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Sotiropoulos JX, Oei JL, Schmölzer GM, Libesman S, Hunter KE, Williams JG, Webster AC, Vento M, Kapadia V, Rabi Y, Dekker J, Vermeulen MJ, Sundaram V, Kumar P, Kaban RK, Rohsiswatmo R, Saugstad OD, Seidler AL. Initial Oxygen Concentration for the Resuscitation of Infants Born at Less Than 32 Weeks' Gestation: A Systematic Review and Individual Participant Data Network Meta-Analysis. JAMA Pediatr 2024; 178:774-783. [PMID: 38913382 PMCID: PMC11197034 DOI: 10.1001/jamapediatrics.2024.1848] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/06/2024] [Accepted: 04/03/2024] [Indexed: 06/25/2024]
Abstract
Importance Resuscitation with lower fractional inspired oxygen (FiO2) reduces mortality in term and near-term infants but the impact of this practice on very preterm infants is unclear. Objective To evaluate the relative effectiveness of initial FiO2 on reducing mortality, severe morbidities, and oxygen saturations (SpO2) in preterm infants born at less than 32 weeks' gestation using network meta-analysis (NMA) of individual participant data (IPD). Data Sources MEDLINE, Embase, CENTRAL, CINAHL, ClinicalTrials.gov, and WHO ICTRP from 1980 to October 10, 2023. Study Selection Eligible studies were randomized clinical trials enrolling infants born at less than 32 weeks' gestation comparing at least 2 initial oxygen concentrations for delivery room resuscitation, defined as either low (≤0.3), intermediate (0.5-0.65), or high (≥0.90) FiO2. Data Extraction and Synthesis Investigators from eligible studies were invited to provide IPD. Data were processed and checked for quality and integrity. One-stage contrast-based bayesian IPD-NMA was performed with noninformative priors and random effects and adjusted for key covariates. Main Outcomes and Measures The primary outcome was all-cause mortality at hospital discharge. Secondary outcomes were morbidities of prematurity and SpO2 at 5 minutes. Results IPD were provided for 1055 infants from 12 of the 13 eligible studies (2005-2019). Resuscitation with high (≥0.90) initial FiO2 was associated with significantly reduced mortality compared to low (≤0.3) (odds ratio [OR], 0.45; 95% credible interval [CrI], 0.23-0.86; low certainty) and intermediate (0.5-0.65) FiO2 (OR, 0.34; 95% CrI, 0.11-0.99; very low certainty). High initial FiO2 had a 97% probability of ranking first to reduce mortality. The effects on other morbidities were inconclusive. Conclusions and Relevance High initial FiO2 (≥0.90) may be associated with reduced mortality in preterm infants born at less than 32 weeks' gestation compared to low initial FiO2 (low certainty). High initial FiO2 is possibly associated with reduced mortality compared to intermediate initial FiO2 (very low certainty) but more evidence is required.
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Affiliation(s)
- James X. Sotiropoulos
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
- School of Women’s and Children’s Health, Faculty of Medicine and Health, University of New South Wales, Kensington, New South Wales, Australia
- Department of Newborn Care, the Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Ju Lee Oei
- School of Women’s and Children’s Health, Faculty of Medicine and Health, University of New South Wales, Kensington, New South Wales, Australia
- Department of Newborn Care, the Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Georg M. Schmölzer
- Department of Pediatrics, Faculty of Medicine and Dentistry, University of Alberta, Edmonton, Alberta, Canada
- Centre for the Studies of Asphyxia and Resuscitation, Neonatology, Royal Alexandra Hospital, Edmonton, Alberta, Canada
| | - Sol Libesman
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Kylie E. Hunter
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Jonathan G. Williams
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Angela C. Webster
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
| | - Maximo Vento
- University and Polytechnic Hospital La Fe, Valencia, Spain
- Health Research Institute La Fe, Valencia, Spain
| | - Vishal Kapadia
- Department of Pediatrics, University of Texas Southwestern Medical Center, Dallas
| | - Yacov Rabi
- Department of Pediatrics, University of Calgary, Alberta Children’s Hospital Research Institute, Calgary, Alberta, Canada
| | - Janneke Dekker
- Willem-Alexander Children’s Hospital, Department of Pediatrics, Division of Neonatology, Leiden University Medical Center, Leiden, the Netherlands
