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Brouwer F, Salverda HH, Cramer SJE, Schmeits C, van der Plas J, Te Pas AB, Dekker J. Comparison of two different oxygen saturation target ranges for automated oxygen control in preterm infants: a randomised cross-over trial. Arch Dis Child Fetal Neonatal Ed 2024; 109:527-534. [PMID: 38316547 DOI: 10.1136/archdischild-2023-326278] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 01/14/2024] [Indexed: 02/07/2024]
Abstract
OBJECTIVE To compare the effect of peripheral oxygen saturation (SpO2) target range (TR) (either 91%-95% and 92%-96%) on the frequency and duration of hypoxic and hyperoxic episodes while on automated oxygen control using the OxyGenie controller. DESIGN Randomised cross-over study. SETTING Tertiary-level neonatal unit in the Netherlands. PATIENTS Infants (n=27) with a median (IQR) gestational age of 27+0 (25+5-27+3) weeks and postnatal age of 16 (10-22) days, receiving invasive or non-invasive respiratory support. INTERVENTIONS In both groups supplemental oxygen was titrated to a TR of 91%-95% (TRlow) or 92%-96% (TRhigh) by the OxyGenie controller (SLE6000 ventilator) for 24 hours each, in random sequence. After a switch in TR, a 1-hour washout period was applied to prevent carry-over bias. MAIN OUTCOME MEASURES Frequency and duration of hypoxic (SpO2<80% for ≥1 s) and hyperoxic episodes (SpO2>98% for ≥1 s). RESULTS Hypoxic episodes were less frequent when the higher range was targeted (TRhigh vs TRlow: 2.5 (0.7-6.2)/hour vs 2.4 (0.9-10.2)/hour, p=0.02), but hyperoxic episodes were more frequent (5.3 (1.8-12.3)/hour vs 2.9 (1.0-7.1)/hour, p<0.001). The duration of the out-of-range episodes was not significantly different (hypoxia: 4.7 (2.8-7.1) s vs 4.4 (3.7-6.5) s, p=0.67; hyperoxia: 4.3 (3.3-4.9) s vs 3.9 (2.8-5.5) s, p=0.89). CONCLUSION Targeting a higher SpO2 TR with the OxyGenie controller reduced hypoxic episodes but increased hyperoxic episodes. This study highlights the feasibility of using an automated oxygen titration device to explore the effects of subtle TR adjustments on clinical outcomes in neonatal care. TRIAL REGISTRATION NUMBER NL9662.
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Affiliation(s)
- Fleur Brouwer
- Willem-Alexander Children's Hospital, Department of Paediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Hylke H Salverda
- Willem-Alexander Children's Hospital, Department of Paediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Sophie J E Cramer
- Willem-Alexander Children's Hospital, Department of Paediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Chantal Schmeits
- Willem-Alexander Children's Hospital, Department of Paediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Jacoline van der Plas
- Willem-Alexander Children's Hospital, Department of Paediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Arjan B Te Pas
- Willem-Alexander Children's Hospital, Department of Paediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Janneke Dekker
- Willem-Alexander Children's Hospital, Department of Paediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
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Sotiropoulos JX, Oei JL, Schmölzer GM, Libesman S, Hunter KE, Williams JG, Webster AC, Vento M, Kapadia V, Rabi Y, Dekker J, Vermeulen MJ, Sundaram V, Kumar P, Kaban RK, Rohsiswatmo R, Saugstad OD, Seidler AL. Initial Oxygen Concentration for the Resuscitation of Infants Born at Less Than 32 Weeks' Gestation: A Systematic Review and Individual Participant Data Network Meta-Analysis. JAMA Pediatr 2024; 178:774-783. [PMID: 38913382 PMCID: PMC11197034 DOI: 10.1001/jamapediatrics.2024.1848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 04/03/2024] [Indexed: 06/25/2024]
Abstract
Importance Resuscitation with lower fractional inspired oxygen (FiO2) reduces mortality in term and near-term infants but the impact of this practice on very preterm infants is unclear. Objective To evaluate the relative effectiveness of initial FiO2 on reducing mortality, severe morbidities, and oxygen saturations (SpO2) in preterm infants born at less than 32 weeks' gestation using network meta-analysis (NMA) of individual participant data (IPD). Data Sources MEDLINE, Embase, CENTRAL, CINAHL, ClinicalTrials.gov, and WHO ICTRP from 1980 to October 10, 2023. Study Selection Eligible studies were randomized clinical trials enrolling infants born at less than 32 weeks' gestation comparing at least 2 initial oxygen concentrations for delivery room resuscitation, defined as either low (≤0.3), intermediate (0.5-0.65), or high (≥0.90) FiO2. Data Extraction and Synthesis Investigators from eligible studies were invited to provide IPD. Data were processed and checked for quality and integrity. One-stage contrast-based bayesian IPD-NMA was performed with noninformative priors and random effects and adjusted for key covariates. Main Outcomes and Measures The primary outcome was all-cause mortality at hospital discharge. Secondary outcomes were morbidities of prematurity and SpO2 at 5 minutes. Results IPD were provided for 1055 infants from 12 of the 13 eligible studies (2005-2019). Resuscitation with high (≥0.90) initial FiO2 was associated with significantly reduced mortality compared to low (≤0.3) (odds ratio [OR], 0.45; 95% credible interval [CrI], 0.23-0.86; low certainty) and intermediate (0.5-0.65) FiO2 (OR, 0.34; 95% CrI, 0.11-0.99; very low certainty). High initial FiO2 had a 97% probability of ranking first to reduce mortality. The effects on other morbidities were inconclusive. Conclusions and Relevance High initial FiO2 (≥0.90) may be associated with reduced mortality in preterm infants born at less than 32 weeks' gestation compared to low initial FiO2 (low certainty). High initial FiO2 is possibly associated with reduced mortality compared to intermediate initial FiO2 (very low certainty) but more evidence is required.
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Affiliation(s)
- James X. Sotiropoulos
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
- School of Women’s and Children’s Health, Faculty of Medicine and Health, University of New South Wales, Kensington, New South Wales, Australia
- Department of Newborn Care, the Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Ju Lee Oei
- School of Women’s and Children’s Health, Faculty of Medicine and Health, University of New South Wales, Kensington, New South Wales, Australia
- Department of Newborn Care, the Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Georg M. Schmölzer
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Centre for the Studies of Asphyxia and Resuscitation, Neonatology, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Sol Libesman
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Kylie E. Hunter
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Jonathan G. Williams
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Angela C. Webster
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Maximo Vento
- University and Polytechnic Hospital La Fe, Valencia, Spain
- Health Research Institute La Fe, Valencia, Spain
| | - Vishal Kapadia
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Yacov Rabi
- Department of Pediatrics, University of Calgary, Alberta Children’s Hospital Research Institute, Calgary, Alberta, Canada
| | - Janneke Dekker
- Willem-Alexander Children’s Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marijn J. Vermeulen
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Venkataseshan Sundaram
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Praveen Kumar
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Risma K. Kaban
- Department of Child Health, University of Indonesia Medical School/Dr Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Rinawati Rohsiswatmo
- Department of Child Health, University of Indonesia Medical School/Dr Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Ola D. Saugstad
- Department of Pediatric Research, University of Oslo, Oslo, Norway
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Anna Lene Seidler
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
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Langanky LO, Kreutzer KB, Poets CF, Franz AR, Schwarz CE. Pulse oximetry signal loss during hypoxic episodes in preterm infants receiving automated oxygen control. Eur J Pediatr 2024; 183:2865-2869. [PMID: 38592485 PMCID: PMC11192802 DOI: 10.1007/s00431-024-05549-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2024] [Revised: 03/25/2024] [Accepted: 03/28/2024] [Indexed: 04/10/2024]
Abstract
The aim of this study was to analyze signal loss (SL) resulting from low signal quality of pulse oximetry-derived hemoglobin oxygen saturation (SpO2) measurements during prolonged hypoxemic episodes (pHE) in very preterm infants receiving automatic oxygen control (AOC). We did a post hoc analysis of a randomized crossover study of AOC, programmed to set FiO2 to "back-up FiO2" during SL. In 24 preterm infants (median (interquartile range)) gestational age 25.3 (24.6 to 25.6) weeks, recording time 12.7 h (12.2 to 13.6 h) per infant, we identified 76 pHEs (median duration 119 s (86 to 180 s)). In 50 (66%) pHEs, SL occurred for a median duration of 51 s (33 to 85 s) and at a median frequency of 2 (1 to 2) SL-periods per pHE. SpO2 before and after SL was similar (82% (76 to 88%) vs 82% (76 to 87%), p = 0.3)). Conclusion: SL is common during pHE and must hence be considered in AOC-algorithm designs. Administering a "backup FiO2" (which reflects FiO2-requirements during normoxemia) during SL may prolong pHE with SL. Trial registration: The study was registered at www. CLINICALTRIALS gov under the registration no. NCT03785899. WHAT IS KNOWN • Previous studies examined SpO2 signal loss (SL) during routine manual oxygen control being rare, but pronounced in lower SpO2 states. • Oxygen titration during SL is unlikely to be beneficial as SpO2 may recover to a normoxic range. WHAT IS NEW • Periods of low signal quality of SpO2 are common during pHEs and while supported with automated oxygen control (SPOC), FiO2 is set to a back-up value reflecting FiO2 requirements during normoxemia in response to SL, although SpO2 remained below target until signal recovery. • FiO2 overshoots following pHEs were rare during AOC and occurred with a delayed onset; therefore, increased FiO2 during SL does not necessarily lead to overshoots.
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Affiliation(s)
- Lukas O Langanky
- Department of Neonatology, University Children's Hospital, Tübingen University Hospital, Tübingen, Germany
| | - Karen B Kreutzer
- Department of Neonatology, University Children's Hospital, Tübingen University Hospital, Tübingen, Germany
| | - Christian F Poets
- Department of Neonatology, University Children's Hospital, Tübingen University Hospital, Tübingen, Germany
| | - Axel R Franz
- Department of Neonatology, University Children's Hospital, Tübingen University Hospital, Tübingen, Germany
- Center for Pediatric Clinical Studies, University Children's Hospital, Eberhard Karls University Tübingen, Tübingen, Germany
| | - Christoph E Schwarz
- Department of Neonatology, University Children's Hospital, Tübingen University Hospital, Tübingen, Germany.
- Department of Neonatology, Center for Pediatric and Adolescent Medicine, University of Heidelberg, Im Neuenheimer Feld 430, 69120, Heidelberg, Germany.
