver and PCP not enrolled; in addition, there is the potential of selec-satisfaction with both inpatient admission and discharge tion bias. Patients who required higher levels of oxygen,after observation in the ED on home oxygen therapy. presented with more respiratory distress, or did not atOnly 15% of the caregivers of the patients discharged first impression seem to have a good home environmentfrom the ED on oxygen therapy at the time of the may have been excluded. Our patient population is also72-hour follow-up questionnaire stated that they would a referred population, so it may not be reflective ofhave preferred hospital admission, whereas 36% of care- patients who present to other sites of care such as agivers of the hospitalized patients would have preferred primary care clinic or office. Caregivers and ED physi-to have been treated at home. Forty-nine percent of the cians were not blinded to which treatment arm thecaregivers of the hospitalized patients preferred hospital patient was assigned, which may have affected treat-admission. The preference for home treatment was ment decisions. Our strict inclusion and exclusion crite-higher among caregivers than among PCPs. PCPs of the ria, as well as the performance of the study at an altitudepatients discharged from the ED would have preferred of 5280 ft (1609 m), limit the external validity of thehospital admission 27% of the time. The reason for this results.is unclear. We feel that the comfort level and preference The study was stopped before the enrollment of thefor discharge on oxygen by parents who experienced desired number of patients in our sample-size calcula-home management were because of specific concerns tion. This occurred for 2 main reasons. ED census wasabout the complexity of home oxygen use before dis- beginning to outstretch inpatient bed availability; there-charge, the use of highly trained respiratory therapists to fore, many patients with bronchiolitis were being dis-explain home care, and prearranged follow-up with charged on oxygen from the ED outside of the study.their PCP. Caregivers of admitted patients did not receive The hospital was also in the process of developing athis education; thus, they may prefer inpatient admis- short-stay unit distinct from the ED observation unit tosion because of misgivings and misconceptions about the attempt to meet the needs of this patient population.challenges of the use of home oxygen, although 79% of Therefore, the decision was made to stop the study pro-the hospitalized patients were eventually discharged tocol, and additional attempts to restart the study werefrom the hospital on home oxygen. It is also interesting unsuccessful.to note that 45% of the parents who were randomly Our sample size is small, and we cannot make state-assigned to home oxygen felt that the observation period ments about safety of discharge on home oxygen, opti-of 8 hours was too long, and only 1 patient (3%) felt it mal observation time period, or criteria that might pre-was too short. Although we did not attempt to ascertain dict which patients might fail and require hospitalwhy, this feeling could be because of adequate explana- admission. A next step will be to systematically follow alltion and education about home oxygen, the fact that the of the patients discharged from the ED on home oxygenmajority of the patients did well, and could be reflective for adverse events and need for subsequent hospitaliza-of a high acceptance by families of home therapies. We tion.developed conservative inclusion criteria including theavailability of transportation to return at 24 and 48 CONCLUSIONShours after discharge, a contact telephone number, liv- This is the first study to demonstrate discharge homeing no more than 30 minutes from an emergency med- from the ED with supplemental oxygen in patients withical facility, and a smoke-free environment to maximize bronchiolitis. We found that an 8-hour observation pe-the safety of discharge home. riod identifies those patients who may resolve their ox- PEDIATRICS Volume 117, Number 3, March 2006 639 Downloaded from www.pediatrics.org. Provided by Indonesia:AAP Sponsored on September 29, 2010
  9. 9. ygen requirement and those who may worsen and re- 8. Thilo EH, Comito J, McCulliss D. Home oxygen therapy in thequire hospital admission, and, because of a low newborn. Costs and parental acceptance. Am J Dis Child. 1987; 141:766 –768incidence of complications, the 8-hour observation pe- 9. Gracey K, Talbot D, Lankford R, Dodge P. The changing face ofriod is an option for management. High acceptance rates bronchopulmonary dysplasia: part 2. Discharging an infantby caregivers and PCPs supports this approach. Addi- home on oxygen. Adv Neonatal Care. 2003;3:88 –98tional study is necessary to determine safety and eco- 10. Wilson DF, Horn SD, Hendley O, Smout R, Gassaway J. Effectnomic impact. of practice variation on resource utilization in infants for viral lower respiratory illness. Pediatrics. 2001;108:851– 855ACKNOWLEDGMENTS 11. Weiss J, Annamalai VR. Discharge criteria for bronchiolitis patients [letter]. Pediatrics. 