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El-Atawi K, Abdul Wahab MG, Alallah J, Osman MF, Hassan M, Siwji Z, Saleh M. Beyond Bronchopulmonary Dysplasia: A Comprehensive Review of Chronic Lung Diseases in Neonates. Cureus 2024; 16:e64804. [PMID: 39156276 PMCID: PMC11329945 DOI: 10.7759/cureus.64804] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/18/2024] [Indexed: 08/20/2024] Open
Abstract
In neonates, pulmonary diseases such as bronchopulmonary dysplasia and other chronic lung diseases (CLDs) pose significant challenges due to their complexity and high degree of morbidity and mortality. This review discusses the etiology, pathophysiology, clinical presentation, and diagnostic criteria for these conditions, as well as current management strategies. The review also highlights recent advancements in understanding the pathophysiology of these diseases and evolving strategies for their management, including gene therapy and stem cell treatments. We emphasize how supportive care is useful in managing these diseases and underscore the importance of a multidisciplinary approach. Notably, we discuss the emerging role of personalized medicine, enabled by advances in genomics and precision therapeutics, in tailoring therapy according to an individual's genetic, biochemical, and lifestyle factors. We conclude with a discussion on future directions in research and treatment, emphasizing the importance of furthering our understanding of these conditions, improving diagnostic criteria, and exploring targeted treatment modalities. The review underscores the need for multicentric and longitudinal studies to improve preventative strategies and better understand long-term outcomes. Ultimately, a comprehensive, innovative, and patient-centered approach can enhance the quality of care and outcomes for neonates with CLDs.
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Affiliation(s)
| | | | - Jubara Alallah
- Neonatology, King Saud Bin Abdulaziz University for Health Sciences, Jeddah, SAU
- Neonatology, King Abdulaziz Medical City, Ministry of National Guard - Health Affairs, Jeddah, SAU
| | | | | | | | - Maysa Saleh
- Pediatrics and Child Health, Al Jalila Children's Specialty Hospital, Dubai, ARE
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2
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Mamidi RR, McEvoy CT. Oxygen in the neonatal ICU: a complicated history and where are we now? Front Pediatr 2024; 12:1371710. [PMID: 38751747 PMCID: PMC11094359 DOI: 10.3389/fped.2024.1371710] [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: 01/16/2024] [Accepted: 04/17/2024] [Indexed: 05/18/2024] Open
Abstract
Despite major advances in neonatal care, oxygen remains the most commonly used medication in the neonatal intensive care unit (NICU). Supplemental oxygen can be life-saving for term and preterm neonates in the resuscitation period and beyond, however use of oxygen in the neonatal period must be judicious as there can be toxic effects. Newborns experience substantial hemodynamic changes at birth, rapid energy consumption, and decreased antioxidant capacity, which requires a delicate balance of sufficient oxygen while mitigating reactive oxygen species causing oxidative stress. In this review, we will discuss the physiology of neonates in relation to hypoxia and hyperoxic injury, the history of supplemental oxygen in the delivery room and beyond, supporting clinical research guiding trends for oxygen therapy in neonatal care, current practices, and future directions.
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Affiliation(s)
- Rachna R. Mamidi
- Division of Neonatology, Oregon Health & Science University, Portland, OR, United States
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3
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Lin ET, Bae Y, Birkett R, Sharma AM, Zhang R, Fisch KM, Funk W, Mestan KK. Cord Blood Adductomics Reveals Oxidative Stress Exposure Pathways of Bronchopulmonary Dysplasia. Antioxidants (Basel) 2024; 13:494. [PMID: 38671941 PMCID: PMC11047351 DOI: 10.3390/antiox13040494] [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: 03/06/2024] [Revised: 04/13/2024] [Accepted: 04/16/2024] [Indexed: 04/28/2024] Open
Abstract
Fetal and neonatal exposures to perinatal oxidative stress (OS) are key mediators of bronchopulmonary dysplasia (BPD). To characterize these exposures, adductomics is an exposure science approach that captures electrophilic addition products (adducts) in blood protein. Adducts are bound to the nucleophilic cysteine loci of human serum albumin (HSA), which has a prolonged half-life. We conducted targeted and untargeted adductomics to test the hypothesis that adducts of OS vary with BPD. We studied 205 preterm infants (≤28 weeks) and 51 full-term infants from an ongoing birth cohort. Infant plasma was collected at birth (cord blood), 1-week, 1-month, and 36-weeks postmenstrual age. HSA was isolated from plasma, trypsin digested, and analyzed using high-performance liquid chromatography-mass spectrometry to quantify previously annotated (known) and unknown adducts. We identified 105 adducts in cord and postnatal blood. A total of 51 known adducts (small thiols, direct oxidation products, and reactive aldehydes) were increased with BPD. Postnatally, serial concentrations of several known OS adducts correlated directly with supplemental oxygen exposure. The application of large-scale adductomics elucidated OS-mediated pathways of BPD. This is the first study to investigate the "neonatal-perinatal exposome" and to identify oxidative stress-related exposure biomarkers that may inform antioxidant strategies to protect the health of future generations of infants.
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Affiliation(s)
- Erika T. Lin
- Department of Pediatrics, Division of Neonatology, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
| | - Yeunook Bae
- Department of Preventive Medicine, Northwestern University, 680 North Lake Shore Drive, Suite 1400, Chicago, IL 60611, USA; (Y.B.)
| | - Robert Birkett
- Department of Pediatrics, Division of Neonatology, Northwestern University, Chicago, IL 60611, USA
| | - Abhineet M. Sharma
- Department of Pediatrics, Division of Neonatology, Northwestern University, Chicago, IL 60611, USA
| | - Runze Zhang
- Department of Preventive Medicine, Northwestern University, 680 North Lake Shore Drive, Suite 1400, Chicago, IL 60611, USA; (Y.B.)
| | - Kathleen M. Fisch
- Department of Obstetrics, Gynecology and Reproductive Sciences, University of California San Diego, La Jolla, CA 92093, USA;
| | - William Funk
- Department of Preventive Medicine, Northwestern University, 680 North Lake Shore Drive, Suite 1400, Chicago, IL 60611, USA; (Y.B.)
| | - Karen K. Mestan
- Department of Pediatrics, Division of Neonatology, University of California San Diego, 9500 Gilman Drive, La Jolla, CA 92093, USA
- Department of Pediatrics, Division of Neonatology, Northwestern University, Chicago, IL 60611, USA
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4
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Schmölzer GM, Asztalos EV, Beltempo M, Boix H, Dempsey E, El-Naggar W, Finer NN, Hudson JA, Mukerji A, Law BHY, Yaskina M, Shah PS, Sheta A, Soraisham A, Tarnow-Mordi W, Vento M. Does the use of higher versus lower oxygen concentration improve neurodevelopmental outcomes at 18-24 months in very low birthweight infants? Trials 2024; 25:237. [PMID: 38576007 PMCID: PMC10996184 DOI: 10.1186/s13063-024-08080-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2023] [Accepted: 03/29/2024] [Indexed: 04/06/2024] Open
Abstract
BACKGROUND Immediately after birth, the oxygen saturation is between 30 and 50%, which then increases to 85-95% within the first 10 min. Over the last 10 years, recommendations regarding the ideal level of the initial fraction of inspired oxygen (FiO2) for resuscitation in preterm infants have changed from 1.0, to room air to low levels of oxygen (< 0.3), up to moderate concentrations (0.3-0.65). This leaves clinicians in a challenging position, and a large multi-center international trial of sufficient sample size that is powered to look at safety outcomes such as mortality and adverse neurodevelopmental outcomes is required to provide the necessary evidence to guide clinical practice with confidence. METHODS An international cluster, cross-over randomized trial of initial FiO2 of 0.3 or 0.6 during neonatal resuscitation in preterm infants at birth to increase survival free of major neurodevelopmental outcomes at 18 and 24 months corrected age will be conducted. Preterm infants born between 230/7 and 286/7 weeks' gestation will be eligible. Each participating hospital will be randomized to either an initial FiO2 concentration of either 0.3 or 0.6 to recruit for up to 12 months' and then crossed over to the other concentration for up to 12 months. The intervention will be initial FiO2 of 0.6, and the comparator will be initial FiO2 of 0.3 during respiratory support in the delivery room. The sample size will be 1200 preterm infants. This will yield 80% power, assuming a type 1 error of 5% to detect a 25% reduction in relative risk of the primary outcome from 35 to 26.5%. The primary outcome will be a composite of all-cause mortality or the presence of a major neurodevelopmental outcome between 18 and 24 months corrected age. Secondary outcomes will include the components of the primary outcome (death, cerebral palsy, major developmental delay involving cognition, speech, visual, or hearing impairment) in addition to neonatal morbidities (severe brain injury, bronchopulmonary dysplasia; and severe retinopathy of prematurity). DISCUSSION The use of supplementary oxygen may be crucial but also potentially detrimental to preterm infants at birth. The HiLo trial is powered for the primary outcome and will address gaps in the evidence due to its pragmatic and inclusive design, targeting all extremely preterm infants. Should 60% initial oxygen concertation increase survival free of major neurodevelopmental outcomes at 18-24 months corrected age, without severe adverse effects, this readily available intervention could be introduced immediately into clinical practice. TRIAL REGISTRATION The trial was registered on January 31, 2019, at ClinicalTrials.gov with the Identifier: NCT03825835.
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Affiliation(s)
- Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, Edmonton, AB, T5H 3V9, Canada.
- Dept. of Pediatrics, University of Alberta, Edmonton, Canada.
| | - Elizabeth V Asztalos
- Department of Newborn & Developmental Paediatrics, Sunnybrook Health Sciences Centre and University of Toronto, Toronto, ON, Canada
| | - Marc Beltempo
- Departement of Pediatrics, Montreal Children's HospitalMcGill University Health CenterMcGill University, Montreal, QC, Canada
| | - Hector Boix
- Division of Neonatology, Dexeus Quironsalud University Hospital, Barcelona, Spain
| | - Eugene Dempsey
- INFANT Research Centre, University College Cork, Cork, Ireland
| | - Walid El-Naggar
- Department of Paediatrics, Dalhousie University, Halifax, Canada
| | - Neil N Finer
- School of Medicine, University of California, San Diego, CA, USA
- Sharp Mary Birch Hospital for Women and Newborns, San Diego, USA
| | - Jo-Anna Hudson
- Faculty of Medicine, Memorial University of Newfoundland, St. John's, NF, Canada
| | - Amit Mukerji
- Division of Neonatology, Department of Pediatrics, McMaster University, Hamilton, ON, Canada
| | - Brenda H Y Law
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue NW, Edmonton, AB, T5H 3V9, Canada
- Dept. of Pediatrics, University of Alberta, Edmonton, Canada
| | - Maryna Yaskina
- Women and Children's Health Research Institute (WCHRI), University of Alberta, Edmonton, Canada
| | - Prakesh S Shah
- Department of Pediatrics, Mount Sinai Hospital and University of Toronto, Toronto, Canada
| | - Ayman Sheta
- Department of Pediatrics and Child Health, University of Manitoba, Winnipeg, MB, Canada
| | - Amuchou Soraisham
- Department of Pediatrics, Foothills Medical Centre, University of Calgary, Calgary, AB, Canada
- Alberta Childrens Hospital Research Institute, University of Calgary, Alberta, Canada
| | - William Tarnow-Mordi
- Trials Centre, National Health and Medical Research Council Clinical, University of Sydney, Camperdown, Australia
| | - Max Vento
- Department of Pediatrics, La Fe University and Polytechnic Hospital, Valencia, Spain
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5
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Sola A, Leslie Altimier, Teresa Montes Bueno M, Muñoz CE. Monitoring SpO 2: The Basics of Retinopathy of Prematurity (Back to Basics) and Targeting Oxygen Saturation. Crit Care Nurs Clin North Am 2024; 36:69-98. [PMID: 38296377 DOI: 10.1016/j.cnc.2023.08.004] [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: 02/05/2024]
Abstract
Oxygen (O2) is a drug frequently used in newborn care. Adverse effects of hypoxia are well known but the damaging effects of excess oxygen administration and oxidative stress have only been studied in the last 2 decades. Many negative effects have been described, including retinopathy of prematurity . Noninvasive pulse oximetry (SpO2) is useful to detect hypoxemia but requires careful evaluation and understanding of the frequently changing relationship between O2 and hemoglobin to prevent hyperoxemia. Intention to treat SpO2 ranges should be individualized for every newborn receiving supplemental O2, according to gestational age, post-natal age, and clinical condition.
