Intermittent vs Continuous Pulse Oximetry in Hospitalized Infants With Stabilized Bronchiolitis: A Randomized Clinical Trial | Critical Care Medicine | JAMA Pediatrics | JAMA Network
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Figure 1.  Flow of Participants in the Trial
Flow of Participants in the Trial

Reasons for meeting exclusion criteria and reasons for not being approached for consent are not mutually exclusive. A total of 101 of 229 infants (44.1%) were recruited from community hospital sites. See the trial protocol in Supplement 1 for further details. PICU indicates pediatric intensive care unit.

Figure 2.  Kaplan-Meier Plot of the Proportion of Infants With Bronchiolitis in Hospital
Kaplan-Meier Plot of the Proportion of Infants With Bronchiolitis in Hospital

Cox proportional hazards regression of the primary outcome of length of stay from randomization to discharge, stratified by site and adjusted for sex, resulted in a hazard ratio of 0.93 (95% CI, 0.71-1.23; P = .62).

Table 1.  Baseline Characteristics of the Enrolled Participantsa
Baseline Characteristics of the Enrolled Participantsa
Table 2.  Primary and Secondary Outcomes of Length of Hospital Stay
Primary and Secondary Outcomes of Length of Hospital Stay
Table 3.  Secondary Outcomes Measured From Time of Randomization
Secondary Outcomes Measured From Time of Randomization
1.
Hasegawa  K, Tsugawa  Y, Brown  DFM, Mansbach  JM, Camargo  CA  Jr.  Trends in bronchiolitis hospitalizations in the United States, 2000-2009.   Pediatrics. 2013;132(1):28-36. doi:10.1542/peds.2012-3877 PubMedGoogle ScholarCrossref
2.
Ralston  SL, Lieberthal  AS, Meissner  HC,  et al; American Academy of Pediatrics.  Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis.   Pediatrics. 2014;134(5):e1474-e1502. doi:10.1542/peds.2014-2742 PubMedGoogle ScholarCrossref
3.
Hartling  L, Fernandes  RM, Bialy  L,  et al.  Steroids and bronchodilators for acute bronchiolitis in the first two years of life: systematic review and meta-analysis.   BMJ. 2011;342:d1714. doi:10.1136/bmj.d1714 PubMedGoogle ScholarCrossref
4.
Mower  WR, Sachs  C, Nicklin  EL, Baraff  LJ.  Pulse oximetry as a fifth pediatric vital sign.   Pediatrics. 1997;99(5):681-686. doi:10.1542/peds.99.5.681 PubMedGoogle ScholarCrossref
5.
Enoch  AJ, English  M, Shepperd  S.  Does pulse oximeter use impact health outcomes? a systematic review.   Arch Dis Child. 2016;101(8):694-700. doi:10.1136/archdischild-2015-309638 PubMedGoogle ScholarCrossref
6.
Cunningham  S, Rodriguez  A, Adams  T,  et al; Bronchiolitis of Infancy Discharge Study (BIDS) group.  Oxygen saturation targets in infants with bronchiolitis (BIDS): a double-blind, randomised, equivalence trial.   Lancet. 2015;386(9998):1041-1048. doi:10.1016/S0140-6736(15)00163-4 PubMedGoogle ScholarCrossref
7.
Schroeder  AR, Marmor  AK, Pantell  RH, Newman  TB.  Impact of pulse oximetry and oxygen therapy on length of stay in bronchiolitis hospitalizations.   Arch Pediatr Adolesc Med. 2004;158(6):527-530. doi:10.1001/archpedi.158.6.527 PubMedGoogle ScholarCrossref
8.
Unger  S, Cunningham  S.  Effect of oxygen supplementation on length of stay for infants hospitalized with acute viral bronchiolitis.   Pediatrics. 2008;121(3):470-475. doi:10.1542/peds.2007-1135 PubMedGoogle ScholarCrossref
9.
Bergman  AB.  Pulse oximetry: good technology misapplied.   Arch Pediatr Adolesc Med. 2004;158(6):594-595. doi:10.1001/archpedi.158.6.594 PubMedGoogle ScholarCrossref
10.
Quinonez  RA, Coon  ER, Schroeder  AR, Moyer  VA.  When technology creates uncertainty: pulse oximetry and overdiagnosis of hypoxaemia in bronchiolitis.   BMJ. 2017;358:j3850. doi:10.1136/bmj.j3850 PubMedGoogle ScholarCrossref
11.
Quinonez  RA, Garber  MD, Schroeder  AR,  et al.  Choosing wisely in pediatric hospital medicine: five opportunities for improved healthcare value.   J Hosp Med. 2013;8(9):479-485. doi:10.1002/jhm.2064 PubMedGoogle ScholarCrossref
12.
Bonafide  CP, Xiao  R, Brady  PW,  et al; Pediatric Research in Inpatient Settings (PRIS) Network.  Prevalence of continuous pulse oximetry monitoring in hospitalized children with bronchiolitis not requiring supplemental oxygen.   JAMA. 2020;323(15):1467-1477. doi:10.1001/jama.2020.2998 PubMedGoogle ScholarCrossref
13.
Cheston  CC, Vinci  RJ.  Overuse of continuous pulse oximetry for bronchiolitis: the need for deimplementation science.   JAMA. 2020;323(15):1449-1450. doi:10.1001/jama.2020.4359 PubMedGoogle ScholarCrossref
14.
Mahant  S, Wahi  G, Giglia  L,  et al.  Intermittent versus continuous oxygen saturation monitoring for infants hospitalised with bronchiolitis: study protocol for a pragmatic randomised controlled trial.   BMJ Open. 2018;8(4):e022707.PubMedGoogle Scholar
15.
Harris  PA, Taylor  R, Thielke  R, Payne  J, Gonzalez  N, Conde  JG.  Research electronic data capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support.   J Biomed Inform. 2009;42(2):377-381. doi:10.1016/j.jbi.2008.08.010 PubMedGoogle ScholarCrossref