2003;111:445This study was funded by the Children’s Hospital Re- 12. Johnson DW, Adair C, Brant R, Holmwood J, Mitchell I. Dif-search Institute and Kaiser Permanente. Funding was ferences in admission rates of children with bronchiolitis byused to support research assistant time in enrolling pa- pediatric and general emergency departments. Pediatrics. 2002;tients, collecting data, performing telephone follow-up, 110(4). Available at: www.pediatrics.org/cgi/content/full/110/and entering data. 4/e49 Lalit Bajaj had full access to all of the data in the study 13. Plint AC, Johnson DW, Wiebe N, et al. Practice variation among pediatric emergency departments in the treatment ofand takes responsibility for the integrity of the data and bronchiolitis. Acad Emerg Med. 2004;11:353–360the accuracy of the data analysis. 14. Christakis DA, Cowan CA, Garrison MM, Molteni R, Marcuse E, Zerr DM. Variation in inpatient testing and management ofREFERENCES bronchiolitis. Pediatrics. 2005;115:878 – 884 1. Shay DK, Holman RC, Newman RD, Liu LL, Stout JW, Ander- 15. Perlstein PH, Kotagal UR, Bolling C, et al. Evaluation of an son LJ. Bronchiolitis-associated hospitalizations among US evidence-based guideline for bronchiolitis. Pediatrics. 1999;104: children, 1980 –1996. JAMA. 1999;282:1140 –1446 1334 –1341 2. Chamberlain JM, Patel KM, Ruttimann UE, Pollack MM. Pe- 16. Perlstein PH, Kotagal UR, Schoettker PJ, et al. Sustaining the diatric risk of admission (PRISA): a measure of severity of implementation of an evidence-based guideline for bronchioli- illness for assessing the risk of hospitalization from the emer- tis. Arch Pediatr Adolesc Med. 2002;154:1001–1107 gency department. Ann Emerg Med. 1998;32:161–169 17. Todd J, Bertoch D, Dolan S. Use of a large national database for 3. Chamberlain JM, Patel KM, Pollack MM. The pediatric risk of comparative evaluation of the effect of a bronchiolitis/viral hospital admission score: a second-generation severity-of- pneumonia clinical care guideline on patient outcome and illness score for pediatric emergency patients. Pediatrics. 2005; research utilization. Arch Pediatr Adolesc Med. 2002;156: 115:388 –395 1086 –1090 4. Mallory MD, Shay DK, Garrett J, Bordley WC. Bronchiolitis 18. Kotagal UR, Robbins JM, Kini NM, Schoettker PL, Atherton management preferences and the influence of pulse oximetry HD, Kirschbaum MS. Impact of a bronchiolitis guideline: a and respiratory rate on the decision to admit. Pediatrics. 2003; multisite demonstration project. Chest. 2002;121:1789 –1797 111(1). Available at: www.pediatrics.org/cgi/content/full/111/ 19. Shay DK, Holman RC, Roosevelt GE, Clarke MJ, Anderson LJ. 1/e45 5. Schroeder AR, Marmor AK, Pantell RH, Newman TB. Impact of Bronchiolitis-associated mortality and estimates of respiratory pulse oximetry and oxygen therapy on length of stay in bron- syncytial virus-associated deaths among US children, chiolitis hospitalizations. Arch Pediatr Adolesc Med. 2004;158: 1979 –1997. J Infect Dis. 2001;183:16 –22 527–530 20. Bergman AB. Pulse oximetry, good technology misapplied. 6. Baraldi E, Carra S, Vencato F, et al. Home oxygen therapy in Arch Pediatr Adolesc Med. 2004;158:594 –595 infants with bronchopulmonary dysplasia: a prospective study. 21. Klassen TP, Rowe PC, Sutcliffe T, Ropp LJ, McDowell IW, Li Eur J Pediatr. 1997;156:878 – 882 MM. Randomized trial of salbutamol in acute bronchiolitis. 7. Greenough A, Alexander J, Burgess S, et al. High versus re- J Pediatr. 1991;118:807– 811 stricted use of home oxygen therapy, health care utilization 22. Rietvald A, de Jonge HCC, Polder JJ, et al. Anticipated costs of and the cost of care in chronic lung disease infants. Eur J Pe- hospitalization for respiratory syncytial virus infection in diatr. 2004;163:292–296 young children at risk. Pediatr Infect Dis J. 2004;23:523–529640 BAJAJ, et al Downloaded from www.pediatrics.org. Provided by Indonesia:AAP Sponsored on September 29, 2010
  10. 10. A Randomized Trial of Home Oxygen Therapy From the Emergency Department for Acute Bronchiolitis Lalit Bajaj, Carol G. Turner and Joan Bothner Pediatrics 2006;117;633-640 DOI: 10.1542/peds.2005-1322Updated Information including high-resolution figures, can be found at:& Services http://www.pediatrics.org/cgi/content/full/117/3/633References This article cites 20 articles, 9 of which you can access for free at: http://www.pediatrics.org/cgi/content/full/117/3/633#BIBLCitations This article has been cited by 6 HighWire-hosted articles: http://www.pediatrics.org/cgi/content/full/117/3/633#otherarticle sPost-Publication One P3R has been posted to this article:Peer Reviews (P3Rs) http://www.pediatrics.org/cgi/eletters/117/3/633Subspecialty Collections This article, along with others on similar topics, appears in the following collection(s): Respiratory Tract http://www.pediatrics.org/cgi/collection/respiratory_tractPermissions & Licensing Information about reproducing this article in parts (figures, tables) or in its entirety can be found online at: http://www.pediatrics.org/misc/Permissions.shtmlReprints Information about ordering reprints can be found online: http://www.pediatrics.org/misc/reprints.shtml Downloaded from www.pediatrics.org. Provided by Indonesia:AAP Sponsored on September 29, 2010

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