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Affiliation(s)
- Augusto Sola
- Iberoamerican Society of Neonatology (SIBEN), 2244 Newbury Drive, Wellington, FL 3341, USA.
| | - Leslie Altimier
- Cardinal Glennon Children's Hospital, 1465 South Grand Avenue, St. Louis, MO 63104, USA
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6
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Sotiropoulos JX, Oei JL. The role of oxygen in the development and treatment of bronchopulmonary dysplasia. Semin Perinatol 2023; 47:151814. [PMID: 37783577 DOI: 10.1016/j.semperi.2023.151814] [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] [Indexed: 10/04/2023]
Abstract
Oxygen (O2) is crucial for both the development and treatment of one of the most important consequences of prematurity: bronchopulmonary dysplasia (BPD). In fetal life, the hypoxic environment is important for alveolar development and maturation. After birth, O2 becomes a double-edged sword. While O2 is needed to prevent hypoxia, it also causes oxidative stress leading to a plethora of morbidities, including retinopathy and BPD. The advent of continuous O2 monitoring with pulse oximeters has allowed clinicians to recognize the narrow therapeutic margins of oxygenation for the preterm infant, but more knowledge is needed to understand what these ranges are at different stages of the preterm infant's life, including at birth, in the neonatal intensive care unit and after hospital discharge. Future research, especially in innovative technologies such as automated O2 control and remote oximetry, will improve the understanding and treatment of the O2 needs of infants with BPD.
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Affiliation(s)
- J X Sotiropoulos
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Australia; Department of Newborn Care, The Royal Hospital for Women, Randwick, New South Wales, Australia; NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Australia
| | - J L Oei
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Australia; Department of Newborn Care, The Royal Hospital for Women, Randwick, New South Wales, Australia; NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Australia.
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7
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Gunawardana S, Arattu Thodika FMS, Murthy V, Bhat P, Williams EE, Dassios T, Milner AD, Greenough A. Respiratory function monitoring during early resuscitation and prediction of outcomes in prematurely born infants. J Perinat Med 2023; 51:950-955. [PMID: 36800988 DOI: 10.1515/jpm-2022-0538] [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: 11/07/2022] [Accepted: 01/25/2023] [Indexed: 02/21/2023]
Abstract
OBJECTIVES Over the last decade, there has been increased use of end-tidal carbon dioxide (ETCO2) and oxygen saturation (SpO2) monitoring during resuscitation of prematurely born infants in the delivery suite. Our objectives were to test the hypotheses that low end-tidal carbon dioxide (ETCO2) levels, low oxygen saturations (SpO2) and high expiratory tidal volumes (VTE) during the early stages of resuscitation would be associated with adverse outcomes in preterm infants. METHODS Respiratory recordings made in the first 10 min of resuscitation in the delivery suite of 60 infants, median GA 27 (interquartile range 25-29) weeks were analysed. The results were compared of infants who did or did not die or did or did not develop intracerebral haemorrhage (ICH) or bronchopulmonary dysplasia (BPD). RESULTS Twenty-five infants (42%) developed an ICH and 23 (47%) BPD; 11 (18%) died. ETCO2 at approximately 5 min after birth was lower in infants who developed an ICH, this remained significant after adjusting for gestational age, coagulopathy and chorioamnionitis (p=0.03). ETCO2 levels were lower in infants who developed ICH or died compared to those that survived without ICH, which remained significant after adjustment for gestational age, Apgar score at 10 min, chorioamnionitis and coagulopathy (p=0.004). SpO2 at approximately 5 min was lower in the infants who died compared to those who survived which remained significant after adjusting for the 5-min Apgar score and chorioamnionitis (p=0.021). CONCLUSIONS ETCO2 and SpO2 levels during early resuscitation in the delivery suite were associated with adverse outcomes.
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Affiliation(s)
- Shannon Gunawardana
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Fahad M S Arattu Thodika
- Department of Women and Children's Health, School of Life Course Sciences, Faculty of Life Sciences and Medicine, King's College London, London, UK
| | - Vadivelam Murthy
- Neonatal Intensive Care Centre, Barts Health NHS Trust, London, UK
| | - Prashanth Bhat
- Neonatal Intensive Care Centre, Brighton and Sussex University Hospital, Sussex, UK
| | - Emma E Williams
- 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
| | - Anthony D Milner
- 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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8
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Sanlorenzo LA, Hatch LD. Developing a Respiratory Quality Improvement Program to Prevent and Treat Bronchopulmonary Dysplasia in the Neonatal Intensive Care Unit. Clin Perinatol 2023; 50:363-380. [PMID: 37201986 DOI: 10.1016/j.clp.2023.01.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/20/2023]
Abstract
Improvements in respiratory care have resulted in improved outcomes for preterm infants over the past three decades. To target the multifactorial nature of neonatal lung diseases, neonatal intensive care units (NICUs) should consider developing comprehensive respiratory quality improvement programs that address all drivers of neonatal respiratory disease. This article presents a potential framework for developing a quality improvement program to prevent bronchopulmonary dysplasia in the NICU. Drawing on available research and quality improvement reports, the authors discuss key components, measures, drivers, and interventions that should be considered when building a respiratory quality improvement program devoted to preventing and treating bronchopulmonary dysplasia.
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Affiliation(s)
- Lauren A Sanlorenzo
- Department of Pediatrics, Division of Neonatology, Columbia University Medical Center, 3959 Broadway Avenue, New York, NY 10032, USA
| | - Leon Dupree Hatch
- Department of Pediatrics, Division of Neonatology, Vanderbilt University Medical Center, 4413 VCH, 2200 Children's Way, Nashville, TN 37232, USA; Center for Child Health Policy, Vanderbilt University Medical Center, Nashville, TN, USA; Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, TN, USA.
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9
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Escrig-Fernández R, Zeballos-Sarrato G, Gormaz-Moreno M, Avila-Alvarez A, Toledo-Parreño JD, Vento M. The Respiratory Management of the Extreme Preterm in the Delivery Room. CHILDREN (BASEL, SWITZERLAND) 2023; 10:children10020351. [PMID: 36832480 PMCID: PMC9955623 DOI: 10.3390/children10020351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/12/2022] [Revised: 02/03/2023] [Accepted: 02/06/2023] [Indexed: 02/12/2023]
Abstract
The fetal-to-neonatal transition poses an extraordinary challenge for extremely low birth weight (ELBW) infants, and postnatal stabilization in the delivery room (DR) remains challenging. The initiation of air respiration and the establishment of a functional residual capacity are essential and often require ventilatory support and oxygen supplementation. In recent years, there has been a tendency towards the soft-landing strategy and, subsequently, non-invasive positive pressure ventilation has been generally recommended by international guidelines as the first option for stabilizing ELBW in the delivery room. On the other hand, supplementation with oxygen is another cornerstone of the postnatal stabilization of ELBW infants. To date, the conundrum concerning the optimal initial inspired fraction of oxygen, target saturations in the first golden minutes, and oxygen titration to achieve desired stability saturation and heart rate values has not yet been solved. Moreover, the retardation of cord clamping together with the initiation of ventilation with the patent cord (physiologic-based cord clamping) have added additional complexity to this puzzle. In the present review, we critically address these relevant topics related to fetal-to-neonatal transitional respiratory physiology, ventilatory stabilization, and oxygenation of ELBW infants in the delivery room based on current evidence and the most recent guidelines for newborn stabilization.
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Affiliation(s)
- Raquel Escrig-Fernández
- Department of Neonatology, Hospital Universitari i Politècnic La Fe, 106 Fernando Abril Martorell Avenue, 46026 Valencia, Spain
- Correspondence:
| | | | - María Gormaz-Moreno
- Department of Neonatology, Hospital Universitari i Politècnic La Fe, 106 Fernando Abril Martorell Avenue, 46026 Valencia, Spain
| | - Alejandro Avila-Alvarez
- Division of Neonatology, Pediatric Department, Complexo Hospitalario Universitario de A Coruña (CHUAC), Sergas, 15006 A Coruña, Spain
| | - Juan Diego Toledo-Parreño
- Department of Neonatology, Hospital Universitari i Politècnic La Fe, 106 Fernando Abril Martorell Avenue, 46026 Valencia, Spain
| | - Máximo Vento
- Department of Neonatology, Hospital Universitari i Politècnic La Fe, 106 Fernando Abril Martorell Avenue, 46026 Valencia, Spain
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10
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Splanchnic oxygen saturation during reoxygenation with 21% or 100% O 2 in newborn piglets. Pediatr Res 2022; 92:445-452. [PMID: 34725499 DOI: 10.1038/s41390-021-01819-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 09/29/2021] [Accepted: 10/06/2021] [Indexed: 12/23/2022]
Abstract
BACKGROUND Increasing evidence recognizes the harm of excess oxygen to lungs, eyes, and brain of preterm infants, but not yet to the intestine. We assessed changes in splanchnic oxygenation during reoxygenation with 21% compared to 100% O2 in a newborn piglet model of perinatal asphyxia. METHODS We randomized 25 piglets to control or intervention. Intervention groups underwent global hypoxia until acidosis and hypotension occurred. Piglets were reoxygenated for 30 min with 21% or 100% O2 and observed for 9 h. We continuously measured regional splanchnic oxygen saturation (rsSO2) using near-infrared spectroscopy (NIRS). We calculated mean rsSO2 and rsCoVar (as SD/mean). We measured PaO2 and SaO2, sampled from the right carotid artery. RESULTS Reoxygenation after global hypoxia restored rsSO2. Reoxygenation with 100% O2 increased rsSO2 to values significantly higher than baseline. In intervention groups, rsCoVar decreased during observation compared to baseline. We found a correlation between rsSO2 and PaO2 (r = 0.420, P < 0.001) and between rsSO2 and SaO2 (r = 0.648, P < 0.001) in pooled data from the entire experiment. CONCLUSION Reoxygenation after global hypoxia improves splanchnic oxygenation, but is associated with reduced variability of rsSO2. Reoxygenation with 100% O2 exposes the intestine to hyperoxia. Splanchnic NIRS is able to detect intestinal hypoxia and hyperoxia. IMPACT Splanchnic oxygenation improves during reoxygenation after global hypoxia, though reoxygenation with 100% O2 exposes the intestine to hyperoxia. Decreased variability of splanchnic oxygenation several hours after hypoxia and reoxygenation seems to be independent of the resuscitation strategy, and may indicate intestinal injury. Splanchnic NIRS monitoring was able to detect intestinal hypoxia and exposure to hyperoxia, as evidenced by a strong correlation between splanchnic oxygenation and arterial oxygen content.
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11
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Oei JL, Kapadia V, Rabi Y, Saugstad OD, Rook D, Vermeulen MJ, Boronat N, Thamrin V, Tarnow-Mordi W, Smyth J, Wright IM, Lui K, van Goudoever JB, Gebski V, Vento M. Neurodevelopmental outcomes of preterm infants after randomisation to initial resuscitation with lower (FiO 2 <0.3) or higher (FiO 2 >0.6) initial oxygen levels. An individual patient meta-analysis. Arch Dis Child Fetal Neonatal Ed 2022; 107:386-392. [PMID: 34725105 DOI: 10.1136/archdischild-2021-321565] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2021] [Accepted: 10/04/2021] [Indexed: 11/03/2022]
Abstract
OBJECTIVE To determine the effects of lower (≤0.3) versus higher (≥0.6) initial fractional inspired oxygen (FiO2) for resuscitation on death and/or neurodevelopmental impairment (NDI) in infants <32 weeks' gestation. DESIGN Meta-analysis of individual patient data from three randomised controlled trials. SETTING Neonatal intensive care units. PATIENTS 543 children <32 weeks' gestation. INTERVENTION Randomisation at birth to resuscitation with lower (≤0.3) or higher (≥0.6) initial FiO2. OUTCOME MEASURES Primary: death and/or NDI at 2 years of age.Secondary: post-hoc non-randomised observational analysis of death/NDI according to 5-minute oxygen saturation (SpO2) below or at/above 80%. RESULTS By 2 years of age, 46 of 543 (10%) children had died. Of the 497 survivors, 84 (17%) were lost to follow-up. Bayley Scale of Infant Development (third edition) assessments were conducted on 377 children. Initial FiO2 was not associated with difference in death and/or disability (difference (95% CI) -0.2%, -7% to 7%, p=0.96) or with cognitive scores <85 (2%, -5% to 9%, p=0.5). Five-minute SpO2 >80% was associated with decreased disability/death (14%, 7% to 21%) and cognitive scores >85 (10%, 3% to 18%, p=0.01). Multinomial regression analysis noted decreased death with 5-minute SpO2 ≥80% (odds (95% CI) 09.62, 0.98 to 0.96) and gestation (0.52, 0.41 to 0.65), relative to children without death or NDI. CONCLUSION Initial FiO2 was not associated with difference in risk of disability/death at 2 years in infants <32 weeks' gestation but CIs were wide. Substantial benefit or harm cannot be excluded. Larger randomised studies accounting for patient differences, for example, gestation and gender are urgently needed.