| | - Marijn J. Vermeulen
- Department of Neonatal and Pediatric Intensive Care, Division of Neonatology, Erasmus Medical Center, Rotterdam, the Netherlands
| | - Venkataseshan Sundaram
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Praveen Kumar
- Division of Neonatology, Department of Pediatrics, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Risma K. Kaban
- Department of Child Health, University of Indonesia Medical School/Dr Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Rinawati Rohsiswatmo
- Department of Child Health, University of Indonesia Medical School/Dr Cipto Mangunkusumo Hospital, Jakarta, Indonesia
| | - Ola D. Saugstad
- Department of Pediatric Research, University of Oslo, Oslo, Norway
- Ann and Robert H. Lurie Children’s Hospital of Chicago, Northwestern University Feinberg School of Medicine, Chicago, Illinois
| | - Anna Lene Seidler
- National Health and Medical Research Council Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia
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2
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Belting C, Rüegger CM, Waldmann AD, Bassler D, Gaertner VD. Rescue nasopharyngeal tube for preterm infants non-responsive to initial ventilation after birth. Pediatr Res 2024; 96:141-147. [PMID: 38273117 PMCID: PMC11257935 DOI: 10.1038/s41390-024-03033-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2023] [Revised: 11/29/2023] [Accepted: 12/29/2023] [Indexed: 01/27/2024]
Abstract
BACKGROUND Physiological changes during the insertion of a rescue nasopharyngeal tube (NPT) after birth are unclear. METHODS Observational study of very preterm infants in the delivery room. Data were extracted at predefined timepoints starting with first facemask placement after birth until 5 min after insertion of NPT. End-expiratory lung impedance (EELI), heart rate (HR) and SpO2/FiO2-ratio were analysed over time. Changes during the same time span of NIPPV via facemask and NIPPV via NPT were compared. RESULTS Overall, 1154 inflations in 15 infants were analysed. After NPT insertion, EELI increased significantly [0.33 AU/kg (0.19-0.57), p < 0.001]. Compared with the mask period, changes in EELI were not significantly larger during the NPT period [median difference (IQR) = 0.14 AU/kg (-0.14-0.53); p = 0.12]. Insertion of the NPT was associated with significant improvement in HR [52 (33-96); p = 0.001] and SpO2/FiO2-ratio [161 (69-169); p < 0.001] not observed during the mask period. CONCLUSIONS In very preterm infants non-responsive to initial facemask ventilation after birth, insertion of an NPT resulted in a considerable increase in EELI. This additional gain in lung volume was associated with an immediate improvement in clinical parameters. The use of a NPT may prevent intubation in selected non-responsive infants. IMPACT After birth, a nasopharyngeal tube may be considered as a rescue airway in newborn infants non-responsive to initial positive pressure ventilation via facemask. Although it is widely used among clinicians, its effect on lung volumes and physiological parameters remains unclear. Insertion of a rescue NPT resulted in a considerable increase in lung volume but this was not significantly larger than during facemask ventilation. However, insertion of a rescue NPT was associated with a significant and clinically important improvement in heart rate and oxygenation. This study highlights the importance of individual strategies in preterm resuscitation and introduces the NPT as a valid option.
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Affiliation(s)
- Carina Belting
- Newborn Research, Department of Neonatology, University Hospital and University of Zürich, Zürich, Switzerland
- Department of Pediatric Intensive Care and Neonatology, Children's Hospital of Eastern Switzerland, St. Gallen, Switzerland
| | - Christoph M Rüegger
- Newborn Research, Department of Neonatology, University Hospital and University of Zürich, Zürich, Switzerland
| | - Andreas D Waldmann
- Department of Anaesthesiology and Intensive Care Medicine, Rostock University Medical Centre, Rostock, Germany
| | - Dirk Bassler
- Newborn Research, Department of Neonatology, University Hospital and University of Zürich, Zürich, Switzerland
| | - Vincent D Gaertner
- Newborn Research, Department of Neonatology, University Hospital and University of Zürich, Zürich, Switzerland.
- Division of Neonatology, Dr von Hauner Children's Hospital, Ludwig-Maximilians-Universität München, Munich, Germany.
