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Schmölzer GM, Asztalos EV, Beltempo M, Boix H, Dempsey E, El-Naggar W, Finer NN, Hudson JA, Mukerji A, Law BHY, Yaskina M, Shah PS, Sheta A, Soraisham A, Tarnow-Mordi W, Vento M. Does the use of higher versus lower oxygen concentration improve neurodevelopmental outcomes at 18-24 months in very low birthweight infants? Trials 2024; 25:237. [PMID: 38576007 PMCID: PMC10996184 DOI: 10.1186/s13063-024-08080-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 03/29/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Immediately after birth, the oxygen saturation is between 30 and 50%, which then increases to 85-95% within the first 10 min. Over the last 10 years, recommendations regarding the ideal level of the initial fraction of inspired oxygen (FiO2) for resuscitation in preterm infants have changed from 1.0, to room air to low levels of oxygen (< 0.3), up to moderate concentrations (0.3-0.65). This leaves clinicians in a challenging position, and a large multi-center international trial of sufficient sample size that is powered to look at safety outcomes such as mortality and adverse neurodevelopmental outcomes is required to provide the necessary evidence to guide clinical practice with confidence. METHODS An international cluster, cross-over randomized trial of initial FiO2 of 0.3 or 0.6 during neonatal resuscitation in preterm infants at birth to increase survival free of major neurodevelopmental outcomes at 18 and 24 months corrected age will be conducted. Preterm infants born between 230/7 and 286/7 weeks' gestation will be eligible. Each participating hospital will be randomized to either an initial FiO2 concentration of either 0.3 or 0.6 to recruit for up to 12 months' and then crossed over to the other concentration for up to 12 months. The intervention will be initial FiO2 of 0.6, and the comparator will be initial FiO2 of 0.3 during respiratory support in the delivery room. The sample size will be 1200 preterm infants. This will yield 80% power, assuming a type 1 error of 5% to detect a 25% reduction in relative risk of the primary outcome from 35 to 26.5%. The primary outcome will be a composite of all-cause mortality or the presence of a major neurodevelopmental outcome between 18 and 24 months corrected age. Secondary outcomes will include the components of the primary outcome (death, cerebral palsy, major developmental delay involving cognition, speech, visual, or hearing impairment) in addition to neonatal morbidities (severe brain injury, bronchopulmonary dysplasia; and severe retinopathy of prematurity). DISCUSSION The use of supplementary oxygen may be crucial but also potentially detrimental to preterm infants at birth. The HiLo trial is powered for the primary outcome and will address gaps in the evidence due to its pragmatic and inclusive design, targeting all extremely preterm infants. Should 60% initial oxygen concertation increase survival free of major neurodevelopmental outcomes at 18-24 months corrected age, without severe adverse effects, this readily available intervention could be introduced immediately into clinical practice. TRIAL REGISTRATION The trial was registered on January 31, 2019, at ClinicalTrials.gov with the Identifier: NCT03825835.
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Affiliation(s)
- Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, Edmonton, AB, T5H 3V9, Canada.
- Dept. of Pediatrics, University of Alberta, Edmonton, Canada.
| | - Elizabeth V Asztalos
- Department of Newborn & Developmental Paediatrics, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada
| | - Marc Beltempo
- Departement of Pediatrics, Montreal Children's HospitalMcGill University Health CenterMcGill University, Montreal, QC, Canada
| | - Hector Boix
- Division of Neonatology, Dexeus Quironsalud University Hospital, Barcelona, Spain
| | - Eugene Dempsey
- INFANT Research Centre, University College Cork, Cork, Ireland
| | - Walid El-Naggar
- Department of Paediatrics, Dalhousie University, Halifax, Canada
| | - Neil N Finer
- School of Medicine, University of California, San Diego, CA, USA
- Sharp Mary Birch Hospital for Women and Newborns, San Diego, USA
| | - Jo-Anna Hudson
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NF, Canada
| | - Amit Mukerji
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Brenda H Y Law
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, Edmonton, AB, T5H 3V9, Canada
- Dept. of Pediatrics, University of Alberta, Edmonton, Canada
| | - Maryna Yaskina
- Women and Children's Health Research Institute (WCHRI), University of Alberta, Edmonton, Canada
| | - Prakesh S Shah
- Department of Pediatrics, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Ayman Sheta
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
| | - Amuchou Soraisham
- Department of Pediatrics, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
- Alberta Childrens Hospital Research Institute, University of Calgary, Alberta, Canada
| | - William Tarnow-Mordi
- Trials Centre, National Health and Medical Research Council Clinical, University of Sydney, Camperdown, Australia
| | - Max Vento
- Department of Pediatrics, La Fe University and Polytechnic Hospital, Valencia, Spain
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Chandrasekharan P, Lakshminrusimha S. Oxygen therapy in preterm infants with pulmonary hypertension. Semin Fetal Neonatal Med 2020; 25:101070. [PMID: 31836427 PMCID: PMC9188671 DOI: 10.1016/j.siny.2019.101070] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Premature neonates <34 weeks gestation can present with early-onset, late-onset and bronchopulmonary dysplasia (BPD) associated pulmonary hypertension (PHT), with clinical, echocardiographic, and histological features similar to term infants with PHT. Changes in pulmonary vascular resistance (PVR) in response to oxygen are diminished in preterm infants compared to term. Studies from preterm lambs and human infants with BPD have shown that PaO2 > 30-55 mm Hg promotes pulmonary vasodilation. Targeting saturations of 80-85% by 5 min, 85-95% by 10 min during resuscitation and 90-95% during the postnatal course are appropriate targets for routine management of preterm infants. Among preterm infants with PHT, avoiding hypoxia/hyperoxia by titrating supplemental oxygen to maintain saturations in low to mid 90s with alarm limits at 90 and 97% seems to be a reasonable approach pending further studies. Further high-quality evidence generated from randomized trials is required to guide oxygen therapy in preterm PHT.
