Home oxygen therapy trial for acute bronchiolitis

A Randomized Trial of Home Oxygen Therapy From the Emergency
Department for Acute Bronchiolitis
Lalit Bajaj, Carol G. Turner and Joan Bothner
Pediatrics 2006;117;633-640
DOI: 10.1542/peds.2005-1322

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located on the World Wide Web at:
http://www.pediatrics.org/cgi/content/full/117/3/633

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ARTICLE

A Randomized Trial of Home Oxygen Therapy From
the Emergency Department for Acute Bronchiolitis
Lalit Bajaj, MD, MPHa, Carol G. Turner, MDb, Joan Bothner, MDa

aDepartment of Pediatrics, Section of Emergency Medicine, University of Colorado Health Sciences Center/Children’s Hospital, Denver, Colorado; bAspen Park Pediatrics,

Conifer, Colorado

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

ABSTRACT
OBJECTIVE. Hypoxia is a common reason for hospital admission in infants and chil-
dren with acute bronchiolitis. No study has evaluated discharge from the emer-
www.pediatrics.org/cgi/doi/10.1542/
gency department (ED) on home oxygen. This study evaluated the feasibility and peds.2005-1322
safety of ED discharge on home oxygen in the treatment of acute bronchiolitis. doi:10.1542/peds.2005-1322
METHODS. This was a prospective, randomized trial of infants and children with acute Key Words
bronchiolitis, hypoxia, oxygen, home
bronchiolitis and hypoxia (room-air saturations of Յ87%) aged 2 to 24 months therapy, observation
presenting to an urban, academic, tertiary care children’s hospital ED from De- Abbreviations
cember 1998 to April 2001. Subjects received inpatient admission or home oxygen PCP—primary care provider
after an 8-hour observation period in the ED. We measured the failure to meet ED— emergency department
RDSS—respiratory distress severity score
discharge criteria during the observation period, return for hospital admission, and
Accepted for publication Jul 22, 2005
incidence of serious complications. Address correspondence to Lalit Bajaj, MD,
MPH, Department of Pediatrics/Section of
RESULTS. Ninety-two patients were enrolled. Fifty three (58%) were randomly as- Emergency Medicine, University of Colorado
signed to home and 39 (42%) to inpatient admission. There were no differences Health Sciences Center/Children’s Hospital,
1056 E 19th Ave B251, Denver, CO 80218. E-
between the groups in age, initial room-air saturation, and respiratory distress mail: bajaj.lalit@tchden.org
severity score. Of 53 patients, 37 (70%) randomly assigned to home oxygen PEDIATRICS (ISSN Numbers: Print, 0031-4005;
completed the observation period and were discharged from the hospital. The Online, 1098-4275). Copyright © 2006 by the
American Academy of Pediatrics
remaining 16 patients were excluded from the study (6), resolved their oxygen
requirement (5), or failed to meet the discharge criteria and were admitted (5).
One discharged patient (2.7%) returned to the hospital and was admitted for a
cyanotic spell at home after the 24-hour follow-up appointment. The patient had
an uncomplicated hospital course with a length of stay of 45 hours. The remaining
36 patients (97%) were treated successfully as outpatients with home oxygen.
Satisfaction with home oxygen was high from the caregiver and the primary care
provider.
CONCLUSIONS. Discharge from the ED on home oxygen after a period of observation
is an option for patients with acute bronchiolitis. Secondary to the low incidence
of complications, the safety of this practice will require a larger study.

