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Bertzouanis A, Sinopidis X, Pelekouda P, Karatza A, Dimitriou G, Fouzas S. Optimizing Oxygen Delivery by Low-Flow Nasal Cannula to Small Infants: A Bench Study. Diagnostics (Basel) 2024; 14:889. [PMID: 38732304 PMCID: PMC11083466 DOI: 10.3390/diagnostics14090889] [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: 03/22/2024] [Revised: 04/18/2024] [Accepted: 04/22/2024] [Indexed: 05/13/2024] Open
Abstract
BACKGROUND In infants treated with a low-flow nasal cannula (LFNC), the oxygen concentration delivered to the lungs (i.e., the effective FiO2) is difficult to estimate. The existing mathematical formulas rely on important assumptions regarding the values of respiratory parameters and, thus, may be inaccurate. We aimed to assess oxygen delivery by LFNC to small infants using realistic simulations on a mechanical breathing model. METHODS A mechanical breathing simulator (infant upper-airway replica, single-space breathing compartment, electric motor, microcontroller) was developed. Breathing simulations (n = 1200) were performed at various tidal volume (VT), inspiratory time (Ti), and respiratory rate (RR) combinations and different cannula flows. RESULTS Minute ventilation (MV) was the most significant predictor of effective FiO2. FiO2 was higher at lower VT and higher Ti values. Benaron and Benitz's formula underestimated the effective FiO2 at lower MV values, while Finer's formula significantly overestimated it. A set of predictive FiO2 charts was developed based on cannula flow, infant body weight, and RR. CONCLUSIONS The effective FiO2 delivered by LFNC to small infants critically depends on VT, Ti, and RR. However, since VT and Ti values are not available in clinical practice, the existing mathematical formulas may be inaccurate. Our novel predictive FiO2 charts could assist in optimizing oxygen delivery by LFNC using easy-to-obtain parameters, such as infant body weight and RR.
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Affiliation(s)
- Aris Bertzouanis
- Department of Pediatrics, Medical School, University of Patras, 26500 Patras, Greece; (X.S.); (P.P.); (A.K.); (G.D.); (S.F.)
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2
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DiBlasi RM, Crandall CN, Engberg RJ, Bijlani K, Ledee D, Kajimoto M, Walther FJ. Evaluation of a Novel Dry Powder Surfactant Aerosol Delivery System for Use in Premature Infants Supported with Bubble CPAP. Pharmaceutics 2023; 15:2368. [PMID: 37896128 PMCID: PMC10609757 DOI: 10.3390/pharmaceutics15102368] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Revised: 09/05/2023] [Accepted: 09/08/2023] [Indexed: 10/29/2023] Open
Abstract
Aerosolized lung surfactant therapy during nasal continuous positive airway pressure (CPAP) support avoids intubation but is highly complex, with reported poor nebulizer efficiency and low pulmonary deposition. The study objective was to evaluate particle size, operational compatibility, and drug delivery efficiency with various nasal CPAP interfaces and gas humidity levels of a synthetic dry powder (DP) surfactant aerosol delivered by a low-flow aerosol chamber (LFAC) inhaler combined with bubble nasal CPAP (bCPAP). A particle impactor characterized DP surfactant aerosol particle size. Lung pressures and volumes were measured in a preterm infant nasal airway and lung model using LFAC flow injection into the bCPAP system with different nasal prongs. The LFAC was combined with bCPAP and a non-heated passover humidifier. DP surfactant mass deposition within the nasal airway and lung was quantified for different interfaces. Finally, surfactant aerosol therapy was investigated using select interfaces and bCPAP gas humidification by active heating. Surfactant aerosol particle size was 3.68 µm. Lung pressures and volumes were within an acceptable range for lung protection with LFAC actuation and bCPAP. Aerosol delivery of DP surfactant resulted in variable nasal airway (0-20%) and lung (0-40%) deposition. DP lung surfactant aerosols agglomerated in the prongs and nasal airways with significant reductions in lung delivery during active humidification of bCPAP gas. Our findings show high-efficiency delivery of small, synthetic DP surfactant particles without increasing the potential risk for lung injury during concurrent aerosol delivery and bCPAP with passive humidification. Specialized prongs adapted to minimize extrapulmonary aerosol losses and nasal deposition showed the greatest lung deposition. The use of heated, humidified bCPAP gases compromised drug delivery and safety. Safety and efficacy of DP aerosol delivery in preterm infants supported with bCPAP requires more research.