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de Jager J, Brouwer F, Reijman J, van der Palen RLF, Steggerda SJ, Visser R, Te Pas AB, Dekker J. Occurrence of hyperoxia during iNO treatment for persistent pulmonary hypertension of the newborn: a cohort study. Eur J Pediatr 2024; 183:2455-2461. [PMID: 38470520 PMCID: PMC11035448 DOI: 10.1007/s00431-024-05506-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/13/2024] [Revised: 02/16/2024] [Accepted: 03/02/2024] [Indexed: 03/14/2024]
Abstract
High concentrations of oxygen are often needed to optimize oxygenation in infants with persistent pulmonary hypertension (PPHN), but this can also increase the risk of hyperoxemia. We determined the occurrence of hyperoxemia in infants treated for PPHN. Medical records of infants ≥ 34 + 0 weeks gestational age (GA) who received inhaled nitric oxide (iNO) were retrospectively reviewed for oxygenation parameters during iNO therapy. Oxygen was manually titrated to target arterial oxygen tension (PaO2) 10-13 kPa and peripheral oxygen saturation (SpO2) 92-98%. The main study outcomes were the incidence and duration of hyperoxemia and hypoxemia and the fraction of inspired oxygen (FiO2). A total of 181 infants were included. The median FiO2 was 0.43 (IQR 0.34-0.56) and the maximum FiO2 was 1.0 in 156/181 (86%) infants, resulting in at least one PaO2 > 13 kPa in 149/181 (82%) infants, of which 46/149 (31%) infants had minimal one PaO2 > 30 kPa. SpO2 was > 98% in 179/181 (99%) infants for 17.7% (8.2-35.6%) of the iNO time. PaO2 < 10 kPa occurred in 160/181 (88%) infants, of which 81/160 (51%) infants had minimal one PaO2 < 6.7 kPa. SpO2 was < 92% in 169/181 (93%) infants for 1.6% (0.5-4.3%) of the iNO time. Conclusion: While treatment of PPHN is focused on preventing and reversing hypoxemia, hyperoxemia occurs inadvertently in most patients. What is Known: • High concentrations of oxygen are often needed to prevent hypoxemia-induced deterioration of PPHN, but this can also increase the risk of hyperoxemia. • Infants with persistent pulmonary hypertension may be particularly vulnerable to the toxic effects of oxygen, and hyperoxemia could further induce pulmonary vasoconstriction, potentially worsening the condition. What is New: • Hyperoxemia occurs in the majority of infants with PPHN during treatment with iNO. • Infants with PPHN spent a considerably longer period with saturations above the target range compared to saturations below the target range.
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Affiliation(s)
- Justine de Jager
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
| | - Fleur Brouwer
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen Reijman
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Roel L F van der Palen
- Division of Pediatric Cardiology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Sylke J Steggerda
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Remco Visser
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Janneke Dekker
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
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Schouten TMR, Abu-Hanna A, van Kaam AH, van den Heuvel MEN, Bachman TE, van Leuteren RW, Hutten GJ, Onland W. Prolonged use of closed-loop inspired oxygen support in preterm infants: a randomised controlled trial. Arch Dis Child Fetal Neonatal Ed 2024; 109:221-226. [PMID: 37827816 DOI: 10.1136/archdischild-2023-325831] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/16/2023] [Accepted: 09/18/2023] [Indexed: 10/14/2023]
Abstract
OBJECTIVE This randomised study in preterm infants on non-invasive respiratory support investigated the effectiveness of automated oxygen control (A-FiO2) in keeping the oxygen saturation (SpO2) within a target range (TR) during a 28-day period compared with manual titration (M-FiO2). DESIGN A single-centre randomised control trial. SETTING A level III neonatal intensive care unit. PATIENTS Preterm infants (<28 weeks' gestation) on non-invasive respiratory support. INTERVENTIONS A-FiO2 versus M-FiO2 control. METHODS Main outcomes were the proportion of time spent and median area of episodes in the TR, hyperoxaemia, hypoxaemia and the trend over 28 days using a linear random intercept model. RESULTS 23 preterm infants (median gestation 25.7 weeks; birth weight 820 g) were randomised. Compared with M-FiO2, the time spent within TR was higher in the A-FiO2 group (68.7% vs 48.0%, p<0.001). Infants in the A-FiO2 group spent less time in hyperoxaemia (13.8% vs 37.7%, p<0.001), but no difference was found in hypoxaemia. The time-based analyses showed that the A-FiO2 efficacy may differ over time, especially for hypoxaemia. Compared with the M-FiO2 group, the A-FiO2 group had a larger intercept but with an inversed slope for the daily median area below the TR (intercept 70.1 vs 36.3; estimate/day -0.70 vs 0.69, p<0.001). CONCLUSION A-FiO2 control was superior to manual control in keeping preterm infants on non-invasive respiratory support in a prespecified TR over a period of 28 days. This improvement may come at the expense of increased time below the TR in the first days after initiating A-FiO2 control. TRIAL REGISTRATION NUMBER NTR6731.
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Affiliation(s)
- Tim M R Schouten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
- Department of Medical Informatics, University of Amsterdam, Amsterdam, the Netherlands
| | - Ameen Abu-Hanna
- Department of Medical Informatics, University of Amsterdam, Amsterdam, the Netherlands
- Amsterdam Public Health Research Institute, Amsterdam, the Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development, Amsterdam, the Netherlands
| | | | | | - Ruud W van Leuteren
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development, Amsterdam, the Netherlands
| | - G Jeroen Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development, Amsterdam, the Netherlands
| | - Wes Onland
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, the Netherlands
- Amsterdam Reproduction & Development, Amsterdam, the Netherlands
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Kim F, Bateman DA, Garey D, Goldshtrom N, Isler JR, Sahni R, Wallman-Stokes A. Association between intermittent hypoxemia and neurodevelopmental outcomes in extremely premature infants: A single-center experience. Early Hum Dev 2024; 188:105919. [PMID: 38118389 DOI: 10.1016/j.earlhumdev.2023.105919] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2023] [Revised: 11/03/2023] [Accepted: 12/07/2023] [Indexed: 12/22/2023]
Abstract
OBJECTIVE To describe the association between intermittent hypoxemic events (IHEs) and severe neurodevelopmental impairment (SNDI) or death in extremely premature infants. STUDY DESIGN Retrospective study of extremely premature infants 230/7-276/7 weeks gestational age (GA) and birthweight (BW) ≤1250 grams (g) admitted to a level IV neonatal intensive care unit (NICU) from 2013 to 2017. IHEs, defined as events with SpO2 ≤ 80 % lasting 10 s to 5 min, were algorithmically identified using data extracted from bedside monitors at 2 s intervals (0.5 Hz). The primary outcome was SNDI at 18-24 months corrected age (CA), defined as a Bayley-III motor, language or cognitive composite score ≤69, or death before discharge while the secondary outcome was SNDI alone. We used mixed-effects regression models to evaluate the relationship between mean daily IHE rate per postnatal week of life for the first 12 weeks and the outcomes, and logistic regression models to assess the association between outcomes and summary measures of hypoxic burden for the entire NICU hospitalization. RESULTS The mortality rate was 7 % (18/249) during NICU hospitalization. Of 249 infants born during this time period, IHE and neurodevelopmental outcome data were fully available for 65 infants (mean GA 26 ± 1.4 weeks, mean birth weight (BW) 738 ± 199 g. The outcome of SNDI alone occurred in 34 % (22/65) with a majority demonstrating motor or language delay on the Bayley-III. Although mean daily IHE rate/week was not associated with SNDI or death, total IHE duration was associated with increased odds of SNDI (OR (95 % CI) 1.03 (1.01, 1.05), p = 0.008) in models adjusted for GA. CONCLUSIONS In a cohort of extremely premature infants 23-27 weeks GA, each hour of total IHE duration (SpO2 ≤ 80 %) was associated with a 2.7 % (0.7 %, 4.8 %) increase in the odds of SNDI at 18-24 months CA.
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Affiliation(s)
- Faith Kim
- Department of Pediatrics, NewYork Presbyterian Morgan Stanley Children's Hospital/Columbia University Irving Medical Center, New York, NY, United States of America.
| | - David A Bateman
- Department of Pediatrics, NewYork Presbyterian Morgan Stanley Children's Hospital/Columbia University Irving Medical Center, New York, NY, United States of America
| | - Donna Garey
- Department of Pediatrics, Phoenix Children's Medical Group, Phoenix, AZ, United States of America
| | - Nimrod Goldshtrom
- Department of Pediatrics, NewYork Presbyterian Morgan Stanley Children's Hospital/Columbia University Irving Medical Center, New York, NY, United States of America
| | - Joseph R Isler
- Department of Pediatrics, NewYork Presbyterian Morgan Stanley Children's Hospital/Columbia University Irving Medical Center, New York, NY, United States of America
| | - Rakesh Sahni
- Department of Pediatrics, NewYork Presbyterian Morgan Stanley Children's Hospital/Columbia University Irving Medical Center, New York, NY, United States of America
| | - Aaron Wallman-Stokes
- Department of Pediatrics, University of Vermont Children's Hospital, Burlington, VT, United States of America
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Christie FG, Kelly R, Boardman JP, Stenson BJ. Measuring Oxygenation in Newborn Infants with Targeted Oxygen Ranges (MONITOR): a randomised crossover pilot study. Arch Dis Child Fetal Neonatal Ed 2023; 108:638-642. [PMID: 37142388 DOI: 10.1136/archdischild-2022-324833] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2022] [Accepted: 04/19/2023] [Indexed: 05/06/2023]
Abstract
OBJECTIVE The Neonatal Oxygenation Prospective Meta-analysis (NeOProM) Collaboration showed that high (91-95%) versus low (85-89%) SpO2 targets reduced mortality. Trials of higher targets are needed to determine whether any more survival advantage may be gained. This pilot study explored the achieved oxygenation patterns observed when targeting SpO2 92-97% to facilitate the design of future trials. DESIGN Single-centre prospective randomised crossover pilot study. Manual FiO2 adjustment. Study time 12 hours per infant. 6 hours targeting SpO2 90-95% and 6 hours targeting SpO2 92-97%. PATIENTS Twenty preterm infants born <29 weeks' gestation, greater than 48 hours old, receiving supplemental oxygen. OUTCOMES Primary outcome was percentage time with SpO2 above 97% and below 90%. Pre-defined secondary outcomes included percentage time spent within, above or below transcutaneous PO2 (TcPO2) 6.7-10.7 kPa (50-80 mm Hg). Comparisons were made using paired-samples t-test (2-tailed). RESULTS With SpO2 target 92-97% versus 90-95%, the mean (IQR) percentage time above SpO2 97% was 11.3% (2.7-20.9) versus 7.8% (1.7-13.9), p=0.02. Percentage time with SpO2 <90% was 13.1% (6.7-19.1) versus 17.9% (11.1-22.4), p=0.003. Percentage time with SpO2 <80% was 1% (0.1-1.4) versus 1.6% (0.4-2.6), p=0.119. Percentage time with TcPO2 <6.7 kPa (50 mm Hg) was 49.6% (30.2-66.0) versus 55% (34.3-73.5), p=0.63. Percentage time above TcPO2 10.7 kPa (80 mm Hg) was 1.4% (0-1.4) versus 1.8% (0-0), p=0.746. CONCLUSIONS Targeting SpO2 92-97% produced a right shift in SpO2 and TcPO2 distribution, with reduced time at SpO2 <90% and increased time at SpO2 >97%, without increasing time with TcPO2 >10.7 kPa (80 mm Hg). Clinical trials targeting this higher SpO2 range could be conducted without significant hyperoxic exposure. TRIAL REGISTRATION NUMBER NCT03360292.
