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Pediatric Pulmonology 44:358–363 (2009


Predictors of Major Intervention in Infants
With Bronchiolitis
Melissa J. Parker, MD, FRCPC MSc,1,2 Upton Allen, MD, FRCPC,2,3,4 Derek Stephens, MSc,4
Amina Lalani, MD, FRCPC FAAP (PEM),1 and Suzanne Schuh, MD, FRCP(C), FAAP1,2,4*
Summary. Objective: We sought to identify predictors of the major medical intervention (MMI) in
infants with bronchiolitis in the Emergency Department (ED) to recognize those in need of
hospitalization versus the candidates for discharge. Patients and Methods: We conducted an
analysis of data from a prospective cohort study of previously healthy infants 2–23 months
presenting to our ED with first episode of wheeze and respiratory distress. Infants were divided into
those with at least one MMI defined as oxygen administration for saturation of <90%, intravenous
(IV) fluids of 20 ml/kg, apnea management, or critical care unit (CCU) admission (MMI group)
versus those without (no-MMI group). The primary outcome was the association between the MMI
versus no-MMI groups and potential risk factors for these outcomes. Results: Of 312 study infants,
52 experienced MMI—all received oxygen for saturation <90%, four also received IV fluids and
none required apnea management or CCU care. The following four risk factors were associated
with MMI: baseline accessory muscle score 6/9 [OR 2.44, 95% CI 1.29; 4.62], oxygen saturation 
92% [OR 2.41, 95% CI 0.96; 6.14], respiratory rate 60 [OR 1.85, 95% CI 0.97; 3.54], and poor
fluid intake [OR 2.65, 95% CI 1.12; 6.26]. Of the 148 infants without predictors 11 (7.4%) received
MMI, 145 required either no MMI or oxygen for 6 hr and 130 (87.8%) stayed for 12 hr.
Conclusions: Infants with bronchiolitis with high-risk predictors should be hospitalized whereas
those without can be considered for outpatient management due to low-risk of MMI. Pediatr
Pulmonol. 2009; 44:358–363. ß 2009 Wiley-Liss, Inc.
Key words: bronchiolitis; oxygen therapy; hospitalization; predictors.


Viral bronchiolitis is the most common lower respiratory tract infection among infants1,2 accounting for
16% of all pediatric hospitalizations and an annual cost of
US $700 million.3 Bronchiolitis carries a major impact on
health care resources with hospitalizations accounting for
62% of the management costs and 30% of infants
evaluated in the pediatric Emergency Departments
(EDs) being hospitalized.4 Currently, there is considerable
practice variation in management and disposition in this
The reasons for hospitalization in bronchiolitis are
often subjective. Many admitted infants do not have severe
distress and many infants experience prolonged hospital
stays solely due to perceived need for oxygen therapy
when clinical discharge criteria are otherwise met.13,14
Furthermore, healthy children admitted with bronchiolitis
are unlikely to deteriorate.15
It may be that some infants admitted with bronchiolitis
could be managed safely on an outpatient basis. Hospitalization is not without risks, and up to 10% of infants
with bronchiolitis experience adverse events during
their hospital stay.16 Most previous studies predicting
hospitalization in this disease have included inpatients,15
infants with co-morbidities7,17–18 or with recurrent
ß 2009 Wiley-Liss, Inc.

wheezing.17,19,20 In one recent large multicenter study of
infants presenting to the ED with bronchiolitis the authors
used logistic regression to identify demographic and
clinical factors associated with safe discharge.21 Importantly, however, no studies have considered actual need for

Division of Pediatric Emergency Medicine, Research Institute, The
Hospital for Sick Children, University of Toronto, Ontario, Canada.
Department of Pediatrics, Research Institute, The Hospital for Sick
Children, University of Toronto, Ontario, Canada.

Infectious Diseases, Research Institute, The Hospital for Sick Children,
University of Toronto, Ontario, Canada.
Child Evaluative Health Sciences, Research Institute, The Hospital for
Sick Children, University of Toronto, Ontario, Canada.