PEDIATRICS Volume 117, Number 3, March 2006 633

B RONCHIOLITIS IS THE most common cause of hospital
admission in children Ͻ1 year of age. An estimated
80 000 to 120 000 children Ͻ1 year of age are admitted
fined as (1) not requiring transfer to the intensive care
unit (ICU), (2) not being readmitted to the hospital after
discharge, and (3) not having any serious complications.
annually. Hospitalization rates have been increasing dra- Serious complications were defined as respiratory arrest,
matically, with estimates of an increase of 239% in apnea, cyanotic spell, and respiratory failure. The success
children Ͻ6 months from 1980 to 1996.1 One of the rate for hospitalized patients was estimated at 99%. Us-
hypotheses for this dramatic increase is the almost uni- ing a minimum success rate of 90% for home oxygen,
versal use of pulse-oximetry screening and the imple- we estimated that ϳ160 patients (80 in each group)
mentation of an oxygen-saturation cut off that warrants would be needed with an ␣ value of .05 and a ␤ value of
hospital admission for supplemental oxygen. The need .20.
for supplemental oxygen therapy in a previously healthy Patients were enrolled over 3 consecutive winter sea-
patient is considered by many to require mandatory sons from December 1998 to April 2001 at an urban,
admission and is included as one of the therapies defin- academic, tertiary care children’s hospital at an elevation
ing mandatory admission in studies evaluating a pediat- of 5280 ft (1609 m). All of the patients received deep
ric risk of admission score.2,3 It has also been demon- nasal suctioning and 2 albuterol treatments (2.5 mg) via
strated that physicians use the oxygen-saturation nebulizer over the first 60 minutes. All of the patients
information frequently to determine whether a patient had their respiratory distress severity score (RDSS) (Ta-
requires hospital admission.4 A recent study addressed ble 1) documented at the start of the study, after suc-
how often patients remain in the hospital only for sup- tioning, and after the nebulizer treatments. The RDSS
plemental oxygen after other clinical parameters (oral has 4 categories: respiratory rate, wheezing, aeration,
intake and work of breathing) have improved and found and retractions, and each category has a scoring system
that 26% of patients have a prolonged stay of an average of 0, 1, or 2 points. The total score is obtained by adding
of 1.6 days.5 the score from each category. All of the patients then
In the years preceding this study, community primary received a chest radiograph, and, if read by the attending
care providers (PCPs) were faced with a rapidly expand- radiologist as consistent with an acute bacterial pneu-
ing population of children and a large burden of patients monia, the patient was not approached for enrollment in
with bronchiolitis requiring oxygen. Hospital beds the study.
around the community were becoming very difficult to Caregivers were approached during times at which a
find, and the practice of arranging home oxygen from research assistant was available to assess whether they
the office setting began to emerge. This was especially met the inclusion criteria or had any of the exclusion
true in practices that had close relationships with their criteria (Table 2). Informed consent was obtained, and
patients and felt comfortable that if any deterioration patients were randomly assigned to traditional inpatient
occurred, the caregivers would quickly notify them and hospitalization or to home oxygen therapy. Randomiza-
present to a local emergency department (ED). To date, tion was performed by using a block-randomization ta-
there are no publications evaluating the use of home ble created before the start of the study. Research assis-
oxygen therapy from the ED or the primary care clinic in tants were blinded to allocation at the time of
patients with acute bronchiolitis requiring supplemental enrollment. The study packet with the assignment could
oxygen. We undertook a prospective, randomized pilot not be opened until informed consent had been ob-
study of home oxygen from the ED compared with tained. Patients randomly assigned to the inpatient arm
traditional inpatient hospitalization to assess for the fea- of the study had an RDSS recorded every 2 hours for the
sibility and safety of this practice. first 8 hours of hospitalization. Other treatments in the
hospital were at the discretion of the inpatient attending,
METHODS and the families were contacted at 1 week by telephone
We conducted a prospective, randomized trial of tradi- and were asked to answer questions from a standardized
tional inpatient hospitalization versus home oxygen questionnaire. A chart review was also performed to
from the ED in a convenience sample of patients with extract hospital complications and length of stay data.
acute bronchiolitis and hypoxia. In preparation for con- Patients randomly assigned to the home oxygen arm
ducting the study, we sent out information letters to all
PCPs who refer patients to our ED to let them know
what the study would require of them if a patient in TABLE 1 RDSS
their practice was enrolled. Score Respiratory Rate Wheezing Aeration Retractions
A sample-size calculation was performed before the 0–1 y 1–2 y
start of the study. The success of the home oxygen 0 20–40 15–30 None All fields None
protocol was defined as (1) not requiring hospitalization 1 41–55 31–45 Mild-Exp Ն4 fields Mild
after ED discharge and (2) not having any serious com- 2 Ͼ55 Ͼ45 Insp and Exp Ͻ4 fields Marked
plications. Success with hospitalized patients was de- Total score: 0 – 4, mild; 5–7, moderate; Ͼ8, severe.