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Affiliation(s)
- Fraser G Christie
- Neonatology, Simpson Centre for Reproductive Health, NHS Lothian University Hospitals Division, Edinburgh, UK
- The University of Edinburgh, Edinburgh, UK
| | - Rod Kelly
- Neonatology, Simpson Centre for Reproductive Health, NHS Lothian University Hospitals Division, Edinburgh, UK
- The University of Edinburgh, Edinburgh, UK
| | - James P Boardman
- Neonatology, Simpson Centre for Reproductive Health, NHS Lothian University Hospitals Division, Edinburgh, UK
- MRC Centre for Reproductive Health, The University of Edinburgh, Edinburgh, UK
| | - Ben J Stenson
- Neonatology, Simpson Centre for Reproductive Health, NHS Lothian University Hospitals Division, Edinburgh, UK
- The University of Edinburgh, Edinburgh, UK
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Kaltsogianni O, Dassios T, Jenkinson A, Greenough A. Does closed-loop automated oxygen control reduce the duration of supplementary oxygen treatment and the amount of time spent in hyperoxia? A randomised controlled trial in ventilated infants born at or near term. Trials 2023; 24:404. [PMID: 37316885 DOI: 10.1186/s13063-023-07415-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2023] [Accepted: 05/26/2023] [Indexed: 06/16/2023] Open
Abstract
BACKGROUND Ventilated infants frequently require supplemental oxygen, but its use should be monitored carefully due to associated complications. The achievement of oxygen saturation (SpO2) targets can be challenging as neonates experience frequent fluctuations of their oxygen levels that further increase the risk of complications. Closed-loop automated oxygen control systems (CLAC) improve achievement of oxygen saturation targets, reduce hyperoxaemic episodes and facilitate weaning of the inspired oxygen concentration in ventilated infants born at or near term. This study investigates whether CLAC compared with manual oxygen control reduces the time spent in hyperoxia and the overall duration of supplemental oxygen treatment in ventilated infants born at or above 34 weeks gestation. METHODS This randomised controlled trial performed at a single tertiary neonatal unit is recruiting 40 infants born at or above 34 weeks of gestation and within 24 h of initiation of mechanical ventilation. Infants are randomised to CLAC or manual oxygen control from recruitment till successful extubation. The primary outcome is the percentage of time spent in hyperoxia (SpO2 > 96%). The secondary outcomes are the overall duration of supplementary oxygen treatment, the percentage of time spent with an oxygen requirement above thirty per cent, the number of days on mechanical ventilation and the length of neonatal unit stay. The study is performed following informed parental consent and was approved by the West Midlands-Edgbaston Research Ethics Committee (Protocol version 1.2, 10/11/2022). DISCUSSION This trial will investigate the effect of CLAC on the overall duration of oxygen therapy and the time spent in hyperoxia. These are important clinical outcomes as hyperoxic injury is related to oxidative stress that can adversely affect multiple organ systems. TRIAL REGISTRATION ClinicalTrials.Gov NCT05657795. Registered on 12/12/2022.
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Affiliation(s)
- Ourania Kaltsogianni
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Theodore Dassios
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
- Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Allan Jenkinson
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Anne Greenough
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.
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9
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Kaltsogianni O, Dassios T, Lee R, Harris C, Greenough A. Closed-loop automated oxygen control in ventilated infants born at or near term: A crossover trial. Acta Paediatr 2023; 112:246-251. [PMID: 36403205 PMCID: PMC10099764 DOI: 10.1111/apa.16598] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/23/2022] [Revised: 10/31/2022] [Accepted: 11/15/2022] [Indexed: 11/21/2022]
Abstract
AIM To determine if the use of closed-loop automated oxygen control (CLAC) reduced the incidence and duration of hypoxemic episodes (SpO2 < 92%) in ventilated infants born at or above 34 weeks of gestation. METHODS Infants were studied on two consecutive days for 6 h each day. They were randomised to receive standard care (manual oxygen control) or standard care with a CLAC system (automated oxygen control) first. RESULTS Sixteen infants with a median (IQR) gestational age of 37.4 (36.6-38.8) weeks were studied at a median (IQR) postmenstrual age of 38.8 (37.4-39.8) weeks. During the automated oxygen control period, infants spent less time in hypoxemia (SpO2 < 92%) (p = 0.033), episodes of desaturation were shorter (p = 0.001), the time spent within target SpO2 range (92%-96%) was increased (p = 0.001), and the FiO2 delivery was lower (p = 0.018). The time spent in hyperoxemia (SpO2 > 96%) was reduced during automated oxygen control (p = 0.011), the episodes of hyperoxemia were of shorter duration (p = 0.008) and fewer manual adjustments were made to the FiO2 (p = 0.005). CONCLUSIONS Closed-loop automated oxygen control in ventilated infants born at or near term was associated with a reduction in the incidence and duration of hypoxemic episodes with more time spent in the target oxygen range.
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Affiliation(s)
- Ourania Kaltsogianni
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Theodore Dassios
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Rebecca Lee
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Christopher Harris
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,Neonatal Intensive Care Centre, King's College Hospital NHS Foundation Trust, London, UK
| | - Anne Greenough
- Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK.,National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy's and St Thomas' NHS Foundation Trust and King's College London, London, UK
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10
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Salverda HH, Dekker J, Lopriore E, Dargaville PA, Pauws SC, Te Pas AB. Comparison of two automated oxygen controllers in oxygen targeting in preterm infants during admission: an observational study. Arch Dis Child Fetal Neonatal Ed 2023:archdischild-2022-324819. [PMID: 36599676 DOI: 10.1136/archdischild-2022-324819] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2022] [Accepted: 12/20/2022] [Indexed: 01/06/2023]
Abstract
OBJECTIVE To compare the effect of two different automated oxygen control devices on time preterm infants spent in different oxygen saturation (SpO2) ranges during their entire stay in the neonatal intensive care unit (NICU). DESIGN Retrospective cohort study of prospectively collected data. SETTING Tertiary level neonatal unit in the Netherlands. PATIENTS Preterm infants (OxyGenie 75 infants, CLiO2 111 infants) born at 24-29 weeks' gestation receiving at least 72 hours of respiratory support between October 2015 and November 2020. INTERVENTIONS Inspired oxygen concentration was titrated by the OxyGenie controller (SLE6000 ventilator) between February 2019 and November 2020 and the CLiO2 controller (AVEA ventilator) between October 2015 and December 2018 as standard of care. MAIN OUTCOME MEASURES Time spent within SpO2 target range (TR, 91-95% for either epoch) and other SpO2 ranges. RESULTS Time spent within the SpO2 TR when receiving supplemental oxygen was higher during OxyGenie control (median 71.5 [IQR 64.6-77.0]% vs 51.3 [47.3-58.5]%, p<0.001). Infants under OxyGenie control spent less time in hypoxic and hyperoxic ranges (SpO2<80%: 0.7 [0.4-1.4]% vs 1.2 [0.7-2.3]%, p<0.001; SpO2>98%: 1.0 [0.5-2.4]% vs 4.0 [2.0-7.9]%, p<0.001). Both groups received a similar FiO2 (29.5 [28.0-33.2]% vs 29.6 [27.7-32.1]%, p=not significant). CONCLUSIONS Oxygen saturation targeting was significantly different in the OxyGenie epoch in preterm infants, with less time in hypoxic and hyperoxic SpO2 ranges during their stay in the NICU.
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Affiliation(s)
- Hylke H Salverda
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, The Netherlands, Leiden University Medical Center, Leiden, The Netherlands .,Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Janneke Dekker
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, The Netherlands, Leiden University Medical Center, Leiden, The Netherlands
| | - Enrico Lopriore
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, The Netherlands, Leiden University Medical Center, Leiden, The Netherlands
| | - Peter A Dargaville
- Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia.,Department of Pediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia
| | - Steffen C Pauws
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, The Netherlands, Leiden University Medical Center, Leiden, The Netherlands.,Tilburg Center for Cognition and Communication, Tilburg University, Tilburg, The Netherlands
| | - Arjan B Te Pas
- Willem-Alexander Children's Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, The Netherlands, Leiden University Medical Center, Leiden, The Netherlands
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11
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Sandal O, Ceylan G, Topal S, Hepduman P, Colak M, Novotni D, Soydan E, Karaarslan U, Atakul G, Schultz MJ, Ağın H. Closed–loop oxygen control improves oxygenation in pediatric patients under high–flow nasal oxygen—A randomized crossover study. Front Med (Lausanne) 2022; 9:1046902. [DOI: 10.3389/fmed.2022.1046902] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/17/2022] [Accepted: 10/26/2022] [Indexed: 11/17/2022] Open
Abstract
BackgroundWe assessed the effect of a closed–loop oxygen control system in pediatric patients receiving high–flow nasal oxygen therapy (HFNO).MethodsA multicentre, single–blinded, randomized, and cross–over study. Patients aged between 1 month and 18 years of age receiving HFNO for acute hypoxemic respiratory failure (AHRF) were randomly assigned to start with a 2–h period of closed–loop oxygen control or a 2–h period of manual oxygen titrations, after which the patient switched to the alternative therapy. The endpoints were the percentage of time spent in predefined SpO2 ranges (primary), FiO2, SpO2/FiO2, and the number of manual adjustments.FindingsWe included 23 patients, aged a median of 18 (3–26) months. Patients spent more time in a predefined optimal SpO2 range when the closed–loop oxygen controller was activated compared to manual oxygen titrations [91⋅3% (IQR 78⋅4–95⋅1%) vs. 63⋅0% (IQR 44⋅4–70⋅7%)], mean difference [28⋅2% (95%–CI 20⋅6–37⋅8%); P < 0.001]. Median FiO2 was lower [33⋅3% (IQR 26⋅6–44⋅6%) vs. 42⋅6% (IQR 33⋅6–49⋅9%); P = 0.07], but median SpO2/FiO2 was higher [289 (IQR 207–348) vs. 194 (IQR 98–317); P = 0.023] with closed–loop oxygen control. The median number of manual adjustments was lower with closed–loop oxygen control [0⋅0 (IQR 0⋅0–0⋅0) vs. 0⋅5 (IQR 0⋅0–1⋅0); P < 0.001].ConclusionClosed-loop oxygen control improves oxygenation therapy in pediatric patients receiving HFNO for AHRF and potentially leads to more efficient oxygen use. It reduces the number of manual adjustments, which may translate into decreased workloads of healthcare providers.Clinical trial registration[www.ClinicalTrials.gov], identifier [NCT 05032365].
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12
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Hou X, Faqeeh A, Amjad R, Pardalos J, Fales R. Clinical Evaluation of an Automatic Oxygen Control System for Premature Infants Receiving High-Flow Nasal Cannula for Respiratory Support: A Pilot Study. J Med Device 2022; 16:031005. [PMID: 35646226 PMCID: PMC9125868 DOI: 10.1115/1.4054250] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2020] [Revised: 03/25/2022] [Indexed: 09/03/2023] Open
Abstract
A pilot clinical study was conducted that compared the peripheral oxygen saturation (SpO2) targeting performance of an automatic oxygen control system with manual oxygen control, which is the standard of care for preterm and low birth weight infants on high-flow nasal cannula (HFNC). The new oxygen control device studied was used to automatically adjust the fraction of inspired oxygen (FiO2) according to a desired SpO2 target setpoint and measured feedback signals including the SpO2 and other signals. A crossover study was designed with several endpoints including the comparison of the percentage of time that the SpO2 was within the target range with the automatic oxygen control device versus manual oxygen control. Other metrics were also compared to assess the performance of the system including the number of bradycardia events. The pilot study included six patients that fit the inclusion criteria. The results showed that there were improvements in all of the measured outcomes considered including statistically significant improvements in the number of bradycardia events during the period when the automatic oxygen control device was used.