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Affiliation(s)
- Ju Lee Oei
- Newborn Intensive Care Unit, The Royal Hospital for Women, Randwick, New South Wales, Australia .,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Vishal Kapadia
- Department of Pediatrics, Howard Hughes Medical Institute-University of Texas Southwestern Medical Center at Dallas, Dallas, Texas, USA
| | - Yacov Rabi
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada
| | - Ola Didrik Saugstad
- Department of Pediatric Research, Oslo University Hospital, Rikshospitalet, University of Oslo, Oslo, Norway
| | - Denise Rook
- Department of Pediatrics, Erasmus MC, Rotterdam, The Netherlands
| | - Marijn J Vermeulen
- Division of Neonatology, Erasmus MC-Sophia Children's Hospital, Rotterdam, The Netherlands
| | - Nuria Boronat
- La Fe Health Research Institute, La Fe University and Polytechnic Hospital, Valencia, Spain.,Division of Neonatology, La Fe University and Polytechnic Hospital, Valencia, Spain
| | - Valerie Thamrin
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - William Tarnow-Mordi
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - John Smyth
- Newborn Intensive Care Unit, The Royal Hospital for Women, Randwick, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Ian M Wright
- College of Medicine and Dentistry, James Cook University, Cairns, Queensland, Australia
| | - Kei Lui
- Newborn Intensive Care Unit, The Royal Hospital for Women, Randwick, New South Wales, Australia.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Johannes B van Goudoever
- Department of Pediatrics, Emma Children's Hospital AMC, Amsterdam, The Netherlands.,Department of Pediatrics, Amsterdam UMC-VUMC location, Amsterdam, The Netherlands
| | - Val Gebski
- NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Maximo Vento
- La Fe Health Research Institute, La Fe University and Polytechnic Hospital, Valencia, Spain.,Division of Neonatology, La Fe University and Polytechnic Hospital, Valencia, Spain
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12
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Abiramalatha T, Ramaswamy VV, Bandyopadhyay T, Somanath SH, Shaik NB, Pullattayil AK, Weiner GM. Interventions to Prevent Bronchopulmonary Dysplasia in Preterm Neonates: An Umbrella Review of Systematic Reviews and Meta-analyses. JAMA Pediatr 2022; 176:502-516. [PMID: 35226067 DOI: 10.1001/jamapediatrics.2021.6619] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/08/2023]
Abstract
IMPORTANCE Bronchopulmonary dysplasia (BPD) has multifactorial etiology and long-term adverse consequences. An umbrella review enables the evaluation of multiple proposed interventions for the prevention of BPD. OBJECTIVE To summarize and assess the certainty of evidence of interventions proposed to decrease the risk of BPD from published systematic reviews. DATA SOURCES MEDLINE, Cochrane Central Register of Controlled Trials, EMBASE, and Web of Science were searched from inception until November 9, 2020. STUDY SELECTION Meta-analyses of randomized clinical trials comparing interventions in preterm neonates that included BPD as an outcome. DATA EXTRACTION AND SYNTHESIS Data extraction was performed in duplicate. Quality of systematic reviews was evaluated using Assessment of Multiple Systematic Reviews version 2, and certainty of evidence was assessed using Grading of Recommendation, Assessment, Development, and Evaluation. MAIN OUTCOMES AND MEASURES (1) BPD or mortality at 36 weeks' postmenstrual age (PMA) and (2) BPD at 36 weeks' PMA. RESULTS A total of 154 systematic reviews evaluating 251 comparisons were included, of which 110 (71.4%) were high-quality systematic reviews. High certainty of evidence from high-quality systematic reviews indicated that delivery room continuous positive airway pressure compared with intubation with or without routine surfactant (relative risk [RR], 0.80 [95% CI, 0.68-0.94]), early selective surfactant compared with delayed selective surfactant (RR, 0.83 [95% CI, 0.75-0.91]), early inhaled corticosteroids (RR, 0.86 [95% CI, 0.75-0.99]), early systemic hydrocortisone (RR, 0.90 [95% CI, 0.82-0.99]), avoiding endotracheal tube placement with delivery room continuous positive airway pressure and use of less invasive surfactant administration (RR, 0.90 [95% CI, 0.82-0.99]), and volume-targeted compared with pressure-limited ventilation (RR, 0.73 [95% CI, 0.59-0.89]) were associated with decreased risk of BPD or mortality at 36 weeks' PMA. Moderate to high certainty of evidence showed that inhaled nitric oxide, lower saturation targets (85%-89%), and vitamin A supplementation are associated with decreased risk of BPD at 36 weeks' PMA but not the competing outcome of BPD or mortality, indicating they may be associated with increased mortality. CONCLUSIONS AND RELEVANCE A multipronged approach of delivery room continuous positive airway pressure, early selective surfactant administration with less invasive surfactant administration, early hydrocortisone prophylaxis in high-risk neonates, inhaled corticosteroids, and volume-targeted ventilation for preterm neonates requiring invasive ventilation may decrease the combined risk of BPD or mortality at 36 weeks' PMA.
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Affiliation(s)
- Thangaraj Abiramalatha
- Department of Neonatology, Kovai Medical Center and Hospital (KMCH) & KMCH Institute of Health Sciences and Research, Coimbatore, India
| | | | - Tapas Bandyopadhyay
- Department of Neonatology, Dr Ram Manohar Lohia Hospital & Post Graduate Institute of Medical Education and Research, New Delhi, India
| | | | | | | | - Gary M Weiner
- Department of Pediatrics-Neonatology, University of Michigan, Ann Arbor
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13
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Abstract
There are no standardized procedures for the resuscitation of micropreemies but respiratory and circulatory stabilization immediately after birth should be prioritized. Without aggressive support by positive pressure ventilation, establishing effective respiration among micropreemies is not possible. The first step in postnatal stabilization is initiated by positive airway pressure with a bag and mask. Once the heart rate increases above 100 beats/m, intratracheal intubation should be achieved because it is unusual for a micropreemie to breathe spontaneously or by non-invasive respiratory support for a protracted duration. Until further information is available, initial FiO2 should be between 0.3 and 0.6, and titrated to achieve SpO2 obtained from healthy term infants for the first 10 min of life. Temperature control of infants is also critical for successful resuscitation and heat-loss minimizing procedures should be used e.g. with insulating bags. After securing the intratracheal tube, the infants should be transferred to the NICU for further procedures, including pulmonary surfactant installation and umbilical cord catheterization. Procedures in a delivery room under a radiant warmer should be limited to the initial resuscitation. In NICUs, the infants should be placed into a closed incubator to maintain high environmental temperature and humidity as well as decrease exposure to intervention and noise. Increased number of staff will also be needed to stabilize the infants further in the NICU. Finally, appropriate equipment (e.g. appropriate sized laryngoscopes) should be made readily available, along with regular practical training and education, whether in person or through SIM courses which are essential for all staff to achieve competence in successful resuscitation of the newborn micropreemie.
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14
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Bruckner M, Schmölzer GM. Physiologic Changes during Neonatal Transition and the Influence of Respiratory Support. Clin Perinatol 2021; 48:697-709. [PMID: 34774204 DOI: 10.1016/j.clp.2021.07.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Marlies Bruckner
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue, Edmonton, Alberta, T5H 3V9, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 30, Graz, Austria
| | - Georg M Schmölzer
- Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, 10240 Kingsway Avenue, Edmonton, Alberta, T5H 3V9, Canada; Department of Pediatrics, University of Alberta, Edmonton, Alberta, Canada; Division of Neonatology, Department of Pediatrics and Adolescent Medicine, Medical University of Graz, Auenbruggerplatz 30, Graz, Austria.
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15
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Higher versus Lower Oxygen Concentration during Respiratory Support in the Delivery Room in Extremely Preterm Infants: A Pilot Feasibility Study. CHILDREN 2021; 8:children8110942. [PMID: 34828655 PMCID: PMC8625238 DOI: 10.3390/children8110942] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/08/2021] [Revised: 10/07/2021] [Accepted: 10/15/2021] [Indexed: 11/28/2022]
Abstract
Background: Optimal starting oxygen concentration for delivery room resuscitation of extremely preterm infants (<29 weeks) remains unknown, with recommendations of 21–30% based on uncertain evidence. Individual patient randomized trials designed to answer this question have been hampered by poor enrolment. Hypothesis: It is feasible to compare 30% vs. 60% starting oxygen for delivery room resuscitation of extremely preterm infants using a change in local hospital policy and deferred consent approach. Study design: Prospective, single-center, feasibility study, with each starting oxygen concentration used for two months for all eligible infants. Population: Infants born at 23 + 0–28 + 6 weeks’ gestation who received delivery room resuscitation. Study interventions: Initial oxygen at 30% or 60%, increasing by 10–20% every minute for heart rate < 100 bpm, or increase to 100% for chest compressions. Primary outcome: Feasibility, defined by (i) achieving difference in cumulative supplied oxygen concentration between groups, and (ii) post-intervention rate consent >50%. Results: Thirty-four infants were born during a 4-month period; consent was obtained in 63%. Thirty (n = 12, 30% group; n = 18, 60% group) were analyzed, including limited data from eight who died or were transferred before parents could be approached. Median cumulative oxygen concentrations were significantly different between the two groups in the first 5 min. Conclusion: Randomized control trial of 30% or 60% oxygen at the initiation of resuscitation of extremely preterm neonates with deferred consent is feasible. Trial registration: Clinicaltrials.gov NCT03706586
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16
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Abstract
Bronchopulmonary dysplasia (BPD) is the most common chronic lung disease in infants and is associated with increased mortality, respiratory morbidity, neurodevelopmental impairment, and increased healthcare costs. In parallel with advances made in the field of neonatal intensive care, the phenotype of BPD has evolved from a fibrocystic disease affecting late preterm infants to one of impaired parenchymal development and dysregulated vascular growth predominantly affecting infants born before 29 weeks' gestational age. BPD has been shown to have significant lifelong consequences. Adults with BPD have been found to have abnormal lung function tests, reduced exercise tolerance, and may be at increased risk for developing chronic obstructive pulmonary disease. Evidence shows that BPD occurs secondary to genetic-environmental interactions in an immature lung. In this review, we evaluate the various clinical definitions, imaging modalities, and biomarker data that are helpful in making an early diagnosis of BPD. In addition, we evaluate recent evidence about the prevention and treatment of BPD. We discuss the invasive and non-invasive ventilation strategies and pharmacological agents used in the early, evolving, and established phases of BPD.
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Affiliation(s)
- Margaret Gilfillan
- Division of Neonatology, St Christopher's Hospital for Children, Philadelphia, PA, USA
- Drexel University College of Medicine, Philadelphia, PA, USA
| | - Anita Bhandari
- Division of Pulmonary and Sleep Medicine, Children's Hospital of Philadelphia, PA, USA
- Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Vineet Bhandari
- Division of Neonatology, The Children's Regional Hospital at Cooper, Camden, NJ, USA
- Cooper Medical School of Rowan University, Camden, NJ, USA
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17
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Lakshminrusimha S, Vali P, Chandrasekharan P, Rich W, Katheria A. Differential Alveolar and Systemic Oxygenation during Preterm Resuscitation with 100% Oxygen during Delayed Cord Clamping. Am J Perinatol 2021; 40:630-637. [PMID: 34062568 DOI: 10.1055/s-0041-1730362] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
Abstract
OBJECTIVE Delayed cord clamping (DCC) and 21 to 30% O2 resuscitation is recommended for preterm infants but is commonly associated with low pulmonary blood flow (Qp) and hypoxia. 100% O2 supplementation during DCC for 60 seconds followed by 30% O2 may increase Qp and oxygen saturation (SpO2). STUDY DESIGN Preterm lambs (125-127 days of gestation) were resuscitated with 100% O2 with immediate cord clamping (ICC, n = 7) or ICC + 30% O2, and titrated to target SpO2 (n = 7) or DCC + 100% O2 for 60 seconds, which followed by cord clamping and 30% O2 titration (n = 7). Seven preterm (23-27 weeks of gestation) human infants received continuous positive airway pressure (CPAP) + 100% O2 for 60 seconds during DCC, cord clamping, and 30% O2 supplementation after cord clamping. RESULTS Preterm lambs in the ICC + 100% O2 group resulted in PaO2 (77 ± 25 mmHg), SpO2 (77 ± 11%), and Qp (27 ± 9 mL/kg/min) at 60 seconds. ICC + 30% O2 led to low Qp (14 ± 3 mL/kg/min), low SpO2 (43 ± 26%), and PaO2 (19 ± 7 mmHg). DCC + 100% O2 led to similar Qp (28 ± 6 mL/kg/min) as ICC + 100% O2 with lower PaO2. In human infants, DCC + CPAP with 100% O2 for 60 seconds, which followed by weaning to 30% resulted in SpO2 of 92 ± 11% with all infants >80% at 5 minutes with 100% survival without severe intraventricular hemorrhage. CONCLUSION DCC + 100% O2 for 60 seconds increased Qp probably due to transient alveolar hyperoxia with systemic normoxia due to "dilution" by umbilical venous return. Larger translational and clinical studies are warranted to confirm these findings. KEY POINTS · Transient alveolar hyperoxia during delayed cord clamping can enhance pulmonary vasodilation.. · Placental transfusion buffers systemic oxygen tension and limits hyperoxia.. · Use of 100% oxygen for 60 seconds during DCC was associated with SpO2 ≥80% by 5 minutes..
