impact of home oxygen therapy on hospital stay for infants with acute bronchiolitis

7/30/2019 Impact of Home Oxygen Therapy on Hospital Stay for Infants With Acute Bronchiolitis

1/6

ORIGINAL ARTICLE

Impact of home oxygen therapy on hospital stay for infants

with acute bronchiolitis

Marie Gauthier & Melanie Vincent & Sylvain Morneau &

Isabelle Chevalier

Received: 3 June 2012 /Revised: 16 August 2012 /Accepted: 4 September 2012# Springer-Verlag 2012

Abstract Acute bronchiolitis has been associated with an

increasing hospitalization rate over the past decades. The

aim of this paper was to estimate the impact of home oxygen

therapy (HOT) on hospital stay for infants with acute bron-chiolitis. A retrospective cohort study was done including

all children aged 12 months discharged from a pediatric

tertiary-care center with a diagnosis of bronchiolitis, be-

tween November 2007 and March 2008. Oxygen was ad-

ministered according to a standardized protocol. We

assumed children with the following criteria could have

bee n sen t home wit h O2, instead of being kept in

hospital: age 2 months, distance between home and

hospital


2/6

have described the use of home O2 in some children with

acute bronchiolitis, discharged either from an emergency

department (ED) [2, 7], a 24-h observation unit [13] or an

inpatient unit [13, 17]. According to these data, home O2therapy (HOT) is an alternative to traditional hospital O2therapy in selected children with acute bronchiolitis. How-

ever, experience with this approach is still limited, and

deserves caution [4, 8].The objective of this study was to estimate the potential

impact of HOT on hospital stay, using pre-defined criteria, for

012-month-old children admitted with acute bronchiolitis.

Material and methods

This cohort study was conducted at an urban, academic,

tertiary-care childrens hospital located at sea level (57 m)

(Sainte-Justine University Hospital Center, Montreal, Can-

ada). This centers emergency department (ED) has an an-

nual volume of 60,000 patient-visits and includes a 16-bed,24-h observation unit (children kept in this unit are not

considered hospitalized).

All children less than 12 months of age hospitalized with

acute bronchiolitis between November 1, 2007 and March,

31 2008 were eligible for the study. Patients were identified

through discharge diagnoses, including the following codes

from the ninth revision of the International Classification of

Diseases: J21.0 (acute bronchiolitis due to respiratory syn-

cytial virus) and J21.9 (acute bronchiolitis, without causa-

tive agent specified). All eligible patients were included,

unless they met at least one of the following criteria: (a)

cyanotic congenital heart disease, or heart disease requiring

digitalisation; (b) chronic pulmonary disease requiring HOT

at the time of admission; (c) chronic hematologic disease

(e.g., sickle cell anemia); (d) immune deficiency; (e) prior

history of cancer; (f) metabolic disease including diabetes

mellitus; (g) neuromuscular disease.

Data were obtained through chart review, performed for

each patient by one of three independent investigators (MG,

MV, SM) using standardized data collection forms. Informa-

tion was obtained on demographic characteristics, length of

stay, clinical course, and treatments received during hospital-

ization. Information about supplemental O2 use, including

duration of administration and O2 flow rates, were abstracted

from the nurses records in the chart. Over the study period,

vital signs, including pulsed O2 saturation (SpO2), and O2flow rates or concentrations were recorded at least every 4 h

for every child admitted with acute respiratory distress. For all

children, dates of hospital admission and discharge were

defined as recorded in the nurses notes.

A clinical protocol outlining the use of supplemental O2for children without chronic cardiopulmonary disease, hos-

pitalized with an acute respiratory illness, was implemented

in 2003 at our hospital. One of its main objectives was to

emphasize the importance of O2 weaning to shorten hospital

stay. According to this protocol, O2 was administered to

maintain a SpO292 %, except in children with severe

respiratory distress (for these patients, a SpO294 % was

the objective). Nurses were instructed to wean O2 in patients

for whom SpO2 were above these levels. They were also

asked to increase the FiO2 in either of the two followinginstances: (a) clinically detectable cyanosis; (b) SaO2 1.0 L/min if it was given through

sources other than nasal cannula (i.e., endotracheal tube, con-

tinuous positive airway pressure, face mask, or hood).The primary outcome of this study was the proportion of

infants hospitalized with acute bronchiolitis who met dis-

charge criteria for HOT. We assumed that children with

criteria defined in Table 1 could have been sent home with

HOT, instead of being kept in hospital. Intravenous fluid

requirement was assessed according to physicians prescrip-

tions. The condition of the child was considered as stable

over the last 24 h if he/she was described as stable in

physicians notes, if the on-call team had not been called

to his/her bedside and if he/she had not been observed in the

pediatric intensive care unit (PICU) over this period of time.