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Affiliation(s)
- Xuefeng Hou
- Mechanical and Aerospace Engineering, University of Missouri-Columbia, E2412 Lafferre Hall, Columbia, MO 65211
| | - Akram Faqeeh
- Department of Mechanical Engineering Technology, Yanbu Industrial College, Yanbu 41912, Saudi Arabia
| | - Ramak Amjad
- Neonatology, University of Missouri Health, 400 N. Keene Street, Columbia, MO 65212
| | - John Pardalos
- Neonatology, University of Missouri Health, 400 N. Keene Street, Columbia, MO 65212
| | - Roger Fales
- Mechanical and Aerospace Engineering, University of Missouri-Columbia, E2412 Lafferre Hall, Columbia, MO 65211
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13
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Soydan E, Ceylan G, Topal S, Hepduman P, Atakul G, Colak M, Sandal O, Sari F, Karaarslan U, Novotni D, Schultz MJ, Agin H. Automated closed–loop FiO2 titration increases the percentage of time spent in optimal zones of oxygen saturation in pediatric patients–A randomized crossover clinical trial. Front Med (Lausanne) 2022; 9:969218. [PMID: 36091711 PMCID: PMC9452913 DOI: 10.3389/fmed.2022.969218] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/14/2022] [Accepted: 08/02/2022] [Indexed: 11/26/2022] Open
Abstract
Introduction We aimed to compare automated ventilation with closed–loop control of the fraction of inspired oxygen (FiO2) to automated ventilation with manual titrations of the FiO2 with respect to time spent in predefined pulse oximetry (SpO2) zones in pediatric critically ill patients. Methods This was a randomized crossover clinical trial comparing Adaptive Support Ventilation (ASV) 1.1 with use of a closed–loop FiO2 system vs. ASV 1.1 with manual FiO2 titrations. The primary endpoint was the percentage of time spent in optimal SpO2 zones. Secondary endpoints included the percentage of time spent in acceptable, suboptimal and unacceptable SpO2 zones, and the total number of FiO2 changes per patient. Results We included 30 children with a median age of 21 (11–48) months; 12 (40%) children had pediatric ARDS. The percentage of time spent in optimal SpO2 zones increased with use of the closed–loop FiO2 controller vs. manual oxygen control [96.1 (93.7–98.6) vs. 78.4 (51.3–94.8); P < 0.001]. The percentage of time spent in acceptable, suboptimal and unacceptable zones decreased. Findings were similar with the use of closed-loop FiO2 controller compared to manual titration in patients with ARDS [95.9 (81.6–98.8) vs. 78 (49.5–94.8) %; P = 0.027]. The total number of closed-loop FiO2 changes per patient was 52 (11.8–67), vs. the number of manual changes 1 (0–2), (P < 0.001). Conclusion In this randomized crossover trial in pediatric critically ill patients under invasive ventilation with ASV, use of a closed–loop control of FiO2 titration increased the percentage of time spent within in optimal SpO2 zones, and increased the total number of FiO2 changes per patient. Clinical trial registration ClinicalTrials.gov, identifier: NCT04568642.
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Affiliation(s)
- Ekin Soydan
- Department of Pediatric Intensive Care Unit, Dr. Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Gokhan Ceylan
- Department of Pediatric Intensive Care Unit, Dr. Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
- Department of Medical Research, Hamilton Medical AG, Bonaduz, Switzerland
- *Correspondence: Gokhan Ceylan
| | - Sevgi Topal
- Department of Pediatric Intensive Care Unit, Dr. Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Pinar Hepduman
- Department of Pediatric Intensive Care Unit, Dr. Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Gulhan Atakul
- Department of Pediatric Intensive Care Unit, Dr. Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Mustafa Colak
- Department of Pediatric Intensive Care Unit, Dr. Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Ozlem Sandal
- Department of Pediatric Intensive Care Unit, Dr. Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Ferhat Sari
- Department of Pediatric Intensive Care Unit, Dr. Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Utku Karaarslan
- Department of Pediatric Intensive Care Unit, Dr. Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
| | - Dominik Novotni
- Department of Medical Research, Hamilton Medical AG, Bonaduz, Switzerland
| | - Marcus J. Schultz
- Department of Medical Research, Hamilton Medical AG, Bonaduz, Switzerland
- Department of Intensive Care, Amsterdam UMC, Location “Academic Medical Center”, Amsterdam, Netherlands
| | - Hasan Agin
- Department of Pediatric Intensive Care Unit, Dr. Behcet Uz Children's Disease and Surgery Training and Research Hospital, Health Sciences University, Izmir, Turkey
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14
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Schwarz CE, Kreutzer KB, Langanky L, Wolf NS, Braun W, O'Sullivan MP, Poets CF, Franz AR. Randomised crossover trial comparing algorithms and averaging times for automatic oxygen control in preterm infants. Arch Dis Child Fetal Neonatal Ed 2022; 107:425-430. [PMID: 34819347 DOI: 10.1136/archdischild-2021-322096] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 10/16/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE Automatic control (SPOC) of the fraction of inspired oxygen (FiO2), based on continuous analysis of pulse oximeter saturation (SpO2), improves the proportion of time preterm infants spend within a specified SpO2-target range (Target%). We evaluated if a revised SPOC algorithm (SPOCnew, including an upper limit for FiO2) compared to both routine manual control (RMC) and the previously tested algorithm (SPOCold, unrestricted maximum FiO2) increases Target%, and evaluated the effect of the pulse oximeter's averaging time on controlling the SpO2 signal during SPOC periods. DESIGN Unblinded, randomised controlled crossover study comparing 2 SPOC algorithms and 2 SpO2 averaging times in random order: 12 hours SPOCnew and 12 hours SPOCold (averaging time 2 s or 8 s for 6 hours each) were compared with 6-hour RMC. A generated list of random numbers was used for allocation sequence. SETTING University-affiliated tertiary neonatal intensive care unit, Germany PATIENTS: Twenty-four infants on non-invasive respiratory support with FiO2 >0.21 were analysed (median gestational age at birth, birth weight and age at randomisation were 25.3 weeks, 585 g and 30 days). MAIN OUTCOME MEASURE Target%. RESULTS Mean (SD) [95% CI] Target% was 56% (9) [52, 59] for RMC versus 69% (9) [65, 72] for SPOCold_2s, 70% (7) [67, 73] for SPOCnew_2s, 71% (8) [68, 74] for SPOCold_8s and 72% (8) [69, 75] for SPOCnew_8s. CONCLUSIONS Irrespective of SpO2-averaging time, Target% was higher with both SPOC algorithms compared to RMC. Despite limiting the maximum FiO2, SPOCnew remained significantly better at maintaining SpO2 within target range compared to RMC. TRIAL REGISTRATION NCT03785899.
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Affiliation(s)
- Christoph E Schwarz
- Department of Neonatology, University Children's Hospital Tübingen, Tübingen, Baden-Württemberg, Germany.,INFANT Research Centre, Cork, Ireland
| | - Karen B Kreutzer
- Department of Neonatology, University Children's Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Lukas Langanky
- Department of Neonatology, University Children's Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Nicole S Wolf
- Department of Neonatology, University Children's Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Wolfgang Braun
- Fritz Stephan GmbH, Gackenbach, Rheinland-Pfalz, Germany
| | - Marc Paul O'Sullivan
- INFANT Research Centre, Cork, Ireland.,Luxembourg Institute of Health, Strassen, Luxembourg
| | - Christian F Poets
- Department of Neonatology, University Children's Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
| | - Axel R Franz
- Department of Neonatology, University Children's Hospital Tübingen, Tübingen, Baden-Württemberg, Germany.,Center for Pediatric Clinical Studies (CPCS), University Children's Hospital Tübingen, Tübingen, Baden-Württemberg, Germany
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15
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Bachman TE, Onland W, van Kaam AH, Roubik K, Hummler HD, Lal M, Lista G, Fajardo CA. Frequency and duration of extreme hypoxemic and hyperoxemic episodes during manual and automatic oxygen control in preterm infants: a retrospective cohort analysis from randomized studies. BMC Pediatr 2022; 22:350. [PMID: 35715764 PMCID: PMC9205075 DOI: 10.1186/s12887-022-03407-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/22/2022] [Accepted: 06/08/2022] [Indexed: 11/10/2022] Open
Abstract
Objective Neonatal exposure to episodic hypoxemia and hyperoxemia is highly relevant to outcomes. Our goal was to investigate the differences in the frequency and duration of extreme low and high SpO2 episodes between automated and manual inspired oxygen control. Design Post-hoc analysis of a cohort from prospective randomized cross-over studies. Setting Seven tertiary care neonatal intensive care units. Patients Fifty-eight very preterm neonates (32 or less weeks PMA) receiving respiratory support and supplemental oxygen participating in an automated versus manual oxygen control cross-over trial. Main measures Extreme hypoxemia was defined as a SpO2 < 80%, extreme hyperoxemia as a SpO2 > 98%. Episode duration was categorized as < 5 seconds, between 5 to < 30 seconds, 30 to < 60 seconds, 60 to < 120 seconds, and 120 seconds or longer. Results The infants were of a median postmenstrual age of 29 (28-31) weeks, receiving a median FiO2 of 0.28 (0.25-0.32) with mostly receiving non-invasive respiratory support (83%). While most of the episodes were less than 30 seconds, longer episodes had a marked effect on total time exposure to extremes. The time differences in each of the three longest durations episodes (30, 60, and 120 seconds) were significantly less during automated than during manual control (p < 0.001). Nearly two-third of the reduction of total time spent at the extremes between automated and manual control (3.8 to 2.1% for < 80% SpO2 and 3.0 to 1.6% for > 98% SpO2) was seen in the episodes of at least 60 seconds. Conclusions This study shows that the majority of episodes preterm infants spent in SpO2 extremes are of short duration regardless of manual or automated control. However, the infrequent longer episodes not only contribute the most to the total exposure, but also their reduction in frequency to the improvement associated with automated control.
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Affiliation(s)
- Thomas E Bachman
- Czech Technical University in Prague, School of Biomedical Engineering, Prague, Czech Republic.
| | - Wes Onland
- Emma Children's Hospital, Department of Neonatology, Amsterdam UMC, Amsterdam, Netherlands.,Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Anton H van Kaam
- Emma Children's Hospital, Department of Neonatology, Amsterdam UMC, Amsterdam, Netherlands.,Amsterdam Reproduction and Development, Amsterdam, The Netherlands
| | - Karel Roubik
- Czech Technical University in Prague, School of Biomedical Engineering, Prague, Czech Republic
| | - Helmut D Hummler
- Department of Neonatology, University Hospital, Tuebingen, Germany
| | - Mithilesh Lal
- James Cook University Hospital, Neonatology, South Tees NHS Trust, Middlesbrough, UK
| | - Gianluca Lista
- Vittore Buzzi Children's Hospital, Neonatology, Milan, Italy
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16
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Abstract
Advances in perinatal care have seen substantial improvements in survival without disability for extremely preterm infants. Protecting the developing brain and reducing neurodevelopmental sequelae of extremely preterm birth are strategic priorities for both research and clinical care. A number of evidence-based interventions exist for neuroprotection in micropreemies, inclusive of prevention of preterm birth and multiple births with implantation of only one embryo during in vitro fertilisation, as well as antenatal care to optimize fetal wellbeing, strategies for supporting neonatal transition, and neuroprotective developmental care. Avoidance of complications that trigger ischemia and inflammation is vital for minimizing brain dysmaturation and injury, particularly of the white matter. Neurodevelopmental surveillance, early diagnosis of cerebral palsy and early intervention are essential for optimizing long-term outcomes and quality of life. Research priorities include further evaluation of putative neuroprotective agents, and investigation of common neonatal interventions in trials adequately powered to assess neurodevelopmental outcome.