16.
World Health Organization. Handbook: Integrated Management of Childhood Illnesses. 2005. Accessed March 15, 2020. https://apps.who.int/iris/handle/10665/42939
17.
Spielberger  CD, Gorssuch  RL, Lushene  PR, Vagg  PR, & Jacobs  GA.  Manual for the State-Trait Anxiety Inventory. Consulting Psychologists Press Inc; 1983.
18.
Mansbach  JM, Piedra  PA, Teach  SJ,  et al; MARC-30 Investigators.  Prospective multicenter study of viral etiology and hospital length of stay in children with severe bronchiolitis.   Arch Pediatr Adolesc Med. 2012;166(8):700-706. doi:10.1001/archpediatrics.2011.1669 PubMedGoogle ScholarCrossref
19.
Fernandes  RM, Bialy  LM, Vandermeer  B,  et al.  Glucocorticoids for acute viral bronchiolitis in infants and young children.   Cochrane Database Syst Rev. 2013;6(6):CD004878. doi:10.1002/14651858.CD004878.pub4 PubMedGoogle Scholar
20.
Zhang  L, Mendoza-Sassi  RA, Wainwright  C, Klassen  TP.  Nebulized hypertonic saline solution for acute bronchiolitis in infants.   Cochrane Database Syst Rev. 2008;7(4):CD006458. doi:10.1002/14651858.CD006458.pub2 PubMedGoogle Scholar
21.
R Core Team. R: A Language and Environment for Statistical Computing. R Foundation for Statistical Computing; 2020.
22.
Price  RM, Bonett  DG.  Distribution-free confidence intervals for difference and ratio of medians.   J Stat Comput Simul. 2002;72(2):119-124. doi:10.1080/00949650212140 Google ScholarCrossref
23.
Kawaguchi  A, Koch  GG.  sanon: an R package for stratified analysis with nonparametric covariable adjustment.   J Stat Softw. 2015; 67(9):1-37. doi:10.18637/jss.v067.i09 Google ScholarCrossref
24.
McCulloh  R, Koster  M, Ralston  S,  et al.  Use of intermittent vs. continuous pulse oximetry for nonhypoxemic infants and young children hospitalized for bronchiolitis: a randomized clinical trial.   JAMA Pediatr. 2015;169(10):898-904. doi:10.1001/jamapediatrics.2015.1746 PubMedGoogle ScholarCrossref
25.
Cunningham  S.  Intermittent monitoring of oxygen saturation in infants and children with acute bronchiolitis: peekaboo paediatrics or good clinical care?   JAMA Pediatr. 2015;169(10):891-892. doi:10.1001/jamapediatrics.2015.1971 PubMedGoogle ScholarCrossref
26.
Mittal  S, Marlowe  L, Blakeslee  S,  et al.  Successful use of quality improvement methodology to reduce inpatient length of stay in bronchiolitis through judicious use of intermittent pulse oximetry.   Hosp Pediatr. 2019;9(2):73-78. doi:10.1542/hpeds.2018-0023 PubMedGoogle ScholarCrossref
27.
Schondelmeyer  AC, Simmons  JM, Statile  AM,  et al.  Using quality improvement to reduce continuous pulse oximetry use in children with wheezing.   Pediatrics. 2015;135(4):e1044-e1051. doi:10.1542/peds.2014-2295 PubMedGoogle ScholarCrossref
28.
Heneghan  M, Hart  J, Dewan  M,  et al.  No cause for alarm: decreasing inappropriate pulse oximetry use in bronchiolitis.   Hosp Pediatr. 2018;8(2):109-111. doi:10.1542/hpeds.2017-0126 PubMedGoogle ScholarCrossref
29.
Hendaus  MA, Nassar  S, Leghrouz  BA, Alhammadi  AH, Alamri  M.  Parental preference and perspectives on continuous pulse oximetry in infants and children with bronchiolitis.   Patient Prefer Adherence. 2018;12:483-487. doi:10.2147/PPA.S152880 PubMedGoogle ScholarCrossref
30.
Schuh  S, Freedman  S, Coates  A,  et al.  Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial.   JAMA. 2014;312(7):712-718. doi:10.1001/jama.2014.8637 PubMedGoogle ScholarCrossref
31.
Vinci  R, Bauchner  H.  Bronchiolitis, deception in research, and clinical decision making.   JAMA. 2014;312(7):699-700. doi:10.1001/jama.2014.8638 PubMedGoogle ScholarCrossref
32.
Young  PJ, Nickson  CP, Perner  A.  When should clinicians act on non-statistically significant results from clinical trials?   JAMA. 2020;323(22):2256-2257. doi:10.1001/jama.2020.3508 PubMedGoogle ScholarCrossref
33.
Principi  T, Coates  AL, Parkin  PC, Stephens  D, DaSilva  Z, Schuh  S.  Effect of oxygen desaturations on subsequent medical visits in infants discharged from the emergency department with bronchiolitis.   JAMA Pediatr. 2016;170(6):602-608. doi:10.1001/jamapediatrics.2016.0114 PubMedGoogle ScholarCrossref
34.
Wainwright  CE, Kapur  N.  Oxygen saturation targets in infants with bronchiolitis.   Lancet. 2015;386(9998):1016-1018. doi:10.1016/S0140-6736(15)00155-5 PubMedGoogle ScholarCrossref
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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
    READ MORE
    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

    Introduction

    Bronchiolitis is the most common acute lower respiratory tract infection in infants. In the US, it accounts for more than 100 000 hospitalizations and more than $1.7 billion in hospitalization costs annually.1 The focus of bronchiolitis inpatient management is supportive care because drug therapies are ineffective.2,3 Clinical and physiologic monitoring guides fluid and oxygen supplementation, respiratory support, and discharge decisions.