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Affiliation(s)
| | - Satyan Lakshminrusimha
- Division of Neonatology, Department of Pediatrics, University of California, Davis, USA.
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Abstract
Transition into the extrauterine world is characterized by a substantial increase in oxygen availability to tissue. Exact oxygen provision may be needed to avoid negative consequences of hypoxia or hyperoxia. For term and near-term infants, it is recommended to start with air and titrate the oxygen supplement to the saturation nomogram. However, oxygen supplementation in infants less than 32 weeks' gestation is an unsolved conundrum. At present, the inspired fraction of oxygen is set according to gestational age and blended to achieve targeted saturations and heart rates. Studies are still needed to overcome uncertainties about oxygen supplementation during preterm stabilization.
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Optimal Inspired Fraction of Oxygen in the Delivery Room for Preterm Infants. CHILDREN-BASEL 2019; 6:children6020029. [PMID: 30791491 PMCID: PMC6406550 DOI: 10.3390/children6020029] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Revised: 02/13/2019] [Accepted: 02/18/2019] [Indexed: 11/20/2022]
Abstract
Postnatal adaptation of preterm infants entails a series of difficulties among which the immaturity of the respiratory system is the most vital. To overcome respiratory insufficiency, caregivers attending in the delivery room use positive pressure ventilation and oxygen. A body of evidence in relation of oxygen management in the delivery room has been accumulated in recent years; however, the optimal initial inspired fraction of oxygen, the time to achieve specific oxygen saturation targets, and oxygen titration have not been yet clearly established. The aim of this review is to update the reader by critically analyzing the most relevant literature.
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Nosherwan A, Cheung PY, Schmölzer GM. Management of Extremely Low Birth Weight Infants in Delivery Room. Clin Perinatol 2017; 44:361-375. [PMID: 28477666 DOI: 10.1016/j.clp.2017.01.004] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Extremely low birth weight (ELBW) infants are particularly vulnerable at birth, and stabilization in the delivery room (DR) remains challenging. After birth, ELBW infants are at high risk for the development of thermal dysregulation, respiratory insufficiency, and hemodynamic instability due to their immature physiology and anatomy. Although successful stabilization facilitates the transition and reduces acute morbidity, suboptimal care in the DR could cause long-term sequelae. This review addresses the challenges in stabilization in the DR and current neonatal resuscitation guidelines and recommendations.
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Affiliation(s)
- Asma Nosherwan
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue Northwest, Edmonton, Alberta T5H 3V9, Canada; Department of Pediatrics, University of Alberta, 116 St & 85 Avenue, Edmonton, Alberta T6G 2R3, Canada
| | - Po-Yin Cheung
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue Northwest, Edmonton, Alberta T5H 3V9, Canada; Department of Pediatrics, University of Alberta, 116 St & 85 Avenue, Edmonton, Alberta T6G 2R3, Canada
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue Northwest, Edmonton, Alberta T5H 3V9, Canada; Department of Pediatrics, University of Alberta, 116 St & 85 Avenue, Edmonton, Alberta T6G 2R3, Canada.