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Affiliation(s)
| | - Payam Vali
- Department of Pediatrics, University of California Davis, Sacramento, California
| | | | - Wade Rich
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, California
| | - Anup Katheria
- Neonatal Research Institute, Sharp Mary Birch Hospital for Women and Newborns, San Diego, California
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18
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Saugstad OD, Kapadia V, Oei JL. Oxygen in the First Minutes of Life in Very Preterm Infants. Neonatology 2021; 118:218-224. [PMID: 33902059 DOI: 10.1159/000516261] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/21/2021] [Accepted: 03/22/2021] [Indexed: 11/19/2022]
Abstract
Even a few minutes of exposure to oxygen in the delivery room in very preterm and immature infants may have detrimental effects. The initial oxygenation in the delivery room should therefore be optimized, but knowledge gaps, including initial fraction of oxygen (FiO2) and how FiO2 should be changed to reach an optimal oxygen saturation measured by pulse oximetry (SpO2) target within the first 5-10 min of life, remain. In order to answer this question, we therefore reviewed relevant literature. For newly born infants with gestational age (GA) <32 weeks in need of positive pressure ventilation (PPV) immediately after birth, we identified 2 fundamental issues: (1) the optimal initial FiO2 and (2) the target SpO2 within the first 5-10 min of life. For newly born infants between 29 and 31 weeks of GA, an initial FiO2 of 0.3 hit the target defined by the International Liaison Committee on Resuscitation (ILCOR) best. Newborn infants with GA <29 weeks in need of PPV and supplementary oxygen, we suggest starting with FiO2 0.3 and adjusting the FiO2 to reach SpO2 of 80% within 5 min of life for best outcomes. Prolonged bradycardia (heart rate <100 bpm for >2 min) is associated with increased risk of adverse outcomes, including death. The combination of strict control of development of SpO2 in the first 10 min of life and a heart rate >100 bpm represents the best tool today to achieve the most optimal outcome in the delivery room of very preterm and immature newborn infants.
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Affiliation(s)
- Ola Didrik 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, USA
| | - Vishal Kapadia
- Division of Neonatal-Perinatal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Ju Lee Oei
- School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
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19
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Optimizing Oxygenation of the Extremely Premature Infant during the First Few Minutes of Life: Start Low or High? J Pediatr 2020; 227:295-299. [PMID: 32663594 DOI: 10.1016/j.jpeds.2020.07.034] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2020] [Revised: 07/02/2020] [Accepted: 07/08/2020] [Indexed: 02/04/2023]
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20
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Abstract
Oxygen is commonly used in the delivery room during neonatal resuscitation. The transition from intrauterine to extrauterine life is a challenge to newborns, and exposure to too much oxygen can cause an increase in oxidative stress. The goal of resuscitation is to achieve normal oxygen levels as quickly as possible while avoiding excessive oxygen exposure and preventing inadequate oxygen supplementation. Although it has been shown that room air resuscitation is as effective as using 100% oxygen, often preterm infants need some degree of oxygen supplementation. The ideal concentration of oxygen with which to initiate resuscitation is yet to be determined. Current delivery room resuscitation guidelines recommend the use of room air for term newborns and preterm newborns of greater than or equal to 35 weeks' gestation and the use of a fraction of inspired oxygen of 0.21 to 0.3 for preterm infants of less than 35 weeks' gestation. Further recommendations include titrating oxygen supplementation as needed to obtain goal saturations. However, there is no current consensus on an intermediate oxygen concentration to start resuscitation or goal range saturations for preterm and asphyxiated term infants.
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Affiliation(s)
- Esther Kim
- Department of Pediatrics, Division of Neonatology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
| | - Margaret Nguyen
- Department of Pediatrics, Division of Neonatology, David Geffen School of Medicine, University of California Los Angeles, Los Angeles, CA
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21
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Oxygen for respiratory support of moderate and late preterm and term infants at birth: Is air best? Semin Fetal Neonatal Med 2020; 25:101074. [PMID: 31843378 DOI: 10.1016/j.siny.2019.101074] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Oxygen has been used for newborn infant resuscitation for more than two centuries. In the last two decades, concerns about oxidative stress and injury have changed this practice. Air (FiO2 0.21) is now preferred as the starting point for respiratory support of infants 34 weeks gestation and above. These recommendations are derived from studies that were conducted on asphyxiated, term infants, recruited more than 10 years ago using strategies that are not commonly used today. The applicability of these recommendations to current practice, is uncertain. In addition, whether initiating respiratory support with air for infants with pulmonary disorders provides sufficient oxygenation is also unclear. This review will address these concerns and provide suggestions for future steps to address knowledge and practice gaps.
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22
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Chandrasekharan P, Lakshminrusimha S. Oxygen therapy in preterm infants with pulmonary hypertension. Semin Fetal Neonatal Med 2020; 25:101070. [PMID: 31836427 PMCID: PMC9188671 DOI: 10.1016/j.siny.2019.101070] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Premature neonates <34 weeks gestation can present with early-onset, late-onset and bronchopulmonary dysplasia (BPD) associated pulmonary hypertension (PHT), with clinical, echocardiographic, and histological features similar to term infants with PHT. Changes in pulmonary vascular resistance (PVR) in response to oxygen are diminished in preterm infants compared to term. Studies from preterm lambs and human infants with BPD have shown that PaO2 > 30-55 mm Hg promotes pulmonary vasodilation. Targeting saturations of 80-85% by 5 min, 85-95% by 10 min during resuscitation and 90-95% during the postnatal course are appropriate targets for routine management of preterm infants. Among preterm infants with PHT, avoiding hypoxia/hyperoxia by titrating supplemental oxygen to maintain saturations in low to mid 90s with alarm limits at 90 and 97% seems to be a reasonable approach pending further studies. Further high-quality evidence generated from randomized trials is required to guide oxygen therapy in preterm PHT.
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Affiliation(s)
| | - Satyan Lakshminrusimha
- Division of Neonatology, Department of Pediatrics, University of California, Davis, USA.
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23
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Lara-Cantón I, Solaz A, Parra-Llorca A, García-Robles A, Millán I, Torres-Cuevas I, Vento M. Oxygen Supplementation During Preterm Stabilization and the Relevance of the First 5 min After Birth. Front Pediatr 2020; 8:12. [PMID: 32083039 PMCID: PMC7005009 DOI: 10.3389/fped.2020.00012] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2019] [Accepted: 01/10/2020] [Indexed: 11/26/2022] Open
Abstract
Fetal to neonatal transition entails cardiorespiratory, hemodynamic, and metabolic changes coinciding with the switch from placental to airborne respiration with partial pressures of oxygen of 4-5 kPa in utero raising to 8-9 kPa ex utero in few minutes. Preterm infants have immature lung and antioxidant defense system. Very preterm infants (<32 weeks' gestation) frequently require positive pressure ventilation and oxygen to establish lung aeration, a functional residual capacity, and overcome a tendency toward hypoxemia and bradycardia in the first minutes after birth. Recent studies have shown that prolonged bradycardia (heart rate <100 beats per minute) and/or hypoxemia (oxygen saturation <80%) are associated with increased mortality and/or intracranial hemorrhage. However, despite the accumulated evidence, the way in which oxygen should be supplemented in the first minutes after birth still has not yet been clearly established. The initial inspired fraction of oxygen and its adjustment within a safe arterial oxygen saturation range measured by pulse oximetry that avoids hyper-or-hypoxia is still a matter of debate. Herewith, we present a current summary aiming to assist the practical neonatologist who has to aerate the lung and establish an efficacious respiration in very preterm infants in the delivery room.
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Affiliation(s)
| | - Alvaro Solaz
- Neonatal Research Group, Health Research Institute La Fe, Valencia, Spain
| | - Anna Parra-Llorca
- Neonatal Research Group, Health Research Institute La Fe, Valencia, Spain
| | - Ana García-Robles
- Neonatal Research Group, Health Research Institute La Fe, Valencia, Spain
| | - Ivan Millán
- Neonatal Research Group, Health Research Institute La Fe, Valencia, Spain
| | | | - Maximo Vento
- Neonatal Research Group, Health Research Institute La Fe, Valencia, Spain.,Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
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24
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Marshall S, Lang AM, Perez M, Saugstad OD. Delivery room handling of the newborn. J Perinat Med 2019; 48:1-10. [PMID: 31834864 PMCID: PMC7771218 DOI: 10.1515/jpm-2019-0304] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Accepted: 11/07/2019] [Indexed: 01/24/2023]
Abstract
For newly born babies, especially those in need of intervention at birth, actions taken during the first minute after birth, the so-called "Golden Minute", can have important implications for long-term outcomes. Both delivery room handling, including identification of maternal and infant risk factors and provision of effective resuscitation interventions, and antenatal care decisions regarding antenatal steroid administration and mode of delivery, are important and can affect outcomes. Anticipating risk factors for neonates at high risk of requiring resuscitation can decrease time to resuscitation and improve the prognosis. Following a review of maternal and fetal risk factors affecting newborn resuscitation, we summarize the current recommendations for delivery room handling of the newborn. This includes recommendations and rationale for the use of delayed cord clamping and cord milking, heart rate assessment [including the use of electrocardiogram (ECG) electrodes in the delivery room], role of suctioning in newborn resuscitation, and the impact of various ventilatory modes. Oxygenation should be monitored by pulse oximetry. Effects of oxygen and surfactant on subsequent pulmonary outcomes, and recommendations for provisions of appropriate thermoregulatory support are discussed. Regular teaching of delivery room handling should be mandatory.
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Affiliation(s)
- Stephanie Marshall
- Ann and Robert H. Lurie, Children’s Hospital of Chicago, Chicago, IL, USA
| | - Astri Maria Lang
- Department of Neonatology, Division of Child Health, and Adolescent Medicine, Oslo University Hospital, 0424 Oslo, Norway
| | - Marta Perez
- Ann and Robert H. Lurie, Children’s Hospital of Chicago, Chicago, IL, USA
| | - Ola D. Saugstad
- Department of Pediatric, Research, University of Oslo, 0424 Oslo, Norway; and Ann and Robert H. Lurie Children’s Hospital of Chicago, 60611 Chicago, IL, USA
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25
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Owen LS, Manley BJ, Davis PG. Delivery room emergencies: Respiratory emergencies in the DR. Semin Fetal Neonatal Med 2019; 24:101039. [PMID: 31645310 DOI: 10.1016/j.siny.2019.101039] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
The majority of newborns transition to extra uterine life without support. However, respiratory emergencies in the delivery room are a common occurrence. Whilst some situations are predictable e.g. the anticipated birth of an extremely preterm infant, others are less so. In this chapter we address the most frequent scenarios that result in delivery room respiratory emergencies and discuss the latest recommendations for their management. We outline the need for a trained resuscitation team and appropriate equipment to provide respiratory support at every birth. We address the basic care that all infants should receive, the detailed application of non-invasive ventilation and the use of advanced airway techniques. We discuss the unique challenges presented by extreme prematurity including umbilical cord management, use of supplemental oxygen, initial modes of respiratory support and surfactant delivery. We will explore optimal techniques in the management of infants with lung hypoplasia, pneumothorax and meconium aspiration.
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Affiliation(s)
- Louise S Owen
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia.
| | - Brett J Manley
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia.
| | - Peter G Davis
- Newborn Research Centre and Neonatal Services, The Royal Women's Hospital, Melbourne, VIC, Australia; Department of Obstetrics and Gynaecology, The University of Melbourne, Melbourne, VIC, Australia; Clinical Sciences, Murdoch Children's Research Institute, Melbourne, VIC, Australia.
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26
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Resuscitation outcomes of infants that do not achieve a 5 min target SpO 2 saturation. J Perinatol 2019; 39:1635-1639. [PMID: 31488904 DOI: 10.1038/s41372-019-0491-x] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Revised: 07/01/2019] [Accepted: 07/12/2019] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To determine differences in the duration and level of resuscitation between infants that achieve a peripheral oxygen saturation (SpO2) of 80% by 5 min compared with those who remain below 80% saturation. STUDY DESIGN Infants < 32 weeks GA were analyzed. Pulse rate, SpO2, airway pressure, and fraction of inspired oxygen were collected during the first 10 min of life. RESULTS Two hundred and eighty-four infants were analyzed of which 100 had SpO2 < 80% at 5 min of life. Composite outcome of death and any IVH was greater in the <80% at 5 min group. These infants had lower heart rates and lower SpO2 despite increased mean airway pressure and higher FiO2 (p < 0.001). CONCLUSION Infants <32 weeks GA that do not achieve a peripheral arterial saturation of 80% by 5 min of life experience more death or severe IVH. This association is amongst the strongest seen of any predictor of morbidity in the delivery room.