    In hospital practice, pulse oximetry for identifying hypoxia is considered the fifth vital sign.4,5 Practitioners choose a pulse oximetry oxygen saturation target to assist with admission and discharge decisions and supplemental oxygen therapy initiation and discontinuation. The American Academy of Pediatrics (AAP) guidelines recommend using an oxygen saturation target of 90% or higher in hospitalized infants with bronchiolitis. This practice is supported by a multicenter trial6 that found that infants randomized to a target of 90% or higher, compared with a target of 94% or higher, were discharged 10 hours earlier and experienced a similarly low rate of adverse events and revisits after discharge.

    Practitioners also choose to use pulse oximetry measured continuously or intermittently, such as performing a spot measurement every 4 hours. Retrospective studies7,8 suggest that stable infants with bronchiolitis stay in the hospital longer than needed because of practitioner reliance on the pulse oximeter to make management decisions. Experts and practitioners postulate that continuous measurement of oxygen saturation results in greater detection of transient and false-positive desaturations, leading to unnecessary additional supplemental oxygen use, more interventions, prolonged hospital stays, and higher costs.2,9,10 Increase in desaturation-related alarms may also increase nursing workload and alarm fatigue.2,10 In contrast, some practitioners and parents fear that intermittent monitoring will delay the detection of hypoxia and compromise patient safety.2

    According to the AAP guidelines, practitioners may choose not to use continuous pulse oximetry based on lower level of evidence.2 The Choosing Wisely campaign recommends not using continuous monitoring in infants with bronchiolitis but without hypoxia.11 A cross-sectional study12 across 56 North American hospitals found that continuous pulse oximetry is used in 46% of infants without hypoxia hospitalized with bronchiolitis, and hospital use of continuous pulse oximetry varies substantially from 2% to 92%. Experts conclude that the evidence supporting the use of continuous vs intermittent pulse oximetry monitoring is “not equivocal, but rather non-existent.”13(p 1449)

    We conducted a multicenter, pragmatic randomized clinical trial in hospitalized infants with stabilized bronchiolitis with and without supplemental oxygen to compare the effect of intermittent vs continuous pulse oximetry. We hypothesized that intermittent pulse oximetry would reduce length of hospital stay compared with continuous pulse oximetry. We also compared the effect of the monitoring strategies on secondary outcomes, including the need for medical interventions, safety, parent anxiety and missed workdays, and nursing satisfaction.

    Methods
    Trial Design and Oversight

    This 6-center, pragmatic, parallel group, superiority randomized clinical trial compared intermittent (every 4 hours) and continuous pulse oximetry monitoring in infants with stabilized bronchiolitis hospitalized from November 1, 2016, to May 31, 2019. The study was conducted by the Canadian Paediatric Inpatient Research Network and included general pediatric inpatient units at 3 children’s and 3 community hospitals. Parents or guardians provided written informed consent to participate. Data were deidentified, and unique study identification numbers were used. (A master code list, stored separately from the deidentified data, linked the study identification numbers to participants identifying information.) Research ethics boards at all hospital sites approved the trial protocol (Supplement 1), which has been published previously.14

    Trial Participants

    After admission to the general pediatric inpatient unit, infants 4 weeks to 24 months of age were eligible for inclusion if they had a clinical diagnosis of first-episode bronchiolitis, were generally healthy, and had a stable clinical status (full eligibility criteria are provided in the trial protocol in Supplement 1). Bronchiolitis was defined as signs and symptoms of respiratory distress associated with a viral respiratory tract infection in accordance with the AAP guidelines.2 Only infants with a stable clinical status were included because during the stabilization period infants would not be considered for discharge because of being too unwell (ie, significant hypoxia) and/or having an uncertain illness trajectory. Stable clinical status criteria were defined by the trial investigators based on clinical consensus, institutional practices, and a pilot trial. Specifically, hospitalized infants who required supplemental oxygen had to be stable for at least 6 hours defined by the following: stable or decreasing requirement for supplemental oxygen, stable or decreasing respiratory rate by at least 2 measurements, respiratory rate less than 70 breaths/min, heart rate less than 180 beats/per min, or oxygen supplementation less than 40% fractional inspired oxygen or 2 L/min by nasal prongs. In infants who did not require supplemental oxygen, the clinical status needed to be stable (as defined above) for at least 6 hours from presentation to the emergency department. Infants who required intensive care unit (ICU) admission for mechanical or noninvasive ventilatory support were excluded. Infants treated with heated high-flow oxygen only became eligible after use of the heated high-flow oxygen was discontinued. Infants whose parents could not complete questionnaires because of limited English-language proficiency were excluded.

    Randomization

    We randomized (1:1) infants to intermittent or continuous oxygen saturation monitoring. A computer-generated randomization sequence, stratified by center, with random permuted block sizes of 4 or 6 was used. A central, internet-based randomization system used the Research Electronic Data Capture software (REDCap) application.15 Research assistants at the sites enrolled infants and then used REDCap to obtain the participant group allocation. Masking of the assigned treatment was not possible, given the obvious differences between the 2 interventions.

    Trial Interventions

    Bronchiolitis management followed institutional practices and the trial protocol (Supplement 1 and eTable 1 in Supplement 2).14 Hospitals used 1 of 2 oxygen saturation targets for clinical management (ie, oxygen supplementation and discharge decision-making) in keeping with their usual practice: (1) 90% or greater in room air while the infant was awake or asleep (2 children’s hospitals and 1 community hospital) and (2) 90% or greater in room air while awake and 88% or greater in room air while asleep (1 children’s hospital and 2 community hospitals). Infants received continuous monitoring in the emergency department and inpatient unit until stabilization as per institutional practices.