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3
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Sotiropoulos JX, Binoy S, Pham TAN, Yates K, Allgood CL, Kunjunju A, Tracy M, Smyth J, Oei JL. Air or Oxygen for Infant Resuscitation: A Prospective Cohort Study of Moderate-Late Preterm Infants Requiring Delivery Room Resuscitation. Neonatology 2024:1-9. [PMID: 38889702 DOI: 10.1159/000539221] [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: 11/28/2023] [Accepted: 04/27/2024] [Indexed: 06/20/2024]
Abstract
INTRODUCTION Due to concerns of oxidative stress and injury, most clinicians currently use lower levels of fractional inspired oxygen (FiO2, 0.21-0.3) to initiate respiratory support for moderate to late preterm (MLPT, 32-36 weeks gestation) infants at birth. Whether this practice achieves recommended oxygen saturation (SpO2) targets is unknown. METHODS We aimed to determine SpO2 trajectories of MLPT infants requiring respiratory support at birth. We conducted a prospective, opportunistic, observational study with consent waiver. Preductal SpO2 readings were obtained during the first 10 min of life from infants between 32 and 36 weeks gestation requiring respiratory support in the delivery room. Primary outcome was reaching a minimum SpO2 80% at 5 min of life. The study was prospectively registered (ACTRN12620001252909). RESULTS A total of 76 eligible infants were recruited between February 2021 and March 2022 from 5 hospitals in Australia. Most (n = 58, 76%) had respiratory support initiated with FiO2 0.21 (range 0.21-1.0) using CPAP (92%). Median SpO2 at 5 min was 81% (interquartile range [IQR] 67-90) and 93% (IQR 86-96) at 10 min. At 5 min, 18/43 (42%) infants had SpO2 below 80% and only 8/43 (19%) reached SpO2 80-85%. CONCLUSIONS Many MLPT infants requiring respiratory support do not achieve recommended SpO2 targets. In very preterm infants, SpO2 <80% at 5 min of life increases risk of death, intraventricular haemorrhage, and neurodevelopmental impairment. The implications on this practice on the health outcomes of MLPT infants are unclear and require further research.
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Affiliation(s)
- James X Sotiropoulos
- Department of Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia,
- NHMRC Clinical Trials Centre, Faculty of Medicine and Health, University of Sydney, Camperdown, New South Wales, Australia,
| | - Sheeba Binoy
- Department of Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Thy A N Pham
- Department of Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Kylie Yates
- Department of Paediatrics, St George Hospital, Kogarah, New South Wales, Australia
| | - Catherine L Allgood
- Department of Paediatrics, Campbelltown Hospital, University of Western Sydney School of Medicine, Campbelltown, New South Wales, Australia
| | - Ansar Kunjunju
- Department of Newborn Care, The Wollongong Hospital, Wollongong, New South Wales, Australia
| | - Mark Tracy
- Department of Newborn Care, Westmead Hospital, Westmead, New South Wales, Australia
| | - John Smyth
- Department of Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia
| | - Ju Lee Oei
- Department of Newborn Care, Royal Hospital for Women, Randwick, New South Wales, Australia
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4
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Ortiz M, Loidl F, Vázquez‐Borsetti P. Transition to extrauterine life and the modeling of perinatal asphyxia in rats. WIREs Mech Dis 2022; 14:e1568. [DOI: 10.1002/wsbm.1568] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2021] [Revised: 05/11/2022] [Accepted: 05/14/2022] [Indexed: 11/07/2022]
Affiliation(s)
- Mauro Ortiz
- Universidad de Buenos Aires Buenos Aires Argentina
| | - Fabián Loidl
- Consejo Nacional de Investigaciones Científicas y Técnicas Buenos Aires Argentina
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5
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Stimulating and maintaining spontaneous breathing during transition of preterm infants. Pediatr Res 2021; 90:722-730. [PMID: 31216570 DOI: 10.1038/s41390-019-0468-7] [Citation(s) in RCA: 12] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2019] [Revised: 05/25/2019] [Accepted: 06/03/2019] [Indexed: 01/30/2023]
Abstract
Most preterm infants breathe at birth, but need additional respiratory support due to immaturity of the lung and respiratory control mechanisms. To avoid lung injury, the focus of respiratory support has shifted from invasive towards non-invasive ventilation. However, applying effective non-invasive ventilation is difficult due to mask leak and airway obstruction. The larynx has been overlooked as one of the causes for obstruction, preventing face mask ventilation from inflating the lung. The larynx remains mostly closed at birth, only opening briefly during a spontaneous breath. Stimulating and supporting spontaneous breathing could enhance the success of non-invasive ventilation by ensuring that the larynx remains open. Maintaining adequate spontaneous breathing and thereby reducing the need for invasive ventilation is not only important directly after birth, but also in the first hours after admission to the NICU. Respiratory distress syndrome is an important cause of respiratory failure. Traditionally, treatment of RDS required intubation and mechanical ventilation to administer exogenous surfactant. However, new ways have been implemented to administer surfactant and preserve spontaneous breathing while maintaining non-invasive support. In this narrative review we aim to describe interventions focused on stimulation and maintenance of spontaneous breathing of preterm infants in the first hours after birth.
