Resuscitation of Preterm Neonates With Limited Versus High Oxygen Strategy

Abstract

WHAT'S KNOWN ON THIS SUBJECT: Preterm infants can be successfully resuscitated with ,100% oxygen (O 2 ); however, initiation with room air remains controversial. Current Neonatal Resuscitation Program (NRP) guidelines suggest using air or blended O 2 to titrate O 2 to meet target preductal saturation goals. WHAT THIS STUDY ADDS:This is the first trial to compare a limited O 2 strategy to target NRP-recommended transitional goal saturations versus a high O 2 strategy in preterm infants. The limited O 2 strategy decreased integrated excess oxygen and oxidative stress and improved respiratory outcomes. abstract OBJECTIVE: To determine whether a limited oxygen strategy (LOX) versus a high oxygen strategy (HOX) during delivery room resuscitation decreases oxidative stress in preterm neonates. METHODS:A randomized trial of neonates of 24 to 34 weeks' gestational age (GA) who received resuscitation was performed. LOX neonates received room air as the initial resuscitation gas, and fraction of inspired oxygen (FIO 2 ) was adjusted by 10% every 30 seconds to achieve target preductal oxygen saturations (SpO 2 ) as described by the 2010 Neonatal Resuscitation Program guidelines. HOX neonates received 100% O 2 as initial resuscitation gas, and FIO 2 was adjusted by 10% to keep preductal SpO 2 at 85% to 94%. Total hydroperoxide (TH), biological antioxidant potential (BAP), and the oxidative balance ratio (BAP/TH) were analyzed in cord blood and the first hour of life. Secondary outcomes included delivery room interventions, respiratory support on NICU admission, and short-term morbidities.RESULTS: Forty-four LOX (GA: 30 6 3 weeks; birth weight: 1678 6 634 g) and 44 HOX (GA: 30 6 3 weeks; birth weight: 1463 6 606 g) neonates were included. LOX decreased integrated excess oxygen (+FIO 2 3 time [min]) in the delivery room compared with HOX (401 6 151 vs 662 6 249; P , .01). At 1 hour of life, BAP/TH was 60% higher for LOX versus HOX neonates (13 [9-16] vs 8 [6-9]) mM/U.CARR, P , .01). LOX decreased ventilator days (3 [0-64] vs 8 [0-96]; P , .05) and reduced the incidence of bronchopulmonary dysplasia (7% vs 25%; P , .05).CONCLUSIONS: LOX is feasible and results in less oxygen exposure, lower oxidative stress, and decreased respiratory morbidities and thus is a reasonable alternative for resuscitation of preterm neonates in the delivery room.

Part 7: Neonatal Resuscitation

“…The quality of evidence was downgraded for imprecision. 175,[177][178][179][180] We found very-low-quality evidence from 1 cohort study including 125 subjects showing no benefit to beginning resuscitation with high-oxygen as compared with low-oxygen concentration (RR, 1.31; 95% CI, 0.41-4.24). The quality of evidence was downgraded for serious imprecision.…”

“…The quality of evidence was downgraded for imprecision. [174][175][176][177][178][179][180] When limited to randomized clinical trials with concealed allocation and oxygen targeting as a cointervention, we found moderate-quality evidence from 5 trials enrolling 468 subjects showing no benefit to beginning resuscitation with a high-oxygen concentration as compared with lowoxygen concentration (RR, 1.33; 95% CI, 0.68-2.62). The quality of evidence was downgraded for imprecision.…”

Part 13: Neonatal Resuscitation

“…125,128,129 When oxygen targeting was used as a cointervention, the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and lowoxygen groups within the first 10 minutes of life. 125,[128][129][130] In all studies, irrespective of whether air or high oxygen (including 100%) was used to initiate resuscitation, most infants were in approximately 30% oxygen by the time of stabilization. Resuscitation of preterm newborns of less than 35 weeks of gestation should be initiated with low oxygen (21% to 30%), and the oxygen concentration should be titrated to achieve preductal oxygen saturation approximating the interquartile range measured in healthy term infants after vaginal birth at sea level 123 (Class I, LOE B-R).…”

“…[124][125][126][127][128][129][130] Similarly, in the subset of studies that evaluated these outcomes, no benefit was seen for the prevention of bronchopulmonary dysplasia, 125,[127][128][129][130] IVH, 125,[128][129][130] or retinopathy of prematurity. 125,128,129 When oxygen targeting was used as a cointervention, the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and lowoxygen groups within the first 10 minutes of life. 125,[128][129][130] In all studies, irrespective of whether air or high oxygen (including 100%) was used to initiate resuscitation, most infants were in approximately 30% oxygen by the time of stabilization.…”

Part 13: Neonatal Resuscitation

“…[124][125][126][127][128][129][130] Similarly, in the subset of studies that evaluated these outcomes, no benefit was seen for the prevention of bronchopulmonary dysplasia, 125,[127][128][129][130] IVH, 125,[128][129][130] or retinopathy of prematurity. 125,128,129 When oxygen targeting was used as a cointervention, the oxygen concentration of resuscitation gas and the preductal oxygen saturation were similar between the high-oxygen and low-oxygen groups within the first 10 minutes of life. 125,[128][129][130] In all studies, irrespective of whether air or high oxygen (including 100%) was used to initiate resuscitation, most infants were in approximately 30% oxygen by the time of stabilization.…”