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17
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Statistical Description of SaO2–SpO2 Relationship for Model of Oxygenation in Premature Infants. ELECTRONICS 2022. [DOI: 10.3390/electronics11091314] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2023]
Abstract
A pulse oximeter model linking arterial (SaO2) and peripheral (SpO2) oxygen saturation is the terminal part of a mathematical model of neonatal oxygen transport. Previous studies have confirmed the overestimation of oxygen saturation measured by pulse oximetry in neonates compared to arterial oxygen saturation and the large variability of measured values over time caused by measurement inaccuracies. This work aimed to determine the SpO2 measurement noise that affects the biased SpO2 value at each time point and integrate the noise description with the systematic bias between SaO2 and SpO2. The SaO2–SpO2 bias was based on previously published clinical data from pathological patients younger than 60 days requiring ventilatory support. The statistical properties of the random SpO2 measurement noise were estimated from the SpO2 continuous recordings of 21 pathological and 21 physiological neonates. The result of the work is a comprehensive characterization of the properties of a pulse oximeter model describing the transfer of the input SaO2 value to the output SpO2 value, including the bias and noise typical for the bedside monitoring of neonates. These results will help to improve a computer model of neonatal oxygen transport.
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18
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Nair V, Lal MK, Gillone J, Kannan Loganathan P, Bachman TE. Comparison of volume guarantee and volume-controlled ventilation both using closed loop inspired oxygen in preterm infants: a randomised crossover study (CLIO-VG study). Arch Dis Child Fetal Neonatal Ed 2022; 107:161-165. [PMID: 34233907 DOI: 10.1136/archdischild-2021-321712] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2021] [Accepted: 06/18/2021] [Indexed: 11/04/2022]
Abstract
OBJECTIVE The objective of this study was to compare two different modes of ventilation in maintaining oxygen saturation (SpO2) in target range (90%-95%) in ventilated preterm infants cared for with automatic control of oxygen delivery (A-FiO2). DESIGN A single-centre randomised crossover study. SETTINGS A level III neonatal intensive care unit. PATIENTS Preterm infants receiving mechanical ventilation and oxygen requirement >21%. INTERVENTIONS Volume guarantee (VG) vs volume controlled ventilation (VCV) modes with automatic oxygen control (A-FiO2). OUTCOMES The primary outcome of this study was the proportion of time spent with oxygen saturations in the target range (90%-95%) . RESULTS Nineteen preterm infants with a median gestation age 25 weeks (IQR: 24-28) and birth weight 685 g (IQR: 595-980) were enrolled in the study. There was no significant difference in primary outcome of median proportion of time spent in target saturation between the two arms (72% (57-81) in VG vs 75% (58-83) in VCV; p=0.98). There was no significant difference in the secondary outcomes of time spent in SpO2 <80% (0.03% vs 0.14%; p=0.51), time spent in SpO2 >98% (0.50% vs 0.08%; p=0.54), the median FiO2 (31% vs 29%; p=0.51) or manual adjustments carried out between VG and VCV, respectively. The number of episodes of prolonged hypoxaemia and hyperoxaemia were similar in the two groups. CONCLUSION There was no significant difference in time spent in target SpO2 range between VG and VCV when A-FiO2 was used as the FiO2 controller in this crossover randomised control study. TRIAL REGISTRATION NUMBER NCT03865069.
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Affiliation(s)
- Vrinda Nair
- Neonatal Intensive Care Unit, James Cook University Hospital, Middlesbrough, UK .,Translational and Clinical Research Institute, Newcastle University, Newcastle upon Tyne, UK
| | - Mithilesh Kumar Lal
- Neonatal Intensive Care Unit, James Cook University Hospital, Middlesbrough, UK
| | - Jenna Gillone
- Neonatal Intensive Care Unit, James Cook University Hospital, Middlesbrough, UK
| | | | - Thomas Edward Bachman
- Medtrx.org, Lake Arrowhead, California, USA.,Biomedical Technology, Czech Technical University, Prague, Czech Republic
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19
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Filippi L, Cammalleri M, Amato R, Ciantelli M, Pini A, Bagnoli P, Dal Monte M. Decoupling Oxygen Tension From Retinal Vascularization as a New Perspective for Management of Retinopathy of Prematurity. New Opportunities From β-adrenoceptors. Front Pharmacol 2022; 13:835771. [PMID: 35126166 PMCID: PMC8814365 DOI: 10.3389/fphar.2022.835771] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/14/2021] [Accepted: 01/05/2022] [Indexed: 12/20/2022] Open
Abstract
Retinopathy of prematurity (ROP) is an evolutive and potentially blinding eye disease that affects preterm newborns. Unfortunately, until now no conservative therapy of active ROP with proven efficacy is available. Although ROP is a multifactorial disease, premature exposition to oxygen concentrations higher than those intrauterine, represents the initial pathogenetic trigger. The increase of oxygenation in a retina still incompletely vascularized promotes the downregulation of proangiogenic factors and finally the interruption of vascularization (ischemic phase). However, the increasing metabolic requirement of the ischemic retina induces, over the following weeks, a progressive hypoxia that specularly increases the levels of proangiogenic factors finally leading to proliferative retinopathy (proliferative phase). Considering non-modifiable the coupling between oxygen levels and vascularization, so far, neonatologists and ophthalmologists have "played defense", meticulously searching the minimum necessary concentration of oxygen for individual newborns, refining their diagnostic ability, adopting a careful monitoring policy, ready to decisively intervene only in a very advanced stage of disease progression. However, recent advances have demonstrated the possibility to pharmacologically modulate the relationship between oxygen and vascularization, opening thus the perspective for new therapeutic or preventive opportunities. The perspective of a shift from a defensive towards an attack strategy is now at hand.
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Affiliation(s)
- Luca Filippi
- Department of Clinical and Experimental Medicine, University of Pisa, Pisa, Italy
| | | | - Rosario Amato
- Department of Biology, University of Pisa, Pisa, Italy
| | | | - Alessandro Pini
- Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy
| | - Paola Bagnoli
- Department of Biology, University of Pisa, Pisa, Italy
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20
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González Á, Estay A. VENTILACIÓN MECÁNICA EN EL RECIÉN NACIDO PREMATURO EXTREMO, ¿HACIA DÓNDE VAMOS? REVISTA MÉDICA CLÍNICA LAS CONDES 2021. [DOI: 10.1016/j.rmclc.2021.10.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
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21
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Dijkman KP, Mohns T, Dieleman JP, van Pul C, Goos TG, Reiss IK, Andriessen P, Niemarkt HJ. Predictive Intelligent Control of Oxygenation (PRICO) in preterm infants on high flow nasal cannula support: a randomised cross-over study. Arch Dis Child Fetal Neonatal Ed 2021; 106:621-626. [PMID: 33972265 DOI: 10.1136/archdischild-2020-320728] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 03/24/2021] [Accepted: 04/08/2021] [Indexed: 12/23/2022]
Abstract
OBJECTIVE To investigate the efficacy of automated control of inspired oxygen (FiO2) by Predictive Intelligent Control of Oxygenation (PRICO) on the Fabian ventilator in maintaining oxygen saturation (SpO2) in preterm infants on high flow nasal cannula (HFNC) support. DESIGN Single-centre randomised two-period crossover study. SETTING Tertiary neonatal intensive care unit. PATIENTS 27 preterm infants (gestational age (GA) <30 weeks) on HFNC support with FiO2 >0.25. INTERVENTION A 24-hour period on automated FiO2-control with PRICO compared with a 24-hour period on routine manual control (RMC) to maintain a SpO2 level within target range of 88%-95% measured at 30 s intervals. MAIN OUTCOME MEASURES Primary outcome: time spent within target range (88%-95%). SECONDARY OUTCOMES time spent above and below target range, in severe hypoxia (SpO2 <80%) and hyperoxia (SpO2 >98%), mean SpO2 and FiO2 and manual FiO2 adjustments. RESULTS 15 patients received PRICO-RMC and 12 RMC-PRICO. The mean time within the target range increased with PRICO: 10.8% (95% CI 7.6 to 13.9). There was a decrease in time below target range: 7.6% (95% CI 4.2 to 11.0), above target range: 3.1% (95% CI 2.9 to 6.2) and in severe hypoxia: 0.9% (95% CI 1.5 to 0.2). We found no difference in time spent in severe hyperoxia. Mean FiO2 was higher during PRICO: 0.019 (95% CI 0.006 to 0.030). With PRICO there was a reduction of manual adjustments: 9/24 hours (95% CI 6 to 12). CONCLUSION In preterm infants on HFNC support, automated FiO2-control by PRICO is superior to RMC in maintaining SpO2 within target range. Further validation studies with a higher sample frequency and different ventilation modes are needed.
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Affiliation(s)
- Koen P Dijkman
- Neonatology, Maxima Medical Centre, Veldhoven, The Netherlands
| | - Thilo Mohns
- Neonatology, Maxima Medical Centre, Veldhoven, The Netherlands
| | | | - Carola van Pul
- Clinical Physics, Maxima Medical Centre, Veldhoven, The Netherlands.,Applied Physics, University of Technology Eindhoven, Eindhoven, The Netherlands
| | - Tom G Goos
- Neonatology, Erasmus MC, Rotterdam, The Netherlands
| | | | - Peter Andriessen
- Neonatology, Maxima Medical Centre, Veldhoven, The Netherlands.,Applied Physics, University of Technology Eindhoven, Eindhoven, The Netherlands
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22
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Automated oxygen saturation targeting strategy in neonates. J Pediatr 2021; 235:303. [PMID: 33940017 PMCID: PMC9749897 DOI: 10.1016/j.jpeds.2021.04.055] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 04/20/2021] [Indexed: 11/23/2022]
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23
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Di Fiore JM, Raffay TM. The relationship between intermittent hypoxemia events and neural outcomes in neonates. Exp Neurol 2021; 342:113753. [PMID: 33984336 DOI: 10.1016/j.expneurol.2021.113753] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2020] [Revised: 04/06/2021] [Accepted: 05/07/2021] [Indexed: 12/20/2022]
Abstract
This brief review examines 1) patterns of intermittent hypoxemia in extremely preterm infants during early postnatal life, 2) the relationship between neonatal intermittent hypoxemia exposure and outcomes in both human and animal models, 3) potential mechanistic pathways, and 4) future alterations in clinical care that may reduce morbidity. Intermittent hypoxemia events are pervasive in extremely preterm infants (<28 weeks gestation at birth) during early postnatal life. An increased frequency of intermittent hypoxemia events has been associated with a range of poor neural outcomes including language and cognitive delays, motor impairment, retinopathy of prematurity, impaired control of breathing, and intraventricular hemorrhage. Neonatal rodent models have shown that exposure to short repetitive cycles of hypoxia induce a pathophysiological cascade. However, not all patterns of intermittent hypoxia are deleterious and some may even improve neurodevelopmental outcomes. Therapeutic interventions include supplemental oxygen, pressure support and pharmacologic drugs but prolonged hyperoxia and pressure exposure have been associated with cardiopulmonary morbidity. Therefore, it becomes imperative to distinguish high risk from neutral and/or even beneficial patterns of intermittent hypoxemia during early postnatal life. Identification of such patterns could improve clinical care with targeted interventions for high-risk patterns and minimal or no exposure to treatment modalities for low-risk patterns.
