Published online September 1, 2006
PEDIATRICS
Vol. 118
No. 3
September 2006, pp.
1320-1321
(doi:10.1542/peds.2006-1667)
A Randomized Trial of Home Oxygen Therapy From the Emergency Department for Acute Bronchiolitis: In Reply
Lalit Bajaj, MD, MPH
Joan Bothner, MD
Department of Pediatrics,
Section of Emergency Medicine,
University of Colorado Health Sciences Center/Children's Hospital,
Denver, CO 80218
Carol Turner, MD
Aspen Park Pediatrics,
Conifer, CO 80433
We thank Joseph et al for their letter to the editor. They bring up good points that we would like to address. They make the comments that "bronchiolitis is a progressive disease with a peak that comes after 48 to 72 hours from the onset of dyspnea" and "[t]he stage of the disease at presentation was not taken into account by the authors." We attempted to obtain data on duration of illness in days from the caregiver and, unfortunately, found that the responses were very inconsistent. The majority of the infants had "runny noses for weeks to months." We, therefore, could not use this piece of information reliably. We also found that many of the infants who met our definition of bronchiolitis had minimal increase in their respiratory effort, as evidenced by their mean respiratory distress severity score scores of 
4 at enrollment and 2 at discharge, which qualify as mild on our scale. Our clinical experience at 1600 m of elevation is that many infants present with hypoxia by our definition and minimal dyspnea on clinical evaluation. This may not be a finding that is generalizable to those at lower altitudes.
We did find the 8-hour observation period to be adequate to identify a subset of patients who could either go home without oxygen or would need to be admitted. As we state in the article, our small sample size did not allow us to determine the ideal observation period. Joseph et al are concerned that the caregivers did not receive adequate return precautions. Our standardized bronchiolitis discharge instructions contained clear instructions to return if there was any concern for apnea or cyanosis, and this was discussed at length with the caregivers at discharge. The study cited by Joseph et al1 found that age of <2 months and a history of apnea at admission were the strongest predictors for recurrent apnea. We did not enroll any patients under the age of 2 months or who had any history of apnea. The authors are concerned that the patient who returned may have had an apneic spell at home; this was not reported by the caregiver, which may again reflect the altitude at which the study was performed. Our clinical experience is that infants may have a history of cyanosis but not a history of apnea.
Patients were not discharged from the hospital with a pulse oximeter. Caregivers were given instruction on how to observe their children for worsening difficulty breathing, apnea, or cyanosis. The difficulties in interpreting continuous pulse oximetry in the hospital setting has been eloquently discussed, and we felt that these difficulties would only be amplified at home.2 The caregivers were not asked to adjust oxygen flow rates at home by themselves; this was done in consultation with their primary physician at their follow-up visits. The primary care physicians felt, when we designed the study, that a 24-hour postdischarge visit was adequate to ensure close follow-up. We thank Joseph et al for their questions and interest in our study.
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- Bergman AB. Pulse oximetry: good technology misapplied.
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PEDIATRICS (ISSN 1098-4275). ©2006 by the American Academy of Pediatrics
