How Do We Monitor Oxygenation during the Management of PPHN? Alveolar, Arterial, Mixed Venous Oxygen Tension or Peripheral Saturation?

Chandrasekharan, Praveen; Rawat, Munmun; Lakshminrusimha, Satyanarayana

doi:10.3390/children7100180

Cited by 12 publications

(6 citation statements)

References 42 publications

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“…With 100% supplemental O 2 , the average arterial O 2 tension (PaO 2 ) was <100 mm Hg in the first 10 min. Perinatal depression, acidosis, and RDS can hamper the decrease in pulmonary vascular resistance and an improvement in pulmonary blood flow [ 8 , 15 , 16 ]. In our study, the use of 30% oxygen was associated with lower peak pulmonary blood flow than the other groups.…”

Section: Discussionmentioning

confidence: 99%

Initial Use of 100% but Not 60% or 30% Oxygen Achieved a Target Heart Rate of 100 bpm and Preductal Saturations of 80% Faster in a Bradycardic Preterm Model

et al. 2022

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Background: Currently, 21–30% supplemental oxygen is recommended during resuscitation of preterm neonates. Recent studies have shown that 58% of infants < 32 week gestation age are born with a heart rate (HR) < 100 bpm. Prolonged bradycardia with the inability to achieve a preductal saturation (SpO2) of 80% by 5 min is associated with mortality and morbidity in preterm infants. The optimal oxygen concentration that enables the achievement of a HR ≥ 100 bpm and SpO2 of ≥80% by 5 min in preterm lambs is not known. Methods: Preterm ovine model (125–127 d, gestation equivalent to human neonates < 28 weeks) was instrumented, and asphyxia was induced by umbilical cord occlusion until bradycardia. Ventilation was initiated with 30% (OX30), 60% (OX60), and 100% (OX100) for the first 2 min and titrated proportionately to the difference from the recommended preductal SpO2. Our primary outcome was the incidence of the composite of HR ≥ 100 bpm and SpO2 ≥ 80%, by 5 min. Secondary outcomes were to evaluate the time taken to achieve the primary outcome, gas exchange, pulmonary/systemic hemodynamics, and the oxidative injury. Results: Eighteen lambs (OX30-6, OX60-5. OX100-7) had an average HR < 91 bpm with a pH of <6.92 before resuscitation. Sixty seven percent achieved the primary outcome in OX100, 40% in OX60, and none in OX30. The time taken to achieve the primary outcome was significantly shorter with OX100 (6 ± 2 min) than with OX30 (10 ± 3 min) (* p = 0.04). The preductal SpO2 was highest with OX100, while the peak pulmonary blood flow was lowest with OX30, with no difference in O2 delivery to the brain or oxidative injury by 10 min. Conclusions: The use of 30%, 60%, and 100% supplemental O2 in a bradycardic preterm ovine model did not demonstrate a significant difference in the composite primary outcome. The current recommendation to use 30% oxygen did not achieve a preductal SpO2 of 80% by 5 min in any preterm lambs. Clinical studies to optimize supplemental O2 in depressed preterm neonates not requiring chest compressions are warranted.

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Section: Discussionmentioning

confidence: 99%

Initial Use of 100% but Not 60% or 30% Oxygen Achieved a Target Heart Rate of 100 bpm and Preductal Saturations of 80% Faster in a Bradycardic Preterm Model

et al. 2022

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“…The release of inflammatory mediators induces vasoconstriction, whereas acidosis further exacerbates increases in PVR 26 . Additionally, regional hypoxic pulmonary vasoconstriction not only diverts blood away from underventilated alveoli but also contributes to the overall increase in PVR and RV afterload effects 27 . Therefore, optimization of lung recruitment is of paramount importance before administration of selective pulmonary vasodilators like iNO to ensure efficacious delivery.…”

Section: Discussionmentioning

confidence: 99%

Clinical and echocardiography predictors of response to inhaled nitric oxide in hypoxemic term and near‐term neonates