634 BAJAJ, et al

TABLE 2 Inclusion/Exclusion Criteria
Inclusion criteria
2–24 mo, minimum of 44 wk after conceptional age
Clinical diagnosis of bronchiolitis defined as an acute respiratory illness
associated with nasal congestion, cough, diffuse wheezing or crackles, and
tachypnea or retractions
Chest radiograph consistent with viral bronchiolitis
First episode of wheezing
Room-air saturation of Յ87% on arrival to the ED
Family has transportation to return to PCP or ED 24 and 48 h after discharge
from the ED
Lives at altitude Յ6000 ft (1829 m)
Lives Յ30 min from an emergency medical facility
Caregivers must maintain a smoke-free environment defined as no smoking in
house or car
Caregivers must have a contact telephone number
Exclusion criteria
Preexisting cardiac, pulmonary (including bronchopulmonary dysplasia),
neuromuscular, or nutritional (including failure to thrive) disorders and
preexisting congenital or acquired airway anomalies
Ͻ44 wk after conceptional age
History of apnea
Acute bacterial pneumonia as defined as a focal infiltrate on chest radiograph
Prior episode of wheezing
Room-air saturations Ͼ87%
No available transportation for follow-up visits
Lives at altitude Ͼ6000 ft (1829 m)
Lives Ͼ30 min from health care facility
Steroid administration
Caregivers unable to stay with patient in observation unit

of the study were placed in the ED observation unit for
an 8-hour observation period. Standard observation
consisted of continuous pulse oximetry and vital-sign
checks every 2 hours. An RDDS was assigned every 2
hours. Four separate pulse-oximetry measurements
were recorded while on oxygen (asleep and feeding
were mandatory). At the end of the observation period,
the following defined discharge criteria had to be met:
saturations of Ն90% on Յ1 L/min nasal cannula oxygen
while the patient was awake, asleep, and feeding; the
FIGURE 1
patient must be able to maintain hydration; the patient Treatment protocol.
must have no signs of deteriorating respiratory status;
the attending physician and caregiver must be comfort-
able with discharge; and 24-hour follow-up must be incidence of serious complications. Secondary outcome
arranged. Patients were taught the operation of the por- measures were caregiver satisfaction, caregiver prefer-
table home oxygen unit and were given the unit before ence, PCP satisfaction, and PCP preference.
discharge. Patients were discharged on Յ1 L nasal can- Data were analyzed by using SPSS 12.0 (SPSS Inc,
nula oxygen. Chicago, IL). Differences between groups were analyzed
Standardized questionnaires were completed by the by the Student’s t test for continuous variables and the
PCP at the 24- and 48-hour visit and were faxed back to ␹2 test for categorical variables. This study was approved
the study coordinator. At 72 hours, a telephone fol- by the Colorado Multiple Institutional Review Board
low-up questionnaire was administered to both the PCP and the Kaiser Permanente Institutional Review Board.
and the caregiver. A 1-week telephone follow-up ques-
tionnaire was also administered to the caregiver. Fig 1 RESULTS
displays the treatment protocol. Ninety-two patients were enrolled over 3 consecutive
Primary outcome measures included failure to meet bronchiolitis seasons. A modified consolidated standards
discharge criteria during the observation period, return of reporting trials diagram is presented in Fig 2. These
for hospital admission after successful discharge, and patients had a mean age of 7.8 months, a mean room-air