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6
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Dekker J, Martherus T, Lopriore E, Giera M, McGillick EV, Hutten J, van Leuteren RW, van Kaam AH, Hooper SB, Te Pas AB. The Effect of Initial High vs. Low FiO 2 on Breathing Effort in Preterm Infants at Birth: A Randomized Controlled Trial. Front Pediatr 2019; 7:504. [PMID: 31921719 PMCID: PMC6927294 DOI: 10.3389/fped.2019.00504] [Citation(s) in RCA: 25] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2019] [Accepted: 11/21/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Infants are currently stabilized at birth with initial low FiO2 which increases the risk of hypoxia and suppression of breathing in the first minutes after birth. We hypothesized that initiating stabilization at birth with a high O2 concentration, followed by titration, would improve breathing effort when compared to a low O2 concentration, followed by titration. Methods: In a bi-center randomized controlled trial, infants <30 weeks gestation were stabilized at birth with an initial O2 concentration of 30 or 100%, followed by oxygen titration. Primary outcome was minute volume of spontaneous breathing. We also assessed tidal volumes, mean inspiratory flow rate (MIFR) and respiratory rate with a respiratory function monitor in the first 5 min after birth, and evaluated the duration of mask ventilation in the first 10 min after birth. Pulse oximetry was used to measure heart rate and SpO2 values in the first 10 min. Hypoxemia was defined as SpO2 < 25th percentile and hyperoxemia as SpO2 >95%. 8-iso-prostaglandin F2α (8iPGF2α) was measured to assess oxidative stress in cord blood and 1 and 24 h after birth. Results: Fifty-two infants were randomized and recordings were obtained in 44 infants (100% O2-group: n = 20, 30% O2-group: n = 24). Minute volumes were significantly higher in the 100% O2-group (146.34 ± 112.68 mL/kg/min) compared to the 30% O2-group (74.43 ± 52.19 mL/kg/min), p = 0.014. Tidal volumes and MIFR were significantly higher in the 100% O2-group, while the duration of mask ventilation given was significantly shorter. Oxygenation in the first 5 min after birth was significantly higher in infants in the 100% O2-group [85 (64-93)%] compared to the 30% O2-group [58 (46-67)%], p < 0.001. The duration of hypoxemia was significantly shorter in the 100% O2-group, while the duration of hyperoxemia was not different between groups. There was no difference in oxidative stress marker 8iPGF2α between the groups. Conclusion: Initiating stabilization of preterm infants at birth with 100% O2 led to higher breathing effort, improved oxygenation, and a shorter duration of mask ventilation as compared to 30% O2, without increasing the risk for hyperoxia or oxidative stress. Clinical Trial Registration: This study was registered in www.trialregister.nl, with registration number NTR6878.