    For the intermittent monitoring group, nurses measured oxygen saturation levels every 4 hours until discharge. If the infant had a clinical deterioration as assessed by the clinical team, the infant could be switched to continuous monitoring and intermittent monitoring restarted when the status stabilized. In the continuous monitoring group, nurses measured oxygen saturation continuously until discharge. For both groups, vital signs were measured every 4 hours, and weaning of supplemental oxygen was managed by the clinical team (Supplement 1).

    Trial Outcomes

    The primary outcome was length of hospital stay from randomization on the inpatient unit to discharge from the hospital, measured in hours. Prespecified secondary outcomes included length of hospital stay from randomization to meeting discharge criteria, defined as absence of fever (temperature <38 °C), no supplemental oxygen, normal respiratory rate (using World Health Organization age-specific criteria16), and parent-reported adequate feeding (defined as a score of ≥7 on a 10-cm visual analog feeding scale); length of hospital stay from inpatient unit admission to discharge; the need for medical interventions after randomization (blood testing, blood culture testing, chest radiography, oxygen supplementation [duration and initiation], bronchodilator treatment, systemic corticosteroid therapy, nasopharyngeal virus testing, nasopharyngeal suctioning, and intravenous fluids nasogastric feeds); parent anxiety level on a 4-point Likert scale after randomization (1 indicating not at all at ease; 2, somewhat at ease; 3, moderately at ease; and 4, very much at ease)17; number of parent workdays missed from randomization to 15 days after discharge; nursing satisfaction with the monitoring strategy assigned to their patient, measured on a 10-mm visual analog scale (0 indicating not at all satisfied and 10 indicating completely satisfied); unscheduled bronchiolitis-related ambulatory physician visits within 15 days of discharge; ICU admission and consultation after randomization; revisits to the emergency department or admission to the inpatient unit at the participating hospital within 15 days of discharge; and mortality. Research staff also assessed participants for crossover from the assigned to the alternate monitoring group by direct observation twice daily and review of electronic records.

    Statistical Analysis

    We anticipated a median length of hospital stay from randomization to discharge of 36 hours based on our pilot study and published studies.18-20 Using a significance level of P < .05 (2-sided), we calculated that a sample size of 210 (105 per group) would provide 90% power to detect a minimum median difference of 12 hours in length of stay between groups. We choose a 12-hour minimal clinically important difference based on discussions with practitioners, administrators, and parents. It is also aligned with the frequency at which discharge decisions are made on the inpatient unit.

    All analyses were specified a priori. The primary and secondary outcomes were analyzed according to the intention-to-treat principle. To control for multiple testing, the level for declaring statistical significance for the secondary outcomes was set at .002 using the Bonferroni correction. Analyses were performed using R software, version 3.6.2.21 All statistical tests were 2-sided.

    For the primary outcome of length of hospital stay from randomization to discharge, we estimated the difference in median time between groups and the ratio of the 2 medians along with a 95% CI.22 Because no censoring was necessary, the groups were compared using a Mann-Whitney–type test stratified for site, using the method of Kawaguchi and Koch.23 A priori, we planned a secondary analysis of the primary outcome adjusted for any clinically important imbalances in baseline variables. Because there were between-group sex differences, additional adjustment of the primary outcome for sex was performed using the method of Kawaguchi and Koch.23 In addition, a Cox proportional hazards regression analysis stratified for site and adjusted for sex was performed. For each of the secondary outcomes, we report the ratio of medians (interquartile ranges [IQRs]), odds ratios (ORs) (95% CIs), or mean differences (95% CIs). Statistical testing for continuous, dichotomous, and count secondary outcomes was performed using linear, logistic, and negative binomial models, respectively, with site as a covariate.

    Results
    Participants

    A total of 229 infants (median [IQR] age, 4.0 [2.2-8.5] months; 136 [59.4%] male) were enrolled in the study, with 101 (44.1%) from community hospital sites (Figure 1 and eMethods in Supplement 2). A total of 100 infants (43.7%) received supplemental oxygen before randomization on the inpatient unit, and 34 (14.8%) were receiving supplemental oxygen at randomization. The median time from inpatient unit admission to randomization was 16.4 hours (IQR, 11.1-24.4 hours). Except for sex, the baseline characteristics of the infants were similar between groups, including the proportion receiving supplemental oxygen, feeding adequacy, and time from inpatient unit admission to randomization (Table 1). For 17 participants (7.4%), there was crossover from the assigned monitoring group: 11 of 114 (9.6%) in the intermittent group and 6 of 115 (5.2%) in the continuous group (eTable 2 in the Supplement).

    Primary Outcome

    The median length of hospital stay from randomization to discharge was 27.6 hours (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); ratio of medians, 1.09 (95% CI, 0.93-1.27; P = .17) (Table 2).23 A Kaplan-Meier plot shows that the length of stay between groups is similar (Figure 2). Sex-adjusted analysis that included hospital site as a stratification variable using Cox proportional hazards models did not show a statistically significant difference in the hazard of discharge between groups (adjusted hazard ratio, 0.93; 95% CI, 0.71-1.23; P = .62).

