At what oxygen saturation is hospitalisation recommended in children with bronchiolitis?

Date First Published:
September 25, 2007
Last Updated:
February 22, 2010
Report by:
Jolita Bekhof, pediatrician (Isala Clinics, Zwolle)
Search checked by:
Jolita Bekhof, Isala Clinics, Zwolle
Three-Part Question:
In children presenting at the ED with bronchiolitis [P], what is the change of developing severe disease [O] at different saturation levels measured with pulse oximetry [I]?
Clinical Scenario:
A 4-month old child is presented at the emergency department with coryza,cough and wheeze. You see an alert, well hydrated wheezing infant with mild respiratory distress and oxygen-saturation 93%. You wonder wether it is safe to send this child with bronchiolitis home.
Search Strategy:
Pubmed
Search Details:
[bronchiolitis] AND [oxygen saturation], limits: English language
Outcome:
130 titels, of which 7 relevant articles. Five of these 7 relevant articles were based on data from a prospective cohort study. Two studies were retrospective, one retrospective cohortstudy and one retrospective case-control study. Only the 5 prospective cohort study were considered in this bestbet.
Relevant Paper(s):
Study Title Patient Group Study type (level of evidence) Outcomes Key results Study Weaknesses
Predictors of major intervention in infants with bronchiolitis Parker MJ 2009 Canada 312 children 2-23 months old with bronchiolitis at
the emergency department		 prospective cohort study major medical intervention (oxygen for sat < 90%) sat < 93%: RR 2,4 (95%CI 1,33-4,32), ARR 21% (95%CI 2-40%)
Prospective multicenter studyof bronchiolitis: predicting safe discharges from the emergency department Mansbach JM 2008 USA 1456 children < 2 years with bronchiolitis at the emergency department prospective cohortstudy Hospitalisation sat <94%: OR 2,28 (95%CI 1,56-3,34)
Clinical predictors of the severity of bronchiolitis Voets S 2006 Belgium 378 children aged 2 weeks- 2 years with RSV-bronchiolitis at the emergency department prospective cohortstudy hospitalisation sat <95%: RR 4,7 (95%CI 3,47-6,51), ARR 55% (95%CI 45-65%)
Outpatient assessment of infants with bronchiolitis Shaw NS 1991 USA 213 children, < 13 months with bronchiolitis at the emergency department prospective cohortstudy severe disease (mild disease is alert/active and well hydrated with oral fluids) sat < 95%: RR 3,3 (95%CI 2,52-4,34)
Clinical findings and severity of acute bronchiolitis Mulholland EK 1990 Australia 60 children < 16 months hospitalised with bronchiolitis prospective cohort FiO2>40% sat <90%: RR 4,6 (95%CI 1,76-12,16), ARR 42% (95%CI 13-71%)
Author Commentary:
The 5 relevant studies looked at that different clinical outcomes using varying oxygen-saturation levels. In none of the studies, the consequences of varying oxygen-saturation levels were considered within the studypopulation.
Most studies considered hospitalisation as outcome measure, only 2 studies looked at actual need for hospitalisation, supported by the administration of supplemental oxygen.
An important issue when considering the outcome measure "severity of disease", is what level of hypoxia is considered clinically relevant.
Bottom Line:
Lower oxygen saturation is associated with more severe disease in children with bronchiolitis. A definitive safe value for oxygensaturation when considering discharge is not straigthforward. However it seems reasonable to consider an oxygen-saturation >92% safe enough for discharge when concerning severe respiratory symptoms.
References:
  1. Parker MJ. Predictors of major intervention in infants with bronchiolitis
  2. Mansbach JM. Prospective multicenter studyof bronchiolitis: predicting safe discharges from the emergency department
  3. Voets S. Clinical predictors of the severity of bronchiolitis
  4. Shaw NS. Outpatient assessment of infants with bronchiolitis
  5. Mulholland EK. Clinical findings and severity of acute bronchiolitis