Is Home Oxygen Therapy an Alternative to Hospitalization for Bronchiolitis?

Abstract

Bronchiolitis is the leading cause of hospitalization in infants and children younger than age 2 years.1 Although recent data demonstrate that admissions for bronchiolitis are decreasing, the burden on the pediatric health care system remains substantial.2 The most common reasons for admission include hypoxia, increased work of breathing, and dehydration. Treatment remains largely supportive. Home treatment options targeting these areas have the potential to alleviate burden on both the health care system and individual family unit.In this issue of Pediatrics, Lawrence et al present a systematic review of literature relating to home oxygen and home nasogastric feeding for infants and toddlers with bronchiolitis.3 The review identified only 10 studies meeting inclusion criteria, all pertaining to home oxygen therapy (HOT). These studies demonstrated feasibility, acceptability, and safety among the high-altitude population but there are notably fewer data on HOT use at lower elevations. Although there is certainly a need for further research into HOT for bronchiolitis at sea level, it is also worth noting that 6 of these studies report data from growing or sustained HOT programs, with 2 reporting high levels of caregiver comfort and satisfaction, adding support to the acceptability, sustainability, and positive impact of HOT for bronchiolitis.The authors also note a paucity of data on health care cost-savings. A recent study from Rodríguez-Martínez et al used a cost-analysis modeling technique and found a potential significant cost savings in home therapy.4 Even without patient-level data, with the high cost of inpatient care, home care is likely to be less expensive than hospitalization in nearly all instances. It is also important to recognize that there are significant costs associated with hospitalization that are difficult to quantify, including the nonmedical costs to the family such as caregiver workdays missed, the cost of childcare for siblings, and disruption to parenting plans that may be associated with hospitalization of a child.Barriers to implementation and feasibility concerns clearly remain. Interestingly, the pandemic may provide some answers with recent literature describing the use of HOT for hypoxic adults with COVID-19, a process begun during the unprecedented volume of emergency department (ED) and hospitalized patients who accompanied the pandemic.5 This suggests that HOT programs may be implemented safely and quickly, even at sea level. Although some of the HOT literature describes ED-initiated HOT, thereby circumventing hospitalization entirely, short-stay, observation, and inpatient units may be the most feasible starting point for new HOT programs, allowing for more time to coordinate discharge planning and working with primary care providers for follow-up.The authors also suggest a potential role for home management of infants traditionally admitted for observation only, with neither supplemental oxygen nor hydration support. Although this is a cohort that could benefit from recent advances in telehealth capabilities, we would caution against the addition of home pulse oximetry monitoring, which is already overrelied on in decision-making in patients with bronchiolitis, difficult for providers to ignore, and linked to increase in hospitalization and length of stay.6 The use of home pulse oximetry could result in an increase in ED visits and hospitalizations in a system not prepared to provide other home care services such as HOT.Moving forward, the current health care climate of understaffed and overcrowded hospitals will likely necessitate changes in the way that we care for patients. The establishment of home care programs such as HOT may be a worthwhile investment for systems that are experiencing hospital bed shortages and boarding patients in EDs. The current data do demonstrate that HOT can decrease length of stay, and improve family-centered care. In regions where dehydration, more than hypoxia, drives bronchiolitis admissions, trials of home nasogastric hydration may be useful. Sharing of data on the implementation logistics used by successful HOT programs for bronchiolitis could be useful for other interested institutions to move forward with implementation of HOT programs and the research that may reaffirm their benefits.