    Secondary Outcomes
    Other Length of Hospital Stay Outcomes

    No significant difference between groups was found for median length of stay from randomization to meeting discharge criteria (18.8 hours [IQR, 2.7-32.6 hours] in the intermittent group and 19.4 hours [IQR, 2.4-30.1 hours] in the continuous group; P = .97) or in the median length of stay from inpatient unit admission to discharge (49.1 hours [IQR, 37.2-87.0 hours] in the intermittent group and 46.0 hours [IQR, 32.5-73.8 hours] in the continuous group; P = .13) (Table 2).23

    Interventions

    Fewer infants in the intermittent group had oxygen supplementation initiated after randomization than in the continuous group (4 of 114 [3.5%] vs 9 of 115 [7.8%]; OR, 0.43; 95% CI, 0.13-1.43; P = .16]), although this finding was not statistically significant. No other significant differences were found between groups in medical interventions, including median duration of oxygen supplementation: 20.6 (IQR, 7.6-46.1) hours vs 21.4 (IQR, 11.6-52.9) hours (ratio of medians, 0.96; 95% CI, 0.37-2.52; P = .66); chest radiography: 8 of 114 (7.0%) vs 11 of 115 (9.6%) (OR, 0.71; 95% CI, 0.28-1.85; P = .49); blood tests: 14 of 114 (12.3%) vs 18 of 115 (15.7%) (OR, 0.75; 95% CI, 0.36-1.60; P = .49); nasopharyngeal virus: 14 of 114 (12.3%) vs 19 of 115 (16.5%) (OR, 0.71; 95% CI, 0.34-1.49; P = .33); blood culture testing: 5 of 114 (4.4%) vs 5 of 115 (4.3%) (OR, 1.01; 95% CI, 0.28-3.58; P = .96); bronchodilator treatment: 21 of 114 (18.4%) vs 20 of 115 (17.4%) (OR, 1.07; 95% CI, 0.55-2.11; P = .88); systemic corticosteroid treatment: 7 of 114 (6.1%) vs 9 of 115 (7.8%) (OR, 0.77; 95% CI, 0.28-2.14; P = .59); or nasal suctioning: 63 of 114 (55.3%) vs 63 of 114 (54.8%) (OR, 1.02; 95% CI, 0.61-1.72; P = .85). Likewise, no statistically significant differences were found in frequency of initiation of intravenous fluid therapy: 9 of 114 (7.9%) vs 8 of 115 (7.0%) (OR, 1.15; 95% CI, 0.43-3.08; P = .76); median duration of intravenous fluid therapy: 26.9 (IQR, 17.0-48.3) hours vs 24.0 (IQR, 17.7-49.4) hours (ratio of medians, 1.12; 95% CI, 0.71-1.76; P = .86); frequency of initiation of nasogastric fluid therapy: 1 of 114 (0.9%) vs 3 of 115 (2.6%) (OR, 0.33; 95% CI, 0.03-3.22; P = .33) or median duration of nasogastric fluid therapy: 34.1 (IQR, 18.1-50.2) hours vs 18.4 (IQR, 10.5-47.2) hours (ratio of medians, 1.86; 95% CI, 0.01-471.44; P = .37) (Table 3).

    Safety

    The frequency of the need for an ICU transfer was similar between groups: 1 of 114 (0.9%) in the intermittent group and 2 of 115 (1.7%) in the continuous group (OR, 0.50; 95% CI, 0.04-5.59; P = .76). Similarly, the frequency of an emergency department revisit within 15 days of discharge was not significantly different between groups: 7 of 114 (6.1%) in the intermittent group and 10 of 115 (8.7%) in the continuous group (OR, 0.69; 95% CI, 0.25-1.87; P = .71), and no statistically significant difference was found in the frequency of readmissions to hospital within 15 days of discharge: 3 of 114 (2.6%) in the intermittent group and 4 of 115 (3.5%) in the continuous group (OR, 0.75; 95% CI, 0.25-3.43; P > .99). No deaths occurred in either group (Table 3).

    Other Secondary Outcomes

    The mean (SD) nursing satisfaction score with the assigned oxygen monitoring group was greater in the intermittent (8.6 [1.7] of 10) compared with the continuous group (7.1 [2.8] of 10) (mean difference, 1.5; 95% CI, 0.9-2.2; P < .001). Parent anxiety score during the hospitalization, frequency of unscheduled visits to a physician within 15 days of discharge, and median workdays missed by parents did not differ significantly between groups (Table 3).

    Discussion

    This pragmatic randomized clinical trial of infants with and without hypoxia hospitalized for bronchiolitis at children’s and community hospitals found that clinical outcomes were similar with intermittent or continuous pulse oximetry when using an oxygen saturation target of 90% or higher. No important differences were found between groups in the primary outcome of median length of hospital stay from randomization. Furthermore, the confidence limits around the difference exclude our prespecified minimal clinically important difference of 12 hours. Although no significant differences were found between groups in medical interventions and safety outcomes as well as parent anxiety or parent workdays missed, nursing satisfaction was greater with intermittent pulse oximetry.

    Several possible explanations exist for why a reduction in length of hospital stay was not found with intermittent monitoring. In contrast to the previous nonrandomized and retrospective studies8,9 that suggested that continuous monitoring prolongs hospital stay, this study was a randomized clinical trial. This trial used the current recommended oxygen target saturation of 90% or higher rather than a target of 93% or higher or 94% used in the earlier retrospective studies.8,9 Oxygen saturation target level may be a more important determinant of oxygen supplementation and length of hospital stay than monitoring frequency. For safety reasons, this trial compared oxygen monitoring strategies when patients were clinically improving and met stability criteria. Although initiation of intermittent monitoring early in the stabilization period when a greater proportion of infants had hypoxia might have been effective in reducing length of hospital stay, that strategy may not be acceptable to many practitioners.

    One previous bronchiolitis trial (n = 161) that compared intermittent with continuous pulse oximetry found no significant differences in mean length of stay or ICU transfer.24 However, that study24 did not include infants with hypoxia; the time of intermittent monitoring initiation was not reported, limiting the comparison on the time saved to discharge25; and parent, nurse, and postdischarge outcomes were not measured.