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27
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Torres-Cuevas I, Corral-Debrinski M, Gressens P. Brain oxidative damage in murine models of neonatal hypoxia/ischemia and reoxygenation. Free Radic Biol Med 2019; 142:3-15. [PMID: 31226400 DOI: 10.1016/j.freeradbiomed.2019.06.011] [Citation(s) in RCA: 52] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/19/2019] [Revised: 05/26/2019] [Accepted: 06/10/2019] [Indexed: 02/08/2023]
Abstract
The brain is one of the main organs affected by hypoxia and reoxygenation in the neonatal period and one of the most vulnerable to oxidative stress. Hypoxia/ischemia and reoxygenation leads to impairment of neurogenesis, disruption of cortical migration, mitochondrial damage and neuroinflammation. The extent of the injury depends on the clinical manifestation in the affected regions. Preterm newborns are highly vulnerable, and they exhibit severe clinical manifestations such as intraventricular hemorrhage (IVH), retinopathy of prematurity (ROP) and diffuse white matter injury (DWMI) among others. In the neonatal period, the accumulation of high levels of reactive oxygen species exacerbated by the immature antioxidant defense systems in represents cellular threats that, if they exceed or bypass physiological counteracting mechanisms, are responsible of significant neuronal damage. Several experimental models in mice mimic the consequences of perinatal asphyxia and the use of oxygen in the reanimation process that produce brain injury. The aim of this review is to highlight brain damage associated with oxidative stress in different murine models of hypoxia/ischemia and reoxygenation.
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Affiliation(s)
| | | | - Pierre Gressens
- INSERM UMR1141, Université Paris Diderot, Sorbonne Paris Cité, Paris, France
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28
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Oei JL, Vento M. Is There a "Right" Amount of Oxygen for Preterm Infant Stabilization at Birth? Front Pediatr 2019; 7:354. [PMID: 31555622 PMCID: PMC6742695 DOI: 10.3389/fped.2019.00354] [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: 06/12/2019] [Accepted: 08/09/2019] [Indexed: 11/16/2022] Open
Abstract
The amount of oxygen given to preterm infants within the first few minutes of birth is one of the most contentious issues in modern neonatology. Just two decades ago, pure oxygen (FiO2 1.0) was standard of care and oximetry monitoring was not routine. Due to concerns about oxidative stress and injury, clinicians rapidly adopted the practice of using less oxygen for the respiratory support of all infants, regardless of gestational maturity and pulmonary function. There is now evidence that initial starting fractional inspired oxygen may not be the only factor involved in providing optimum oxygenation and that the amount of oxygen given to babies within the first 10 min of life is a crucial factor in determining outcomes, including death and neurodevelopmental injury. In addition, evolving practice, such as non-invasive respiratory support and delayed cord clamping, need to be taken into consideration when considering oxygen delivery to preterm infants. This review will discuss evidence to date and address the major knowledge gaps that need to be answered in this pivotal aspect of neonatal practice.
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Affiliation(s)
- Ju Lee Oei
- Department of Newborn Care, The Royal Hospital for Women, Randwick, NSW, Australia
- School of Women's and Children's Health, Faculty of Medicine, University of New South Wales, Randwick, NSW, Australia
| | - Maximo Vento
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
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Abstract
Low- and middle-income countries and resource-limited regions are major contributors to perinatal and infant mortality. Oxygen is widely used for resuscitation in high- and middle-income settings. However, oxygen supplementation is not available in resource-limited regions. Oxygen supplementation for resuscitation at birth has adverse effects in human/animal model studies. There has been a change with resultant recommendations for restrictive oxygen use in neonatal resuscitation. Neonatal resuscitation without supplemental oxygen decreases mortality and morbidities. Oxygen in resource-limited settings for neonatal resuscitation is ideal as a backup for selected resuscitations but should not be a limiting factor for implementing basic life-saving efforts.
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Abstract
Transition into the extrauterine world is characterized by a substantial increase in oxygen availability to tissue. Exact oxygen provision may be needed to avoid negative consequences of hypoxia or hyperoxia. For term and near-term infants, it is recommended to start with air and titrate the oxygen supplement to the saturation nomogram. However, oxygen supplementation in infants less than 32 weeks' gestation is an unsolved conundrum. At present, the inspired fraction of oxygen is set according to gestational age and blended to achieve targeted saturations and heart rates. Studies are still needed to overcome uncertainties about oxygen supplementation during preterm stabilization.
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31
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Lim J, Hagen E. Reducing Germinal Matrix-Intraventricular Hemorrhage: Perinatal and Delivery Room Factors. Neoreviews 2019; 20:e452-e463. [PMID: 31371554 DOI: 10.1542/neo.20-8-e452] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/10/2023]
Abstract
Germinal matrix hemorrhage-intraventricular hemorrhage (IVH) is the most common form of brain injury in preterm infants. Although severe IVH has declined over the years, it still affects approximately 6% of infants born before 32 weeks of gestation. Most IVH cases are detectable by the first 24 hours after birth; therefore interventions to prevent IVH should focus on antenatal management for pregnant women and delivery room management. Obstetrical interventions, including antenatal corticosteroids, maternal rather than infant transport, and possibly elective cesarean delivery have been associated with a decreased risk of IVH. Neonatal interventions in the delivery room, including delayed cord clamping or umbilical cord milking, maintaining normothermia, avoiding fluctuations in cerebral blood flow, and optimal ventilation management are associated with a decreased risk of IVH. Multiple clinical trials are under way to further identify IVH risk factors, ability to monitor or predict IVH, and ideally prevent IVH altogether. This discussion will focus on reviewing current obstetric and neonatal management practices and their associations with germinal matrix hemorrhage-IVH.
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Affiliation(s)
- Jina Lim
- Neonatal-Perinatal Medicine Division, Children's Hospital of Orange County, Orange, CA
| | - Eunice Hagen
- Fetal and Neonatal Institute, Division of Neonatology, Children's Hospital Los Angeles, Department of Pediatrics, Keck School of Medicine, University of Southern California, Los Angeles, CA
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32
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Foglia EE, Carper B, Gantz M, DeMauro SB, Lakshminrusimha S, Walsh M, Schmidt B. Association between Policy Changes for Oxygen Saturation Alarm Settings and Neonatal Morbidity and Mortality in Infants Born Very Preterm. J Pediatr 2019; 209:17-22.e2. [PMID: 30961990 PMCID: PMC6535348 DOI: 10.1016/j.jpeds.2019.01.048] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/21/2018] [Revised: 01/08/2019] [Accepted: 01/29/2019] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the impact of policy changes for pulse oximetry oxygen saturation (SpO2) alarm limits on neonatal mortality and morbidity among infants born very preterm. STUDY DESIGN This was a retrospective cohort study of infants born very preterm in the Eunice Kennedy Shriver National Institute of Child Health and Human Development Neonatal Research Network. Infants were classified based on treatment at a hospital with an SpO2 alarm policy change and study epoch (before vs after policy change). We used a generalized linear mixed model to determine the effect of hospital group and epoch on the primary outcomes of mortality and severe retinopathy of prematurity (ROP) and secondary outcomes of necrotizing enterocolitis, bronchopulmonary dysplasia, and any ROP. RESULTS There were 3809 infants in 10 hospitals with an SpO2 alarm policy change and 3685 infants in 9 hospitals without a policy change. The nature of most policy changes was to narrow the SpO2 alarm settings. Mortality was lower in hospitals without a policy change (aOR 0.63; 95% CI 0.50-0.80) but did not differ between epochs in policy change hospitals. The odds of bronchopulmonary dysplasia were greater for hospitals with a policy change (aOR 1.65; 95% CI 1.36-2.00) but did not differ for hospitals without a policy change. Severe ROP and necrotizing enterocolitis did not differ between epochs for either group. The adjusted odds of any ROP were lower in recent years in both hospital groups. CONCLUSIONS Changing SpO2 alarm policies was not associated with reduced mortality or increased severe ROP among infants born very preterm.
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Affiliation(s)
- Elizabeth E Foglia
- Division of Neonatology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA.
| | | | - Marie Gantz
- RTI International, Research Triangle Park, NC
| | - Sara B DeMauro
- Division of Neonatology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
| | | | | | - Barbara Schmidt
- Division of Neonatology, Department of Pediatrics, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA
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33
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Solevåg AL, Schmölzer GM, Cheung PY. Is Supplemental Oxygen Needed in Cardiac Compression?-The Influence of Oxygen on Cerebral Perfusion in Severely Asphyxiated Neonates With Bradycardia or Cardiac Asystole. Front Pediatr 2019; 7:486. [PMID: 31824899 PMCID: PMC6879425 DOI: 10.3389/fped.2019.00486] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/24/2019] [Accepted: 11/06/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Previous studies have investigated hemodynamic recovery using 21% vs. 100% oxygen during cardiopulmonary resuscitation (CPR) with chest compression (CC) in term infants. Animal studies indicate that systemic circulatory recovery is the same whether 21 or 100% oxygen is used during neonatal CPR. One of the main goals of resuscitation is to maintain cerebral oxygen delivery and prevent cerebral hypo- and hyperoxygenation. Oxygen delivery to the brain depends on cerebral hemodynamics, concentration of inhaled oxygen and blood oxygen content. The aim of this paper was to synthesize available research about cerebral oxygen delivery during CPR using different oxygen concentrations. Our research questions included how do different oxygen concentrations during CPR with CC influence cerebral perfusion and oxygen delivery, and how do cerebral hemodynamics during CC influence outcomes. Methods: A search in Medline Ovid using the search terms hypoxia AND oxygen AND cerebrovascular circulation AND infant, newborn. Inclusion criteria included studies of hypoxia and resuscitation of term infants. Studies were excluded if no measures of cerebral blood flow (CBF), oxygenation, or perfusion were reported. Results: The search retrieved 21 papers. None of the studies directly fulfilled our inclusion criteria. The reference lists of some of the retrieved papers provided relevant animal studies with slightly conflicting results regarding blood flow and oxygen delivery to the brain using 21 or 100% oxygen. No study in term infants was identified, but we included one study in preterm infants. Studies in asphyxiated animals indicate that 100% oxygen increases CBF and oxygenation during and after CC with a potential increase in oxidative stress. Conclusion: In asphyxia, cerebral autoregulation may be impaired. Pure oxygen administration during CC may result in cerebral hyperperfusion and increased cerebral oxygen delivery, which may be associated with oxidative stress-related damage to the brain tissue. As systemic circulatory recovery is the same whether 21 or 100% oxygen is used during neonatal CPR, it is important to investigate whether brain damage could be aggravated when 100% oxygen is used.
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Affiliation(s)
- Anne Lee Solevåg
- Department of Paediatric and Adolescent Medicine, Akershus University Hospital, Lørenskog, Norway
| | - Georg M Schmölzer
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
| | - Po-Yin Cheung
- Neonatal Research Unit, Centre for the Studies of Asphyxia and Resuscitation, Royal Alexandra Hospital, Edmonton, AB, Canada.,Department of Pediatrics, University of Alberta, Edmonton, AB, Canada
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Welsford M, Nishiyama C, Shortt C, Weiner G, Roehr CC, Isayama T, Dawson JA, Wyckoff MH, Rabi Y. Initial Oxygen Use for Preterm Newborn Resuscitation: A Systematic Review With Meta-analysis. Pediatrics 2019; 143:peds.2018-1828. [PMID: 30578326 DOI: 10.1542/peds.2018-1828] [Citation(s) in RCA: 47] [Impact Index Per Article: 9.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 09/11/2018] [Indexed: 11/24/2022] Open
Abstract
UNLABELLED : media-1vid110.1542/5839981895001PEDS-VA_2018-1828Video Abstract CONTEXT: The International Liaison Committee on Resuscitation prioritized to review the initial fraction of inspired oxygen (Fio2) during the resuscitation of preterm newborns. OBJECTIVES This systematic review and meta-analysis provides the scientific summary of initial Fio2 in preterm newborns (<35 weeks' gestation) who receive respiratory support at birth. DATA SOURCES Medline, Embase, Evidence-Based Medicine Reviews, and Cumulative Index to Nursing and Allied Health Literature were searched between January 1, 1980 and August 10, 2018. STUDY SELECTION Studies were selected by pairs of independent reviewers in 2 stages with a Cohen's κ of 0.8 and 1.0. DATA EXTRACTION Pairs of independent reviewers extracted data, appraised the risk of bias (RoB), and assessed Grading of Recommendations Assessment, Development and Evaluation certainty. RESULTS Ten randomized controlled studies and 4 cohort studies included 5697 patients. There are no statistically significant benefits of or harms from starting with lower compared with higher Fio2 in short-term mortality (n = 968; risk ratio = 0.83 [95% confidence interval 0.50 to 1.37]), long-term mortality, neurodevelopmental impairment, or other key preterm morbidities. A sensitivity analysis in which 1 study with a high RoB was excluded failed to reveal a reduction in mortality with initial low Fio2 (n = 681; risk ratio = 0.63 [95% confidence interval 0.38 to 1.03]). LIMITATIONS The Grading of Recommendations Assessment, Development and Evaluation certainty of evidence was very low for all outcomes due to RoB, inconsistency, and imprecision. CONCLUSIONS The ideal initial Fio2 for preterm newborns is still unknown, although the majority of newborns ≤32 weeks' gestation will require oxygen supplementation.
