Bronchiolitis - PECARN

1 BronchiolitisClinical Characteristics Associated With Hospitalizationand Length of StayHoward M. Corneli, MD,* Joseph J. Zorc, MD, Richard Holubkov, PhD, Joan S. Bregstein, MD, Kathleen M. Brown, MD,|| Prashant Mahajan, MD, MPH, MBA, Nathan Kuppermann, MD, MPH,#and The Bronchiolitis Study Group for the Pediatric Emergency Care Applied Research NetworkObjectives: Bronchiolitis is a leading cause of infant hospitalization inthe United States; the mean length of stay (LOS) is days. We soughtto identify the initial clinical characteristics of Bronchiolitis associatedwith admission and with longer LOS in a large multicenter clinical :This study was a secondary analysis of a randomized trialconducted in 20 emergency departments in the Pediatric Emergency CareApplied Research Network.

2 We examined age, sex, days of illness,Respiratory Distress Assessment Instrument score, vital signs, and oxy-gen saturation by pulse oximetry (SpO2) at presentation in 598 infantsaged 2 to 12 months with moderate to severe Bronchiolitis . We usedclassification and regression tree and logistic regression analyses toidentify associations with admission and longer LOS (defined as LOS91 night).Results:Of the 598 infants, 240 (40%) were hospitalized; two thirdsunderwent longer LOS. The best predictor of hospitalization was initialSpO2value of less than 94%, followed by Respiratory Distress Assess-ment Instrument score of greater than 11 and respiratory rate of greaterthan 60.

3 For this model, the sensitivity was 56% (95% confidence in-terval, 50%Y62%) and the specificity was 74% (95% confidence inter-val, 70%Y79%). Among admitted patients, the only decision point forprediction of longer LOS was initial SpO2value of 97% or :A model using objective findings had limited accuracyfor predicting hospitalization after emergency department evaluation forbronchiolitis. In these infants with moderate to severe Bronchiolitis ,however, initial SpO2was the best predictor of hospital admission and oflonger LOS. Efforts to better define and manage hypoxemia in bronch-iolitis may be Words: Bronchiolitis , hospitalization, length of stay, projectionsand predictions, hypoxia(Pediatr Emer Care2012;28: 99Y103) Bronchiolitis is the leading cause of infant hospitalizationin the United States,1with nearly 150,000 admissions rates for Bronchiolitis among infantsmore than doubled between 1980 and 1996, and the proportionof hospitalizations due to Bronchiolitis more than tripled, from5% to 16%.

4 3 Hospitalization for Bronchiolitis is expensive, with US hos-pital charges alone exceeding $1 billion in chargesin part reflect length of stay (LOS) in the hospital. The meanLOS for Bronchiolitis in the United States is ,4 Hos-pitalization might decrease if infants with Bronchiolitis could betreated in short-stay or 24-hour observation units, but patientswith Bronchiolitis often fail in such ,6 Many therapiesare provided to infants hospitalized with Bronchiolitis , but evi-dence in general does not demonstrate an effect on the many possible indications for hospitalization ininfants with Bronchiolitis , most are subjective.

5 Identifying ob-jective factors that predict hospitalization and especially longerhospitalization could help focus research on safe and effectivemeasures to prevent some hospitalizations and shorten others,thus reducing the burden on parents, hospitals, and factors predicting LOS could also help selectpatients more likely to succeed in short-stay observation goal of this study was to identify objective variables notedduring initial emergency department (ED) evaluation that bestpredicted hospital admission and longer data for this study were collected as part of a ran-domized controlled trial of dexamethasone for bronchiolitis12( no.)

6 NCT00119002) conducted in 20 EDs ofthe Pediatric Emergency Care Applied Research Network during3 Bronchiolitis seasons (November through April) from January2004 through April 2006. Infants were eligible if they were aged2 to 12 months with first-time Bronchiolitis , defined as wheez-ing with no history of any similar condition, and if their diseasewas moderate to severe, defined as a Respiratory Distress As-sessment Instrument (RDAI)13score of 6 or greater. The com-ponents of the RDAI score used here are shown in Table original study excluded infants with a previous adversereaction to dexamethasone, known heart disease or lung disease(eg, cystic fibrosis), premature birth with less than 36 weeks ofgestation, immune suppression or immune deficiency, treatmentwith corticosteroids within the previous 14 days, active varicella,known exposure to varicella within 21 days, or inability of theparents to speak English or Spanish.

7 Patients with life-threateningcomplications of Bronchiolitis , including apnea, respiratory fail-ure, or the clinical appearance of sepsis or shock, were also ex-cluded. The institutional review boards at all sites approved theORIGINALARTICLEP ediatric Emergency Care&Volume 28, Number 2, February the *University of Utah and Primary Children s Medical Center, SaltLake City, UT; Children s Hospital of Philadelphia and University ofPennsylvania, Philadelphia, PA; Central Data Management and Coordinat-ing Center, Pediatric Emergency Care Applied Research Network, Salt LakeCity, UT; Columbia University and Morgan Stanley Children s Hospital ofNew York-Presbyterian, New York, NY.

8 ||Children s National Medical Centerand George Washington University, Washington, DC; Children s Hospital ofMichigan and Wayne State University, Detroit, MI; #School of Medicine,University of California, Davis, Sacramento, : The authors have no conflict of interest to : howard M. Corneli, MD, PO Box 581289, Salt Lake City,UT 84158 (e-mail: reprints available for this study was supported by grant R40MC042980100 from the Maternal andChild Health Bureau Research Program, and the Pediatric EmergencyCare Applied Research Network is supported by cooperativeagreements U03MC00001, U03MC00003, U03MC00006,U03MC00007, and U03MC00008 from the Emergency MedicalServices for Children program of the Maternal and Child Health Bureau,Health Resources and Services Administration, US Department ofHealth and Human *2012 by Lippincott Williams & WilkinsISSN.)

9 0749-5161 Copyright 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is Written informed consent was obtained from the parentsof all enrollment, trained study clinicians confirmed clini-cal Bronchiolitis , recorded the duration of symptoms, anddetermined an RDAI score. A nurse recorded clinical vari-ables including respiratory and heart rates, temperature, andoxygen saturation by pulse oximetry (SpO2) while breathingambient the original trial, the patients were randomized toreceive either oral dexamethasone or placebo.

10 All other bronch-iolitis treatments during study evaluation were administeredaccording to clinician preference and local standards. Wefound no difference in the number of such treatments betweenthe dexamethasone and placebo groups. Although no treat-ment effect was demonstrated in that study, treatment groupassignment was included as a potential variable in the outcomes of our study were (1) hospital admission and(2) longer admission. We defined longer admission as LOS ofmore than 1 night to exclude the patients who would have suc-ceeded in 24-hour observation care and those whose admissionmight not have been necessary in retrospect.