Clinical features can help predict which infants with bronchiolitis will need hospital admission

Article Outline

• Question
• Design
• Setting
• Participants
• Intervention
• Outcomes
• Main Results
• Conclusions
• Commentary
• References
• Copyright

Marlais M, Evans J, Abrahamson E. Clinical predictors of admission in infants with acute bronchiolitis. Arch Dis Child 2011;96:648-52.

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Question 

Among infants presenting to the emergency department with bronchiolitis, what factors predict admission to the hospital?

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Design 

Prospective cohort study.

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Setting 

Single pediatric emergency department in the United Kingdom.

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Participants 

449 infants who presented with acute bronchiolitis between April 2009 and March 2010 (298 [66%] male), mean age 23±14.5 weeks.

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Intervention 

Two authors reviewed the charts for each infant and recorded clinical features at the time of admission, demographic data, and clinical history.

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Outcomes 

The strongest predictors of admission were assimilated into a simple clinical risk scoring system.

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Main Results 

163 (36%) infants were admitted to the hospital. The five best predictors of admission (age, respiratory rate, heart rate, oxygen saturations, and duration of symptoms) were incorporated into the bronchiolitis risk of admission scoring system. The area under the receiver operator characteristic curve was 0.81 (95% CI, 0.77 to 0.85) at the optimal cut-off, demonstrating good diagnostic accuracy.

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Conclusions 

Patient age, respiratory rate, heart rate, oxygen saturation, and duration of symptoms can be included in a simple clinical risk scoring system to predict admission in acute bronchiolitis.

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Commentary 

Although many historical, environmental, and medical factors have been associated with the severity of bronchiolitis, Marlais et al eliminated many of these factors (eg, gestational age, birth weight, signs of dehydration, apnea, and decreased feeding) due to lack of data or the factor's subjective nature. They also did not examine exposure to tobacco smoke in- or ex-utero, which has been associated with severe bronchiolitis.¹, ² The authors, however, successfully created a simple clinical rule that contains commonly measured objective factors. The area under the receiver operating characteristic curve demonstrates that, in one emergency department population, this rule is able to discriminate between admitted and discharged children. Although “clinical judgment can let these children down” and this rule may be particularly useful as an “early warning system” for inexperienced clinicians, we are not sure from these data if the hospital admission was truly necessary. Indeed, in children with bronchiolitis, our inability to predict reliably impending apnea and/or the need for supportive care drives some unnecessary admissions. Future validation studies of this rule in different populations still need to be performed. For these studies, it would be informative to not only examine the outcome of hospital admission, but also investigate the more restrictive outcome of hospital admission requiring supportive care.

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References 

1. Semple MG, Taylor-Robinson DC, Lane S, Smyth RL. Household tobacco smoke and admission weight predict severe bronchiolitis in infants independent of deprivation: prospective cohort study. PLoS ONE. 2011;6:e22425
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2. Carroll KN, Gebretsadik T, Griffin MR, Dupont WD, Mitchel EF, Wu P, et al. Maternal asthma and maternal smoking are associated with increased risk of bronchiolitis during infancy. Pediatrics. 2007;119:1104–1112
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