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Affiliation(s)
- Michelle Welsford
- Division of Emergency Medicine, McMaster University, Hamilton, Ontario, Canada; .,Centre for Paramedic Education and Research, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Chika Nishiyama
- Department of Critical Care Nursing, Graduate School of Human Health Science, Kyoto University, Kyoto, Japan
| | - Colleen Shortt
- Centre for Paramedic Education and Research, Hamilton Health Sciences, Hamilton, Ontario, Canada
| | - Gary Weiner
- Department of Pediatrics and Communicable Diseases, University of Michigan and Charles Stewart Mott Children's Hospital, Ann Arbor, Michigan
| | - Charles Christoph Roehr
- Medical Sciences Division, Department of Paediatrics, University of Oxford, Oxford, United Kingdom.,Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, National Health Service Foundation Trust, Oxford, United Kingdom
| | - Tetsuya Isayama
- Division of Neonatology, National Center for Child Health and Development, Tokyo, Japan
| | - Jennifer Anne Dawson
- Neonatal Services, The Royal Women's Hospital and The University of Melbourne, Melbourne, Australia
| | - Myra H Wyckoff
- Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas
| | - Yacov Rabi
- Department of Pediatrics, University of Calgary, Calgary, Alberta, Canada; and.,Alberta Children's Hospital Research Institute, Calgary, Alberta, Canada
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35
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Martherus T, Oberthuer A, Dekker J, Kirchgaessner C, van Geloven N, Hooper SB, Kribs A, Te Pas AB. Comparison of Two Respiratory Support Strategies for Stabilization of Very Preterm Infants at Birth: A Matched-Pairs Analysis. Front Pediatr 2019; 7:3. [PMID: 30761276 PMCID: PMC6362425 DOI: 10.3389/fped.2019.00003] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/11/2018] [Accepted: 01/04/2019] [Indexed: 01/19/2023] Open
Abstract
Objective: Respiratory support for stabilizing very preterm infants at birth varies between centers. We retrospectively compared two strategies that involved either increasing continuous positive airway pressures (CPAP), or increasing oxygen supplementation. Methods: Matched-pairs of infants (<28 weeks of gestation) were born either at the Leiden University Medical Center [low-pressure: CPAP 5-8 cmH2O and/or positive pressure ventilation (PPV) and fraction of inspired oxygen (FiO2) 0.3-1.0; n = 27], or at the University Hospital of Cologne (high-pressure: CPAP 12-35 cmH2O, no PPV and FiO2 0.3-0.4; n = 27). Respiratory support was initiated non-invasively via facemask at both units. Infants (n = 54) were matched between centers for gestational age and birth weight, to compare physiological and short-term clinical outcomes. Results: In the low-pressure group, 20/27 (74%) infants received 1-2 sustained inflations (20, 25 cm H2O) and 22/27 (81%) received PPV (1:19-3:01 min) using pressures of 25-27 cm H2O. Within 3 min of birth [median (IQR)], mean airway pressures [12 (6-15) vs. 19 (16-23) cmH2O, p < 0.001] and FiO2 [0.30 (0.28-0.31) vs. 0.22 (0.21-0.30), p < 0.001] were different in low- vs. high-pressure groups, respectively. SpO2 and heart rates were similar. After 3 min, higher FiO2 levels [0.62 (0.35-0.98) vs. 0.28 (0.22-0.38), p = 0.005] produced higher SpO2 levels [77 (50-92) vs. 53 (42-69)%, p < 0.001] in the low-pressure group, but SpO2/FiO2 and heart rates were similar. While intubation rates during admission were significantly different (70 vs. 30%, p = 0.013), pneumothorax rates (4 vs. 19%, p = 0.125) and the occurrence of spontaneous intestinal perforations (0 vs. 15%, p = 0.125) were similar between groups. Conclusion: Infants (<28 weeks) can be supported non-invasively at birth with either higher or lower pressures and while higher-pressure support may require less oxygen, it does not eliminate the need for oxygen supplementation. Future studies need to examine the effect of high pressures and pressure titration in the delivery room.
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Affiliation(s)
- Tessa Martherus
- Department of Paediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - André Oberthuer
- Department of Neonatology, Children's Hospital University of Cologne, Cologne, Germany
| | - Janneke Dekker
- Department of Paediatrics, Leiden University Medical Center, Leiden, Netherlands
| | | | - Nan van Geloven
- Medical Statistics, Department of Biomedical Data Sciences, Leiden University Medical Center, Leiden, Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Angela Kribs
- Department of Neonatology, Children's Hospital University of Cologne, Cologne, Germany
| | - Arjan B Te Pas
- Department of Paediatrics, Leiden University Medical Center, Leiden, Netherlands
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36
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Bancalari E, Jain D. Bronchopulmonary Dysplasia: 50 Years after the Original Description. Neonatology 2019; 115:384-391. [PMID: 30974430 DOI: 10.1159/000497422] [Citation(s) in RCA: 82] [Impact Index Per Article: 16.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2019] [Accepted: 01/29/2019] [Indexed: 11/19/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is one of the few diseases in neonatal medicine that has continued to evolve since its first description about 50 years ago. Over these years, advancements in neonatal medicine such as antenatal steroids and exogenous surfactant therapy have significantly reduced neonatal mortality and lowered the limits of viability for preterm infants. Although the incidence of BPD continues to be high, especially in extremely low birth weight infants, the clinical picture has evolved into a milder disease with low mortality or significant morbidities. This new BPD is the result of complex interactions between altered alveolar and vascular development, injury by ante- and postnatal pathogenic factors, and reparative processes in the lung. There has been significant progress in our understanding of risk factors for BPD, but challenges persist in its definition, and in finding effective preventive strategies. There are promising developments with newer preventive interventions such as mesenchymal stem cells, exosomes, immunomodulators, and growth factors, but they are still in preclinical stage. The future challenges include finding ways to define BPD based on the severity of lung pathology, which can better predict long-term outcomes, development of early predictors of lung disease, and finding innovative and evidence-based preventive and management strategies.
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Affiliation(s)
- Eduardo Bancalari
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA,
| | - Deepak Jain
- Division of Neonatology, Department of Pediatrics, University of Miami Miller School of Medicine, Miami, Florida, USA
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37
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Oxygen therapy of the newborn from molecular understanding to clinical practice. Pediatr Res 2019; 85:20-29. [PMID: 30297877 DOI: 10.1038/s41390-018-0176-8] [Citation(s) in RCA: 43] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/15/2018] [Revised: 08/21/2018] [Accepted: 08/23/2018] [Indexed: 01/30/2023]
Abstract
Oxygen is one of the most critical components of life. Nature has taken billions of years to develop optimal atmospheric oxygen concentrations for human life, evolving from very low, peaking at 30% before reaching 20.95%. There is now increased understanding of the potential toxicity of both too much and too little oxygen, especially for preterm and asphyxiated infants and of the potential and lifelong impact of oxygen exposure, even for a few minutes after birth. In this review, we discuss the contribution of knowledge gleaned from basic science studies and their implication in the care and outcomes of the human infant within the first few minutes of life and afterwards. We emphasize current knowledge gaps and research that is needed to answer a problem that has taken Nature a considerably longer time to resolve.
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38
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Özkan H, Erdeve Ö, Kutman HGK. Turkish Neonatal Society guideline on the management of respiratory distress syndrome and surfactant treatment. Turk Arch Pediatr 2018; 53:S45-S54. [PMID: 31236018 PMCID: PMC6568291 DOI: 10.5152/turkpediatriars.2018.01806] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Respiratory distress syndrome is the leading cause of respiratory failure in preterm infants. The incidence and severity of respiratory distress syndrome are inversely related to the gestational age of the newborn. The major underlying pathophysiologic mechanisms are surfactant deficiency and anatomic, structural immaturity of the lung. Recent improvements such as antenatal steroid treatment to enhance pulmonary maturity, appropriate resuscitation facilitated by placental transfusion and immediate use of continuous positive airway pressure for alveolar recruitment, early rescue administration of surfactant, ventilation with gentler modes to minimize damage to the immature lungs, and the other supportive therapies have significantly decreased respiratory distress syndrome-related morbidity and mortality. This guideline was addressed to overview the mentioned improvements in order to standardize respiratory distress syndrome management in neonatal intensive care units in Turkey.
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Affiliation(s)
- Hasan Özkan
- Division of Neonatology, Department of Pediatrics, Dokuz Eylül University, Faculty of Medicine, İzmir, Turkey
| | - Ömer Erdeve
- Division of Neonatology, Department of Pediatrics, Ankara University, Faculty of Medicine, Ankara, Turkey
| | - H Gözde Kanmaz Kutman
- Division of Neonatology, Department of Pediatrics, University of Health Sciences, Zekai Tahir Burak Womens' Health Training and Research Hospital, Ankara, Turkey
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39
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Vali P, Underwood M, Lakshminrusimha S. Hemoglobin oxygen saturation targets in the neonatal intensive care unit: Is there a light at the end of the tunnel? 1. Can J Physiol Pharmacol 2018; 97:174-182. [PMID: 30365906 DOI: 10.1139/cjpp-2018-0376] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
The optimal oxygenation target needed to prevent the extremes of hypoxia and oxygen toxicity in premature and sick newborns has been the subject of much research and debate. The advent of the pulse oximeter has allowed the continuous monitoring of oxyhemoglobin saturation and the delivery of oxygen with greater precision. Well-run, large clinical trials to determine the safest oxygen concentration have led to several revisions in guidelines for neonatal care. However, monitoring of oxyhemoglobin saturation has its limitations and does not provide a comprehensive assessment of tissue oxygenation. To identify optimal oxygen therapy, various other factors (partial pressure of arterial carbon dioxide, hemoglobin concentration, blood pH, and tissue metabolic demand) that influence perfusion and tissue oxygenation need to be considered.
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Affiliation(s)
- Payam Vali
- Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA 95817, USA.,Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA 95817, USA
| | - Mark Underwood
- Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA 95817, USA.,Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA 95817, USA
| | - Satyan Lakshminrusimha
- Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA 95817, USA.,Department of Pediatrics, UC Davis School of Medicine, Sacramento, CA 95817, USA
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40
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Kapadia V, Rabi Y, Oei JL. The Goldilocks principle. Oxygen in the delivery room: When is it too little, too much, and just right? Semin Fetal Neonatal Med 2018; 23:347-354. [PMID: 29983332 DOI: 10.1016/j.siny.2018.06.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
Oxygen has been used to stabilize newborn infants for more than a century. Over the last two decades, a paradigm shift towards using less oxygen has occurred but without firm evidence of benefit. Using lower levels of oxygen has also added new conundrums to clinical care. Can oxygen delivery to sick newborn babies meet the Goldilocks principle, of being "just right"? This review discusses the history of oxygen use in the delivery room and the impetus to change from the long-established practice of using pure oxygen to using lower oxygen concentrations. The review also highlights knowledge gaps, particularly for oxygen exposure and monitoring, as well as the sequelae of oxygen administration, including short- and long-term outcomes.
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Affiliation(s)
- Vishal Kapadia
- Division of Neonatal-Perinatal Medicine, UT Southwestern Medical Center at Dallas, Texas, USA
| | - Yacov Rabi
- Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada
| | - Ju Lee Oei
- Department of Newborn Care, The Royal Hospital for Women, Randwick, New South Wales, Australia; School of Women's and Children's Health, University of New South Wales, Randwick, New South Wales, Australia; NHMRC Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia.
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41
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Thamrin V, Saugstad OD, Tarnow-Mordi W, Wang YA, Lui K, Wright IM, De Waal K, Travadi J, Smyth JP, Craven P, McMullan R, Coates E, Ward M, Mishra P, See KC, Cheah IGS, Lim CT, Choo YM, Kamar AA, Cheah FC, Masoud A, Oei JL. Preterm Infant Outcomes after Randomization to Initial Resuscitation with FiO 2 0.21 or 1.0. J Pediatr 2018; 201:55-61.e1. [PMID: 30251639 DOI: 10.1016/j.jpeds.2018.05.053] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2017] [Revised: 04/28/2018] [Accepted: 05/31/2018] [Indexed: 11/29/2022]
Abstract
OBJECTIVE To determine rates of death or neurodevelopmental impairment (NDI) at 2 years corrected age (primary outcome) in children <32 weeks' gestation randomized to initial resuscitation with a fraction of inspired oxygen (FiO2) value of 0.21 or 1.0. STUDY DESIGN Blinded assessments were conducted at 2-3 years corrected age with the Bayley Scales of Infant and Toddler Development, Third Edition or the Ages and Stages Questionnaire by intention to treat. RESULTS Of the 290 children enrolled, 40 could not be contacted and 10 failed to attend appointments. Among the 240 children for whom outcomes at age 2 years were available, 1 child had a lethal congenital anomaly, 1 child had consent for follow-up withdrawn, and 23 children died. The primary outcome, which was available in 238 (82%) of those randomized, occurred in 47 of the 117 (40%) children assigned to initial FiO2 0.21 and in 38 of the 121 (31%) assigned to initial FiO2 1.0 (OR, 1.47; 95% CI, 0.86-2.5; P = .16). No difference in NDI was found in 215 survivors randomized to FiO2 0.21 vs 1.0 (OR, 1.26; 95% CI, 0.70-2.28; P = .11). In post hoc exploratory analyses in the whole cohort, children with a 5-minute blood oxygen saturation (SpO2) <80% were more likely to die or to have NDI (OR, 1.85; 95% CI, 1.07-3.2; P = .03). CONCLUSIONS Initial resuscitation of infants <32 weeks' gestation with initial FiO2 0.21 had no significant effect on death or NDI compared with initial FiO2 1.0. Further evaluation of optimum initial FiO2, including SpO2 targeting, in a large randomized controlled trial is needed. TRIAL REGISTRATION Australian and New Zealand Clinical Trials Network Registry ACTRN 12610001059055 and the National Malaysian Research Registry NMRR-07-685-957.