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Affiliation(s)
- Juliann M Di Fiore
- Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, OH, United States of America; Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States of America.
| | - Thomas M Raffay
- Division of Neonatology, Rainbow Babies and Children's Hospital, Cleveland, OH, United States of America; Department of Pediatrics, Case Western Reserve University, Cleveland, OH, United States of America
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24
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Muehlbacher T, Bassler D, Bryant MB. Evidence for the Management of Bronchopulmonary Dysplasia in Very Preterm Infants. CHILDREN (BASEL, SWITZERLAND) 2021; 8:298. [PMID: 33924638 PMCID: PMC8069828 DOI: 10.3390/children8040298] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Revised: 04/08/2021] [Accepted: 04/09/2021] [Indexed: 12/15/2022]
Abstract
BACKGROUND Very preterm birth often results in the development of bronchopulmonary dysplasia (BPD) with an inverse correlation of gestational age and birthweight. This very preterm population is especially exposed to interventions, which affect the development of BPD. OBJECTIVE The goal of our review is to summarize the evidence on these daily procedures and provide evidence-based recommendations for the management of BPD. METHODS We conducted a systematic literature research using MEDLINE/PubMed on antenatal corticosteroids, surfactant-replacement therapy, caffeine, ventilation strategies, postnatal corticosteroids, inhaled nitric oxide, inhaled bronchodilators, macrolides, patent ductus arteriosus, fluid management, vitamin A, treatment of pulmonary hypertension and stem cell therapy. RESULTS Evidence provided by meta-analyses, systematic reviews, randomized controlled trials (RCTs) and large observational studies are summarized as a narrative review. DISCUSSION There is strong evidence for the use of antenatal corticosteroids, surfactant-replacement therapy, especially in combination with noninvasive ventilation strategies, caffeine and lung-protective ventilation strategies. A more differentiated approach has to be applied to corticosteroid treatment, the management of patent ductus arteriosus (PDA), fluid-intake and vitamin A supplementation, as well as the treatment of BPD-associated pulmonary hypertension. There is no evidence for the routine use of inhaled bronchodilators and prophylactic inhaled nitric oxide. Stem cell therapy is promising, but should be used in RCTs only.
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Affiliation(s)
- Tobias Muehlbacher
- Department of Neonatology, University Hospital Zurich, 8091 Zurich, Switzerland; (D.B.); (M.B.B.)
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25
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Abdo M, Hanbal A, Asla MM, Ishqair A, Alfar M, Elnaiem W, Ragab KM, Nourelden AZ, Zaazouee MS. Automated versus manual oxygen control in preterm infants receiving respiratory support: a systematic review and meta-analysis. J Matern Fetal Neonatal Med 2021; 35:6069-6076. [PMID: 33832390 DOI: 10.1080/14767058.2021.1904875] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Ventilated preterm infants are exposed to deviations from the intended arterial oxygen saturation range. Therefore, an automated control system was developed to rapidly modulate the fraction of inspired oxygen. The aim of this review is to compare the efficacy and safety of automated versus manual oxygen delivery control. METHODS In December 2020, we systematically searched four electronic databases; PubMed, Cochrane Library, Scopus, and Web of Science for eligible randomized controlled trials. We extracted and pooled data as mean difference and 95% confidence interval in an inverse variance method using RevMan software. RESULTS Thirteen trials were included in this systematic review and meta-analysis, enrolling 343 preterm infants on respiratory support. Automated oxygen control increased the time spent within the target arterial oxygen saturation range of 85-96% (MD = 8.96; 95% CI [6.26, 11.67], p<.00001), and 90-95% (MD = 18.25; 95% CI [4.58, 31.65], p = .008). In addition, it reduced the time of hypoxia (<80%); (MD = -1.24; 95% CI [-2.05, -0.43], p = .003), (MD = -0.82; 95% CI [-1.23, -0.41], p<.0001) with predetermined ranges of 85-96% and 90-95%, respectively. Automated control system reduced as well the time of hyperoxia (>98%) (MD = -0.99; 95% CI [-1.74, -0.25], p = .009) at intended range of 90-95%, and number of manual inspired oxygen fraction adjustments (MD = -2.82; 95% CI [-4.56, -1.08], p = .002). CONCLUSIONS Automated oxygen delivery is rapid and effective in controlling infants' oxygen saturation. It can be used to reduce the load over the nurses, but not to substitute the clinical supervision. Further long-term trials of large-scale are required to evaluate the prolonged clinical outcomes.
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Affiliation(s)
- Mohamed Abdo
- Faculty of Medicine, Assiut University, Assiut, Egypt.,International Medical Research Association (IMedRA), Cairo, Egypt
| | - Ahmed Hanbal
- International Medical Research Association (IMedRA), Cairo, Egypt.,Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Moamen Mostafa Asla
- International Medical Research Association (IMedRA), Cairo, Egypt.,Faculty of Medicine, Zagazig University, Zagazig, Egypt
| | - Anas Ishqair
- International Medical Research Association (IMedRA), Cairo, Egypt.,Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Merana Alfar
- International Medical Research Association (IMedRA), Cairo, Egypt.,Faculty of Medicine, The Hashemite University, Zarqa, Jordan
| | - Walaa Elnaiem
- International Medical Research Association (IMedRA), Cairo, Egypt.,Faculty of Medicine, University of Khartoum, Khartoum, Sudan
| | - Khaled Mohamed Ragab
- International Medical Research Association (IMedRA), Cairo, Egypt.,Faculty of Medicine, Minia University, Minia, Egypt
| | - Anas Zakarya Nourelden
- International Medical Research Association (IMedRA), Cairo, Egypt.,Faculty of Medicine, Al-Azhar University, Cairo, Egypt
| | - Mohamed Sayed Zaazouee
- International Medical Research Association (IMedRA), Cairo, Egypt.,Faculty of Medicine, Al-Azhar University, Assiut, Egypt
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26
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Abstract
PURPOSE OF REVIEW Over the past two decades, numerous algorithms for automated control of the fraction of inspired oxygen (FiO2) have been developed and incorporated into contemporary neonatal ventilators and high-flow devices in an attempt to optimize supplemental oxygen therapy in preterm infants. This review explores whether current evidence is sufficient to recommend widespread adoption of automated oxygen control in neonatal care. RECENT FINDINGS To date, 15 studies have compared automated versus manual control of FiO2 in preterm infants on respiratory support. This includes four new randomized cross-over trials published in the last 2 years. Available evidence consistently demonstrates a significant improvement in time spent within the target saturation range with automated FiO2 control. There are fewer episodes of severe hypoxemia and fewer manual FiO2 adjustments with automated oxygen control. Nursing workload may be reduced. However, no currently completed studies report on clinical outcomes, such as chronic lung disease or retinopathy of prematurity. SUMMARY Automated oxygen control appears to be a reasonable option for FiO2 titration in preterm infants on respiratory support, if resources are available, and might substantially reduce nursing workload. Further randomized clinical trials to explore its effects on clinical outcomes are required.
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Affiliation(s)
- Souvik Mitra
- Division of Neonatal Perinatal Medicine, Department of Pediatrics, Dalhousie University and IWK Health
- Department of Community Health & Epidemiology, Dalhousie University, Halifax, Nova Scotia, Canada
| | - Douglas McMillan
- Division of Neonatal Perinatal Medicine, Department of Pediatrics, Dalhousie University and IWK Health
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27
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Salverda HH, Cramer SJE, Witlox RSGM, Dargaville PA, Te Pas AB. Automated oxygen control in preterm infants, how does it work and what to expect: a narrative review. Arch Dis Child Fetal Neonatal Ed 2021; 106:215-221. [PMID: 32732378 DOI: 10.1136/archdischild-2020-318918] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2020] [Revised: 06/10/2020] [Accepted: 06/11/2020] [Indexed: 11/03/2022]
Abstract
BACKGROUND Automated oxygen control systems are finding their way into contemporary ventilators for preterm infants, each with its own algorithm, strategy and effect. OBJECTIVE To provide guidance to clinicians seeking to comprehend automated oxygen control and possibly introduce this technology in their practice. METHOD A narrative review of the commercially available devices using different algorithms incorporating rule-based, proportional-integral-derivative and adaptive concepts are described and explained. An overview of how they work and, if available, the clinical effect is given. RESULTS All algorithms have shown a beneficial effect on the proportion of time that oxygen saturation is within target range, and a decrease in hyperoxia and severe hypoxia. Automated oxygen control may also reduce the workload for bedside staff. There is concern that such devices could mask clinical deterioration, however this has not been reported to date. CONCLUSIONS So far, trials involving different algorithms are heterogenous in design and no head-to-head comparisons have been made, making it difficult to differentiate which algorithm is most effective and what clinicians can expect from algorithms under certain conditions.
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Affiliation(s)
- Hylke H Salverda
- Neonatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Sophie J E Cramer
- Neonatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Ruben S G M Witlox
- Neonatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
| | - Peter A Dargaville
- Department of Pediatrics, Royal Hobart Hospital, Hobart, Tasmania, Australia.,Menzies Institute for Medical Research, University of Tasmania, Hobart, Tasmania, Australia
| | - Arjan B Te Pas
- Neonatology, Leiden University Medical Center, Leiden, Zuid-Holland, The Netherlands
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Schwarz CE, Kidszun A, Bieder NS, Franz AR, König J, Mildenberger E, Poets CF, Seyfang A, Urschitz MS. Is faster better? A randomised crossover study comparing algorithms for closed-loop automatic oxygen control. Arch Dis Child Fetal Neonatal Ed 2020; 105:369-374. [PMID: 31527093 DOI: 10.1136/archdischild-2019-317029] [Citation(s) in RCA: 18] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 08/27/2019] [Accepted: 09/04/2019] [Indexed: 01/10/2023]
Abstract
OBJECTIVE Closed-loop automatic control (CLAC) of the fractional inspired oxygen (FiO2) improved oxygen administration to preterm infants on respiratory support. We investigated whether a revised CLAC algorithm (CLACfast, ≤2 FiO2 adjustments/min), compared with routine manual control (RMConly), increased the proportion of time with arterial haemoglobin oxygen saturation measured by pulse oximetry within prespecified target ranges (Target%) while not being inferior to the original algorithm (CLACslow: ≤0.3 FiO2 adjustments/min). DESIGN Unblinded randomised controlled crossover study comparing three modes of FiO2 control in random order for 8 hours each: RMC supported by CLACfast was compared with RMConly and RMC supported by CLACslow. A computer-generated list of random numbers using a block size of six was used for the allocation sequence. SETTING Two German tertiary university neonatal intensive care units. PATIENTS Of 23 randomised patients, 19 were analysed (mean±SD gestational age 27±2 weeks; age at randomisation 24±10 days) on non-invasive (n=18) or invasive (n=1) respiratory support at FiO2 >0.21. MAIN OUTCOME MEASURE Target%. RESULTS Mean±SD [95% CI] Target% was 68%±11% [65% to 71%] for CLACfast versus 65%±11% [61% to 68%] for CLACslow versus 58%±11% [55% to 62%] for RMConly. Prespecified hypothesis tests of: (A) superiority of CLACfast versus RMConly and (B) non-inferiority of CLACfast versus CLACslow with margin of 5% yielded one-sided p values of <0.001 for both comparisons. CONCLUSIONS This revised and faster CLAC algorithm was still superior to routine care in infants on respiratory support and not inferior to a previously tested slower algorithm. TRIAL REGISTRATION NUMBER NCT03163108.
