Stollar Fabiola, Gervaix Alain, Argiroffo Constance Barazzone
General Pediatric Division, Children's Hospital, University Hospitals of Geneva, Geneva, Switzerland.
Pediatric Emergency Division, Children's Hospital, University Hospitals of Geneva, Geneva, Switzerland.
PLoS One. 2016 Sep 30;11(9):e0163217. doi: 10.1371/journal.pone.0163217. eCollection 2016.
Recent publications have established the pulse oxygen saturation (SpO2) threshold of 90% for the hospitalization and discharge of infant patients with bronchiolitis. However, there is no clear recommendation regarding the Emergency Department (ED) observation period necessary before allowing safe home discharge for patients with SpO2 above 90%-92%. Our primary aims were to evaluate the risk factors associated with delayed desaturation in infants with SpO2 ≥ 92% on arrival at the ED as well as the ED observation period necessary before allowing safe home discharge. A secondary aim was to identify the risk factors for ED readmission. Of 581 episodes of bronchiolitis in patients < 1 year old admitted to the ED, only 47 (8%) had SpO2 < 92% on arrival there, although 106 (18%) exhibited a delayed desaturation (to < 92%) during ED observation. Female sex, age < 3 months old, ED readmission, more severe initial clinical presentation, and higher pCO2 level (> 6KPa) were risk factors for delayed desaturation with OR varying from 1.7 to 7.5. In patients < 3 months old, mean desaturation occured later than in older patients [6.0 hours (IQR 3.0-14.0) vs. 3.0 hours (IQR 2.0-6.0), P = 0.0018]. In 95% of patients with a delayed desaturation this decrease occurred within 25 hours for patients < 3 months old and within 11 hours for patients ≥ 3 months old. In patients < 3 months old with respiratory rates above the normal range for their age the desaturation occurred earlier than in patients < 3 months with normal respiratory rates [4.4 hours (IQR 3.0-11.7) vs. 14.6 hours (IQR 7.6-22.2), P = 0.037]. Based on the present study's results, we propose a five step guide for pediatricians on discharging children with bronchiolitis from the ED. By using the threshold of an 11 hour ED observation period for patients ≥ 3 months old and a 25 hour period for patients < 3 months old we are able to detect 95% of the patients with bronchiolitis who are at risk of delayed desaturation.
近期发表的文献已确定，毛细支气管炎婴儿患者住院和出院的脉搏血氧饱和度（SpO2）阈值为90%。然而，对于SpO2高于90%-92%的患者，在允许安全出院回家之前，急诊科（ED）所需的观察期尚无明确建议。我们的主要目的是评估急诊就诊时SpO2≥92%的婴儿中与延迟脱氧相关的危险因素，以及允许安全出院回家之前所需的急诊科观察期。次要目的是确定再次急诊入院的危险因素。在急诊科收治的581例1岁以下毛细支气管炎患者中，只有47例（8%）就诊时SpO2<92%，不过106例（18%）在急诊科观察期间出现延迟脱氧（降至<92%）。女性、年龄<3个月、再次急诊入院、初始临床表现更严重以及更高的pCO2水平（>6KPa）是延迟脱氧的危险因素，比值比在1.7至7.5之间。在<3个月的患者中，平均脱氧发生时间晚于年龄较大的患者[6.0小时（四分位间距3.0 - 14.0）对3.0小时（四分位间距2.0 - 6.0），P = 0.0018]。在95%出现延迟脱氧的患者中，<3个月的患者在25小时内出现脱氧降低，≥3个月的患者在11小时内出现。在<3个月且呼吸频率高于其年龄正常范围的患者中，脱氧比呼吸频率正常的<3个月患者更早出现[4.4小时（四分位间距3.0 - 11.7）对14.6小时（四分位间距7.6 - 22.2），P = 0.037]。基于本研究结果，我们为儿科医生提出了一份关于毛细支气管炎患儿从急诊科出院的五步指南。通过使用3个月及以上患者11小时的急诊科观察期阈值和3个月以下患者25小时的观察期阈值，我们能够检测出95%有延迟脱氧风险的毛细支气管炎患者。