TABLE 3 Demographics/Clinical Characteristics of Randomized
Patients (n ‫)29 ؍‬
Characteristic Overall Home Inpatient P
(n ϭ 92) (n ϭ53) (n ϭ 39)
Age, mo
Mean 7.8 7.6 8.2 .606a
Range 2–23 2–21.4 2.1–23
Gender, n (%)
Male 52 (57) 29 (55) 23 (59) .424b
Female 40 (43) 24 (45) 16 (41)
Maternal age, y
Mean 27.06 26.68 27.59 .541a
Range 16–43 18–43 16–43
Initial RDSS
Mean 4.23 4.13 4.43 .366a
Initial room-air saturation, 85.0 84.3 85.8 .208a
mean, %
8-h RDSS, mean 2.28 2.31 2.25 .876a
8-h O2 required, L/min
Mean 0.485 0.436 0.560 .037a
Range 0.125–1 0.125–1 0.125–1
a Student’s t test.
b ␹2 test.

TABLE 4 Demographics/Clinical Characteristics of Patients
FIGURE 2 Completing Study (n ‫)07 ؍‬
Modified consolidated standards of reporting trials diagram.
Characteristic Overall Home Inpatient P
(n ϭ70) (n ϭ 37) (n ϭ 33)
Age, mo
saturation of 85%, a mean RDSS of 4.23, and a mean Mean 7.54 7.09 8.02 .438a
Range 2–22.4 2–17.4 2–22.4
oxygen requirement of 0.485 L/min.
Gender, n (%)
Fifty-three patients (58%) were randomly assigned to Male 39 (55.7) 19 (51.4) 20 (60.6) .478b
home, and 39 (42%) were randomly assigned to inpa- Female 31 (44.3) 18 (48.6) 13 (39.4)
tient admission. There were no differences between the Initial RDSS, mean 4.04 3.72 4.39 .069a
groups in age, initial room-air saturation, and initial Initial room-air saturation, 85.1 84.8 85.4 .659a
mean, %
RDSS. There was a statistically significant difference in
8-h RDSS, mean 2.04 1.86 2.25 .262a
the amount of oxygen required at 8 hours for the pa- 8-h O2 required, L/min
tients who had been admitted versus those who were Mean 0.492 0.434 0.563 .013a
discharged (Table 3). These relationships remained the Range 0.125–1 0.125–1 0.125–1
same when patients completing the study were analyzed a Student’s t test.
b ␹2 test.
(Table 4). Based on the actual number of patients en-
rolled and a success rate of 99% in the hospitalized
patients, we would detect an 80% success rate in the
home oxygen patients as a statistically significant differ- tion period and were discharged with no supplemental
ence. oxygen. These 5 patients did not return to the study
Of the 53 patients, 37 (70%) randomly assigned to institution in the following week for any additional care.
home oxygen completed the observation period and The remaining 5 patients did not meet discharge criteria
were discharged from the hospital. Six patients (11.3%) and were subsequently admitted to the hospital for fur-
failed to complete the observation period: 2 patients ther care: 2 patients had concerns from the nursing staff
were diagnosed with pneumonia from their chest radio- and attending physician for inadequate oral intake, 2
graph that was obtained after enrollment instead of be- patients had concerns for increased work of breathing,
fore randomization, 3 withdrew secondary to caregiver and 1 patient was given a change in diagnosis to reactive
anxiety, and 1 was excluded secondary to transfer from airways disease and was given oral corticosteroids. Thir-
another facility, which did not allow for the ascertain- ty-seven patients were successfully sent home with
ment of initial data. home oxygen.
Ten patients completed the observation period but One patient (2.7%; 95% confidence interval: 0.6 –
were unable to complete the remainder of the study: 5 13.8%) of the 37 discharged from the ED returned to the
resolved their oxygen requirement during the observa- hospital and was admitted for a cyanotic spell at home