Oxygen requirement was not included per se in the defini-

tion ofstable condition.

A secondary outcome was the number of patient-days of

hospitalization that could have been saved in this cohort, had

HOT been available. The potential date of discharge with

HOT was defined as the date all criteria for early discharge

with HOT were first met. The number of days of hospitaliza-

tion that could have been saved for an individual patient using

HOT was the difference in days between the real date of

discharge and the potential date of discharge with HOT. The

number of patient-days of hospitalization that could have been

saved with HOT in the entire cohort was computed by sum-

ming up the number of days potentially saved in individual

patients, had HOT been available. This is reported as an

absolute number and as a proportion of the total patient-days

of hospitalization for bronchiolitis over the study period (cal-

culated by summing up the total number of days of hospital-

ization for all infants in the cohort).

All analyses were performed using SPSS statistical soft-

ware, version 17.0.1. Descriptive statistics were calculated

for the entire cohort. Odds ratios and corresponding 95 %

confidence intervals of meeting criteria for discharge with

Eur J Pediatr


3/6

HOT were calculated through univariate and multivariate

logistic regression. Maximum likelihood estimates of re-

gression coefficients were used to estimate crude and ad-

justed odds ratios for each of the exposure variables. Ninety-

five percent confidence intervals (95%CI) were calculated

for all estimates reported. The following variables were

included in regression models: prematurity, sex, first epi-

sode of bronchiolitis, use of endotracheal intubation and

mechanical ventilation, use of non-invasive ventilation. This

study was approved by Sainte-Justine University Hospital

Centers institutional review board.

Results

One hundred and ninety-two infants were eligible for the

study (Fig. 1). Fifteen patients were excluded because they

met at least one exclusion criterion, thus 177 infants were

included. Their clinical characteristics are described in Table 2.

Median age was 2.0 months (range 011) and median length

of stay was 3.0 days (range 018).

Forty-eight percent of patients (85/177) received supple-

mental O2 in the course of their hospital stay. Their median

length of stay was 5 days (range 118). The median duration

of O2 administration was 2 days (range 014). Almost two

thirds (32/52) of infants who received supplemental O2more than 24 h while in hospital were less than 2 months

of age; 22/30 of infants who received O2 more than 48 h

were in this age group. Oxygen administration was initiated

within 24 h of admission in 88.2 % of children who received

supplemental O2. Maximal O2 flow rate given during the

entire hospital stay was 1.0 L/min in 52.9 % of instances.

Thirteen infants met criteria for discharge with HOT

(15.3 % of infants who had received O2 and 7.3 % of all

patients), a media n of 2 days (range 04) prior to real

discharge. The number of patient-days of hospitalization

which would have been saved had HOT been available

was 21, representing 4.2 % of patient-days of hospitalization

for children who had received O2 (21/496) and 3.0 % of

total patient-days of hospitalization for bronchiolitis over

the study period (21/701). If children meeting criteria for

HOT were considered eligible for this treatment regardless

of the distance between their home and the hospital, 5.4 %

of total patient-days of hospitalization for bronchiolitis

would have been saved using HOT.

No significant association on crude or multivariate anal-

ysis was found between prematurity, sex, first episode of

bronchiolitis, or use of non-invasive ventilation and eligi-

bility for HOT, as shown in Table 3. No children who had

been intubated and mechanically ventilated were eligible for

HOT, therefore no odds ratios were computed for this

variable.

Discussion

Our study shows that in the setting of a pediatric tertiary-care hospital, using pre-defined criteria, HOT would not

significantly decrease the overall burden of hospitalization

for 012-month-old children hospitalized with bronchiolitis.

Table 1 Criteria of potential el-

igibility for home oxygen

therapy

Age 2 months

Home within 50 km of the hospital

In-hospital observation 24 h

Intravenous fluids


4/6

More than half of children who received O2 during their

hospital stay were less than 2 months of age, and the

majority of patients who required supplemental O2 for more

than 24 or 48 h were in this age group. These children were

not considered eligible for HOT in the study design. Young

age was thus a major obstacle to HOT in our study. Supple-

mental O2, when it was used, was given for a short duration

(median of 2 days); a longer need for O2 administration

would have increased the potential usefulness of HOT.

The 21 patient-days of hospitalization potentially saved with

HOT among the 13 eligible patients described in Fig. 1

could be considered as clinically relevantindeed, for a

few patients, HOT could have saved 12 days of hospitali-

zationbut they only represented 4 % of patient-days of

hospitalization for children who had received O2 and 3.0 %

of total patient-days of hospitalization for bronchiolitis over

the study period. This could be considered significant inother settings where demand for hospital beds is not being

met, and inpatient costs are high. However, other ways of

limiting duration of hospitalization for infants with bron-

chiolitis, namely reducing SpO2 threshold to 90 % in stable

children instead of 9293 % or instituting procedures to

wean O2 more efficiently, may have more effect than

HOT, without its potential risks and the need for logistical

organization.