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Affiliation(s)
- Robert M. DiBlasi
- Department of Respiratory Care Therapy, Seattle Children’s Hospital, Seattle, WA 98105, USA
- Center for Respiratory Biology and Therapeutics, Seattle Children’s Research Institute, Seattle, WA 98101, USA; (C.N.C.); (R.J.E.); (M.K.)
| | - Coral N. Crandall
- Center for Respiratory Biology and Therapeutics, Seattle Children’s Research Institute, Seattle, WA 98101, USA; (C.N.C.); (R.J.E.); (M.K.)
- Quality and Clinical Effectiveness, Seattle Children’s Hospital, Seattle, WA 98105, USA
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, WA 98101, USA
| | - Rebecca J. Engberg
- Center for Respiratory Biology and Therapeutics, Seattle Children’s Research Institute, Seattle, WA 98101, USA; (C.N.C.); (R.J.E.); (M.K.)
- Center for Clinical and Translational Research, Seattle Children’s Research Institute, Seattle, WA 98101, USA
| | - Kunal Bijlani
- Mechanical Engineering, Zewski Corporation, Magnolia, TX 77354, USA;
| | - Dolena Ledee
- Division of Cardiology, Department of Pediatrics, University of Washington, Seattle, WA 98195, USA;
| | - Masaki Kajimoto
- Center for Respiratory Biology and Therapeutics, Seattle Children’s Research Institute, Seattle, WA 98101, USA; (C.N.C.); (R.J.E.); (M.K.)
| | - Frans J. Walther
- Department of Pediatrics, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA 90095, USA;
- Lundquist Institute for Biomedical Innovation at Harbor-UCLA Medical Center, Torrance, CA 90502, USA
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Retinopathy of Prematurity in the 21st Century and the Complex Impact of Supplemental Oxygen. J Clin Med 2023; 12:jcm12031228. [PMID: 36769876 PMCID: PMC9918247 DOI: 10.3390/jcm12031228] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Revised: 01/19/2023] [Accepted: 01/23/2023] [Indexed: 02/05/2023] Open
Abstract
Retinopathy of prematurity (ROP) is a leading cause of childhood blindness. Not only do the epidemiologic determinants and distributions of patients with ROP vary worldwide, but clinical differences have also been described. The Third Edition of the International Classification of ROP (ICROP3) acknowledges that aggressive ROP (AROP) can occur in larger preterm infants and involve areas of the more anterior retina, particularly in low-resource settings with unmonitored oxygen supplementation. As sub-specialty training programs are underway to address an epidemic of ROP in sub-Saharan Africa, recognizing characteristic retinal pathology in preterm infants exposed to unmonitored supplemental oxygen is important to proper diagnosis and treatment. This paper describes specific features associated with various ROP presentations: oxygen-induced retinopathy in animal models, traditional ROP seen in high-income countries with modern oxygen management, and ROP related to excessive oxygen supplementation in low- and middle-income countries: oxygen-associated ROP (OA-ROP).
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Hedstrom AB, Nyonyintono J, Saxon EA, Nakamura H, Namakula H, Niyonshaba B, Nakakande J, Simpson N, Vaughan M, Wollen A, Mubiri P, Waiswa P, Coffey PS, Batra M. Feasibility and usability of a very low-cost bubble continuous positive airway pressure device including oxygen blenders in a Ugandan level two newborn unit. PLOS GLOBAL PUBLIC HEALTH 2023; 3:e0001354. [PMID: 36963078 PMCID: PMC10021653 DOI: 10.1371/journal.pgph.0001354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/04/2022] [Accepted: 02/07/2023] [Indexed: 03/10/2023]
Abstract
BACKGROUND Preterm birth and resulting respiratory failure is a leading cause of newborn death- the majority of which occur in resource-constrained settings and could be prevented with bubble continuous positive airway pressure (bCPAP). Commercialized devices are expensive, however, and sites commonly use improvised devices utilizing 100% oxygen which can cause blindness. To address this, PATH and a multidisciplinary team developed a very low-cost bCPAP device including fixed-ratio oxygen blenders. OBJECTIVE We assessed feasibility of use of the device on neonatal patients as well as the usability and acceptability of the device by healthcare workers. This study did not evaluate device effectiveness. METHODS The study took place in a Ugandan level two unit. Neonates with respiratory failure were treated with the bCPAP device. Prospective data were collected through observation as well as likert-style scales and interviews with healthcare workers. Data were analyzed using frequencies, means and standard deviation and interviews via a descriptive coding method. Retrospectively registered via ClinicalTrials.gov number NCT05462509. RESULTS Fourteen neonates were treated with the bCPAP device in October-December 2021. Patients were born onsite (57%), with median weight of 1.3 kg (IQR 1-1.8). Median treatment length was 2.5 days (IQR 2-6). bCPAP was stopped due to: improvement (83%) and death (17%). All patients experienced episodes of saturations >95%. Median time for device set up: 15 minutes (IQR 12-18) and changing the blender: 15 seconds (IQR 12-27). After initial device use, 9 out of 9 nurses report the set-up as well as blender use was "easy" and their overall satisfaction with the device was 8.5/10 (IQR 6.5-9.5). Interview themes included the appreciation for the ability to administer less than 100% oxygen, desire to continue use of the device, and a desire for additional blenders. CONCLUSIONS In facilities otherwise using 100% oxygen, use of the bCPAP device including oxygen blenders is feasible and acceptable to healthcare workers. TRIAL REGISTRATION ClinicalTrials.gov, Identifier NCT05462509.