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Affiliation(s)
- Christoph E Schwarz
- Department of Neonatology, University Children's Hospital, Tuebingen, Germany
| | - André Kidszun
- Department of Neonatology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Nicole S Bieder
- Department of Neonatology, University Children's Hospital, Tuebingen, Germany
| | - Axel R Franz
- Department of Neonatology, University Children's Hospital, Tuebingen, Germany.,Center for Paediatric Clinical Studies, University Children's Hospital, Tuebingen, Germany
| | - Jochem König
- Division of Paediatric Epidemiology, Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center Mainz, Mainz, Germany
| | - Eva Mildenberger
- Department of Neonatology, University Medical Centre of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Christian F Poets
- Department of Neonatology, University Children's Hospital, Tuebingen, Germany
| | - Andreas Seyfang
- Division of Paediatric Epidemiology, Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center Mainz, Mainz, Germany
| | - Michael S Urschitz
- Division of Paediatric Epidemiology, Institute of Medical Biostatistics, Epidemiology and Informatics, University Medical Center Mainz, Mainz, Germany
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29
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Sturrock S, Williams E, Dassios T, Greenough A. Closed loop automated oxygen control in neonates-A review. Acta Paediatr 2020; 109:914-922. [PMID: 31715041 DOI: 10.1111/apa.15089] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2019] [Revised: 11/07/2019] [Accepted: 11/11/2019] [Indexed: 11/26/2022]
Abstract
AIM Neonates frequently require supplementary oxygen but may develop complications if the oxygen saturation is outside the target range. This review aimed to determine whether the algorithms used in closed loop automated oxygen control systems influenced their efficacy and whether use of the systems reduced relevant, long-term neonatal complications. METHODS A literature search was conducted using PubMed and Google Scholar. The search terms were 'closed loop' or 'automat*', 'oxygen' and 'neonat*'. RESULTS Eighteen studies were identified: sixteen comparison clinical studies, an observational study and an animal study. Overall, closed loop automated oxygen control was associated with an increased percentage of time spent within the target oxygen saturation range and there were fewer manual adjustments to the inspired oxygen concentration when compared with manual oxygen control. The systems were effective in infants on non-invasive respiratory support or mechanically ventilated, but no study included term-born infants. No long-term data were available to determine if complications of oxygen toxicity were reduced. CONCLUSION Closed loop automated oxygen control has been shown in short term trials including preterm and low birth weight infants to improve target saturation achievement. Whether long-term outcomes will be improved with their use requires investigation.
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Affiliation(s)
- Sarah Sturrock
- Women and Children’s Health School of Life Course Sciences Faculty of Life Sciences and Medicine King’s College London London UK
| | - Emma Williams
- Women and Children’s Health School of Life Course Sciences Faculty of Life Sciences and Medicine King’s College London London UK
| | - Theodore Dassios
- Women and Children’s Health School of Life Course Sciences Faculty of Life Sciences and Medicine King’s College London London UK
- Neonatal Intensive Care Centre King’s College Hospital London UK
| | - Anne Greenough
- Women and Children’s Health School of Life Course Sciences Faculty of Life Sciences and Medicine King’s College London London UK
- The Asthma UK Centre in Allergic Mechanisms of Asthma King's College London London UK
- National Institute for Health Research (NIHR) Biomedical Research Centre based at Guy’s and St Thomas’ NHS Foundation Trust King’s College London London UK
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30
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Walker PJB, Bakare AA, Ayede AI, Oluwafemi RO, Olubosede OA, Olafimihan IV, Tan K, Duke T, Falade AG, Graham H. Using intermittent pulse oximetry to guide neonatal oxygen therapy in a low-resource context. Arch Dis Child Fetal Neonatal Ed 2020; 105:316-321. [PMID: 31462405 PMCID: PMC7363784 DOI: 10.1136/archdischild-2019-317630] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/27/2019] [Revised: 07/31/2019] [Accepted: 08/08/2019] [Indexed: 01/20/2023]
Abstract
OBJECTIVE To evaluate the effectiveness of intermittent pulse oximetry in guiding oxygen therapy in neonates in a low-resource setting. DESIGN AND SETTING Prospective validation study at three hospitals in southwest Nigeria. We performed concealed continuous pulse oximetry on participants to evaluate intermittent SpO2 monitoring. PATIENTS We recruited all preterm or low birthweight neonates, and all term neonates who required oxygen therapy, who were admitted to the neonatal ward(s) of the study hospitals during the study period. MAIN OUTCOME MEASURES Proportion of time preterm/low birthweight neonates on oxygen spent within, above and below the target SpO2 range of 90%-95%; and the proportion of time term neonates and neonates not on oxygen spent within and below the target range of 90%-100%. RESULTS Preterm/low birthweight neonates receiving oxygen therapy (group A) spent 15.7% (95% CI 13.3 to 18.9) of time in the target SpO2 range of 90%-95%. They spent 75.0% (63.6-81.1) of time above 95%, and 2.7% (1.7-5.6) of time below 85%. Term neonates and all neonates not receiving oxygen (group B) spent 97.3% (95% CI 96.4 to 98.6) of time within the target range of 90%-100%, and 0.9% (0.3-1.4) of time below 85%. Guidelines recommended SpO2 monitoring 3 times per day for all patients, however neonates in groups A and B were monitored an average of 4.7 and 5.3 times per day, respectively. CONCLUSIONS To better maintain SpO2 within the target range, preterm/low birthweight neonates on oxygen should have their SpO2 monitored more frequently than the current 4.7 times per day. In all other neonates, however, monitoring SpO2 5.3 times per day appears suitable.
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Affiliation(s)
- Patrick James Berkeley Walker
- Centre for International Child Health, Department of Paediatrics, The University of Melbourne, Parkville, Victoria, Australia .,Medicine, Nursing & Health Sciences, Monash University, Clayton, Victoria, Australia
| | - Ayobami Adebayo Bakare
- Department of Paediatrics, University of Ibadan, Ibadan, Nigeria,University College Hospital Ibadan, Ibadan, Nigeria
| | | | | | | | | | - Kenneth Tan
- Department of Paediatrics, Monash University, Melbourne, Victoria, Australia,Monash Newborn, Monash Children's Hospital, Melbourne, Victoria, Australia
| | - Trevor Duke
- Intensive Care Unit and University of Melbourne Department of Paediatrics, Royal Children's Hospital, Parkville, Victoria, Australia,Department of Child Health, School of Medicine and Health Sciences, University of Papua New Guinea, Port Moresby, Papua New Guinea
| | - Adegoke Gbadegesin Falade
- College of Medicine, University of Ibadan, Ibadan, Nigeria,Department of Paediatrics, University College Hospital Ibadan, Ibadan, Nigeria
| | - Hamish Graham
- Centre for International Child Health, University of Melbourne, Royal Children's Hospital, Parkville, Victoria, Australia
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31
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Huizing MJ, Villamor-Martínez E, Meus S, de Jonge FM, Villamor E. Dutch Neonatal Intensive Care Nurses' Perceptions of Pulse Oximeter Saturation Target Limits for Preterm Infants. J Pediatr Nurs 2019; 49:e36-e41. [PMID: 31439356 DOI: 10.1016/j.pedn.2019.08.005] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/24/2019] [Revised: 08/07/2019] [Accepted: 08/07/2019] [Indexed: 10/26/2022]
Abstract
PURPOSE To conduct a national survey to assess practice, knowledge, barriers, and perceptions regarding oxygen saturation (SpO2) target limits among Dutch neonatal intensive care unit (NICU) nurses. DESIGN AND METHODS Cross-sectional, web-based survey among 667 nurses from 9 level 3 Dutch NICUs. Part of the questions were based on a clinical scenario (28-weeks preterm infant, treated with CPAP, FiO2 0.4). RESULTS 328 (53.6%) nurses responded to the survey. Of these, 281 (85.7%) reported to know the local policy of SpO2 target limits, and 261 (79.6%) and 244 (74.4%) rightly identified the lower and upper limit, respectively. Six NICUs recently increased their lower SpO2 limit and for 62.0% of their nurses this led to a significant alarm increase. For the majority of the respondents, the baby from the clinical scenario would spend <10% of the time outside the lower or upper SpO2 limits. Automated oxygen control systems were considered a good idea by 59.2% of the respondents, but 53.9% considered allowing parents to participate in FiO2 titration a bad or very bad idea. CONCLUSIONS: The majority of the respondents identified their unit's policy-specified SpO2 target limits and reported that the increase in SpO2 target limits may have led to more alarms. Titration of FiO2 is a part of care that respondents were reluctant to share with parents. PRACTICE IMPLICATIONS A potential increase in the number of SpO2 alarms may lead to alarm fatigue. Although family-centered care philosophy is widely accepted across Dutch NICUs, there are still barriers to overcome.
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Affiliation(s)
- Maurice J Huizing
- Department of Pediatrics, Neonatal Intensive Care Unit, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Eduardo Villamor-Martínez
- School for Oncology and Developmental Biology (GROW), Maastricht University, Maastricht, the Netherlands
| | - Stefanie Meus
- Department of Pediatrics, Neonatal Intensive Care Unit, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Fred M de Jonge
- Department of Pediatrics, Neonatal Intensive Care Unit, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands
| | - Eduardo Villamor
- Department of Pediatrics, Neonatal Intensive Care Unit, Maastricht University Medical Centre (MUMC+), Maastricht, the Netherlands; School for Oncology and Developmental Biology (GROW), Maastricht University, Maastricht, the Netherlands.
