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 Table of Contents  
COMMENTARY
Year : 2022  |  Volume : 11  |  Issue : 4  |  Page : 233-235

The trade-off between home oxygen and length of stay


Department of Pediatrics, Louisiana State University Health Sciences Center, Shreveport, LA, USA

Date of Submission16-Jun-2022
Date of Decision10-Jul-2022
Date of Acceptance11-Jul-2022
Date of Web Publication04-Oct-2022

Correspondence Address:
Shabih Manzar
Department of Pediatrics, Louisiana State University Health Sciences Center, 1501 Kings Highway, Shreveport, LA 71103
USA
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcn.jcn_71_22

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How to cite this article:
Hernandez B, Manzar S. The trade-off between home oxygen and length of stay. J Clin Neonatol 2022;11:233-5

How to cite this URL:
Hernandez B, Manzar S. The trade-off between home oxygen and length of stay. J Clin Neonatol [serial online] 2022 [cited 2022 Dec 9];11:233-5. Available from: https://www.jcnonweb.com/text.asp?2022/11/4/233/357821




  Case Study Top


The infant reached 36 0/7 weeks postmenstrual age (PMA). He was born at 26 3/7 weeks of gestational age (GA). Currently, he is receiving 100% supplemental O2 through a low-flow nasal cannula at 0.2 liters per minute (LPM). He is tolerating all feeds orally and is gaining weight. Two pathways for disposition exist – either the infant is discharged home on supplemental O2 (plan A) or the patient remains admitted to wean O2 (plan B). Basing his decisions on the literature review, the attending physician opted to follow plan B. He started a 14-day course of oral prednisolone (OP) intending to wean O2 before discharge, thereby avoiding the stressors that come with obtaining home O2 equipment, training caregivers, and parent's anxiety. While on OP, the infant failed room air trial and finally was discharged home on O2 at 38 0/7 week PMA. The infant ended up staying 14 days in the hospital.


  Discussion Top


As per the definition, the infant had moderate bronchopulmonary dysplasia (BPD) (<30% O2 requirement at 36-week PMA).[1] It has been reported that 43% of infants with grade 1 and 2 BPD go home on O2.[2] In another study, Shukla et al.[3] reported that 48% of preterm infants born at 22–25 weeks GA went home on O2. OP has been shown to wean O2 in cases of BPD[4] and is being used in different courses.[5] However, determining the best trade-off is difficult. As noted in the brief synopsis of the case, the infant failed a trial of OP intended to wean O2. The other alternative was to send the infant home on O2, shortening the patient's length of stay (LOS) (plan A).

The comparative data on this case study is presented in [Table 1]. With the decision of OP to wean O2, the infant remained in the hospital for 14 days extra and gained 493 g of weight with an improvement in the z-score from −0.09 to 0.01 [Figure 1]. Compared to previously reported data on infants born at 26 weeks of GA, the infant in the case study exceeded the median and 95% confidence interval ranges for the LOS (9 [8–10]), without achieving the reported range of changes in the weight and discharge z-score (351–400 g and 0.25–032).[6] As noted, the pulmonary acuity score (PAS) went up from 0.29 to 0.47 after starting OP while effective FiO2 decreased from 0.29 to 0.27 [Table 1]. To decipher the clinical significance of these findings would be difficult.
Figure 1: Growth chart showing parameters at 36-week and 38-week PMA. PMA: Postmenstrual age

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Table 1: Comparison at 36 and 38 weeks PMA

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Bhandari et al.[4] showed OP to be beneficial in weaning O2. Within the study, OP was found effective in patients with a PAS score of <0.5 and PCO2 of <48.5 mmHg. However, in their retrospective cohort study, the LOS was significantly higher in the OP group (mean of 107 days vs. 80.5 days). Further, 37.4% of the infants receiving OP were discharged home on O2, as compared to 14.5% not receiving OP. Shukla et al.[3] studied infants born between 22 and 25 weeks and reported no change in O2 from 36 to 38 weeks. They reported that 48% of the infants were on O2 at both 36-week PMA and 38-week PMA.

An overall increased LOS for preterm infants has been reported by Edwards et al.[6] Findings suggest an upward drift in the discharge weight and GA of patients over 14 years. Findings may be influenced by the fact that there is a higher volume of premature babies (with more comorbidities) being saved now, as compared to the year 2005.