    This trial and several quality improvement reports found similar percentages of ICU transfers and hospital revisits with intermittent pulse oximetry, supporting the safety of this strategy in infants with stabilized bronchiolitis.26-28 Of importance, this study also found that parental anxiety in the hospital was similar between groups, suggesting that less monitoring does not erode parental confidence, as has been postulated.13,29

    Current AAP guideline recommendations to limit continuous pulse oximetry in hospitalized infants with bronchiolitis carry “the worst evidence-quality grade (D) and weakest recommendation strength.”2,13(p 1449) Almost half of infants without hypoxia hospitalized with bronchiolitis in North American hospitals are monitored continuously.12 This practice continues because of the weak evidence base; perceived value that nurses, physicians, and parents may place on technology when dealing with uncertainty30,31; and barriers to deimplementing the established practice of continuous monitoring.13

    This trial found that clinical outcomes were similar between intermittent and continuous pulse oximetry. Young et al32 suggest application of broader considerations to make a practice recommendation when a randomized trial of 2 established treatments finds nonstatistically and nonclinically significant differences in the primary outcome based on the prespecified criteria. Broader considerations for the use of intermittent vs continuous pulse oximetry argue for the use of less intense monitoring. These considerations include, first, lower nursing workload because of fewer oximeter alarms and enhanced patient safety because of reduced alarm fatigue.2,10 Of importance, this study found that nursing satisfaction was greater with intermittent monitoring. Second, infants recovering from bronchiolitis commonly experience transient desaturations that are of little clinical importance.33 Third, intermittent monitoring better aligns with the parent and child hospital-to-home transition preparation. Fourth, doing less simplifies care, which is a valued principle in hospital care.32 Given these considerations, 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.

    Limitations

    This study has several limitations. First, it was not possible to mask the oxygen monitoring intervention. However, in this pragmatic trial, the interest was in the real-world effect of the intervention, with practitioner and parent knowledge of the monitoring strategy used. Second, this trial does not exclude smaller differences between groups in the primary outcome of length of stay from randomization to discharge, such as 4 hours. Third, data on the frequency of desaturations were not collected, which might have provided a mechanistic understanding between monitoring strategies and clinical outcomes. In addition, future qualitative studies will provide further understanding of nursing monitoring preferences. Fourth, revisits to hospital after discharge did not capture revisits to other hospitals. Fifth, neurocognitive outcomes were not assessed; although there is controversy, some have raised concern that transient hypoxia associated with the acute illness may have neurocognitive impacts.34

    Conclusions

    In infants hospitalized with stabilized bronchiolitis with and without hypoxia and managed using an oxygen saturation target of 90% or higher, clinical outcomes of intermittent and continuous pulse oximetry monitoring were similar. Given that other important clinical practice considerations favor less intense monitoring, these findings support the standard use of intermittent pulse oximetry in infants hospitalized with stabilized bronchiolitis.

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    Article Information

    Accepted for Publication: October 6, 2020.

    Published Online: March 1, 2021. doi:10.1001/jamapediatrics.2020.6141

    Corresponding Author: Sanjay Mahant, MD, MSc, Department of Pediatrics, Hospital for Sick Children, 555 University Avenue, Toronto ON M5G 1X8, Canada (sanjay.mahant@sickkids.ca).

    Author Contributions: Drs Mahant and Barrowman had full access to all the data in the study and take responsibility for the integrity of the data and the accuracy of the data analysis.

    Concept and design: Mahant, Wahi, Giglia, Sakran, Breen-Reid, Willan, Schuh, Parkin.

    Acquisition, analysis, or interpretation of data: Mahant, Wahi, Bayliss, Kanani, Pound, Sakran, Kozlowski, Breen-Reid, Arafeh, Moretti, Agarwal, Barrowman, Willan, Parkin.

    Drafting of the manuscript: Mahant, Sakran, Agarwal, Willan, Schuh.

    Critical revision of the manuscript for important intellectual content: Mahant, Wahi, Bayliss, Giglia, Kanani, Pound, Kozlowski, Breen-Reid, Arafeh, Moretti, Agarwal, Barrowman, Schuh, Parkin.

    Statistical analysis: Moretti, Agarwal, Barrowman, Willan.

    Obtained funding: Mahant, Wahi, Breen-Reid, Schuh, Parkin.

    Administrative, technical, or material support: Mahant, Bayliss, Sakran, Kozlowski, Breen-Reid, Arafeh, Moretti.

    Supervision: Mahant, Bayliss, Sakran, Kozlowski.

    Conflict of Interest Disclosures: Dr Mahant reported receiving grants from the Canadian Institutes of Health Research (CIHR) during the conduct of the study and grants from the CIHR and personal fees from the Journal of Hospital Medicine outside the submitted work. Dr Wahi reported receiving grants from the CIHR during the conduct of the study and grants from the CIHR and the Hamilton Health Sciences Foundation outside the submitted work. Dr Bayliss reported receiving grants from the CIHR during the conduct of the study. Dr Kozlowski reported receiving grants from the CIHR during the conduct of the study. Dr Breen-Reid reported receiving grants from the CIHR during the conduct of the study. Dr Moretti reported receiving grants from the CIHR during the conduct of the study. Dr Schuh reported receiving grants from the CIHR during the conduct of the study. Dr Parkin reported receiving grants from the CIHR during the conduct of the study, grants from the CIHR and Hospital for Sick Children Foundation and nonfinancial support from Mead Johnson Nutrition outside the submitted work, and peer-reviewed grants for completed investigator-initiated studies from Danone Institute of Canada (2002-2004 and 2006-2009) and the Dairy Farmers of Ontario (2008-2010). No other disclosures were reported.

    Funding/Support: This trial was funded by grant PJT-148635 from the CIHR, a grant from the Department of Pediatrics, Hospital for Sick Children, Toronto, Ontario, Canada, and funds from the Pediatric Outcomes Research Team, Hospital for Sick Children, which receives funds from the SickKids Foundation, Toronto, Ontario, Canada.

    Role of the Funder/Sponsor: The funding sources had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.