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Maiwald CA, Niemarkt HJ, Poets CF, Urschitz MS, König J, Hummler H, Bassler D, Engel C, Franz AR. Effects of closed-loop automatic control of the inspiratory fraction of oxygen (FiO 2-C) on outcome of extremely preterm infants - study protocol of a randomized controlled parallel group multicenter trial for safety and efficacy. BMC Pediatr 2019; 19:363. [PMID: 31630690 PMCID: PMC6802113 DOI: 10.1186/s12887-019-1735-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/31/2019] [Accepted: 09/20/2019] [Indexed: 01/08/2023] Open
Abstract
BACKGROUND Most extremely low gestational age neonates (ELGANS, postmenstrual age at birth (PMA) < 28 completed weeks) require supplemental oxygen and experience frequent intermittent hypoxemic and hyperoxemic episodes. Hypoxemic episodes and exposure to inadequately high concentrations of oxygen are associated with an increased risk of retinopathy of prematurity (ROP), chronic lung disease of prematurity (BPD), necrotizing enterocolitis (NEC), neurodevelopmental impairment (NDI), and death beyond 36 weeks PMA. Closed-loop automated control of the inspiratory fraction of oxygen (FiO2-C) reduces time outside the hemoglobin oxygen saturation (SpO2) target range, number and duration of hypo- and hyperoxemic episodes and caregivers' workload. Effects on clinically important outcomes in ELGANs such as ROP, BPD, NEC, NDI and mortality have not yet been studied. METHODS An outcome-assessor-blinded, randomized controlled, parallel-group trial was designed and powered to study the effect of FiO2-C (in addition to routine manual control (RMC) of FiO2), compared to RMC only, on death and severe complications related to hypoxemia and/or hyperoxemia. 2340 ELGANS with a GA of 23 + 0/7 to 27 + 6/7 weeks will be recruited in approximately 75 European tertiary care neonatal centers. Study participants are randomly assigned to RMC (control-group) or FiO2-C in addition to RMC (intervention-group). Central randomization is stratified for center, gender and PMA at birth (< 26 weeks and ≥ 26 weeks). FiO2-C is provided by commercially available and CE-marked ventilators with an FiO2-C algorithm intended for use in newborn infants. The primary outcome variable (composite of death, severe ROP, BPD or NEC) is assessed at 36 weeks PMA (or, in case of ROP, until complete vascularization of the retina, respectively). The co-primary outcome variable (composite outcome of death, language/cognitive delay, motor impairment, severe visual impairment or hearing impairment) is assessed at 24 months corrected age. DISCUSSION Short-term studies on FiO2-C showed improved time ELGANs spent within their assigned SpO2 target range, but effects of FiO2-C on clinical outcomes are yet unknown and will be addressed in the FiO2-C trial. This will ensure an appropriate assessment of safety and efficacy before FiO2-C may be implemented as standard therapy. TRIAL REGISTRATION The study is registered at www.ClinicalTrials.gov: NCT03168516 , May 30, 2017.
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Affiliation(s)
- Christian A. Maiwald
- Department of Neonatology, University Children’s Hospital Tübingen, Calwerstr. 7, 72076 Tübingen, Germany
- Center for Pediatric Clinical Studies (CPCS), University Children’s Hospital Tübingen, Calwerstr. 7, 72076 Tübingen, Germany
| | | | - Christian F. Poets
- Department of Neonatology, University Children’s Hospital Tübingen, Calwerstr. 7, 72076 Tübingen, Germany
| | - Michael S. Urschitz
- Institute of Medical Biostatistics, Epidemiology and Informatics, Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | - Jochem König
- Institute of Medical Biostatistics, Epidemiology and Informatics, Medical Center of the Johannes Gutenberg-University Mainz, Mainz, Germany
| | | | | | - Corinna Engel
- Center for Pediatric Clinical Studies (CPCS), University Children’s Hospital Tübingen, Calwerstr. 7, 72076 Tübingen, Germany
| | - Axel R. Franz
- Department of Neonatology, University Children’s Hospital Tübingen, Calwerstr. 7, 72076 Tübingen, Germany
- Center for Pediatric Clinical Studies (CPCS), University Children’s Hospital Tübingen, Calwerstr. 7, 72076 Tübingen, Germany
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Travers CP, Carlo WA. New Methods for Noninvasive Oxygen Administration. Clin Perinatol 2019; 46:449-458. [PMID: 31345540 DOI: 10.1016/j.clp.2019.05.012] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Oxygen therapy is an essential part of neonatal care. Targeting oxygen saturations and preventing hypoxemia and hyperoxemia is difficult, particularly in preterm infants. The mode of oxygen delivery directly affects the stability of oxygen saturations, hypoxemia, and hyperoxemia. This stability has important clinical implications. New methods of noninvasive oxygen administration, including closed-loop automated control and servo-controlled oxygen environments, have been developed to improve oxygen saturation targeting and decrease episodes of hyperoxemia and hypoxemia.
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Affiliation(s)
- Colm P Travers
- Division of Neonatology, The University of Alabama at Birmingham, Suite 9380 WIC, 1700 6th Avenue South, Birmingham, AL 35249, USA
| | - Waldemar A Carlo
- Division of Neonatology, The University of Alabama at Birmingham, Suite 9380 WIC, 1700 6th Avenue South, Birmingham, AL 35249, USA.
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Evaluation of two SpO 2 alarm strategies during automated FiO 2 control in the NICU: a randomized crossover study. BMC Pediatr 2019; 19:142. [PMID: 31060536 PMCID: PMC6501373 DOI: 10.1186/s12887-019-1496-5] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/04/2019] [Accepted: 04/09/2019] [Indexed: 12/04/2022] Open
Abstract
Background Changes in oxygen saturation (SpO2) exposure have been shown to have a marked impact on neonatal outcomes and therefore careful titration of inspired oxygen is essential. In routine use, however, the frequency of SpO2 alarms not requiring intervention results in alarm fatigue and its corresponding risk. SpO2 control systems that automate oxygen adjustments (Auto-FiO2) have been shown to be safe and effective. We speculated that when using Auto-FiO2, alarm settings could be refined to reduce unnecessary alarms, without compromising safety. Methods An unblinded randomized crossover study was conducted in a single NICU among infants routinely managed with Auto-FiO2. During the first 6 days of respiratory support a tight and a loose alarm strategy were switched each 24 h. A balanced block randomization was used. The tight strategy set the alarms at the prescribed SpO2 target range, with a 30-s delay. The loose strategy set the alarms 2 wider, with a 90-s delay. The effectiveness outcome was the frequency of SpO2 alarms, and the safety outcomes were time at SpO2 extremes (< 80, > 98%). We hypothesized that the loose strategy would result in a marked decrease in the frequency of SpO2 alarms, and no increases at SpO2 extremes with 20 subjects. Within subject differences between alarm strategies for the primary outcomes were evaluated with Wilcoxon signed-rank test. Results During a 13-month period 26 neonates were randomized. The analysis included 21 subjects with 49 days of both tight and loose intervention. The loose alarm strategy resulted in a reduction in the median rate of SpO2 alarms from 5.2 to 1.6 per hour (p < 0.001, 95%-CI difference 1.6–3.7). The incidence of hypoxemia and hyperoxemia were very low (less than 0.1%-time) with no difference associated with the alarm strategy (95%-CI difference less than 0.0–0.2%). Conclusions In this group of infants we found a marked advantage of the looser alarm strategy. We conclude that the paradigms of alarm strategies used for manual titration of oxygen need to be reconsidered when using Auto-FiO2. We speculate that with optimal settings false positive SpO2 alarms can be minimized, with better vigilance of clinically relevant alarms. Trial registration Retrospectively registered 15 May 2018 at ISRCTN (49239883). Electronic supplementary material The online version of this article (10.1186/s12887-019-1496-5) contains supplementary material, which is available to authorized users.
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Sweet DG, Carnielli V, Greisen G, Hallman M, Ozek E, Te Pas A, Plavka R, Roehr CC, Saugstad OD, Simeoni U, Speer CP, Vento M, Visser GHA, Halliday HL. European Consensus Guidelines on the Management of Respiratory Distress Syndrome - 2019 Update. Neonatology 2019; 115:432-450. [PMID: 30974433 PMCID: PMC6604659 DOI: 10.1159/000499361] [Citation(s) in RCA: 654] [Impact Index Per Article: 130.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
As management of respiratory distress syndrome (RDS) advances, clinicians must continually revise their current practice. We report the fourth update of "European Guidelines for the Management of RDS" by a European panel of experienced neonatologists and an expert perinatal obstetrician based on available literature up to the end of 2018. Optimising outcome for babies with RDS includes prediction of risk of preterm delivery, need for appropriate maternal transfer to a perinatal centre and timely use of antenatal steroids. Delivery room management has become more evidence-based, and protocols for lung protection including initiation of CPAP and titration of oxygen should be implemented immediately after birth. Surfactant replacement therapy is a crucial part of management of RDS, and newer protocols for its use recommend early administration and avoidance of mechanical ventilation. Methods of maintaining babies on non-invasive respiratory support have been further developed and may cause less distress and reduce chronic lung disease. As technology for delivering mechanical ventilation improves, the risk of causing lung injury should decrease, although minimising time spent on mechanical ventilation using caffeine and, if necessary, postnatal steroids are also important considerations. Protocols for optimising general care of infants with RDS are also essential with good temperature control, careful fluid and nutritional management, maintenance of perfusion and judicious use of antibiotics all being important determinants of best outcome.
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Affiliation(s)
- David G Sweet
- Regional Neonatal Unit, Royal Maternity Hospital, Belfast, United Kingdom,
| | - Virgilio Carnielli
- Department of Neonatology, Polytechnic University of Marche, and Azienda Ospedaliero-Universitaria Ospedali Riuniti Ancona, Ancona, Italy
| | - Gorm Greisen
- Department of Neonatology, Rigshospitalet and University of Copenhagen, Copenhagen, Denmark
| | - Mikko Hallman
- Department of Pediatrics and Adolescence, Oulu University Hospital, and PEDEGO Research Unit, Medical Research Center, University of Oulu, Oulu, Finland
| | - Eren Ozek
- Department of Pediatrics, Marmara University Medical Faculty, Istanbul, Turkey
| | - Arjan Te Pas
- Leiden University Medical Centre, Leiden, The Netherlands
| | - Richard Plavka
- Division of Neonatology, Department of Obstetrics and Gynecology, General Faculty Hospital and 1st Faculty of Medicine, Charles University, Prague, Czechia
| | - Charles C Roehr
- Department of Paediatrics, University of Oxford, Medical Sciences Division, Newborn Services, John Radcliffe Hospitals, Oxford, United Kingdom
| | - Ola D Saugstad
- Department of Pediatric Research, Oslo University Hospital Rikshospitalet, University of Oslo, Oslo, Norway
| | - Umberto Simeoni
- Division of Pediatrics, CHUV & University of Lausanne, Lausanne, Switzerland
| | - Christian P Speer
- Department of Pediatrics, University Children's Hospital, Würzburg, Germany
| | - Maximo Vento
- Department of Pediatrics and Neonatal Research Unit, Health Research Institute La Fe, University and Polytechnic Hospital La Fe, Valencia, Spain
| | - Gerhard H A Visser
- Department of Obstetrics and Gynecology, University Medical Centre, Utrecht, The Netherlands
| | - Henry L Halliday
- Department of Child Health, Queen's University Belfast and Royal Maternity Hospital, Belfast, United Kingdom
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Faqeeh A, Hou X, Zaniletti I, Pardalos J, Amjad R, Fales R. Comparison of Automated and Manual Peripheral Oxygen Saturation Control Applied to One Human Subject at a High Target Range. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2018; 2018:3346-3349. [PMID: 30441105 DOI: 10.1109/embc.2018.8513048] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Newborn infants, mainly those born prematurely, often require respiratory support with a varying concentration of the fraction of inspired oxygen (FiO$_{\mathbf {2}}$) to keep the peripheral oxygen saturation (SpO$_{\mathbf {2}}$) within the desired range to prevent adverse health effects due to both high and low SpO$_{\mathbf {2}}$. Manual adjustment, by nurses, is the common practice. However, the efficacy of the manual control is questionable. A novel automatic controller is evaluated clinically with application to one human subject at a high target SpO$_{\mathbf {2}}$. The automatic controller demonstrated the ability to improve oxygen saturation control over the everyday routine manual control by increasing the proportion of time where SpO$_{\mathbf {2}}\textbf{v}$alues were within the desired range.
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