Healthcare providers should avoid pulse oximetry in young children with bronchiolitis, according to a research analysis published online August 16, 2017, in the BMJ.
“Pulse oximetry as a technology represents a major and significant advance in medicine.… However, its increasing and widespread use in stable infants and young children with bronchiolitis, a self limited disease with a generally benign course, has led to technology driven overdiagnosis of hypoxaemia — fueling uncertainty, increased use of resources, and patient harm,” write Ricardo Quinonez, MD, from Baylor College of Medicine in Houston, Texas, and colleagues.
The American Board of Internal Medicine Foundation (ABIM) recognizes this problem in its Choosing Wisely campaign, which is aimed at decreasing overuse of unnecessary medical practices. In 2013, the Society of Hospital Medicine published a list of five tests and treatments to avoid in hospitalized children as part of that effort. That list includes avoiding continuous pulse oximetry in children admitted for respiratory illness who are not receiving supplemental oxygen.
Updated American Academy of Pediatrics (AAP) clinical practice guidelines also advise against use of continuous pulse oximetry in bronchiolitis.
At the same time, guidelines and clinical practice differ on standard definitions for hypoxemia. The AAP has set lower thresholds for hypoxemia, at 90%, on the basis of research suggesting that this level is safe and may have better outcomes than higher thresholds. The UK National Institute for Health and Care Excellence guidelines recommend a higher threshold, at 92%.
However, the evidence from three randomized controlled trials suggests that “exposing children to lower probabilities of diagnosis of hypoxaemia seems to be safe and could also lead to improved outcomes,” the authors write.
Most studies have been too small to find a measurable benefit of increased pulse oximetry in short- to medium-term outcomes such as mortality, rehospitalization, or need for increased care, the authors explain. Some studies have suggested reduced mortality rates or possible cognitive benefits, but these have been done in developing countries, in critically ill children, or in children with chronic disease; therefore, the results may not apply to those in developed countries or otherwise healthy children.
Aside from live births, bronchiolitis represents the leading cause of hospital admission in US infants during the first year of life. Bronchiolitis is a viral infection of the lower respiratory tract that mostly affects children up to age 2. Treatment is mostly supportive.
Admissions for bronchiolitis have almost tripled during the last 30 years, mirroring the increased use of pulse oximetry for measuring blood oxygen saturation. As bronchiolitis-related disease severity and mortality have not decreased during that time, some experts suggest that borderline low oxygen levels, likely detected by increased use of pulse oximetry, have led to overdiagnosis of hypoxemia.
The best-documented harms of such overdiagnosis are unnecessary hospitalization and increased length of hospital stay, the authors write. Both can increase the risk for hospital-acquired infections and other adverse events.
Unnecessary admission and overly aggressive care also increase healthcare costs. At least one study estimates the cost of bronchiolitis at approximately $652 million per year. An economic analysis of data from one trial found lowering oxygen saturation thresholds may decrease costs by $377 per patient; those savings increase after factoring in other variables including travel and missed work.
“The cost savings from preventing overdiagnosis could prove significant, both for individual patients and at a societal level,” the authors explain.
“The current body of evidence suggests that we should challenge assumptions regarding the detection and aggressive management of borderline hypoxaemia in non-critically ill infants with bronchiolitis,” they stress.
“The most impactful intervention may be to decrease overdependence on pulse oximetry as a major decision point in admission of children with bronchiolitis,” the authors conclude.
The authors have disclosed no relevant financial relationships.
The BMJ. Published online August 16, 2017. Full text
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