Fifteen percent of our patients were admitted to the PICU

during their hospital stay, 8 % were intubated, and 8.5 %

required non-invasive ventilation. These numbers indicate

similar, if not greater, seriousness of disease compared withanother series describing children hospitalized for bronchio-

litis at the Childrens Medical Center in Dallas, Texas,

between 2002 and 2007, where requirement for PICU and

ventilatory support were 10 and 5 %, respectively [6]. In this

same series, the percentage of children requiring supple-

mental O2 administration was 53 %, and the mean duration

of O2 administration was 2 days; these numbers are compa-

rable to ours. In a recent cohort study including infants aged

up to 6 months admitted to hospital with bronchiolitis,

oxygen was administered in 61 % (201/328) of patients,

but only 3 % (11/328) required artificial ventilation [18].

Thus, the low potential impact of HOT on hospital days

found in our study cannot be explained by the fact that

bronchiolitis was mild in our patients.

In this cohort, all infants were followed on a daily basis

by full time hospital-based pediatricians, and a clinical

protocol for O2 administration on the pediatric wards had

been implemented for several years at the time of the study.

Results may have been different in another context, partic-

ularly in a setting allowing a more liberal use of O2.

So far, four publications have reported the use of HOT in

children with bronchiolitis. Two studies were prospective

randomized trials, comparing discharge with HOT to either

hospitalization [2] or prolongation of hospitalization [17] in

children aged 224 months. The third was a prospective

observational study describing a group of 20 children of

unspecified age discharged with HOT either from a 24-

h observation unit or after inpatient admission [13]. In these

three studies, a total of 79 patients were treated with HOT

and only two required readmission to hospital; there were no

significant complications related to O2 therapy at home.

Neither of these three studies evaluated the impact of HOT

on hospital stay for the entire group of children treated for

Table 2 Clinical characteristics of children hospitalized with acute

bronchiolitis (N0177)

Patient characteristics

Age at admissionmonths, median (range) 2.0 (011)

Prematurity (gestational age


5/6

bronchiolitis at their institution, be it in the ED or on a

hospital ward. In two of these studies, the authors used a

convenience sample [2, 13], and it is unclear what fraction

of all children with bronchiolitis these children represented.

Halstead et al. performed a retrospective chart review of

children who presented at the Childrens Hospital of Denver

(Colorado) ED with bronchiolitis during a 5-year period [7].

The objective of their study was to evaluate the impact of ahome O2 clinical care protocol on admission rates. In this

study, inclusion criteria for HOT were met in 4,194 instan-

ces overall, and in 15 % of these (649/4,194), patients were

discharged with home O2. The overall admission rate for

bronchiolitis dropped from 40 to 31 % during the study

period, and there were no PICU admissions in patients dis-

charged on HOT. So far, published data are thus in favor of

HOT in selected groups of children with bronchiolitis. How-

ever, three of these studies come from US cities located at

moderate altitude, Denver (1,600 m) [2, 7] and Salt Lake

City (1,300 m) [13]. At moderate altitudes, normal SpO2

values are somewhat lower [5]. It is therefore possible thatchildren with SpO2 50 km from the hospital would not be eligible

for HOT, given that frequent transportation to and from the

hospital would be too cumbersome for their parents. Other

authors have also taken some practical aspects of surveillancein consideration when defining criteria for HOT eligibility,

namely distance between home and health care facility [2],

availability ofhospital in the home nurses to do home visits

at least twice daily [17], and availability of primary care

physicians to perform a follow-up visit [13]. Had we consid-

ered that all infants in the study were eligible for HOT regard-

less of the distance between their home and the hospital, the

proportion of patient-days of hospitalizations saved would

have been only marginally increased (5 vs 4 %). In other

words, the distance criterion did not have a significant impact

on our results, most likely because to be eligible for HOT,

several criteria had to be met at the same time, distance

between home and hospital being only one of them.

There were some limitations to our study. First, it was held

at a single pediatric tertiary-care center and patients were

included over a period of only one winter season. Second, it

was limited to children aged 0 to 12 months. We chose not to

include the 1224-month-old group because of the heteroge-

neity of diagnoses in this population. Children older than

12 months who are admitted for respiratory distress and

wheezing after a viral upper respiratory prodrome may be

diagnosed as having bronchiolitis, asthma, or bronchial hyper-

responsiveness, depending on clinicians. Third, retrospective

assessment through chart review may have led, in some cases,

to under- or overestimation of clinical stability. Fourth, some

unnecessary increments of the FiO2 could have happened

despite our instructions. As oxygen requirement 1.0 L/min

was one criterion for potential discharge with HOT, it is

therefore possible that some patients were considered not

eligible for HOT because of unnecessary upward adjustments

of the FiO2. Fifth, there are several potential barriers to dis-

charging children hospitalized with bronchiolitis, such as the

need for suctioning, and parental and treating physicians

Eur J Pediatr


6/6

discomfort [13]; an acceptable SpO2 on room air can also be

required [2, 3]. These elements were not evaluated in our

study; had they been, the impact of HOT would possibly have

been even lower.