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Affiliation(s)
- Valerie Thamrin
- School of Women's and Children's Health, The University of New South Wales, Sydney, NSW, Australia
| | - Ola D Saugstad
- Department of Pediatric Research, The University of Oslo, Oslo, Norway
| | - William Tarnow-Mordi
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, NSW, Australia; Westmead International Network for Neonatal Education and Research, Sydney, NSW, Australia
| | - Yueping Alex Wang
- Faculty of Health, University of Technology Sydney, Sydney, NSW, Australia
| | - Kei Lui
- School of Women's and Children's Health, The University of New South Wales, Sydney, NSW, Australia; Department of Newborn Care, The Royal Hospital for Women, Sydney, NSW, Australia
| | - Ian M Wright
- Illawarra Health and Medical Research Institute and Graduate School of Medicine, The University of Wollongong, Wollongong, NSW, Australia; Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia
| | - Koert De Waal
- Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia; Department of Neonatology, The John Hunter Hospital, Newcastle, NSW, Australia
| | - Javeed Travadi
- Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia; Department of Neonatology, The John Hunter Hospital, Newcastle, NSW, Australia
| | - John P Smyth
- School of Women's and Children's Health, The University of New South Wales, Sydney, NSW, Australia; Department of Pediatric Research, The University of Oslo, Oslo, Norway
| | - Paul Craven
- Hunter Medical Research Institute, University of Newcastle, Newcastle, NSW, Australia; Department of Neonatology, The John Hunter Hospital, Newcastle, NSW, Australia
| | - Rowena McMullan
- Department of Neonatology, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Elisabeth Coates
- NHMRC Clinical Trials Centre, The University of Sydney, Sydney, NSW, Australia
| | - Meredith Ward
- School of Women's and Children's Health, The University of New South Wales, Sydney, NSW, Australia; Department of Newborn Care, The Royal Hospital for Women, Sydney, NSW, Australia
| | - Parag Mishra
- School of Women's and Children's Health, The University of New South Wales, Sydney, NSW, Australia; Department of Newborn Care, The Royal Hospital for Women, Sydney, NSW, Australia
| | - Kwee Ching See
- Department of Neonatology, Sungai Buloh Hospital, Selangor, Malaysia
| | - Irene G S Cheah
- Department of Neonatology, Hospital Kuala Lumpur, Kuala Lumpur, Malaysia
| | - Chin Theam Lim
- Department of Neonatology, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Yao Mun Choo
- Department of Neonatology, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Azanna Ahmad Kamar
- Department of Neonatology, University of Malaya Medical Centre, Kuala Lumpur, Malaysia
| | - Fook Choe Cheah
- Department of Paediatrics, Universiti Kebangsaan Malaysia Medical Centre, Kuala Lumpur, Malaysia
| | | | - Ju Lee Oei
- School of Women's and Children's Health, The University of New South Wales, Sydney, NSW, Australia; NHMRC Clinical Trials Centre, The University of Sydney, Sydney, NSW, Australia; Department of Newborn Care, The Royal Hospital for Women, Sydney, NSW, Australia.
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Oei JL, Finer NN, Saugstad OD, Wright IM, Rabi Y, Tarnow-Mordi W, Rich W, Kapadia I, Rook D, Smyth JP, Lui K, Vento M. Outcomes of oxygen saturation targeting during delivery room stabilisation of preterm infants. Arch Dis Child Fetal Neonatal Ed 2018; 103:F446-F454. [PMID: 28988158 PMCID: PMC6490957 DOI: 10.1136/archdischild-2016-312366] [Citation(s) in RCA: 83] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 09/13/2017] [Accepted: 09/14/2017] [Indexed: 12/11/2022]
Abstract
OBJECTIVE To determine the association between SpO2 at 5 min and preterm infant outcomes. DESIGN Data from 768 infants <32 weeks gestation from 8 randomised controlled trials (RCTs) of lower (≤0.3) versus higher (≥0.6) initial inspiratory fractions of oxygen (FiO2) for resuscitation, were examined. SETTING Individual patient analysis of 8 RCTs INTERVENTIONS: Lower (≤0.3) versus higher (≥0.6) oxygen resuscitation strategies targeted to specific predefined SpO2 before 10 min of age. PATIENTS Infants <32 weeks gestation. MAIN OUTCOME MEASURES Relationship between SpO2 at 5 min, death and intraventricular haemorrhage (IVH) >grade 3. RESULTS 5 min SpO2 data were obtained from 706 (92%) infants. Only 159 (23%) infants met SpO2 study targets and 323 (46%) did not reach SpO280%. Pooled data showed decreased likelihood of reaching SpO280% if resuscitation was initiated with FiO2 <0.3 (OR 2.63, 95% CI 1.21 to 5.74, p<0.05). SpO2 <80% was associated with lower heart rates (mean difference -8.37, 95% CI -15.73 to -1.01, *p<0.05) and after accounting for confounders, with IVH (OR 2.04, 95% CI 1.01 to 4.11, p<0.05). Bradycardia (heart rate <100 bpm) at 5 min increased risk of death (OR 4.57, 95% CI 1.62 to 13.98, p<0.05). Taking into account confounders including gestation, birth weight and 5 min bradycardia, risk of death was significantly increased with time taken to reach SpO280%. CONCLUSION Not reaching SpO280% at 5 min is associated with adverse outcomes, including IVH. Whether this is because of infant illness or the amount of oxygen that is administered during stabilisation is uncertain and needs to be examined in randomised trials.
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Affiliation(s)
- Ju Lee Oei
- Department of Newborn Care, The Royal Hospital for Women, Randwick, New South Wales, Australia,School of Women’s and Children’s Health, University of New South Wales, Randwick, New South Wales, Australia,Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Neil N Finer
- Department of Pediatrics, Neonatology, University of California, San Diego, California, USA,Sharp Mary Birch Hospital for Women and Newborns, San Diego, California, USA
| | - Ola Didrik Saugstad
- Department of Pediatric Research, The University of Oslo, Oslo University Hospital, Oslo, Norway
| | - Ian M Wright
- Illawarra Health and Medical Research Institute and Graduate Medicine, The University of Wollongong, Wollongong, New South Wales, Australia
| | - Yacov Rabi
- Department of Neonatology, University of Calgary, Alberta, Canada,Alberta Children’s Hospital Research Institute, Alberta, Canada
| | - William Tarnow-Mordi
- Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
| | - Wade Rich
- Sharp Mary Birch Hospital for Women and Newborns, San Diego, California, USA
| | - ishal Kapadia
- Division of Neonatal-Perinatal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Denise Rook
- Department of Pediatrics, Neonatology, Erasmus Medical Centre, Sophia Children’s Hospital, Rotterdam, The Netherlands
| | - John P Smyth
- Department of Newborn Care, The Royal Hospital for Women, Randwick, New South Wales, Australia,School of Women’s and Children’s Health, University of New South Wales, Randwick, New South Wales, Australia
| | - Kei Lui
- Department of Newborn Care, The Royal Hospital for Women, Randwick, New South Wales, Australia,School of Women’s and Children’s Health, University of New South Wales, Randwick, New South Wales, Australia
| | - Maximo Vento
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
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43
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Abstract
Oxygen is the most commonly used medicine used during neonatal resuscitation in the delivery room. Oxygen therapy in delivery room should be used judiciously to avoid oxygen toxicity while delivering sufficient oxygen to prevent hypoxia. Measurement of appropriate oxygenation relies on pulse oximetry, but adequate ventilation and perfusion are equally important for oxygen delivery. In this article, we review oxygenation while transitioning from fetal to neonatal life, the importance of appropriate oxygen therapy, its measurement in the delivery room, and current recommendations for oxygen therapy and its limitations.
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Affiliation(s)
- Vishal Kapadia
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9063, USA.
| | - Myra H Wyckoff
- Department of Pediatrics, Division of Neonatal-Perinatal Medicine, University of Texas Southwestern Medical Center, 5323 Harry Hines Boulevard, Dallas, TX 75390-9063, USA
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44
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Lui K, Jones LJ, Foster JP, Davis PG, Ching SK, Oei JL, Osborn DA. Lower versus higher oxygen concentrations titrated to target oxygen saturations during resuscitation of preterm infants at birth. Cochrane Database Syst Rev 2018; 5:CD010239. [PMID: 29726010 PMCID: PMC6494481 DOI: 10.1002/14651858.cd010239.pub2] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
BACKGROUND Initial resuscitation with air is well tolerated by most infants born at term. However, the optimal fractional inspired oxygen concentration (FiO2 - proportion of the breathed air that is oxygen) targeted to oxygen saturation (SpO2 - an estimate of the amount of oxygen in the blood) for infants born preterm is unclear. OBJECTIVES To determine whether lower or higher initial oxygen concentrations, when titrated according to oxygen saturation targets during the resuscitation of preterm infants at birth, lead to improved short- and long-term mortality and morbidity. SEARCH METHODS We conducted electronic searches of the Cochrane Central Register of Controlled Trials (13 October 2017), Ovid MEDLINE (1946 to 13 October 2017), Embase (1974 to 13 October 2017) and CINAHL (1982 to 13 October 2017); we also searched previous reviews (including cross-references), contacted expert informants, and handsearched journals. SELECTION CRITERIA We included randomised controlled trials (including cluster- and quasi-randomised trials) which enrolled preterm infants requiring resuscitation following birth and allocated them to receive either lower (FiO2 < 0.4) or higher (FiO2 ≥ 0.4) initial oxygen concentrations titrated to target oxygen saturation. DATA COLLECTION AND ANALYSIS Two review authors independently assessed the eligibility of studies for inclusion, extracted data and assessed methodological quality. Primary outcomes included mortality near term or at discharge (latest reported) and neurodevelopmental disability. We conducted meta-analysis using a fixed-effect model. We assessed the quality of the evidence using GRADE. MAIN RESULTS The search identified 10 eligible trials. Meta-analysis of the 10 included studies (914 infants) showed no difference in mortality to discharge between lower (FiO2 < 0.4) and higher (FiO2 ≥ 0.4) initial oxygen concentrations targeted to oxygen saturation (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.68 to 1.63). We identified no heterogeneity in this analysis. We graded the quality of the evidence as low due to risk of bias and imprecision. There were no significant subgroup effects according to inspired oxygen concentration strata (FiO2 0.21 versus ≥ 0.4 to < 0.6; FiO2 0.21 versus ≥ 0.6 to 1.0; and FiO2 ≥ 0.3 to < 0.4 versus ≥ 0.6 to 1.0). Subgroup analysis identified a single trial that reported increased mortality from use of lower (FiO2 0.21) versus higher (FiO2 1.0) initial oxygen concentration targeted to a lowest SpO2 of less than 85%, whereas meta-analysis of nine trials targeting a lowest SpO2 of 85% to 90% found no difference in mortality.Meta-analysis of two trials (208 infants) showed no difference in neurodevelopmental disability at 24 months between infants receiving lower (FiO2 < 0.4) versus higher (FiO2 > 0.4) initial oxygen concentrations targeted to oxygen saturation. Other outcomes were incompletely reported by studies. Overall, we found no difference in use of intermittent positive pressure ventilation or intubation in the delivery room; retinopathy (damage to the retina of the eyes, measured as any retinopathy and severe retinopathy); intraventricular haemorrhage (any and severe); periventricular leukomalacia (a type of white-matter brain injury); necrotising enterocolitis (a condition where a portion of the bowel dies); chronic lung disease at 36 weeks' gestation; mortality to follow up; postnatal growth failure; and patent ductus arteriosus. We graded the quality of the evidence for these outcomes as low or very low. AUTHORS' CONCLUSIONS There is uncertainty as to whether initiating post birth resuscitation in preterm infants using lower (FiO2 < 0.4) or higher (FiO2 ≥ 0.4) oxygen concentrations, targeted to oxygen saturations in the first 10 minutes, has an important effect on mortality or major morbidity, intubation during post birth resuscitation, other resuscitation outcomes, and long-term outcomes including neurodevelopmental disability. We assessed the quality of the evidence for all outcomes as low to very low. Further large, well designed trials are needed to assess the effect of using different initial oxygen concentrations and the effect of targeting different oxygen saturations.