*Correspondence to: Suzanne Schuh, MD, FRCP(C), FAAP, Department
of Pediatric Emergency Medicine, The Hospital for Sick Children, 555
University Avenue, Toronto, Ontario, Canada M5G 1X8.
Received 12 August 2008; Revised 15 October 2008; Accepted 18 October
DOI 10.1002/ppul.21010
Published online 12 March 2009 in Wiley InterScience

Identification of the predictors of these major interventions and absence thereof would define infants in whom hospitalization should be considered versus those who could be safely sent home. rehydration therapy or the need for intensive monitoring or airway stabilization. Patients were divided into two groups. any treatment for apnea. Bronchiolitis was defined as coryza. The usual bronchiolitis therapy in our ED consists of supplemental oxygen given for saturation of <90%. Potential predictors of this outcome were defined a priori and included age. or chronic systemic disease. Secondary Outcomes The proportions of patients with any significant highrisk predictors and those without who either received the MMI. or admission to the Critical Care Unit (CCU). DEFINITIONS We defined a priori any of the following as MMI: Oxygen administration for 30 min or more for saturation <90% in room air. Prolonged stay was used as a surrogate marker for hospitalization and defined as the interval from the first nebulization to discharge of 12 hr or more. either in the ED or on an inpatient ward. accessory muscle score of the Respiratory Distress Assessment Instrument (RDAI). neuromuscular disease. presence of hypoxia and/or marked respiratory distress at presentation would predict the need for major medical intervention (MMI). duration of respiratory distress. recorded patient disposition and telephoned all families on day 7 regarding subsequent hospitalizations. and history of compromised oral intake or urine output. experienced prolonged hospital stay or were briefly treated with oxygen for 6 hr or less.Predictors of Major Intervention in Bronchiolitis hospitalization supported by the administration of supplemental oxygen for significant hypoxia. Poor self-hydration was defined as the history of either decreased oral fluid intake by 50% or more or of poor urinary output. cough. Criteria for admission to our CCU include concern regarding potential need for intubation and mechanical ventilation for either recurrent apnea with desaturations or for a possibility of impending respiratory failure. aspiration. and the first episode of respiratory distress with wheeze or crepitations in a non-toxic infant.6 This convenience sample was collected consecutively while one of three trained study nurses was on duty. oxygen saturation. intravenous (IV) fluid hydration in infants with dehydration or extreme respiratory distress and a trial of nebulized bronchodilators such as albuterol ABBREVIATIONS MMI ED CCU OR RDAI Major medical intervention Emergency department Critical care unit Odds ratio Respiratory disease assessment instrument 359 or epinephrine. We hypothesized that the inability to sustain hydration. DATA ANALYSIS Potential a priori postulated predictors of the MMI were initially analyzed by univariate logistic regression to Pediatric Pulmonology . children with previously diagnosed cardiopulmonary disease. heart rate. Excluded were children with previous wheeze/bronchodilator therapy. Children who in the opinion of the ED attending are considered to be in marked respiratory distress and those thought to require supplemental oxygen/rehydration are admitted to hospital. PATIENTS AND METHODS Patient Population and Study Design The Hospital for Sick Children is a tertiary care center with 54. These patients consume inpatient resources and therefore have to be considered hospitalized. Some children are discharged home after a long stay in the ED (more than 12 hr) due to lack of inpatient beds. MAIN OUTCOMES Primary Outcome The identification of independent predictors of the MMI. birth weight <2. In this study we utilized data from a recent prospective cohort study of 312 children between 2 and 23 months of age presenting to our ED with this disease. All charts were reviewed by a single investigator (MP).22 IV fluid bolus of 20 ml/kg or more. A written consent was obtained from all participating families and the study was approved by our Research Ethics Board. The primary objective of this study was therefore to identify predictors of MMI in infants presenting to the ED with acute bronchiolitis. Supplemental information for this study regarding additional clinical data and details of the medical interventions and follow-up were obtained from a review of patient electronic charts. The accessory muscle score was chosen since it best reflects the work of breathing used by most physicians as a reflection of bronchiolitis severity.500 g or neonatal ventilation for more than 24 hr. The research nurses recorded historical information and measured relevant baseline clinical parameters.000 ED patient visits annually. and a data extraction form was used to systematically record data of interest. baseline respiratory rate. those with MMI as defined below within 7 days of the initial ED visit and those without MMI. those with prematurity <35 weeks gestation.