636 BAJAJ, et al

after the 24-hour follow-up appointment. This was a 1 patient resolved the oxygen requirement before reach-
4-month-old who was sent to the ED from the 24-hour ing the inpatient bed, 1 family became uncomfortable
follow-up visit with a history of a possible cyanotic spell with being in a research study, and 2 patients had in-
at home. The patient had an uncomplicated hospital complete medical charts for review. The patient dis-
course with a length of stay of 45 hours. This is the only charged who no longer required supplemental oxygen
patient who had a serious complication in the study. The did not return in the following week for additional care
remaining 36 patients (97%; 95% confidence interval: to the study institution. The remaining 33 patients were
86 –99%) were treated successfully as outpatients with available for analysis.
home oxygen therapy. The hospitalized patients had a mean length of stay of
Of the 37 patients, 33 (89%) had a 24- or 48-hour 1.8 days, with a range of 0.58 to 6.3 days. Five of the
survey completed by their PCP; 33 (89%) had a com- patients (15.2%) had a hospital stay of Ͼ3 days (Table
pleted 72-hour telephone follow-up; and 35 (95%) had 6). Of these 5 patients, 2 were diagnosed with pneumo-
a completed 1-week telephone follow-up. All 37 (100%) nia on subsequent chest radiograph, and 1 was diag-
of the patients had at least 1 of the 3 follow-up surveys nosed with pneumonia and required intravenous fluids.
completed (Table 5). One patient was a former 29-week infant who had no
At the 24/48-hour follow-up, 97% of the caregivers complications noted, and the remaining patient had no
were satisfied with their child at home, and 94% of the complications noted. Twenty six of the patients (79%)
PCPs were satisfied with the patient being at home. At were discharged from the inpatient medical service on
the 72-hour telephone follow-up we asked about pref- home oxygen. There were no patients who required
erence, and 79% of the caregivers stated that they pre- transfer to the ICU, and there were no readmissions
ferred to be at home, and 15% of the caregivers would within 1 week after discharge. All 33 of the patient’s
have preferred to be in the hospital. Sixty-four percent caregivers were successfully contacted at the 1-week
of the PCPs stated they preferred their patients to be at telephone follow-up; 36% of the caregivers would have
home, whereas 27% of them would have preferred the preferred home care, 49% preferred hospital care, and
hospital. At the 72-hour survey, 100% of the caretakers 15% had no opinion (Table 7).
felt they had received adequate instruction on the use of Analysis of self-reported data on missed days from
home oxygen. Ninety-seven percent (34 of 35) of the work showed a trend in less missed days from work in
patients at the 7-day follow-up were satisfied with home the home oxygen group versus the hospitalized group
oxygen for their child. Four patients (11%) were still on (mean: 1.72 vs 2.69, respectively). This finding was not
oxygen at a week follow-up (Table 5). statistically significant.
Thirty-nine patients (42%) were randomly assigned
to traditional inpatient hospitalization. Six patients were DISCUSSION
excluded from the study: 2 patients were diagnosed with This study describes the discharge on home oxygen from
pneumonia from their chest radiograph that was ob- the ED after an 8-hour period of observation of infants
tained after enrollment instead of before randomization, with uncomplicated bronchiolitis. This practice is be-

TABLE 5 Caregiver/PCP Satisfaction With Home O2 (n ‫)73 ؍‬
Variable 24/48-h Visit 72-h Telephone 7-d Telephone
Questionnaire at Questionnaire Questionnaire
PCP Office (33 of 37), n (%) (33 of 37), n (%) (35 of 37), n (%)
Caregiver satisfied at home 32/33 (97) 31/33 (94) 34/35 (97)
Caregiver preference
Home 26 (79)
Hospital 5 (15)
No preference 2 (6)
PCP preference
Home 21 (64)
Hospital 9 (27)
No preference 3 (9)
PCP satisfaction 31/33 (94)
Adequate instruction 33/33 (100)
Parent observation length
Too short 1 (3)
Right 13 (40)
Too long 15 (45)
No opinion 4 (12)
Still on O2 at 1 wk 4/35 (11.4)