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Affiliation(s)
- Kei Lui
- Royal Hospital for WomenDepartment of Newborn CareBarker StreetRandwickNew South WalesAustralia2031
- Lei LuiSchool of Women's and Children's HealthSydneyNSWAustralia2052
| | - Lisa J Jones
- University of SydneyCentral Clinical School, Discipline of Obstetrics, Gynaecology and NeonatologyCamperdownNSWAustralia
- John Hunter Children's HospitalDepartment of NeonatologyNew LambtonNSWAustralia2305
| | - Jann P Foster
- University of SydneyCentral Clinical School, Discipline of Obstetrics, Gynaecology and NeonatologyCamperdownNSWAustralia
- Western Sydney UniversitySchool of Nursing and MidwiferyPenrith DCAustralia
- Ingham Research InstituteLiverpoolNSWAustralia
| | - Peter G Davis
- The Royal Women's HospitalNewborn Research Centre and Neonatal ServicesMelbourneAustralia
- Murdoch Childrens Research InstituteMelbourneAustralia
- University of MelbourneDepartment of Obstetrics and GynecologyMelbourneAustralia
| | | | - Ju Lee Oei
- Royal Hospital for WomenNewborn CareBarker StreetRandwickNSWAustralia2031
| | - David A Osborn
- University of SydneyCentral Clinical School, Discipline of Obstetrics, Gynaecology and NeonatologySydneyNSWAustralia2050
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45
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Abstract
PURPOSE OF REVIEW To evaluate current evidence for the use of lower or higher oxygen strategies for preterm infant resuscitation RECENT FINDINGS: The equipoise for using higher fraction of inspired oxygen (FiO2) (>0.4) to initiate preterm infant respiratory stabilization has been lost. Recent meta-analyses of randomized controlled trials assessing outcomes after using higher (FiO2 ≥ 0.6) vs. lower (FiO2 ≤ 0.3) oxygen strategies to initiate preterm resuscitation shows no difference in the rates of death or major morbidities. However, not achieving pulse oximetry saturations of at least 80% by 5 min of age, whether it was due to iatrogenic oxygen insufficiency or poor infant pulmonary function, was associated with lower heart rates (mean difference -8.37, 95% confidence interval: -15.73, -1.01) and major intraventricular hemorrhage. There remains scarce neurodevelopmental data in this area and information about the impact of oxygen targeting strategies in low resourced areas. These knowledge gaps are research priorities that must be addressed in large, well designed randomized controlled trials. SUMMARY Most clinicians now use lower oxygen strategies to initiate respiratory support for all infants, including preterm infants with significant lung disease. However, the impact of such strategies, particularly for neurodevelopmental outcomes and for lower resourced areas, remains uncertain and must be urgently addressed.
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Affiliation(s)
- Ju-Lee Oei
- Department of Newborn Care, The Royal Hospital for Women.,School of Women's and Children's Health, University of New South Wales, Sydney, New South Wales, Australia
| | - Ola D Saugstad
- Department of Pediatric Research, The University of Oslo, Oslo University Hospital, Oslo, Norway
| | - Maximo Vento
- Division of Neonatology, University and Polytechnic Hospital La Fe, Valencia, Spain
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46
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Kapadia VS, Lal CV, Kakkilaya V, Heyne R, Savani RC, Wyckoff MH. Impact of the Neonatal Resuscitation Program-Recommended Low Oxygen Strategy on Outcomes of Infants Born Preterm. J Pediatr 2017; 191:35-41. [PMID: 29173319 PMCID: PMC5726565 DOI: 10.1016/j.jpeds.2017.08.074] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2017] [Revised: 07/28/2017] [Accepted: 08/28/2017] [Indexed: 11/23/2022]
Abstract
OBJECTIVE To evaluate the impact of the Neonatal Resuscitation Program (NRP)-recommended low oxygen strategy (LOX) on neonatal morbidities, mortality, and neurodevelopmental outcomes in neonates born preterm. STUDY DESIGN In March 2011, Parkland Hospital changed from a high oxygen strategy (HOX) of resuscitation with initial 100% oxygen and targeting 85%-94% oxygen saturation for delivery room resuscitation to a LOX with initial 21% oxygen and titrating oxygen to meet NRP-recommended transitional target saturations. Neonates ≤28 weeks' gestational age born between August 2009 and April 2012 were identified. In this retrospective, observational study, neonates exposed to LOX vs HOX were compared for short-term morbidity, mortality, and long-term neurodevelopmental outcomes. Regression analysis was performed to control for confounding variables. RESULTS Of 199 neonates, 110 were resuscitated with HOX and 89 with LOX. Compared with HOX, neonates exposed to LOX had lower oxygen exposure in the delivery room (5.2 ± 1.5 vs 7.8 ± 2.8 [∑FiO2 × time min], P < .01), spent fewer days on oxygen (30 [5, 54] vs 46 [11, 82], P = .01), and had lower odds of developing bronchopulmonary dysplasia (aOR 0.4 [0.2, 0.9]). There was no difference in mortality (17 [20%] vs 20 [18%]), but neonates exposed to LOX had greater motor composite scores on Bayley Scales of Infant and Toddler Development-Third edition assessment (91 [85, 97] vs 88 [76, 94], P < .01). CONCLUSION The NRP-recommended LOX strategy was associated with improved respiratory morbidities and neurodevelopmental outcomes with no increase in mortality. Prospective trials to confirm the optimal oxygen strategy for the resuscitation of neonates born preterm are needed.
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Affiliation(s)
- Vishal S Kapadia
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX.
| | - Charitharth V Lal
- Department of Pediatrics, University of Alabama at Birmingham, Birmingham, AL
| | - Venkat Kakkilaya
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Roy Heyne
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Rashmin C Savani
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
| | - Myra H Wyckoff
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas, TX
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47
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Reanimación neonatal en prematuros de 27 a 30 semanas de gestación, con determinación de requerimientos de oxígeno, porcentaje de saturación y su relación con la morbilidad neonatal. PERINATOLOGÍA Y REPRODUCCIÓN HUMANA 2017. [DOI: 10.1016/j.rprh.2018.03.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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48
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Foglia EE, Jensen EA, Kirpalani H. Delivery room interventions to prevent bronchopulmonary dysplasia in extremely preterm infants. J Perinatol 2017; 37:1171-1179. [PMID: 28569744 PMCID: PMC5687993 DOI: 10.1038/jp.2017.74] [Citation(s) in RCA: 49] [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: 10/13/2016] [Revised: 03/31/2017] [Accepted: 04/27/2017] [Indexed: 12/11/2022]
Abstract
Bronchopulmonary dysplasia (BPD) is the most common chronic respiratory complication of preterm birth. Preterm infants are at risk for acute lung injury immediately after birth, which predisposes to BPD. In this article, we review the current evidence for interventions applied during neonatal transition (delivery room and first postnatal hours of life) to prevent BPD in extremely preterm infants: continuous positive airway pressure (CPAP), sustained lung inflation, supplemental oxygen use during neonatal resuscitation, and surfactant therapy including less-invasive surfactant administration. Preterm infants should be stabilized with CPAP in the delivery room, reserving invasive mechanical ventilation for infants who fail non-invasive respiratory support. For infants who require endotracheal intubation and mechanical ventilation soon after birth, surfactant should be given early (<2 h of life). We recommend prudent titration of supplemental oxygen in the delivery room to achieve targeted oxygen saturations. Promising interventions that may further reduce BPD, such as sustained inflation and non-invasive surfactant administration, are currently under investigation.
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Affiliation(s)
- Elizabeth E. Foglia
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, USA,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Erik A. Jensen
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, USA,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
| | - Haresh Kirpalani
- Division of Neonatology, The Children’s Hospital of Philadelphia, Philadelphia, USA,Department of Pediatrics, University of Pennsylvania Perelman School of Medicine, Philadelphia, USA
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49
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Soraisham AS, Rabi Y, Shah PS, Singhal N, Synnes A, Yang J, Lee SK, Lodha AK, Lodha AK. Neurodevelopmental outcomes of preterm infants resuscitated with different oxygen concentration at birth. J Perinatol 2017; 37:1141-1147. [PMID: 28594395 DOI: 10.1038/jp.2017.83] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2017] [Revised: 04/20/2017] [Accepted: 05/04/2017] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To compare the neurodevelopmental outcomes at 18 to 21 months corrected age (CA) of infants born at <29 weeks that received room air, an intermediate oxygen concentration or 100% oxygen at the initiation of resuscitation. STUDY DESIGN In this retrospective cohort study, we compared neonatal and neurodevelopmental outcomes at 18 to 21 months CA among inborn infants born before 29 weeks' gestation that received room air, intermediate oxygen concentration or 100% oxygen at the initiation of resuscitation. RESULTS Of 1509 infants, 445 received room air, 483 received intermediate oxygen concentrations and 581 received 100% oxygen. Compared to infants that received room air, the primary outcome of death or neurodevelopmental impairment (NDI) was not different in intermediate oxygen (adjusted odds ratio (aOR) 1.01; 95% confidence interval (CI) 0.77, 1.34) or 100% oxygen (aOR 1.03; 95% CI 0.78, 1.35). Compared to room air, there was no difference in odds of death or severe NDI in intermediate oxygen (aOR 1.14; 95% CI 0.82, 1.58) or 100% oxygen group (aOR 1.22; 95% CI 0.90, 1.67). The odds of severe NDI among survivors were significantly higher in infants that received 100% oxygen as compared to room air (aOR 1.57, 95% CI 1.05, 2.35). CONCLUSIONS We observed no significant difference in the primary composite outcomes of death or NDI and death or severe NDI at 18 to 21 months CA between infants that received room air, intermediate oxygen concentration or 100% oxygen at the initiation of resuscitation. However, use of 100% oxygen was associated with increased odds of severe NDI among survivors as compared to room air.
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Affiliation(s)
- A S Soraisham
- Department of Paediatrics, Section of Neonatal Perinatal Medicine, University of Calgary, Alberta Children's Hospital Research Institute, Foothills Medical Centre, Calgary, AB, Canada
| | - Y Rabi
- Department of Paediatrics, Section of Neonatal Perinatal Medicine, University of Calgary, Alberta Children's Hospital Research Institute, Foothills Medical Centre, Calgary, AB, Canada
| | - P S Shah
- Department of Paediatrics, Section of Neonatal Perinatal Medicine, University of Toronto, Mount Sinai Hospital, Toronto, ON, Canada
| | - N Singhal
- Department of Paediatrics, Section of Neonatal Perinatal Medicine, University of Calgary, Alberta Children's Hospital Research Institute, Foothills Medical Centre, Calgary, AB, Canada
| | - A Synnes
- Department of Paediatrics, University of British Columbia, Vancouver, BC, Canada
| | - J Yang
- Department of Paediatrics, Section of Neonatal Perinatal Medicine, University of Toronto, Mount Sinai Hospital, Toronto, ON, Canada
| | - S K Lee
- Department of Paediatrics, Section of Neonatal Perinatal Medicine, University of Toronto, Mount Sinai Hospital, Toronto, ON, Canada
| | - A K Lodha
- Department of Paediatrics, Section of Neonatal Perinatal Medicine, University of Calgary, Alberta Children's Hospital Research Institute, Foothills Medical Centre, Calgary, AB, Canada
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50
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Deepak J, Eduardo B. Prevention of bronchopulmonary dysplasia: current strategies. ZHONGGUO DANG DAI ER KE ZA ZHI = CHINESE JOURNAL OF CONTEMPORARY PEDIATRICS 2017; 19:841-851. [PMID: 28774356 PMCID: PMC7390045 DOI: 10.7499/j.issn.1008-8830.2017.08.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 12/09/2016] [Accepted: 03/28/2017] [Indexed: 06/07/2023]
Abstract
Bronchopulmonary dysplasia (BPD) is one of the few diseases affecting premature infants that have continued to evolve since its first description about half a century ago. The current form of BPD, a more benign and protracted respiratory failure in extremely preterm infants, is in contrast to the original presentation of severe respiratory failure with high mortality in larger premature infants. This new BPD is end result of complex interplay of various antenatal and postnatal factors causing lung injury and subsequent abnormal repair leading to altered alveolar and vascular development. The change in clinical and pathologic picture of BPD over time has resulted in new challenges in developing strategies for its prevention and management. While some of these strategies like Vitamin A supplementation, caffeine and volume targeted ventilation have stood the test of time, others like postnatal steroids are being reexamined with great interest in last few years. It is quite clear that BPD is unlikely to be eliminated unless some miraculous strategy cures prematurity. The future of BPD prevention will probably be a combination of antenatal and postnatal strategies acting on multiple pathways to minimize lung injury and abnormal repair as well as promote normal alveolar and vascular development.
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Affiliation(s)
- Jain Deepak
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL 33101, USA
| | - Bancalari Eduardo
- Department of Pediatrics, University of Miami Miller School of Medicine, Miami, FL 33101, USA
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