6. The odds of major intervention for each predictor after adjustment for the remaining predictors are summarized in Table 2. Of the 52 children who received oxygen for desaturations below 90% while in hospital.1%) 27 (51. severe retractions (accessory muscle component of the RDAI score of 6/9 or more. and the others had desaturated later. 40 (47%) did not require any MMI.9%) 9 (17. using the group without predictors as a reference.007 0. i. Of the 148 patients without any high-risk predictors. only 1 had saturation below 90% at baseline.002 <0.2%) 19 (7. Student’s t-test and chisquare test were used to compare the rate of MMI.9%) 37. experienced prolonged stay of 12 hr or more.96.29.3%) 11 (21.4 15 (28.5%) 8.12. 3.26 1.9%) 37.. their saturations decreased below 90% while undergoing monitoring in the ED. TABLE 1— Baseline Characteristics of Patients With and Without Major Intervention 1 Age (months) Duration of respiratory distress (hr)1 Family history of atopy Temperature (8C) Respiratory rate 60 at baseline Accessory muscle score of the RDAI at baseline 6/9 Oxygen saturation 92% at baseline Decreased hydration Prolonged stay >12 hr Major intervention (N ¼ 52) No major intervention (N ¼ 260) P-value 6.4%) 0. TABLE 2— Adjusted Odds Ratios of Major Intervention for Significant Predictors Decreased hydration Accessory muscle score 6/9 Oxygen saturation 92% Respiratory rate 60 N Odds ratio 95% CI 30 96 25 94 2. severe retractions) on arrival. which only lasted 6 hr or less in eight children (Table 4). At follow-up. and temperature. very brief oxygen therapy and the total length of stay in infants with and without significant predictors of the MMI.002 0. are depicted in Table 3.5%) 16 (6. Another child with a blood culture positive for several strains of viridans streptococci Pediatric Pulmonology during the initial admission had received one dose of Ceftriaxone.9  0.7 45. prolonged stay of more than 12 hr. RESULTS Of the 312 patients in this study who presented to the ED.65 2.8  55. We also examined how much more likely children with one. using the group without predictors as a reference. None of the children discharged home from the ED experienced subsequent hospitalizations due to respiratory deterioration.8 32 (12. and baseline hypoxia (Table 1).3  5.9 25 (48. 52 required MMI while 260 did not. examine their individual association with the outcome. This consisted of supplemental oxygen therapy.0003 0.4%) 69 (26.173 0.54 . that is. he had negative cultures and recovered well. 4 of these also received IV fluid bolus of 20 ml/kg or more. 6.44 2.4% experienced MMI.62 0. With the exception of the drop in oxygen saturation no other change in respiratory status was noted at the time supplemental oxygen was started or thereafter. two. Four variables were found to be independently significant predictors of MMI: history of compromised oral intake.14 0.7 43.6 101 (38. There was no statistical difference between the patients with versus without MMI with respect to the duration of respiratory distress. A total of 86 study patients were hospitalized.0001 1 Mean  standard deviation. Predictors achieving statistical significance were then included in multivariate logistic regression analysis to examine their independent association with the MMI.3  4.360 Parker et al. Few infants in this low-risk group also experienced prolonged stay for more than 12 hr and only three received oxygen for more than 6 hr (Table 5). 4. which was stopped due to negative repeat cultures.0  36. retractions. or three predictors were to experience the MMI than those without any predictors.3%) 46 (88. baseline oxygen saturation 92% or less and respiratory rate 60/min or more.053 0. and no patient required treatment for apnea or CCU admission. All 52 infants required oxygen supplementation for oxygen saturation <90% during their hospital stay.41 1.05. Patients in the MMI group were younger and had greater tachypnea.85 1.97. one child originally discharged was admitted several days later for high fever and leukocytosis to rule out sepsis.7  0. The odds ratios of the MMI for one or more predictors. typically during sleep (Table 4). Of these. Infants with three or more high-risk features were 13 times more likely to experience the MMI compared to those without any predictors. While all 11 patients without predictors who received the MMI had baseline saturations 93% or higher (Table 4). The group without predictors was thus assigned the odds ratio of 1 and a chi-square analysis was used to determine the odds ratios and appropriate 95% confidence intervals (CI) for the MMI in infants with various numbers of significant predictors.649 0. 11 or 7.021 0.e.3%) 40 (15. with significance determined at P < 0. atopic history.

