Children belong at home with their parents. But what when children become ill? At every pediatric hospital, the duration of hospital admissions decreases steadily and the number of ambulatory services is forever increasing. Especially for children with chronic conditions, home support programs have been developed. These range from home intravenous antibiotic therapy, home total parenteral nutrition, home peritoneal dialysis, home oxygen therapy, home noninvasive ventilation to home support for children on palliative care. But all these conditions have one item in common: they are aimed at supporting children with a chronic disorder. In these situations, the gain for the child and family is large, the caregiver is accustomed with the medical condition, the transfer home can be prepared. For sure, the pioneers who initiated these programs faced resilience from their colleagues. Still, in affluent societies, such pediatric programs are now well embedded in the care landscape. In the current issue of the European Journal of Pediatrics, the authors enter an entirely different arena: they calculate the potential gain of hospital days when infants and toddlers with bronchiolitis, the prototype of an acute and possibly life-threatening disease, are discharged home on oxygen [5]. Is this a bridge too far? Surely, some have prescribed home oxygen therapy for bronchiolitis and claim it can be done safely [3, 6, 8, 12]. And indeed, depending on the cost of hospital admission versus the cost and extent of home care support, some Euros can be saved. Is sending infants with an acute respiratory infection home on oxygen therapy because of the perceived need for supplemental oxygen the correct strategy? Several pieces of evidence cast serious doubt. The introduction of routine oximetry has been accompanied by an increase in the rate and duration of hospital admissions for bronchiolitis [10]. Even a small change in oxygen saturation from 94 to 92 % apparently has much more impact on the physicians’ decision to admit infants with bronchiolitis, than the degree of respiratory distress [7]. The perceived need for supplemental oxygen is reported as the sole reason for prolongation of hospital admission in about 25 % of infants with bronchiolitis [9]. When all clinical parameters have improved, oxygen supplementation is still continued for an average of 66 h [13]. This leads to the relevant question of which infants require supplemental oxygen during the course of acute bronchiolitis, especially in the convalescent phase. I do not think we always know the answer. Pulse oximetry allows for a simple, noninvasive, and reasonably accurate estimation of arterial oxygen saturation [4]. But users should be aware of its limitations, which include: motion artifacts, poor perfusion at the site of measurement, irregular rhythms, ambient light or electromagnetic interference, skin pigmentation, nail polish, calibration assumptions, probe positioning, time lag in detecting hypoxic events, venous pulsation, intravenous dyes, and presence of abnormal hemoglobin molecules [4]. The apparatus’ accuracy (the closeness of measurement of a quantity to that quantity’s true value) is only in the order of ±2 % and the apparatus’ precision (the degree to which repeated measurements under unchanged conditions show the same results, also called reproducibility or repeatability) is only in the order of 4 % [4]. In addition, oxygen delivery to tissues also depends on hemoglobin levels and cardiac output. Neither is taken into account in oximetry. It is often forgotten that for the same cardiac output, a hemoglobin level of 8 g/dl and 100 % oxygen saturation, is associated with lower oxygen K. De Boeck (*) Division of Pediatric Pulmonology and Pediatric Infectious Diseases, University of Leuven, Leuven, Belgium e-mail: Christiane.DeBoeck@uzleuven.be
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Jun 1, 2014
Cl Sullivan + 1
Open Access