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Analysis Too Much Medicine

When technology creates uncertainty: pulse oximetry and overdiagnosis of hypoxaemia in bronchiolitis

BMJ 2017; 358 doi: (Published 16 August 2017) Cite this as: BMJ 2017;358:j3850
  1. Ricardo A Quinonez, associate professor (clinical) and section chief1,
  2. Eric R Coon, assistant professor (clinical)2,
  3. Alan R Schroeder, associate professor (clinical) and associate chief for research3,
  4. Virginia A Moyer, vice president, maintenance of certification and quality4
  1. 1Section of Pediatric Hospital Medicine, Department of Pediatrics, Baylor College of Medicine, Houston, TX, USA
  2. 2Department of Pediatrics, University of Utah School of Medicine, Salt Lake City, UT
  3. 3Department of Pediatrics, Stanford University School of Medicine, Stanford, CA
  4. 4American Board of Pediatrics, Chapel Hill, NC
  1. Correspondence to: RA Quinonez raquinon{at}

Pulse oximetry drives overtreatment in children with bronchiolitis without improving clinical outcomes, argue Ricardo Quinonez and colleagues

Key messages

  • Bronchiolitis admissions have increased substantially over the past 30 years, without a concomitant change in disease severity or mortality

  • The increase in admission rates for bronchiolitis coincides with the increased widespread use of pulse oximetry in the 1980s

  • Hypoxaemia may be a main driver for decisions to admit children with bronchiolitis, evidence shows

  • Overdiagnosis of hypoxaemia may be at least partially responsible for increased admission rates of children with bronchiolitis, recent evidence shows

  • Lower thresholds for oxygen concentration to determine treatment may be associated with better outcomes such as decreased length of stay, with no demonstrated evidence of adverse outcomes

Karl Matthes, a German physician, is credited with developing the first device to measure oxygen saturation.1 Wide scale use began in the 1980s with the introduction of the first commercial devices.2 Since then, pulse oximetry has permeated healthcare to the point where it has been dubbed the “fifth vital sign” and has become the standard method for non-invasive measurement of oxygenation.34

Pulse oximetry is widely used to help evaluate children with bronchiolitis, a lower respiratory tract viral infection that primarily affects children in their first two years.5 Excluding live births, bronchiolitis is the leading cause of hospital admission in infants under 12 months of age in the United States, accounting for 18% of all admissions in this age group. Each year nearly 3% of all US infants are admitted with bronchiolitis.6

Bronchiolitis is a self limited illness for which most therapeutic interventions have failed to have a positive effect on important outcomes. Treatment, even when children are admitted to hospital, is primarily supportive.57 Different strains of respiratory syncytial virus, the most common agent responsible for …

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