    The Canadian Paediatric Inpatient Research Network (PIRN): Sanjay Mahant, MD; Gita Wahi, MD; Ann Bayliss, MD; Lucy Giglia, MD; Ronik Kanani, MD; Catherine M. Pound, MD; Mahmoud Sakran, MD; Natascha Kozlowski, MPH; Dana Arafeh, BSc; Patricia C. Parkin, MD.

    Data Sharing Statement: See Supplement 3.

    Additional Contributions: The site research staff included Nurshad Begum, MD, Cynthia Fleming, BSc, Liz Lee, BSc, Alexandra Lostun, BSc, Barbara Murchison, RN, Mobina Khurram, BSc, Kimberley Kraseich, BSc, Rizani Rivindran, BSc, Arezoo Ebnahmady, BSc, Shelly Ke, BSc, CCRP, Natalia Guira, BSc, Amna Ali, BSc, CCRP, and Martin Romano, BSc. Site practitioners included Laila Premji, MD, and Mollie Lavigne, MSN. The Pediatric Research in Inpatient Settings Network executive council provided input into the early concept of the trial. We thank the children and their families for participating in this trial and the trial investigators and staff across all sites for the dedication and diligent conduct of the trial. The site research staff were compensated for their work.

    References
    1.
    Hasegawa  K, Tsugawa  Y, Brown  DFM, Mansbach  JM, Camargo  CA  Jr.  Trends in bronchiolitis hospitalizations in the United States, 2000-2009.   Pediatrics. 2013;132(1):28-36. doi:10.1542/peds.2012-3877 PubMedGoogle ScholarCrossref
    2.
    Ralston  SL, Lieberthal  AS, Meissner  HC,  et al; American Academy of Pediatrics.  Clinical practice guideline: the diagnosis, management, and prevention of bronchiolitis.   Pediatrics. 2014;134(5):e1474-e1502. doi:10.1542/peds.2014-2742 PubMedGoogle ScholarCrossref
    3.
    Hartling  L, Fernandes  RM, Bialy  L,  et al.  Steroids and bronchodilators for acute bronchiolitis in the first two years of life: systematic review and meta-analysis.   BMJ. 2011;342:d1714. doi:10.1136/bmj.d1714 PubMedGoogle ScholarCrossref
    4.
    Mower  WR, Sachs  C, Nicklin  EL, Baraff  LJ.  Pulse oximetry as a fifth pediatric vital sign.   Pediatrics. 1997;99(5):681-686. doi:10.1542/peds.99.5.681 PubMedGoogle ScholarCrossref
    5.
    Enoch  AJ, English  M, Shepperd  S.  Does pulse oximeter use impact health outcomes? a systematic review.   Arch Dis Child. 2016;101(8):694-700. doi:10.1136/archdischild-2015-309638 PubMedGoogle ScholarCrossref
    6.
    Cunningham  S, Rodriguez  A, Adams  T,  et al; Bronchiolitis of Infancy Discharge Study (BIDS) group.  Oxygen saturation targets in infants with bronchiolitis (BIDS): a double-blind, randomised, equivalence trial.   Lancet. 2015;386(9998):1041-1048. doi:10.1016/S0140-6736(15)00163-4 PubMedGoogle ScholarCrossref
    7.
    Schroeder  AR, Marmor  AK, Pantell  RH, Newman  TB.  Impact of pulse oximetry and oxygen therapy on length of stay in bronchiolitis hospitalizations.   Arch Pediatr Adolesc Med. 2004;158(6):527-530. doi:10.1001/archpedi.158.6.527 PubMedGoogle ScholarCrossref
    8.
    Unger  S, Cunningham  S.  Effect of oxygen supplementation on length of stay for infants hospitalized with acute viral bronchiolitis.   Pediatrics. 2008;121(3):470-475. doi:10.1542/peds.2007-1135 PubMedGoogle ScholarCrossref
    9.
    Bergman  AB.  Pulse oximetry: good technology misapplied.   Arch Pediatr Adolesc Med. 2004;158(6):594-595. doi:10.1001/archpedi.158.6.594 PubMedGoogle ScholarCrossref
    10.
    Quinonez  RA, Coon  ER, Schroeder  AR, Moyer  VA.  When technology creates uncertainty: pulse oximetry and overdiagnosis of hypoxaemia in bronchiolitis.   BMJ. 2017;358:j3850. doi:10.1136/bmj.j3850 PubMedGoogle ScholarCrossref
    11.
    Quinonez  RA, Garber  MD, Schroeder  AR,  et al.  Choosing wisely in pediatric hospital medicine: five opportunities for improved healthcare value.   J Hosp Med. 2013;8(9):479-485. doi:10.1002/jhm.2064 PubMedGoogle ScholarCrossref
    12.
    Bonafide  CP, Xiao  R, Brady  PW,  et al; Pediatric Research in Inpatient Settings (PRIS) Network.  Prevalence of continuous pulse oximetry monitoring in hospitalized children with bronchiolitis not requiring supplemental oxygen.   JAMA. 2020;323(15):1467-1477. doi:10.1001/jama.2020.2998 PubMedGoogle ScholarCrossref
    13.
    Cheston  CC, Vinci  RJ.  Overuse of continuous pulse oximetry for bronchiolitis: the need for deimplementation science.   JAMA. 2020;323(15):1449-1450. doi:10.1001/jama.2020.4359 PubMedGoogle ScholarCrossref
    14.
    Mahant  S, Wahi  G, Giglia  L,  et al.  Intermittent versus continuous oxygen saturation monitoring for infants hospitalised with bronchiolitis: study protocol for a pragmatic randomised controlled trial.   BMJ Open. 2018;8(4):e022707.PubMedGoogle Scholar
    15.
