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Babies discharged from the emergency department (ED) for bronchiolitis saw mixed benefits from enhanced nasal suctioning, a randomized trial found.

Additional resource use -- a composite of unscheduled revisits for bronchiolitis or use of additional suctioning devices for feeding or breathing concerns -- occurred in 37.0% of the patients receiving minimal bulb suction compared to 26.2% of patients receiving enhanced suction with a battery-operated device (P=0.03), reported Suzanne Schuh, MD, of the University of Toronto, and coauthors of the SNOT trial.

The difference was driven by greater use of additional suctioning devices in the minimal suction group (17.9% vs 6.0%, P<0.001), not by any discernible reduction in unscheduled ED revisits in the enhanced suction group (25.5% vs 21.9%, P=0.46), the SNOT group showed in .

Schuh and colleagues noted that bronchiolitis remains one of the most common causes of infant hospitalization, but therapeutic options outside of support remain limited. It is believed that suctioning may provide relief, as the nasal congestion associated with the airway infection can lead to a wide array of health and feeding issues, particularly among infants, who tend to heavily breathe through their nose.

Study authors reported that enhanced suctioning made no difference in the number of all bronchiolitis revisits, ED revisits, parental care satisfaction, infant feeding, infant sleeping, or parental sleeping.

However, parents who had children assigned minimal suction reported being less satisfied with their suction devices, with only 33.7% reporting satisfaction, compared to parents with children in the enhanced suction group who reported 79.2% satisfaction (P<0.001).

Suction volumes are likely directly related to caregiver satisfaction, Schuh's group suggested. "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."

Alan Schroeder, MD, of the Stanford University School of Medicine, California, and coauthors noted in an that guardian care prior to bringing a child to the hospital may play a role in the findings from SNOT.

"We can expect that most families are already performing some form of suctioning before they present to the emergency department and have a reasonable chance of being unsatisfied with recommendations to use a bulb syringe. For families that are not suctioning or only using a bulb syringe, upgrading to a mouth-to-nose or battery-operated device is a reasonable recommendation, although costs should be a consideration," the group noted.

"If affordability is an issue, clinicians and parents can be comforted by the findings in this trial that the most expensive device does not appear to confer meaningful clinical outcomes over the cheapest," Schroeder and colleagues wrote.

The SNOT trial had 372 children randomized at four tertiary-care pediatric EDs in Canada. Over 60% of the population were boys and the median patient age was 4 months.

The trial took place between March 2020 and December 2022.

Researchers noted that caregivers could not be blinded to the intervention in the study, and that the study was underpowered to detect small differences in the primary endpoint. They stressed the need for further trials.

"Short-term physiologic responses might be more objective measures of efficacy compared with satisfaction measures, as the latter may be biased in favor of more advanced technologies. Similarly, subsequent outpatient trials could compare mouth-to-nose with a battery-operated device, examine the use of saline drops and sprays, and compare different frequencies of suctioning," they suggested.

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