The estimated cost of a stay in intensive care for low-birth-weight neonates is $1128.00 per day (https://www.mednax.com/wp-content/uploads/2021/01/AlaskaDisclosurefor2020.pdf). From this, it is a safe assumption that the cost of our patient's 14-day extension was $15,792. It is important to note, although that this estimate is (1) not all-inclusive, (2) may increase with additional treatment (i.e., medications, treatment, imaging, and laboratory workup), and (3) it excludes costs outside of the hospital (i.e. cost of parent travel to and from the hospital). When considering hospital resources, plan A requires the participation and pay of intensive staff, limits resources for others' treatment, and eliminates an available bed for those at higher acuity. In comparison, local estimates approximate home oxygen to cost $350 a month, or near $11 a day-nearly 102 times less than the hospital stay discussed. With plan B, caregivers are provided oxygen and accessories (i.e., tubes and tanks), receive assistance with setup and replacement by contracted employees, and do not have to travel to and from the hospital. Family stressors concerning caring for the patient at home become minuscule compared to the separation experienced in plan A. Ultimately, the risks, costs, and harms of plan A are lessened by plan B.

When assessing the value, the pursuit of either plan A or plan B may influence the quality and cost of care very differently. For example, in the pursuit of plan B, it has been demonstrated from the case study that the overall outcome of health and patient experience is equal to or lesser than its alternative. The costs of plan A, however, increase exponentially, therefore compromising value. In summary, plan A lengthens hospitalization stay, does not improve patient experience or outcome, and leaves heightened direct and indirect costs for the family to incur making it low-value care.

It is important to note that the data regarding the use of OP to wean O2 is limited by retrospective design and has shown to increase the LOS for patients. In addition, weaning from O2 occurred in fairly stable infants (PAS <0.5 and PCO <48.4 mmHg).[4] The disposition plan in preterm infants with established BPD remains a dilemma. On one end, efforts should be taken to lessen the family burden of having to provide home O2 to the patient; however, elongating the patient's hospital stay using OP to wean O2 should be viewed critically. The decision to choose OP for weaning may be beneficial in selective cases. As the data from Shukla et al.[3] showed that there is not much change in the supplemental O2 requirement from 36 to 38 weeks PMA. Thus, an infant who has reached 36-week PMA and is clinically stable to go home (nippling all feeds orally with adequate weight gain without other reasons to stay admitted) should be considered for discharge home on O2. This would ultimately prevent a prolonged separation from the family, reduce LOS, and decrease the burden of a higher hospitalization cost.[7]

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Jobe AH, Bancalari E. Bronchopulmonary dysplasia. Am J Respir Crit Care Med 2001;163:1723-9.  Back to cited text no. 1
    
2.
Jensen EA, Edwards EM, Greenberg LT, Soll RF, Ehret DE, Horbar JD. Severity of bronchopulmonary dysplasia among very preterm infants in the united states. Pediatrics 2021;148:e2020030007.  Back to cited text no. 2
    
3.
Shukla A, Beshers C, Worley S, Chowdhary V, Collin M. In the grey zone-survival and morbidities of periviable births. J Perinatol. 2022;10.1038/s41372-022-01355-z. [doi: 10.1038/s41372-022-01355-z].  Back to cited text no. 3
    
4.
Bhandari A, Schramm CM, Kimble C, Pappagallo M, Hussain N. Effect of a short course of prednisolone in infants with oxygen-dependent bronchopulmonary dysplasia. Pediatrics 2008;121:e344-9.  Back to cited text no. 4
    
5.
Htun ZT, Schulz EV, Desai RK, Marasch JL, McPherson CC, Mastrandrea LD, et al. Postnatal steroid management in preterm infants with evolving bronchopulmonary dysplasia. J Perinatol 2021;41:1783-96.  Back to cited text no. 5
    
6.
Edwards EM, Greenberg LT, Ehret DE, Lorch SA, Horbar JD. Discharge age and weight for very preterm infants: 2005-2018. Pediatrics 2021;147:e2020016006.  Back to cited text no. 6
    
7.
Walsh M, Engle W, Laptook A, Kazzi SN, Buchter S, Rasmussen M, et al. Oxygen delivery through nasal cannulae to preterm infants: Can practice be improved? Pediatrics 2005;116:857-61.  Back to cited text no. 7
    


    Figures

  [Figure 1]
 
 
    Tables

  [Table 1]



 

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