    Harris  PA, Taylor  R, Thielke  R, Payne  J, Gonzalez  N, Conde  JG.  Research electronic data capture (REDCap): a metadata-driven methodology and workflow process for providing translational research informatics support.   J Biomed Inform. 2009;42(2):377-381. doi:10.1016/j.jbi.2008.08.010 PubMedGoogle ScholarCrossref
    16.
    World Health Organization. Handbook: Integrated Management of Childhood Illnesses. 2005. Accessed March 15, 2020. https://apps.who.int/iris/handle/10665/42939
    17.
    Spielberger  CD, Gorssuch  RL, Lushene  PR, Vagg  PR, & Jacobs  GA.  Manual for the State-Trait Anxiety Inventory. Consulting Psychologists Press Inc; 1983.
    18.
    Mansbach  JM, Piedra  PA, Teach  SJ,  et al; MARC-30 Investigators.  Prospective multicenter study of viral etiology and hospital length of stay in children with severe bronchiolitis.   Arch Pediatr Adolesc Med. 2012;166(8):700-706. doi:10.1001/archpediatrics.2011.1669 PubMedGoogle ScholarCrossref
    19.
    Fernandes  RM, Bialy  LM, Vandermeer  B,  et al.  Glucocorticoids for acute viral bronchiolitis in infants and young children.   Cochrane Database Syst Rev. 2013;6(6):CD004878. doi:10.1002/14651858.CD004878.pub4 PubMedGoogle Scholar
    20.
    Zhang  L, Mendoza-Sassi  RA, Wainwright  C, Klassen  TP.  Nebulized hypertonic saline solution for acute bronchiolitis in infants.   Cochrane Database Syst Rev. 2008;7(4):CD006458. doi:10.1002/14651858.CD006458.pub2 PubMedGoogle Scholar
    21.
    R Core Team. R: A Language and Environment for Statistical Computing. R Foundation for Statistical Computing; 2020.
    22.
    Price  RM, Bonett  DG.  Distribution-free confidence intervals for difference and ratio of medians.   J Stat Comput Simul. 2002;72(2):119-124. doi:10.1080/00949650212140 Google ScholarCrossref
    23.
    Kawaguchi  A, Koch  GG.  sanon: an R package for stratified analysis with nonparametric covariable adjustment.   J Stat Softw. 2015; 67(9):1-37. doi:10.18637/jss.v067.i09 Google ScholarCrossref
    24.
    McCulloh  R, Koster  M, Ralston  S,  et al.  Use of intermittent vs. continuous pulse oximetry for nonhypoxemic infants and young children hospitalized for bronchiolitis: a randomized clinical trial.   JAMA Pediatr. 2015;169(10):898-904. doi:10.1001/jamapediatrics.2015.1746 PubMedGoogle ScholarCrossref
    25.
    Cunningham  S.  Intermittent monitoring of oxygen saturation in infants and children with acute bronchiolitis: peekaboo paediatrics or good clinical care?   JAMA Pediatr. 2015;169(10):891-892. doi:10.1001/jamapediatrics.2015.1971 PubMedGoogle ScholarCrossref
    26.
    Mittal  S, Marlowe  L, Blakeslee  S,  et al.  Successful use of quality improvement methodology to reduce inpatient length of stay in bronchiolitis through judicious use of intermittent pulse oximetry.   Hosp Pediatr. 2019;9(2):73-78. doi:10.1542/hpeds.2018-0023 PubMedGoogle ScholarCrossref
    27.
    Schondelmeyer  AC, Simmons  JM, Statile  AM,  et al.  Using quality improvement to reduce continuous pulse oximetry use in children with wheezing.   Pediatrics. 2015;135(4):e1044-e1051. doi:10.1542/peds.2014-2295 PubMedGoogle ScholarCrossref
    28.
    Heneghan  M, Hart  J, Dewan  M,  et al.  No cause for alarm: decreasing inappropriate pulse oximetry use in bronchiolitis.   Hosp Pediatr. 2018;8(2):109-111. doi:10.1542/hpeds.2017-0126 PubMedGoogle ScholarCrossref
    29.
    Hendaus  MA, Nassar  S, Leghrouz  BA, Alhammadi  AH, Alamri  M.  Parental preference and perspectives on continuous pulse oximetry in infants and children with bronchiolitis.   Patient Prefer Adherence. 2018;12:483-487. doi:10.2147/PPA.S152880 PubMedGoogle ScholarCrossref
    30.
    Schuh  S, Freedman  S, Coates  A,  et al.  Effect of oximetry on hospitalization in bronchiolitis: a randomized clinical trial.   JAMA. 2014;312(7):712-718. doi:10.1001/jama.2014.8637 PubMedGoogle ScholarCrossref
    31.
    Vinci  R, Bauchner  H.  Bronchiolitis, deception in research, and clinical decision making.   JAMA. 2014;312(7):699-700. doi:10.1001/jama.2014.8638 PubMedGoogle ScholarCrossref
    32.
    Young  PJ, Nickson  CP, Perner  A.  When should clinicians act on non-statistically significant results from clinical trials?   JAMA. 2020;323(22):2256-2257. doi:10.1001/jama.2020.3508 PubMedGoogle ScholarCrossref
    33.
    Principi  T, Coates  AL, Parkin  PC, Stephens  D, DaSilva  Z, Schuh  S.  Effect of oxygen desaturations on subsequent medical visits in infants discharged from the emergency department with bronchiolitis.   JAMA Pediatr. 2016;170(6):602-608. doi:10.1001/jamapediatrics.2016.0114 PubMedGoogle ScholarCrossref
    34.
    Wainwright  CE, Kapur  N.  Oxygen saturation targets in infants with bronchiolitis.   Lancet. 2015;386(9998):1016-1018. doi:10.1016/S0140-6736(15)00155-5 PubMedGoogle ScholarCrossref
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