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Affiliation(s)
- Anna B Hedstrom
- Department of Pediatrics and Global Health, University of Washington, Seattle, Washington, United States of America
| | | | - Eugene A Saxon
- EPFL EssentialTech Centre, the Swiss Federal Institute of Technology, Lausanne, Switzerland
| | | | | | | | | | | | | | - Alec Wollen
- Medical Devices and Health Technologies, PATH, Seattle, Washington, United States of America
| | - Paul Mubiri
- Department of Health Policy, Planning and Management, Makerere University, Kampala, Uganda
| | - Peter Waiswa
- Department of Health Policy, Planning and Management, Makerere University, Kampala, Uganda
| | - Patricia S Coffey
- Medical Devices and Health Technologies, PATH, Seattle, Washington, United States of America
| | - Maneesh Batra
- Department of Pediatrics and Global Health, University of Washington, Seattle, Washington, United States of America
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5
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Lategan I, Price C, Rhoda NR, Zar HJ, Tooke L. Respiratory Interventions for Preterm Infants in LMICs: A Prospective Study From Cape Town, South Africa. Front Glob Womens Health 2022; 3:817817. [PMID: 35464776 PMCID: PMC9019119 DOI: 10.3389/fgwh.2022.817817] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2021] [Accepted: 03/18/2022] [Indexed: 01/13/2023] Open
Abstract
Background Preterm birth is a global public health issue and complications of preterm birth result in the death of approximately 1 million infants each year, 99% of which are in low-and-middle income countries (LMIC). Although respiratory interventions such as continuous positive airway pressure (CPAP) and surfactant have been shown to improve the outcomes of preterm infants with respiratory distress, they are not readily available in low-resourced areas. The aim of this study was to report the respiratory support needs and outcomes of preterm infants in a low-resourced setting, and to estimate the impact of a lack of access to these interventions on neonatal mortality. Methods We conducted a six-month prospective observational study on preterm infants <1,801 g admitted at Groote Schuur Hospital and Mowbray Maternity Hospital neonatal units in Cape Town, South Africa. We extrapolated results from the study to model the potential outcomes of these infants in the absence of these interventions. Results Five hundred and fifty-two infants (552) <1,801 g were admitted. Three hundred (54.3%) infants received CPAP, and this was the initial respiratory intervention for most cases of respiratory distress syndrome. Surfactant was given to 100 (18.1%) infants and a less invasive method was the most common method of administration. Invasive mechanical ventilation was offered to 105 (19%) infants, of which only 57 (54.2%) survived until discharge from hospital. The overall mortality of the cohort was 14.1% and the hypothetical removal of invasive mechanical ventilation, surfactant and CPAP would result in an additional 157 deaths and increase the overall mortality to 42.5%. A lack of CPAP availability would have the largest impact on mortality and result in the largest number of additional deaths (109). Conclusion This study highlights the effect that access to key respiratory interventions has on preterm outcomes in LMICs. CPAP has the largest impact on neonatal mortality and improving its coverage should be the primary goal for low-resourced areas to save newborn lives.