TABLE 6 Hospitalized Patients (n ‫)33 ؍‬ with supplemental oxygen for bronchiolitis. Other au-
Variable Hospitalized Patients thors have indicated that the management of bronchi-
(n ϭ 33) olitis varies widely in both the ED setting, as well as the
Length of stay, d inpatient setting, and is not based on clear evidence of
Mean 1.83 efficacy of treatment options.12–14
Range 0.58–6.33 The implementation of clinical care pathways have
Ͼ3 d of hospitalization, n/N (%) 5/33 (15.2)
been shown to decrease ancillary testing and overall cost
Discharged on home O2, n/N (%) 26/33 (79)
Telephone questionnaire at 7 d, n/N (%) 33/33 (100) and length of stay; however, use of home oxygen after
Caregiver preference ED evaluation and observation have not been part of
Home, n (%) 12 (36) published guidelines to date.15–18 Hospitalization rates for
Hospital, n (%) 16 (49) bronchiolitis have increased 239% over the past 2 de-
No opinion, n (%) 5 (15)
cades for children Ͻ6 months of age.1 During that time
period, mortality rates remained relatively constant.19
This increase in admission frequency has been postu-
TABLE 7 Days Missed From Work: Home Versus Hospital lated to relate to perhaps an increased reliance on pulse-
Days Home Hospital P oximetry measurements.4 In a retrospective analysis of
Missed (n ϭ 37) (n ϭ 33)
62 patients admitted for bronchiolitis, Schroeder et al5
Mean 1.72 2.69 .145a showed that hospitalization was prolonged by an aver-
a Student’s t test.
age of 1.6 days in 16 patients (26%) because of oxygen-
ation concerns based on pulse-oximetry readings after
all of the other discharge criteria were met. These pro-
coming more common in many sectors of the medical longed hospitalizations are not without potential addi-
community and in PCP offices without benefit of mea- tional costs and the risk of adverse events.20
surement of return rates, subsequent ED visit for wors- To enroll patients with uncomplicated cases of bron-
ening disease, or hospital admission. The reasons for this chiolitis, we chose to obtain a chest radiograph on all of
change in clinical practice are not known but could the patients to exclude possible bacterial pneumonia,
reflect a perceived overcrowding of EDs, the belief that foreign bodies, pulmonary edema, and other cardiac or
bronchiolitis is a mild disease in most infants, that the respiratory tract abnormalities. Standard care at the time
need for oxygen is often the only reason for hospital of our study included deep nasal suction and a trial of
admission, ease of care of patients on home oxygen, and beta agonists. We realize that these aspects of bronchi-
the fact that home oxygen has become easily accessible olitis care, with the exception of nasal suctioning, may
from home health care companies in recent years. no longer be necessary. We used a respiratory distress
The use of home oxygen therapy and subsequent score modeled from a previously published respiratory
early nursery discharge has been evaluated in the man- distress score to have an objective measure of respiratory
agement of premature infants with bronchopulmonary distress to allow for comparison between the 2 groups at
dysplasia and chronic lung disease and has been shown enrollment and discharge home.21 However, we did not
to be safe and effective, with an associated decrease in incorporate this score as either inclusion or exclusion
cost and no increase in morbidity or readmission rates.6,7 criteria or as discharge criteria. The study investigator
Families, when surveyed, responded 94% of the time team felt that incorporating an absolute cut-off score for
that they would again take an infant home on oxygen, discharge home would be difficult and that the clinical
and this practice is now routine.8,9 This approach has not measures listed in the discharge criteria would be more
yet become the standard of care for older infants and clinically relevant.
children with acute respiratory tract illness. In 2001, Our methodology also included a mandatory 8-hour
Wilson et al10 evaluated care for patients Ͻ1 year of age observation period to allow for varying stages of disease
admitted with bronchiolitis in 10 children’s medical cen- at the time of enrollment. This observation period
ters and found that care varied widely, that variations proved to be of significant benefit and affected care in 10
could not be explained by difference in disease severity, (21%) of 47 patients. Five patients were found to no
and that there was no evidence that a greater intensity of longer require supplemental oxygen and were dis-
care affected morbidity or mortality. The use of home charged from the hospital. These patients were an un-
oxygen was not measured. In a letter to the editor of expected finding. We removed the patients from the
Pediatrics concerning this publication, Weiss and Anna- study at that time, because it did not seem reasonable to
malai11 queried the issue of standardized discharge cri- require these families to adhere to the stringent fol-
teria from the hospital for patients with bronchiolitis. low-up requirements. They did receive standard bron-
They report on a survey of chief residents at 30 chil- chiolitis discharge instructions to return immediately for
dren’s hospitals, and, of the 17 responses, only 2 hospi- any concern of increased work of breathing, cyanosis,
tals reported that they routinely send patients home poor feeding, or any other concerns. Because these pa-