Conclusions

At a single pediatric tertiary-care center located at sea level,

HOT would be minimally effective at reducing the number

of days of hospitalization in 012-month-old children with

bronchiolitis. In a state-of-the-art on HOT in children,

Balfour-Lynn mentioned that acute HOT can be considered

for children who have acute bronchiolitis, after a period of

hospital observation [3]. HOT is described as a novel

approach for bronchiolitis by Zorc and Breese Hall [19].

Clearly, more data are needed before this option becomes

routine care, including effectiveness, and cost analysis of

the redistribution of care costs from hospital to home [4].

Conflict of interest The authors declare that they have no conflict of

interest. They did not have any affiliation, financial agreement, or other

involvement with any company for this study.

References

1. American Academy of Pediatrics (2006) Diagnosis and manage-

ment of bronchiolitis. Pediatrics 118:17741793

2. Bajaj L, Turner CG, Bothner J (2006) A randomized trial of home

oxygen therapy from the emergency department for acute bron-

chiolitis. Pediatrics 117:633640

3. Balfour-Lynn IM (2009) Domiciliary oxygen for children. Pediatr

Clin North Am 56:275296

4. Cunningham S (2009) A hospital is no place to be sick Samuel

Goldwyn (18821974). Arch Dis Child 94:565566

5. Fouzas S, Priftis KN, Anthracopoulos MB (2011) Pulse oximetry

in pediatric practice. Pediatrics 128:740752

6. Garcia CG, Bhore R, Soriano-Fallas A, Trost M, Chason R, Ramilo

O, Mejias A (2010) Risk factors in children hospitalized with RSV

bronchiolitis versus non-RSV bronchiolitis. Pediatrics 126:e1453

e1460

7. Halstead S, Roosevelt G, Deakyne S, Bajaj L (2012) Discharged

on supplemental oxygen from an emergency department in patients

with bronchiolitis. Pediatrics 129:e605e610

8. Joseph L, Goldberg S, Picard E (2006) A randomized trial of homeoxygen therapy from the emergency department for acute bron-

chiolitis (letter). Pediatrics 118:13191320

9. Mallory MD, Shay DK, Garrett J, Bordley WC (2003) Bron-

chiolitis management preferences and the influence of pulse

oximetry and respiratory rate on the decision to admit. Pediat-

rics 111:e45e51

10. Pelletier AJ, Mansbach JM, Camargo CA Jr (2006) Direct medical

costs of bronchiolitis hospitalizations in the United States. Pediat-

rics 118:24182423

11. Perlstein PH, Kotagal UR, Bolling C, Steele R, Schoettker PJ,

Atherton HD, Farrell MK (1999) Evaluation of an evidence-

based guideline for bronchiolitis. Pediatrics 104:13341341

12. Samuels MO (2004) The effects of flight and altitude. Arch Dis

Child 89:448455

13. Sandweiss DR, Corneli HM, Kadish HA (2010) Barriers to dis-charge from a 24-h observation unit for children with bronchiolitis.

Pediatr Emerg Care 26:892896

14. Schroeder AR, Marmor AK, Pantell RH, Newman TB (2004)

Impact of pulse oximetry and oxygen therapy on length of stay

in bronchiolitis hospitalizations. Arch Pediatr Adolesc Med

158:527530

15. Schuh S (2011) Update on management of bronchiolitis. Curr Opin

Pediatr 23:110114

16. Shay DK, Holman RC, Newman RD, Liu LL, Stout JW, Anderson

LJ (1999) Bronchiolitis-associated hospitalizations among US

children, 19801996. JAMA 282:14401446

17. Tie SW, Hall GL, Peter S, Vine J, Verheggen M, Pascoe EM,

Wilson AC, Chaney G, Stick SM, Martin AC (2009) Home

oxygen for children with acute bronchiolitis. Arch Dis Child

94:641643

18. Walker C, Danby S, Turner S (2012) Impact of a bronchiolitis

clinical care pathway on treatment and hospital stay. Eur J Pediatr

171:827832

19. Zorc JJ, Hall CB (2010) Bronchiolitis: recent evidence on diagno-

sis and management. Pediatrics 125:342349

Eur J Pediatr

impact of home oxygen therapy on hospital stay for infants with acute bronchiolitis

Documents