Abstract
Recent publications have established the pulse oxygen saturation (SpO2) threshold of 90% for the hospitalization and discharge of infant patients with bronchiolitis. However, there is no clear recommendation regarding the Emergency Department (ED) observation period necessary before allowing safe home discharge for patients with SpO2 above 90%-92%. Our primary aims were to evaluate the risk factors associated with delayed desaturation in infants with SpO2 ≥ 92% on arrival at the ED as well as the ED observation period necessary before allowing safe home discharge. A secondary aim was to identify the risk factors for ED readmission. Of 581 episodes of bronchiolitis in patients < 1 year old admitted to the ED, only 47 (8%) had SpO2 < 92% on arrival there, although 106 (18%) exhibited a delayed desaturation (to < 92%) during ED observation. Female sex, age < 3 months old, ED readmission, more severe initial clinical presentation, and higher pCO2 level (> 6KPa) were risk factors for delayed desaturation with OR varying from 1.7 to 7.5. In patients < 3 months old, mean desaturation occured later than in older patients [6.0 hours (IQR 3.0–14.0) vs. 3.0 hours (IQR 2.0–6.0), P = 0.0018]. In 95% of patients with a delayed desaturation this decrease occurred within 25 hours for patients < 3 months old and within 11 hours for patients ≥ 3 months old. In patients < 3 months old with respiratory rates above the normal range for their age the desaturation occurred earlier than in patients < 3 months with normal respiratory rates [4.4 hours (IQR 3.0–11.7) vs. 14.6 hours (IQR 7.6–22.2), P = 0.037]. Based on the present study’s results, we propose a five step guide for pediatricians on discharging children with bronchiolitis from the ED. By using the threshold of an 11 hour ED observation period for patients ≥ 3 months old and a 25 hour period for patients < 3 months old we are able to detect 95% of the patients with bronchiolitis who are at risk of delayed desaturation.
Highlights
Bronchiolitis is the leading cause of hospitalization for infants with an estimated 3.4 million admissions globally every year [1], most children arriving at an emergency department (ED) with bronchiolitis are discharged home after their medical consultation [2,3]
During two respiratory syncytial virus (RSV) seasons (2010–2012), children were eligible for inclusion in the study if they were aged less than 1 year old and their primary or secondary discharge diagnosis was bronchiolitis (International Classification of Diseases, version 2010, codes: J21, acute bronchiolitis; J21.0, acute bronchiolitis due to RSV; and J21.9, acute bronchiolitis, unspecified) identified from computerized hospital charts
Of the 546 infants presenting with bronchiolitis to the ED during the study period, 478 (161 female: 317 male) under one year old and without chronic diseases were included, corresponding to 581 episodes
Summary
There is no clear recommendation regarding the ED observation period necessary before allowing safe discharge home for patients with SpO2 above 90%-92%. Mansbach et al created a low risk model including cut-off points for age, respiratory rate (RR) and oxygen saturation with which to identify children who might experience an unanticipated clinical deterioration and a more severe outcome [8]. Another retrospective study found that oxygen saturation and clinical assessment failed to differentiate between patients with bronchiolitis who had consulted a second time and required hospital admission, and patients who had not [9]. Previous studies have not provided information about the ideal observation period necessary before considering an ED discharge to be without risk
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