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Original Investigation
March 1, 2021

Intermittent vs Continuous Pulse Oximetry in Hospitalized Infants With Stabilized Bronchiolitis: A Randomized Clinical Trial

Author Affiliations
  • 1Department of Pediatrics, University of Toronto, Toronto, Ontario, Canada
  • 2Institute for Health Policy, Management and Evaluation, University of Toronto, Toronto, Ontario, Canada
  • 3Child Health Evaluative Sciences, Research Institute, Hospital for Sick Children, Toronto, Ontario, Canada
  • 4Division of General Pediatrics, Department of Pediatrics, McMaster University and McMaster Children’s Hospital, Hamilton, Ontario, Canada
  • 5Children’s Health Division, Trillium Health Partners, Mississauga, Ontario, Canada
  • 6North York General Hospital, Toronto, Ontario, Canada
  • 7Department of Pediatrics, Children’s Hospital of Eastern Ontario, University of Ottawa, Ottawa, Ontario, Canada
  • 8Department of Pediatrics, Queens University, Kingston, Ontario, Canada
  • 9Department of Pediatrics, Lakeridge Health, Oshawa, Ontario, Canada
  • 10Learning Institute, Hospital for Sick Children and Lawrence S. Bloomberg Faculty of Nursing, University of Toronto, Toronto, Ontario, Canada
  • 11Ontario Child Health Support Unit, SickKids Research Institute, Toronto, Ontario, Canada
  • 12Children’s Hospital of Eastern Ontario Research Institute, Ottawa, Ontario, Canada
  • 13Dalla Lana School of Public Health, University of Toronto, Toronto, Ontario, Canada
JAMA Pediatr. 2021;175(5):466-474. doi:10.1001/jamapediatrics.2020.6141
Key Points

Question  What is the effect of intermittent vs continuous pulse oximetry in infants hospitalized with stabilized bronchiolitis?

Findings  In this multicenter randomized clinical trial of 229 infants hospitalized with stabilized bronchiolitis with and without supplemental oxygen and with care managed using an oxygen saturation target of 90% or higher, length of hospital stay, medical interventions, safety, and parent-reported outcomes were similar. Nursing satisfaction was greater with intermittent monitoring.

Meaning  Given that other important considerations for clinical practice favor less intense monitoring, these findings support the standard use of intermittent pulse oximetry in hospitalized infants with stabilized bronchiolitis.

Abstract

Importance  There is low level of evidence and substantial practice variation regarding the use of intermittent or continuous monitoring in infants hospitalized with bronchiolitis.

Objective  To compare the effect of intermittent vs continuous pulse oximetry on clinical outcomes.

Design, Setting, and Participants  This multicenter, pragmatic randomized clinical trial included infants 4 weeks to 24 months of age who were hospitalized with bronchiolitis from November 1, 2016, to May 31, 2019, with or without supplemental oxygen after stabilization at community and children’s hospitals in Ontario, Canada.

Interventions  Intermittent (every 4 hours, n = 114) or continuous (n = 115) pulse oximetry, using an oxygen saturation target of 90% or higher.

Main Outcomes and Measures  The primary outcome was length of hospital stay from randomization to discharge. Secondary outcomes included length of stay from inpatient unit admission to discharge and outcomes measured from randomization: medical interventions, safety (intensive care unit transfer and revisits), parent anxiety and workdays missed, and nursing satisfaction.

Results  Among 229 infants enrolled (median [IQR] age, 4.0 [2.2-8.5] months; 136 [59.4%] male; 101 [44.1%] from community hospital sites), the median length of hospital stay from randomization to discharge was 27.6 hours (interquartile range [IQR], 18.8-49.6 hours) in the intermittent group and 25.4 hours (IQR, 18.3-47.6 hours) in the continuous group (difference of medians, 2.2 hours; 95% CI, −1.9 to 6.3 hours; P = .17). No significant differences were observed between the intermittent and continuous groups in the median length of stay from inpatient unit admission to discharge: 49.1 (IQR, 37.2-87.0) hours vs 46.0 (IQR, 32.5-73.8) hours (P = .13) or in frequencies or durations of hospital interventions, such as oxygen supplementation initiation: 4 of 114 (3.5%) vs. 9 of 115 (7.8%) (P = .16) and median duration of oxygen supplementation: 20.6 (IQR, 7.6-46.1) hours vs. 21.4 (11.6-52.9) hours (P = .66). Similarly, there were no significant differences in frequencies of intensive care unit transfer: 1 of 114 (0.9%) vs 2 of 115 (2.7%) (P = .76); readmission to hospital: 3 of 114 (2.6%) in the intermittent group vs 4 of 115 (3.5%) in the continuous group (P > .99); parent anxiety: mean (SD) parent anxiety score, 2.9 (0.9) in the intermittent group vs 2.8 (0.9) in the continuous group (P = .40); or parent workdays missed: median workdays missed, 1.5 (IQR, 0.5-3.0) vs 1.5 (IQR, 0.5-2.5) (P = .36). Mean (SD) nursing satisfaction with monitoring was significantly greater in the intermittent group: 8.6 (1.7) vs 7.1 (2.8) of 10 workdays; the mean difference was 1.5 (95% CI, 0.9-2.2; P < .001).