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Affiliation(s)
- Janneke Dekker
- Department of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Tessa Martherus
- Department of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Enrico Lopriore
- Department of Neonatology, Leiden University Medical Center, Leiden, Netherlands
| | - Martin Giera
- Center Proteomics Metabolomics, Leiden University Medical Center, Leiden, Netherlands
| | - Erin V McGillick
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Jeroen Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Ruud W van Leuteren
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, University of Amsterdam, Amsterdam, Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Arjan B Te Pas
- Department of Neonatology, Leiden University Medical Center, Leiden, Netherlands
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7
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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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8
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Dekker J, Hooper SB, Croughan MK, Crossley KJ, Wallace MJ, McGillick EV, DeKoninck PLJ, Thio M, Martherus T, Ruben G, Roehr CC, Cramer SJE, Flemmer AW, Croton L, Te Pas AB, Kitchen MJ. Increasing Respiratory Effort With 100% Oxygen During Resuscitation of Preterm Rabbits at Birth. Front Pediatr 2019; 7:427. [PMID: 31696099 PMCID: PMC6817611 DOI: 10.3389/fped.2019.00427] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2019] [Accepted: 10/07/2019] [Indexed: 11/13/2022] Open
Abstract
Background: Spontaneous breathing is essential for successful non-invasive respiratory support delivered by a facemask at birth. As hypoxia is a potent inhibitor of spontaneous breathing, initiating respiratory support with a high fraction of inspired O2 may reduce the risk of hypoxia and increase respiratory effort at birth. Methods: Preterm rabbit kittens (29 days gestation, term ~32 days) were delivered and randomized to receive continuous positive airway pressure with either 21% (n = 12) or 100% O2 (n = 8) via a facemask. If apnea occurred, intermittent positive pressure ventilation (iPPV) was applied with either 21% or 100% O2 in kittens who started in 21% O2, and remained at 100% O2 for kittens who started the experiment in 100% O2. Respiratory rate (breaths per minute, bpm) and variability in inter-breath interval (%) were measured from esophageal pressure recordings and functional residual capacity (FRC) was measured from synchrotron phase-contrast X-ray images. Results: Initially, kittens receiving 21% O2 had a significantly lower respiratory rate and higher variability in inter-breath interval, indicating a less stable breathing pattern than kittens starting in 100% O2 [median (IQR) respiratory rate: 16 (4-28) vs. 38 (29-46) bpm, p = 0.001; variability in inter-breath interval: 33.3% (17.2-50.1%) vs. 27.5% (18.6-36.3%), p = 0.009]. Apnea that required iPPV, was more frequently observed in kittens in whom resuscitation was started with 21% compared to 100% O2 (11/12 vs. 1/8, p = 0.001). After recovering from apnea, respiratory rate was significantly lower and variability in inter-breath interval was significantly higher in kittens who received iPPV with 21% compared to 100% O2. FRC was not different between study groups at both timepoints. Conclusion: Initiating resuscitation with 100% O2 resulted in increased respiratory activity and stability, thereby reducing the risk of apnea and need for iPPV after birth. Further studies in human preterm infants are mandatory to confirm the benefit of this approach in terms of oxygenation. In addition, the ability to avoid hyperoxia after initiation of resuscitation with 100% oxygen, using a titration protocol based on oxygen saturation, needs to be clarified.
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Affiliation(s)
- Janneke Dekker
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands.,The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Michelle K Croughan
- School of Physics and Astronomy, Monash University, Melbourne, VIC, Australia
| | - Kelly J Crossley
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Megan J Wallace
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Erin V McGillick
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Philip L J DeKoninck
- The Ritchie Centre, Hudson Institute of Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Erasmus MC, University Medical Center, Rotterdam, Netherlands
| | - Marta Thio
- Women's Newborn Research Centre, The Royal Women's Hospital, Melbourne, VIC, Australia.,Centre of Research Excellence in Newborn Medicine, Murdoch Children's Research Institute, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, University of Melbourne, Melbourne, VIC, Australia
| | - Tessa Martherus
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Gary Ruben
- School of Physics and Astronomy, Monash University, Melbourne, VIC, Australia
| | - Charles C Roehr
- Newborn Services, John Radcliffe Hospital, Oxford University Hospitals, NHS Foundation Trust, Oxford, United Kingdom.,Medical Sciences Division, Department of Pediatrics, University of Oxford, Oxford, United Kingdom
| | - Sophie J E Cramer
