Discussion
bronchiolitis
DISEASE COURSE, DISEASE, BRONCHIOLITIS
In this randomized clinical trial of infants with bronchiolitis discharged home from the ED, enhanced suctioning did not alter the disease course compared with minimal suctioning, as demonstrated by comparable rates of bronchiolitis-related revisits within 72 hours after discharge. The proportions of infants with normal feeding and sleeping at 72 hours also did not differ, supporting the lack of effect of enhanced suctioning on bronchiolitis severity. The observed difference in the additional resource use was almost entirely associated with a substantial between-group difference in the use of nonassigned devices due to parent-perceived lack of feeding or breathing improvement.A retrospective studyOur study demonstrates that enhanced suctioning after discharge does not yield fewer unscheduled revisits than minimal suctioning. The most important reason is that enhanced suctioning does not alter the disease course. The study infants were suitable for discharge home and had mild disease, which likely also contributed to the observed lack of incremental benefit of enhanced suction on feeding and sleeping adequacy. Second, we excluded infants with comorbidities, who represent a high-risk category for more severe outcomes.Minimal suctioning resulted in a significantly higher rate of additional device use than enhanced suctioning. The bulb allows minimal time for negative pressure generation, which likely yielded low suctioned volumes, as confirmed in the questionnaire where poor suctioning represented the majority of reasons for dissatisfaction with minimal suctioning. For this and other reasons, the parents in this group were less satisfied with the device than those assigned to the enhanced battery-operated device with high negative pressures, and they, thus, resorted to additional devices. In addition, more than one-half of the families were using mouth-to-nose devices before arrival, so those assigned to minimal suctioning were understandably motivated to upgrade the suction mode with the devices previously used. Indeed, almost all noncompliant parents resorted to the mouth-to-nose devices and three-quarters of them had used these tools previously. This study highlights parental tendency to do something, and this was particularly true of the parents using minimal suctioning. There is a physician bias for perceived benefit of medications they prescribe,The lack of incremental benefit of enhanced suctioning in changing bronchiolitis course should provide physicians with reassurance in addressing parental fear about their infant’s potential for having worse outcomes while doing less in bronchiolitis. Parents should also be counseled that enhanced suctioning comes at a cost: battery-operated suctioning devices are substantially more costly than the bulb (approximately $45 vs $5, respectively).