Bischoff

Giesinger

Neary

et al. 2021

Pediatric Pulmonology

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Approximately 40% of hypoxemic term/near‐term neonates are nonresponders to inhaled nitric oxide (iNO). Phenotypic characterization of patients less likely to respond may improve diagnostic precision and therapeutic decisions. We conducted a retrospective cohort study of neonates born ≥35 weeks gestation with hypoxemia who received iNO in the first 72 h of life and classified them into responders and nonresponders according to changes in the fraction of inspired oxygen, saturations and/or arterial partial pressure of oxygen after 1 h of administration. Comprehensive targeted neonatal echocardiography (TnECHO) data were collected when performed up to 6 h prior or 24 h after iNO initiation. Descriptive statistics, univariate analysis, and binary logistic regression were used to compare the groups. There were 183 patients included (63% responders) and TnECHO was performed in 54 infants. The presence of lung disease, and particularly meconium aspiration syndrome (p = .004), was associated with nonresponse to iNO. Nonresponders were characterized by a higher need for rescue high‐frequency ventilation (p < .001), longer duration of mechanical ventilation (p < .001), and need for oxygen support (p = .003). Pulmonary hypertension documented on TnECHO was present in 96.3% of the patients but there was no difference in frequency or severity of pulmonary hypertension, or rates of low cardiac output between the groups. Moderate‐to‐severe right ventricular systolic dysfunction (p > .05) and lower left ventricular strain (p < .05) were more likely in the nonresponder group. In summary, response to iNO is influenced by lung disease, choice of ventilation strategy, and perhaps underlying cardiovascular physiology. Prospective pre‐ and post‐iNO echocardiography data may provide novel physiologic insights.

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“…Asphyxia with combined respiratory and metabolic acidosis shifts the hemoglobin-oxygen dissociation curve leading to lower SpO 2 for a given PaO 2 . We speculate that with better ventilation (lower PaCO 2 ) and higher pH in the DCCV group, SpO 2 values were higher despite lower PaO 2 levels in DCCV compared to ECCV [ 26 ]. By 5 min, the highest PaO 2 in DCCV was 38 ± 9 mmHg compared to ECCV, where it was 96 ± 65 mmHg.…”

Section: Discussionmentioning

confidence: 99%

“…Although the change point (PaO 2 value) for pulmonary vascular transition in an asphyxiated preterm neonate/model remains unknown, we have previously shown that in a non-asphyxiated preterm model, a PaO 2 of 31 ± 0.7 mmHg led to a drop in PVR [ 36 ]. In our study, we speculate that despite the lower PaO 2 observed in the arterial blood, higher alveolar PAO 2 helped overcome hypoxic pulmonary vasoconstriction and an improvement in pulmonary vascular transition in the DCCV group [ 26 ]. Custer et al have shown that alveolar hypoxia could worsen hypoxic pulmonary vasoconstriction leading to a redistribution of pulmonary blood flow in a newborn ovine model [ 37 ].…”

Section: Discussionmentioning

confidence: 99%

Resuscitation with an Intact Cord Enhances Pulmonary Vasodilation and Ventilation with Reduction in Systemic Oxygen Exposure and Oxygen Load in an Asphyxiated Preterm Ovine Model

et al. 2021

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(1) Background: Optimal initial oxygen (O2) concentration in preterm neonates is controversial. Our objectives were to compare the effect of delayed cord clamping with ventilation (DCCV) to early cord clamping followed by ventilation (ECCV) on O2 exposure, gas exchange, and hemodynamics in an asphyxiated preterm ovine model. (2) Methods: Asphyxiated preterm lambs (127–128 d) with heart rate <90 bpm were randomly assigned to DCCV or ECCV. In DCCV, positive pressure ventilation (PPV) was initiated with 30–60% O2 and titrated based on preductal saturations (SpO2) with an intact cord for 5 min, followed by clamping. In ECCV, the cord was clamped, and PPV was initiated. (3) Results: Fifteen asphyxiated preterm lambs were randomized to DCCV (N = 7) or ECCV (N = 8). The inspired O2 (40 ± 20% vs. 60 ± 20%, p < 0.05) and oxygen load (520 (IQR 414–530) vs. 775 (IQR 623–868), p-0.03) in the DCCV group were significantly lower than ECCV. Arterial oxygenation and carbon dioxide (PaCO2) levels were significantly lower and peak pulmonary blood flow was higher with DCCV. (4) Conclusion: In asphyxiated preterm lambs, resuscitation with an intact cord decreased O2 exposure load improved ventilation with an increase in peak pulmonary blood flow in the first 5 min.

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How Do We Monitor Oxygenation during the Management of PPHN? Alveolar, Arterial, Mixed Venous Oxygen Tension or Peripheral Saturation?

Cited by 12 publications

References 42 publications

Initial Use of 100% but Not 60% or 30% Oxygen Achieved a Target Heart Rate of 100 bpm and Preductal Saturations of 80% Faster in a Bradycardic Preterm Model

Initial Use of 100% but Not 60% or 30% Oxygen Achieved a Target Heart Rate of 100 bpm and Preductal Saturations of 80% Faster in a Bradycardic Preterm Model

Clinical and echocardiography predictors of response to inhaled nitric oxide in hypoxemic term and near‐term neonates

Resuscitation with an Intact Cord Enhances Pulmonary Vasodilation and Ventilation with Reduction in Systemic Oxygen Exposure and Oxygen Load in an Asphyxiated Preterm Ovine Model

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