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands.,Department of Instrumental Affairs, Leiden University Medical Center, Leiden, Netherlands
| | - Andreas W Flemmer
- Department of Neonatology, Dr. v. Haunersches Kinderspital & Perinatal Center Grosshadern, Medical Center of the University of Munich, Munich, Germany
| | - Linda Croton
- School of Physics and Astronomy, Monash University, Melbourne, VIC, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Marcus J Kitchen
- School of Physics and Astronomy, Monash University, Melbourne, VIC, Australia
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9
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Dekker J, Hooper SB, Giera M, McGillick EV, Hutten GJ, Onland W, van Kaam AH, Te Pas AB. High vs. Low Initial Oxygen to Improve the Breathing Effort of Preterm Infants at Birth: Study Protocol for a Randomized Controlled Trial. Front Pediatr 2019; 7:179. [PMID: 31134170 PMCID: PMC6514187 DOI: 10.3389/fped.2019.00179] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Accepted: 04/17/2019] [Indexed: 12/31/2022] Open
Abstract
Background: Although most preterm infants breathe at birth, their respiratory drive is weak and supplemental oxygen is often needed to overcome hypoxia. This could in turn lead to hyperoxia. To reduce the risk of hyperoxia, currently an initial low oxygen concentration (21-30%) is recommended during stabilization at birth, accepting the risk of a hypoxic period. However, hypoxia inhibits respiratory drive in preterm infants. Starting with a higher level of oxygen could lead to a shorter duration of hypoxia by stimulating breathing effort of preterm infants, and combined with subsequent titration based on oxygen saturation, prolonged hyperoxia might be prevented. Study design: This multi-center randomized controlled trial will include 50 infants with a gestational age between 24 and 30 weeks. Eligible infants will be randomized to stabilization with an initial FiO2 of either 1.0 or 0.3 at birth. Hereafter, FiO2 will be titrated based on the oxygen saturation target range. In both groups, all other interventions during stabilization and thereafter will be similar. The primary outcome is respiratory effort in the first 5 min after birth expressed as average minute volume/kg. Secondary outcomes include inspired tidal volumes/kg, rate of rise to maximum tidal volume/kg, percentage of recruitment breaths with tidal volumes above 8 mL/kg, duration of hypoxia and hyperoxia and plasma levels of markers of oxidative stress (8-iso-prostaglandin F2α). Discussion: Current resuscitation guidelines recommend oxygen titration if infants fail to achieve the 25th percentile of the SpO2 reference ranges. It has become clear that, using this approach, most preterm infants are at risk for hypoxia in the first 5 min after birth, which could suppress the breathing effort. In addition, for compromised preterm infants who need respiratory support at birth, higher SpO2 reference ranges in the first minutes after birth might be needed to prevent prolonged hypoxia. Enhancing breathing effort by achieving an adequate level of oxygenation could potentially lead to a lower incidence of intubation and mechanical ventilation in the delivery room, contributing to a lower risk on lung injury in high-risk preterm infants. Measuring 8-iso-prostaglandin F2α could lead to a reflection of the true amount of oxygen exposure in both study groups.
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Affiliation(s)
- Janneke Dekker
- Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - Martin Giera
- Center Proteomics Metabolomics, Leiden University Medical Center, Leiden, Netherlands
| | - Erin V McGillick
- The Ritchie Centre, Hudson Institute for Medical Research, Melbourne, VIC, Australia.,Department of Obstetrics and Gynaecology, Monash University, Melbourne, VIC, Australia
| | - G Jeroen Hutten
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, Netherlands
| | - W Onland
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, Netherlands
| | - Anton H van Kaam
- Department of Neonatology, Emma Children's Hospital, Amsterdam UMC, Amsterdam, Netherlands
| | - Arjan B Te Pas
- Department of Pediatrics, Leiden University Medical Center, Leiden, Netherlands
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Abstract
Oxygen administration is often assumed to be required for all patients who are acutely or critically ill. However, in many situations, this assumption is not based on evidence. Injured body tissues and cells throughout the body respond both beneficially and adversely to delivery of supplemental oxygen. Available evidence indicates that oxygen administration is not warranted for patients who are not hypoxemic, and hyperoxia may contribute to increased tissue damage and mortality. Nurses must be aware of implications related to oxygen administration for all types of acutely and critically ill patients. These implications include having knowledge of oxygenation processes and pathophysiology; assessing global, tissue, and organ oxygenation status; avoiding either hypoxia or hyperoxia; and creating partnerships with respiratory therapists. Nurses can contribute to patients' oxygen status well-being by being proficient in determining each patient's specific oxygen needs and appropriate oxygen administration.
