Published online March 1, 2007
PEDIATRICS Vol. 119 No. 3 March 2007, pp. 611 (doi:10.1542/peds.2006-3002)
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COMMENTARY

Oxygen Therapy for Bronchiolitis

Joel L. Bass, MDa and David Gozal, MDb

a Department of Pediatrics, Newton-Wellesley Hospital, MassGeneral Hospital for Children, Harvard Medical School, Boston, Massachusetts
b Department of Pediatrics, Kosair Children's Hospital Research Institute, University of Louisville, Louisville, Kentucky

Abbreviations: SpO2, pulse oxygen saturation

An American Academy of Pediatrics clinical practice guideline on the diagnosis and management of bronchiolitis was published recently in Pediatrics.1 This important guideline was evidence based and intended to help guide practitioners in the management of this commonly encountered and potentially serious condition.

Recommendation 7a in the guideline includes the following statement: "If the SpO2 [pulse oxygen saturation] does persistently fall below 90%, adequate supplemental oxygen should be used to maintain SpO2 at or above 90%. Oxygen may be discontinued if SpO2 is at or above 90%... ."1

The authors state in their discussion of the recommendation that healthy infants have an SpO2 >95% in room air, but they justify the lower cutoff for therapy on the grounds that, on the basis of the oxyhemoglobin dissociation curve, otherwise healthy infants gain little benefit in PaO2 with supplemental oxygen at SpO2 levels ≥90%. The subcommittee also suggested that clinicians consider maintaining a higher SpO2 in children with risk factors such as fever, acidosis, or some hemoglobinopathies. In the evidence profile that they cite as the basis for this recommendation, the benefit of use is stated as "shorter hospitalization," and the potential harm is stated as "inadequate oxygenation." Using these parameters, it is understandable how the subcommittee arrived at its recommendation.

It is unfortunate that the recommendation fails to address another significant consideration, viz, the impact of chronic or intermittent hypoxia on later cognitive and behavioral outcomes. A recently published review of the evidence on this topic2 documented a very convincing association between hypoxia and adverse cognitive outcomes in a wide variety of clinical circumstances including both short-term and intermittent exposures at SpO2 levels in the range of 90% to 94%. Although none of the articles cited in the review were specific to bronchiolitis, this was because there were no published studies relating to bronchiolitis, not because it has been studied and shown to be uniquely without consequence.

Given the overwhelming evidence in so many other clinical circumstances, we think it would have been prudent for the subcommittee to state that in other clinical situations adverse cognitive and behavioral outcomes have been reported at SpO2 levels between 90% and 94% and that this information should be taken into consideration when making decisions regarding administration of supplemental oxygen. Although this is not as clear cut as the 90% level, it is a more accurate representation of the potential risks of withholding supplemental oxygen therapy. This is an area in which physician discretion and informed parental input need to be considered and taken into account when making clinical decisions. Additional research into this issue should also be encouraged so that more definitive answers might be available in the future.


   FOOTNOTES
 
Accepted Oct 18, 2006.

Address correspondence to Joel L. Bass, MD, Department of Pediatrics, Newton-Wellesley Hospital, 2014 Washington St, Boston, MA 02462. E-mail: jbass{at}partners.org

The authors have indicated they have no financial relationships relevant to this article to disclose.

Opinions expressed in these commentaries are those of the authors and not necessarily those of the American Academy of Pediatrics or its Committees.


   REFERENCES
TOP
 REFERENCES
 

  1. American Academy of Pediatrics, Subcommittee on Diagnosis and Management of Bronchiolitis. Diagnosis and management of bronchiolitis. Pediatrics. 2006;118 :1774 –1793[Abstract/Free Full Text]
  2. Bass JL, Corwin M, Gozal D, et al. The effect of chronic or intermittent hypoxia on cognition in childhood: a review of the evidence. Pediatrics. 2004;114 :805 –816[Abstract/Free Full Text]
PEDIATRICS (ISSN 1098-4275). ©2007 by the American Academy of Pediatrics



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