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Zeballos Sarrato G, Salguero García E, Aguayo Maldonado J, Gómez Robles C, Thió Lluch M, Iriondo Sanz M. Changes in the international recommendations on neonatal stabilisation and resuscitation (2015). ANALES DE PEDIATRÍA (ENGLISH EDITION) 2017. [DOI: 10.1016/j.anpede.2016.08.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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Boronat N, Aguar M, Rook D, Iriondo M, Brugada M, Cernada M, Nuñez A, Izquierdo M, Cubells E, Martinez M, Parra A, van Goudoever H, Vento M. Survival and Neurodevelopmental Outcomes of Preterms Resuscitated With Different Oxygen Fractions. Pediatrics 2016; 138:peds.2016-1405. [PMID: 27940687 DOI: 10.1542/peds.2016-1405] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/21/2016] [Indexed: 11/24/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Stabilization of preterm infants after birth frequently requires oxygen supplementation. At present the optimal initial oxygen inspiratory fraction (Fio2) for preterm stabilization after birth is still under debate. We aimed to compare neurodevelopmental outcomes of extremely preterm infants at 24 months corrected age randomly assigned to be stabilized after birth with an initial Fio2 of 0.3 versus 0.6 to 0.65 in 3 academic centers from Spain and the Netherlands. METHODS Randomized, controlled, double-blinded, multicenter, international clinical trial enrolling preterm infants <32 weeks' gestation assigned to an initial Fio2 of 0.3 (Lowox group) or 0.6 to 0.65 (Hiox group). During stabilization, arterial pulse oxygen saturation and heart rate were continuously monitored and Fio2 was individually titrated to keep infants within recommended ranges. At 24 months, blinded researchers used the Bayley Scales of Infant and Toddler Development, Third Edition (Bayley-III) to assess visual acuity, neurosensory deafness, and language skills. RESULTS A total of 253 infants were recruited and 206 (81.4%) completed follow-up. No differences in perinatal characteristics, oxidative stress, or morbidities during the neonatal period were assessed. Mortality at hospital discharge or when follow-up was completed didn't show differences between the groups. No differences regarding Bayley-III scale scores (motor, cognitive, and language composites), neurosensorial handicaps, cerebral palsy, or language skills between groups were found. CONCLUSIONS The use of an initial lower (0.3) or higher (0.6-0.65) Fio2 during stabilization of extremely preterm infants in the delivery room does not influence survival or neurodevelopmental outcomes at 24 months.
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Affiliation(s)
- Nuria Boronat
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Marta Aguar
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Denise Rook
- Division of Neonatology, Sophia Children's Hospital, Erasmus Medical Center, Rotterdam, Netherlands
| | - Martin Iriondo
- Division of Neonatology, Hospital Sant Joan de Deu, Barcelona, Spain
| | - María Brugada
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - María Cernada
- Neonatal Research Unit, Health Research Institute La Fe, Valencia, Spain; and
| | - Antonio Nuñez
- Neonatal Research Unit, Health Research Institute La Fe, Valencia, Spain; and
| | | | - Elena Cubells
- Neonatal Research Unit, Health Research Institute La Fe, Valencia, Spain; and
| | - María Martinez
- Neonatal Research Unit, Health Research Institute La Fe, Valencia, Spain; and
| | - Anna Parra
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Hans van Goudoever
- Department of Pediatric, Emma Children's Hospital, Academic Medical Center-Amsterdam, VU University Medical Center, Amsterdam, Netherlands
| | - Máximo Vento
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain; .,Neonatal Research Unit, Health Research Institute La Fe, Valencia, Spain; and
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Zeballos Sarrato G, Salguero García E, Aguayo Maldonado J, Gómez Robles C, Thió Lluch M, Iriondo Sanz M. [Changes in the international recommendations on neonatal stabilisation and resuscitation (2015)]. An Pediatr (Barc) 2016; 86:51.e1-51.e9. [PMID: 27746074 DOI: 10.1016/j.anpedi.2016.08.007] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/27/2016] [Accepted: 08/04/2016] [Indexed: 11/29/2022] Open
Abstract
The International Liaison Committee on Resuscitation (ILCOR) recommendations provide a universal guide of measures to support the transition and resuscitation of newborn after their birth. This guide is expected to be adapted by local groups or committees on resuscitation, according to their own circumstances. The objective of this review is to analyse the main changes, to discuss several of the controversies that have appeared since 2010, and contrasting with other national and international organisations, such as European Resuscitation Council (ERC), American Heart Association (AHA), or the Australian-New Zealand Committee on Resuscitation (ANZCOR). Thus, the Neonatal Resuscitation Group of the Spanish Society of Neonatology (GRN-SENeo) aims to give clear answers to many of the questions when different options are available, generating the forthcoming recommendations of our country to support the transition and/or resuscitation of a newborn after birth, safely and effectively.
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Affiliation(s)
| | | | - Josefa Aguayo Maldonado
- Sección de Neonatología, Hospital Universitario Virgen del Rocío, Facultad de Medicina, Universidad de Sevilla, Sevilla, España
| | - Celia Gómez Robles
- Servicio de Neonatología, Hospital Materno Infantil Carlos Haya, Málaga, España
| | - Marta Thió Lluch
- Newborn Research Centre & Neonatal Services, The Royal Women's Hospital, Melbourne, Australia
| | - Martín Iriondo Sanz
- Servicio de Neonatología Sant Joan de Déu; BCNatal; Hospital Sant Joan de Déu-Hospital Clínic; Universidad de Barcelona, Barcelona, España
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Reply to: ‘What initial oxygen is best for preterm infants in the delivery room?—A response to the 2015 neonatal resuscitation guidelines.’. Resuscitation 2016; 101:e9. [DOI: 10.1016/j.resuscitation.2016.01.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2016] [Accepted: 01/13/2016] [Indexed: 11/19/2022]
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