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Affiliation(s)
- Debra Siela
- Debra Siela is an associate professor, Ball State University School of Nursing, Muncie, Indiana. .,Michelle Kidd is a critical care clinical nurse specialist, Indiana University Health, Ball Memorial Hospital, Muncie, Indiana.
| | - Michelle Kidd
- Debra Siela is an associate professor, Ball State University School of Nursing, Muncie, Indiana.,Michelle Kidd is a critical care clinical nurse specialist, Indiana University Health, Ball Memorial Hospital, Muncie, Indiana
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Huberts TJP, Foglia EE, Narayen IC, van Vonderen JJ, Hooper SB, Te Pas AB. The Breathing Effort of Very Preterm Infants at Birth. J Pediatr 2018; 194:54-59. [PMID: 29336795 DOI: 10.1016/j.jpeds.2017.11.008] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/17/2017] [Revised: 10/23/2017] [Accepted: 11/01/2017] [Indexed: 11/26/2022]
Abstract
OBJECTIVE To compare the respiratory effort of very preterm infants receiving positive pressure ventilation (PPV) with infants breathing on continuous positive airway pressure (CPAP), directly after birth. STUDY DESIGN Recorded resuscitations of very preterm infants receiving PPV or CPAP after birth were analyzed retrospectively. The respiratory effort (minute volume and recruitment breaths [>8 mL/kg], heart rate, oxygen saturation, and oxygen requirement were analyzed for the first 2 minutes and in the fifth minute after birth. RESULTS Respiratory effort was analyzed in 118 infants, 87 infants receiving PPV and 31 infants receiving CPAP (median gestational age, 28 weeks [IQR, 26-29] vs 29 weeks [IQR, 29-30; P < .001); birth weight, 1059 g [IQR, 795-1300] vs 1205 g [IQR, 956-1418; P = .06]). The minute volume of spontaneous breaths of infants receiving PPV was lower at 2 minutes (37 mL/kg/minute [IQR, 15-69] vs 188 mL/kg/minute [IQR, 128-297; P < .001]) and at 5 minutes (112 mL/kg/minute [IQR, 46-229] vs 205 mL/kg/minute [IQR, 174-327; P < .001]). Recruitment breaths occurred less in the PPV group at 2 minutes (0 breaths/minute [IQR, 0-1] vs 4 breaths/minute [IQR, 1-8; P < .001]) and 5 minutes (0 breaths/minute [IQR, 0-3] vs 2 breaths/minute [IQR, 0-11; P = .01). The heart rate was lower in the PPV group (94 beats/minute [IQR, 68-128] vs 124 beats/minute [IQR, 100-144; P = .02]) as was oxygen saturation (50% [IQR, 35%-66%] vs 67% [IQR, 34%-80%; P = .04]), but not different at 5 minutes (heart rate, 149 beats/minute [IQR, 131-162] vs 150 beats/minute [IQR, 132-160; P = NS]; oxygen saturation , 91% [IQR, 80%-95%] vs 92% [IQR, 89%-97%; P = NS]). The oxygen requirement was higher (at 2 minutes, 30% [IQR, 21%-53%] vs 21% [IQR, 21%-29%; P = .05]; at 5 minutes, 39% [IQR, 22%-91%] vs 22% [IQR, 21%-31%; P = .003]). CONCLUSION Very preterm infants breathe at birth when receiving PPV, but the respiratory effort was significantly lower when compared with infants receiving CPAP only. The reduced breathing effort observed likely justified applying PPV in most infants.
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Affiliation(s)
- Tom J P Huberts
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Elizabeth E Foglia
- The Children's Hospital of Philadelphia and The University of Pennsylvania Perelman School of Medicine, Philadelphia, PA
| | - Ilona C Narayen
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Jeroen J van Vonderen
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands
| | - Stuart B Hooper
- The Ritchie Centre, Hudson Institute of Medical Research, Monash University, Melbourne, Australia; Department of Obstetrics and Gynecology, Monash University, Melbourne, Australia
| | - Arjan B Te Pas
- Division of Neonatology, Department of Pediatrics, Leiden University Medical Center, Leiden, The Netherlands.
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