638 BAJAJ, et al

tients were observed for an extended period of time and Bronchiolitis is the most common cause of lower
were found to be hypoxic at the start of their evaluation, respiratory disease that requires hospital admission and
we performed chart review on these patients, and none contributes significantly to health care costs.22 Home
of them returned to the study institution in the follow- management may decrease these costs, as has been dem-
ing week for additional care. The remaining 5 patients onstrated with infants discharged on home oxygen from
were subsequently admitted to the hospital. None of the newborn nursery. Although it did not reach signifi-
these patients were transferred to the ICU. Only 1 pa- cance, we also demonstrated a trend toward less missed
tient was readmitted for a questionable cyanotic episode days of work for families who were randomly assigned to
at home and experienced no additional episodes during home therapy. Family economic impact, ability to com-
the subsequent 45-hour inpatient admission. ply with prescribed care plans, and overall acceptance of
Our sample size is too small to evaluate the ideal home oxygen therapy for acute respiratory disease in
period of observation, although the 8-hour time period infants and children has not been fully evaluated and
we chose allowed some patients to improve and identi- warrants further study.
fied some patients that failed. Our results do support the Our study has several limitations. This is a conve-
use of an observation period rather than immediate nience sample of patients who presented with bronchi-
discharge after evaluation and diagnosis. olitis, and we have no information on patients who were
Our study showed high rates of caregiver and PCP not enrolled; in addition, there is the potential of selec-
satisfaction with both inpatient admission and discharge tion bias. Patients who required higher levels of oxygen,
after observation in the ED on home oxygen therapy. presented with more respiratory distress, or did not at
Only 15% of the caregivers of the patients discharged first impression seem to have a good home environment
from the ED on oxygen therapy at the time of the may have been excluded. Our patient population is also
72-hour follow-up questionnaire stated that they would a referred population, so it may not be reflective of
have preferred hospital admission, whereas 36% of care- patients who present to other sites of care such as a
givers of the hospitalized patients would have preferred primary care clinic or office. Caregivers and ED physi-
to have been treated at home. Forty-nine percent of the cians were not blinded to which treatment arm the
caregivers of the hospitalized patients preferred hospital patient was assigned, which may have affected treat-
admission. The preference for home treatment was ment decisions. Our strict inclusion and exclusion crite-
higher among caregivers than among PCPs. PCPs of the ria, as well as the performance of the study at an altitude
patients discharged from the ED would have preferred of 5280 ft (1609 m), limit the external validity of the
hospital admission 27% of the time. The reason for this results.
is unclear. We feel that the comfort level and preference The study was stopped before the enrollment of the
for discharge on oxygen by parents who experienced desired number of patients in our sample-size calcula-
home management were because of specific concerns tion. This occurred for 2 main reasons. ED census was
about the complexity of home oxygen use before dis- beginning to outstretch inpatient bed availability; there-
charge, the use of highly trained respiratory therapists to fore, many patients with bronchiolitis were being dis-
explain home care, and prearranged follow-up with charged on oxygen from the ED outside of the study.
their PCP. Caregivers of admitted patients did not receive The hospital was also in the process of developing a
this education; thus, they may prefer inpatient admis- short-stay unit distinct from the ED observation unit to
sion because of misgivings and misconceptions about the attempt to meet the needs of this patient population.
challenges of the use of home oxygen, although 79% of Therefore, the decision was made to stop the study pro-
the hospitalized patients were eventually discharged tocol, and additional attempts to restart the study were
from the hospital on home oxygen. It is also interesting unsuccessful.
to note that 45% of the parents who were randomly Our sample size is small, and we cannot make state-
assigned to home oxygen felt that the observation period ments about safety of discharge on home oxygen, opti-
of 8 hours was too long, and only 1 patient (3%) felt it mal observation time period, or criteria that might pre-
was too short. Although we did not attempt to ascertain dict which patients might fail and require hospital
why, this feeling could be because of adequate explana- admission. A next step will be to systematically follow all
tion and education about home oxygen, the fact that the of the patients discharged from the ED on home oxygen
majority of the patients did well, and could be reflective for adverse events and need for subsequent hospitaliza-
of a high acceptance by families of home therapies. We tion.
developed conservative inclusion criteria including the
availability of transportation to return at 24 and 48 CONCLUSIONS
hours after discharge, a contact telephone number, liv- This is the first study to demonstrate discharge home
ing no more than 30 minutes from an emergency med- from the ED with supplemental oxygen in patients with
ical facility, and a smoke-free environment to maximize bronchiolitis. We found that an 8-hour observation pe-
the safety of discharge home. riod identifies those patients who may resolve their ox-


