The outpatient and inpatient management of most children with viral bronchiolitis has remained essentially unchanged for decades. Clinicians continue to carefully assess a child’s overall work of breathing, oxygen requirements, hydration status, risk of complications, and illness trajectory. They then provide supportive care as needed with supplemental oxygen, intravenous fluids, positive airway pressure, and assisted ventilation. Options for active or passive immunization to prevent or to attenuate infections are limited, whereas options for treatment (including bronchodilators, systemic and inhaled steroids, nebulized hypertonic saline, helium/oxygen mixtures, and antiviral agents) remain controversial and largely unsatisfactory. In short, clinicians have remarkably few “tools in their tool chests” to address this common disorder, and it remains a significant source of morbidity, mortality, and health care expense.
Of note, persistent hypoxia among inpatients with bronchiolitis remains a common cause of prolonged hospital admission.1 The use of supplemental oxygen at home is an attractive, patient-centered supportive modality. With their retrospective analysis in a moderately sized cohort of infants and toddlers with mild to moderate bronchiolitis discharged from the hospital on home oxygen therapy from a single emergency department located at high altitude in Denver, Flett et al2 provide the most comprehensive and rigorous assessment to date of short-term outcomes associated with the use of this still relatively new tool. Of the 234 unique patients from largely disadvantaged and minority families who were followed longitudinally after emergency department discharge, >90% remained outpatients until disease resolution and >90% were successfully weaned off oxygen by 2 weeks. No subsequently admitted patients required management in an ICU or assisted ventilation, and none died. Predictable associations with a prolonged home oxygen requirement included young age and a history of prematurity, whereas fever at the initial visit was the only variable associated with subsequent admission. Logistical problems with oxygen delivery to the home were rare, and adherence to recommended clinical follow-up was high. Unfortunately, no data on viral etiology were available for risk stratification despite growing evidence of an association between viral etiology and disease severity among hospitalized children.3
The study benefited from a multiyear experience and from the close integration of outpatient and inpatient services within Denver Health, a safety-net health care system insuring 40% of Denver’s children. We can feel confident that most of the important end points (follow-up, hospital admissions, and complications) were captured. The work builds on previous reports of home oxygen therapy for bronchiolitis from Denver4,5 and Utah6 (high-altitude sites) and Perth7 (sea-level site), which together documented associations with reduced hospital admissions, lower overall costs, and high caregiver satisfaction and patient safety.
The immediate clinical implications of Flett et al’s findings are unfortunately limited, however, by the highly selected nature of the population studied. The group of patients was relatively homogenous with mild to moderate disease managed by inconsistently applied criteria under unique high-altitude physiologic circumstances where low oxygen saturations are more common. As noted above, multivariate analysis was not able to identify helpful variables predictive of the need for subsequent admission. Clinicians working at lower altitudes should therefore exercise caution before routinely embracing this practice. Nonetheless, in the context of a disease with so few “tools in the toolbox,” those managing these children should be encouraged by Flett et al’s mostly reassuring findings. And they should clamor to have them replicated in larger trials among more diverse cohorts, including more at sea level!
- Accepted February 19, 2014.
- Address correspondence to Stephen J. Teach, MD, MPH, Division of Emergency Medicine, Children’s National Health System, 111 Michigan Ave, NW, Washington, DC 20010. E-mail:
Opinions expressed in these commentaries are those of the author and not necessarily those of the American Academy of Pediatrics or its Committees.
FINANCIAL DISCLOSURE: Dr Teach receives support from the National Institute for Allergy and Infectious Diseases for research on bronchiolitis.
FUNDING: No external funding.
POTENTIAL CONFLICT OF INTEREST: The author has indicated he has no potential conflicts of interest to disclose.
COMPANION PAPER: A companion to this article can be found on page 769, and online at www.pediatrics.org/cgi/doi/10.1542/peds.2013-1872.R2.
- Unger S,
- Cunningham S
- Flett KB,
- Breslin K,
- Braun PL,
- Hambidge SJ
- Bajaj L,
- Turner CG,
- Bothner J
- Halstead S,
- Roosevelt G,
- Deakyne S,
- Bajaj L
- Tie SW,
- Hall GL,
- Peter S,
- et al
- Copyright © 2014 by the American Academy of Pediatrics