Conclusions and Relevance  In this randomized clinical trial, among infants hospitalized with stabilized bronchiolitis with and without hypoxia and managed using an oxygen saturation target of 90% or higher, clinical outcomes, including length of hospital stay and safety, were similar with intermittent vs continuous pulse oximetry. Nursing satisfaction was greater with intermittent monitoring. Given that other important clinical practice considerations favor less intense monitoring, these findings support the standard use of intermittent pulse oximetry in stable infants hospitalized with bronchiolitis.

Trial Registration  ClinicalTrials.gov Identifier: NCT02947204

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    1 Comment for this article
    EXPAND ALL
    Deimplementation of Pulse Oximetry Monitoring in Bronchiolitis: A Note of Caution
    Jonathan Pelletier, MD | UPMC Children's Hospital of Pittsburgh
    In their recent randomized-controlled trial, Dr. Mahant et. al. conclude that “the findings of this study support the standard use of intermittent pulse oximetry in infants hospitalized with stabilized bronchiolitis and provide strong evidence for quality improvement efforts in deimplementing continuous pulse oximetry.” We advise caution.

    No significant difference was observed in hospital length-of-stay between the two groups, nor in any of the patient-centered secondary outcomes. Notably, this trial was insufficiently powered to detect clinically meaningful differences in patient deterioration between the two groups. A noninferiority study designed to examine differences in intensive care unit (ICU) transfer rates
    would have required thousands of infants. Additionally, the study relied on stringent inclusion criteria (absence of comorbidity, age >4 weeks, and determination of stability after 6 hours of continuous monitoring), and the very low rates of ICU transfer likely do not reflect the ward populations of many hospitals in the United States. Over the past 10 years at our institution, ward-to-ICU transfers occurred among 12.9% (340/2,643) of children with bronchiolitis, with a median time-to-transfer of 18.7 (interquartile range 8.9-38.1) hours. In the United States, the ICU admission fraction in bronchiolitis has doubled over the past decade (24.5% in 2019). Predicting clinical deterioration in bronchiolitis remains challenging, and pulse oximetry monitoring is inexpensive, noninvasive, highly sensitive, and facilitates intervention before hypoxemia results in neuronal injury or cardiac arrest. These characteristics make continuous oximetry a near-ideal monitoring strategy.

    As most hospital courses for children with bronchiolitis are uneventful, the greater challenge facing pediatricians is to prevent rare but potentially devastating poor outcomes. Broad deimplimentation of continuous pulse oximetry is likely to result in delayed detection of a small number of preventable clinical deteriorations, with no apparent clinical benefit based on the study results by Dr. Mahant et. al. Thus, pediatricians must carefully weigh the potential benefits to nursing satisfaction against patient safety. Further, Dr. Mahant et. al. hypothesized that continuous pulse oximetry monitoring would result in longer hospital length-of-stay because clinicians would react to transient, clinically meaningless hypoxemia and institute unnecessary therapy. Yet neither the duration of oxygen therapy nor the length-of-stay were different between the groups. This refutes the study hypothesis and argues that clinicians are capable of correctly assessing which oximetry values require intervention. Given that continuous oximetry was not associated with harm or excess costs, it remains an appropriate monitoring approach to help pediatricians achieve the best possible bronchiolitis outcomes.

    Jonathan H. Pelletier, MD

    Christopher M. Horvat, MD, MHA

    Department Critical Care Medicine, Division of Pediatric Critical Care Medicine, UPMC Children’s Hospital of Pittsburgh

    Department of Pediatrics, Division of Health Informatics, UPMC Children’s Hospital of Pittsburgh; Pittsburgh, Pennsylvania
    CONFLICT OF INTEREST: None Reported
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