ygen requirement and those who may worsen and re- 8. Thilo EH, Comito J, McCulliss D. Home oxygen therapy in the
quire hospital admission, and, because of a low newborn. Costs and parental acceptance. Am J Dis Child. 1987;
141:766 –768
incidence of complications, the 8-hour observation pe-
9. Gracey K, Talbot D, Lankford R, Dodge P. The changing face of
riod is an option for management. High acceptance rates bronchopulmonary dysplasia: part 2. Discharging an infant
by caregivers and PCPs supports this approach. Addi- home on oxygen. Adv Neonatal Care. 2003;3:88 –98
tional study is necessary to determine safety and eco- 10. Wilson DF, Horn SD, Hendley O, Smout R, Gassaway J. Effect
nomic impact. of practice variation on resource utilization in infants for viral
lower respiratory illness. Pediatrics. 2001;108:851– 855
ACKNOWLEDGMENTS 11. Weiss J, Annamalai VR. Discharge criteria for bronchiolitis
patients [letter]. Pediatrics. 2003;111:445
This study was funded by the Children’s Hospital Re-
12. Johnson DW, Adair C, Brant R, Holmwood J, Mitchell I. Dif-
search Institute and Kaiser Permanente. Funding was ferences in admission rates of children with bronchiolitis by
used to support research assistant time in enrolling pa- pediatric and general emergency departments. Pediatrics. 2002;
tients, collecting data, performing telephone follow-up, 110(4). Available at: www.pediatrics.org/cgi/content/full/110/
and entering data. 4/e49
Lalit Bajaj had full access to all of the data in the study 13. Plint AC, Johnson DW, Wiebe N, et al. Practice variation
among pediatric emergency departments in the treatment of
and takes responsibility for the integrity of the data and
bronchiolitis. Acad Emerg Med. 2004;11:353–360
the accuracy of the data analysis. 14. Christakis DA, Cowan CA, Garrison MM, Molteni R, Marcuse
E, Zerr DM. Variation in inpatient testing and management of
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640 BAJAJ, et al

A Randomized Trial of Home Oxygen Therapy From the Emergency
Department for Acute Bronchiolitis
Lalit Bajaj, Carol G. Turner and Joan Bothner
Pediatrics 2006;117;633-640
DOI: 10.1542/peds.2005-1322
Updated Information including high-resolution figures, can be found at:
& Services http://www.pediatrics.org/cgi/content/full/117/3/633
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