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Affiliation(s)
- Ilse Lategan
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Caris Price
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Natasha Raygaan Rhoda
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
| | - Heather J. Zar
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- South African Medical Research Council (SA-MRC) Unit on Child and Adolescent Health, University of Cape Town, Cape Town, South Africa
| | - Lloyd Tooke
- Department of Paediatrics and Child Health, University of Cape Town, Cape Town, South Africa
- *Correspondence: Lloyd Tooke
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Soares GF, Almeida OM, Menezes JWM, Kozlov SSA, Rodrigues JJPC. Air–Oxygen Blenders for Mechanical Ventilators: A Literature Review. SENSORS 2022; 22:s22062182. [PMID: 35336353 PMCID: PMC8954851 DOI: 10.3390/s22062182] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 01/12/2022] [Revised: 02/26/2022] [Accepted: 03/08/2022] [Indexed: 02/01/2023]
Abstract
Respiratory diseases are one of the most common causes of death in the world and this recent COVID-19 pandemic is a key example. Problems such as infections, in general, affect many people and depending on the form of transmission they can spread throughout the world and weaken thousands of people. Two examples are severe acute respiratory syndrome and the recent coronavirus disease. These diseases have mild and severe forms, in which patients gravely affected need ventilatory support. The equipment that serves as a basis for operation of the mechanical ventilator is the air–oxygen blender, responsible for carrying out the air–oxygen mixture in the proper proportions ensuring constant supply. New blender models are described in the literature together with applications of control techniques, such as Proportional, Integrative and Derivative (PID); Fuzzy; and Adaptive. The results obtained from the literature show a significant improvement in patient care when using automatic controls instead of manual adjustment, increasing the safety and accuracy of the treatment. This study presents a deep review of the state of the art in air–oxygen benders, identifies the most relevant characteristics, performs a comparison study considering the most relevant available solutions, and identifies open research directions in the topic.
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Affiliation(s)
- Gabryel F. Soares
- Department of Electrical Engineering, Universidade Federal do Piauí, Teresina 64049-550, Brazil; (G.F.S.); (O.M.A.)
| | - Otacílio M. Almeida
- Department of Electrical Engineering, Universidade Federal do Piauí, Teresina 64049-550, Brazil; (G.F.S.); (O.M.A.)
| | - José W. M. Menezes
- Departament of Telematics, Federal Institute of Ceará, Fortaleza 60040-531, Brazil;
| | - Sergei S. A. Kozlov
- Photonics and Optoinformatics Faculty, ITMO University, 191002 St. Petersburg, Russia;
| | - Joel J. P. C. Rodrigues
- Photonics and Optoinformatics Faculty, ITMO University, 191002 St. Petersburg, Russia;
- Research, Post-Graduation, and Innovation, Senac Faculty of Ceará, Fortaleza 60160-194, Brazil
- Covilhã Delegation, Instituto de Telecomunicações, 6201-001 Covilhã, Portugal
- Correspondence:
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7
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Ng E, Dundek M, Burke TF. Evaluation of an innovative low flow oxygen blender system for global access. Front Pediatr 2022; 10:981821. [PMID: 36186642 PMCID: PMC9519358 DOI: 10.3389/fped.2022.981821] [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: 06/29/2022] [Accepted: 08/23/2022] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Safe and effective oxygen delivery methods are not available for the majority of infants and young children globally. A novel oxygen blender system was designed to accurately deliver concentration-controlled, oxygen-enriched air to hypoxemic children up to age five. The system does not require compressed medical air, is compatible with both oxygen tanks and oxygen concentrators, and is low cost. This is the first study that tested the performance of the innovative oxygen blender system. METHODS The performance of the oxygen blender system was assessed in vitro based on delivered oxygen levels and flow rates with an oxygen tank, an oxygen tank using a nasal occlusion model, and an oxygen concentrator. RESULTS The measured %O2 of the performance test was within ± 5% of full scale (FS) of the target value across all flows and all nasal cannulas. Occlusion testing demonstrated that 50% occlusion did not significantly affect the system outputs. The oxygen blender system was shown to be compatible with both oxygen tanks and oxygen concentrators. CONCLUSIONS The novel oxygen blender system accurately controls oxygen concentrations and blended air flow rates, and is compatible with both oxygen tanks and oxygen concentrators. This innovation may be an opportunity for improved infant and child oxygen treatment worldwide.