However. A recent study found that a 2% decrease in mean saturation level 6 hr after hospitalizations for bronchiolitis increased the proportion of children receiving supplemental oxygen TABLE 4— Infants With No High-Risk Features Who Received Major Intervention Patient 1 2 3 4 5 6 7 8 9 10 11 Age (months) Baseline saturation (percent) Lowest saturation (percent) Lowest saturation when asleep Baseline RR Duration of oxygen therapy (hr) Duration of hospital stay (hr) 17 13 3 4 5 3 3 4 14 8 6 93 95 94 98 99 98 93 99 96 93 93 89 86 89 88 89 87 87 88 88 86 85 n/a þ þ þ þ þ  þ  þ  58 50 54 32 50 42 58 38 46 52 36 4 6 5. regardless of the degree of respiratory distress. respiratory rate above 45 per min and age <6 months predicting hospitalization. The utility of baseline oxygen saturation to predict hospitalization varies between studies.17–19 Our study excluded babies under 8 weeks of age which may explain lack of association between age and MMI. Pediatric Pulmonology .Predictors of Major Intervention in Bronchiolitis TABLE 3— Odds Ratios of Major Intervention for Predictors Alone and in Combination Predictor None Any one predictor Any two predictors Three or more predictors N Odds ratio 95% CI 148 100 48 16 1 2.9 DISCUSSION We have identified four significant predictors of MMI in otherwise healthy infants presenting to the ED with bronchiolitis: severe retractions on arrival. Hospitalization in this population may not always be necessary. Young age is a frequently cited high-risk factor in bronchiolitis. 13. Recently. Infants presenting to the ED without such high-risk predictors are at a low-risk of requiring MMI and are therefore almost always good candidates for discharge home.2 5. Shaw et al.20 There is little evidence as to when supplemental oxygen is required. 4. these cut-offs were determined a priori and identified a large proportion of infants with bronchiolitis at risk for hospitalization.19 had derived and validated a sensitive prediction model consisting of young age. our study sought to identify infants at risk of a MMI during the course of their illness who should be considered for hospital admission versus those in whom such interventions are unlikely to happen. it is likely that these desaturations represent natural fluctuations in oxygenation in response to various physiologic factors such as sleep rather than a true change in disease severity. As a result. the model involves a complex mathematical formula difficult to use in a busy ED.23–27 but without evidence regarding potential risks and benefits. many infants with mild distress and mildly diminished saturations are admitted for oxygen therapy. Since none of these patients required either supplemental oxygen on arrival or experienced deterioration in respiratory status when oxygen was commenced later.7 12. the American Academy of Pediatrics has recommended that previously healthy infants with bronchiolitis with saturations 90% or greater are unlikely to benefit from supplemental oxygen.1 4. dehydration. Criteria for hospitalization in bronchioli- 361 tis are highly variable and often influenced by social and other factors.4. the need for prolonged stay in this low-risk population is open to question.0. Desaturations frequently occur after bronchodilator therapy28.0. 41. those with multiple predictors are at a high-risk of MMI and should therefore be considered for hospitalization. Therefore. saturation <95%.5 40 72 n/a.9 1. Several previous studies have addressed the issue of predicting hospitalization in previously healthy outpatients with bronchiolitis.20 had found saturation <95%. Walsh et al. respiratory rate 60/min or more and history of poor fluid intake. baseline oxygen saturation 92% or less. Voets et al. prematurity.22 The majority of the 11 infants without high-risk predictors who received MMI had mild hypoxia during sleep and had supplemental oxygen administered for only several hours. In contrast.8 2. or state of wakefulness. data not available. increased work of breathing. and baseline heart rate above 97th percentile for age for hospitalization lasting more than 24 hr.29 and during sleep. In contrast. duration of desaturation. respiratory rate above 70 per min and age <3 months as predictors of moderate to severe illness.30 without any change in the respiratory status.1. However.17 had identified toxic appearance. with currently suggested saturation thresholds ranging from 90% to 94%. Recently.5 200 150 1 18 4 1 6 4 48 23 18 240 216 48 57 60 7.

Roback MG. Pediatrics 2005. Cowan CA. 2.157:215–220. Reeves SD. International RSV Study Group. Shaw KN. details such as the precise reasons prompting physicians to start supplemental oxygen were not always specified. Differences in admission rates of children with bronchiolitis by paediatric and general emergency departments. Pantell RH. Practice variation among pediatric emergency departments in the treatment of bronchiolitis.18. Allen U. Baskin MN. Acad Emerg Med 2004. Brown KM. Lalani A. Dick P. Schuh S. Schroeder AR. International variation in the management of infants hospitalized with respiratory syncytial virus. In contrast. the baseline saturation of 92% or less can be considered a predictor of the need for subsequent oxygen therapy. Joubert G. These infants may improve dramatically on oxygen therapy. .9  30.158: 527–530. Bronchiolitis in US emergency departments 1992 to 2000: epidemiology and practice variation. regardless of their initial oximetry. 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