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Affiliation(s)
- Ellie Ng
- Vayu Global Health Foundation, Boston, MA, United States
| | - Michelle Dundek
- Vayu Global Health Foundation, Boston, MA, United States.,Global Health Innovation Lab, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States
| | - Thomas F Burke
- Vayu Global Health Foundation, Boston, MA, United States.,Global Health Innovation Lab, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA, United States.,Department of Emergency Medicine, Harvard Medical School, Boston, MA, United States.,Department of Global Health and Population, Harvard TH Chan School of Public Health, Boston, MA, United States
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Ekhaguere OA, Okonkwo IR, Batra M, Hedstrom AB. Respiratory distress syndrome management in resource limited settings-Current evidence and opportunities in 2022. Front Pediatr 2022; 10:961509. [PMID: 35967574 PMCID: PMC9372546 DOI: 10.3389/fped.2022.961509] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/04/2022] [Accepted: 06/30/2022] [Indexed: 01/19/2023] Open
Abstract
The complications of prematurity are the leading cause of neonatal mortality worldwide, with the highest burden in the low- and middle-income countries of South Asia and Sub-Saharan Africa. A major driver of this prematurity-related neonatal mortality is respiratory distress syndrome due to immature lungs and surfactant deficiency. The World Health Organization's Every Newborn Action Plan target is for 80% of districts to have resources available to care for small and sick newborns, including premature infants with respiratory distress syndrome. Evidence-based interventions for respiratory distress syndrome management exist for the peripartum, delivery and neonatal intensive care period- however, cost, resources, and infrastructure limit their availability in low- and middle-income countries. Existing research and implementation gaps include the safe use of antenatal corticosteroid in non-tertiary settings, establishing emergency transportation services from low to high level care facilities, optimized delivery room resuscitation, provision of affordable caffeine and surfactant as well as implementing non-traditional methods of surfactant administration. There is also a need to optimize affordable continuous positive airway pressure devices able to blend oxygen, provide humidity and deliver reliable pressure. If the high prematurity-related neonatal mortality experienced in low- and middle-income countries is to be mitigated, a concerted effort by researchers, implementers and policy developers is required to address these key modalities.
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Affiliation(s)
- Osayame A Ekhaguere
- Department of Pediatrics, Indiana University School of Medicine, Indianapolis, IN, United States
| | - Ikechukwu R Okonkwo
- Department of Pediatrics, University of Benin Teaching Hospital, Benin City, Nigeria
| | - Maneesh Batra
- Departments of Pediatrics and Global Health, University of Washington, Seattle, WA, United States
| | - Anna B Hedstrom
- Departments of Pediatrics and Global Health, University of Washington, Seattle, WA, United States
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9
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Dargaville PA, Marshall AP, McLeod L, Salverda HH, Te Pas AB, Gale TJ. Automation of oxygen titration in preterm infants: Current evidence and future challenges. Early Hum Dev 2021; 162:105462. [PMID: 34511288 DOI: 10.1016/j.earlhumdev.2021.105462] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
For the preterm infant with respiratory insufficiency requiring supplemental oxygen, tight control of oxygen saturation (SpO2) is advocated, but difficult to achieve in practice. Automated control of oxygen delivery has emerged as a potential solution, with six control algorithms currently embedded in commercially-available respiratory support devices. To date, most clinical evaluations of these algorithms have been short-lived crossover studies, in which a benefit of automated over manual control of oxygen titration has been uniformly noted, along with a reduction in severe SpO2 deviations and need for manual FiO2 adjustments. A single non-randomised study has examined the effect of implementation of automated oxygen control with the CLiO2 algorithm as standard care for preterm infants; no clear benefits in relation to clinical outcomes were noted, although duration of mechanical ventilation was lessened. The results of randomised controlled trials are awaited. Beyond the gathering of evidence regarding a treatment effect, we contend that there is a need for a better understanding of the function of contemporary control algorithms under a range of clinical conditions, further exploration of techniques of adaptation to individualise algorithm performance, and a concerted effort to apply this technology in low resource settings in which the majority of preterm infants receive care. Attainment of these goals will be paramount in optimisation of oxygen therapy for preterm infants globally.
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Affiliation(s)
- Peter A Dargaville
- Department of Paediatrics, Royal Hobart Hospital, Hobart, Australia; Menzies Institute for Medical Research, University of Tasmania, Hobart, Australia.
| | - Andrew P Marshall
- School of Engineering, University of Tasmania, Hobart, Tasmania, Australia
| | - Lachlann McLeod
- School of Engineering, University of Tasmania, Hobart, Tasmania, Australia
| | - Hylke H Salverda
- 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
| | - Timothy J Gale
- School of Engineering, University of Tasmania, Hobart, Tasmania, Australia
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10
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Mantena S, Burke TF. Oxygen Blending is Urgently Needed in Resource-Limited Settings. J Pediatr 2021; 237:288-291. [PMID: 33940015 DOI: 10.1016/j.jpeds.2021.04.060] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2021] [Revised: 04/22/2021] [Accepted: 04/27/2021] [Indexed: 12/23/2022]
Affiliation(s)
- Sreekar Mantena
- Departments of Statistics and Molecular and Cellular Biology, Harvard University, Cambridge, MA.
| | - Thomas F Burke
- Global Health Innovation Laboratory, Department of Emergency Medicine, Massachusetts General Hospital, Boston, MA; Harvard Medical School, Boston, MA; Harvard T.H. Chan School of Public Health, Boston, MA
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