Safe oxygen saturation targeting and monitoring in preterm infants: can we avoid hypoxia and hyperoxia?

Sola, Augusto; Golombek, Sergio; Montes, María Teresa Escobar Gil de; Lemus-Varela, Lourdes; Zuluaga, Claudia; Domínguez, Fernándo; Baquero, Hernando; Sarmiento, Alejandro E Young; Natta, Diego; Perez, José Maria Rodriguez; Deulofeut, R.; Quiroga, Ana; Flores, Gabriel Lara; Morgues, Mónica; Pérez, Alfredo García-Alix; Overmeire, Bart Van; Bel, Frank van

doi:10.1111/apa.12692

Cited by 112 publications

(118 citation statements)

References 67 publications

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“…52 The mechanism(s) by which maintaining lower oxygen saturation levels might increase the risk of death is unclear, as the data from these trials suggest that tissue hypoxia was unlikely to be a factor. 23 In particular, in the SUPPORT trial, the proportion of infants with median oxygen saturations <85% was no different between the low and high saturation groups. 43 Conversely, a post hoc analysis from the SUPPORT trial found a disproportionally higher mortality rate in small-forgestational-age infants in the lower oxygen saturation target group, suggesting a possible interaction 54 ; if this observation can be confirmed in the other oxygen saturation trials, and more importantly in the individual patient analysis, it would suggest that small-for-gestational-age infants may be more vulnerable to lower oxygen saturations.…”

Section: Randomized Clinical Trials Of Oxygen Targetingmentioning

confidence: 88%

“…50 In the 1187 infants monitored with the revised algorithm, those assigned to the lower target range had a significantly increased mortality rate at 36 weeks' gestational age (23 46 a pooled analysis from all 3 BOOST-II sites, as originally planned, showed no significant difference in this outcome between the 2 arms (46.8% in the lower vs 43.4% in the higher saturation group; P = .10). 47 Two-year outcomes for the COT were published.…”

Section: Randomized Clinical Trials Of Oxygen Targetingmentioning

confidence: 92%

“…This differential compliance with low versus high alarms could be attributable to an increased tendency for the high alarm limit to be reached, the assumption that hypoxemia is more detrimental than hyperoxemia, and/or the fact that many monitors automatically reset to a high alarm limit of 100% when first turned on. 23 A balance must be struck between setting alarm limits too narrow (increasing the number of unnecessary alarms) or too wide (decreasing the safety margin for intervention). Studies have shown that matching the alarm limits with the target range is associated with more time spent within the target range.…”

Section: Alarm Limitsmentioning

confidence: 99%

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Oxygen Targeting in Extremely Low Birth Weight Infants

Cummings¹,

Polin²,

Newborn³

2016

Pediatrics

114

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The use of supplemental oxygen plays a vital role in the care of the critically ill preterm infant, but the unrestricted use of oxygen can lead to unintended harms, such as chronic lung disease and retinopathy of prematurity. An overly restricted use of supplemental oxygen may have adverse effects as well. Ideally, continuous monitoring of tissue and cellular oxygen delivery would allow clinicians to better titrate the use of supplemental oxygen, but such monitoring is not currently feasible in the clinical setting. The introduction of pulse oximetry has greatly aided the clinician by providing a relatively easy and continuous estimate of arterial oxygen saturation, but pulse oximetry has several practical, technical, and physiologic limitations. Recent randomized clinical trials comparing different pulse oximetry targets have been conducted to better inform the practice of supplemental oxygen use. This clinical report discusses the benefits and limitations of pulse oximetry for assessing oxygenation, summarizes randomized clinical trials of oxygen saturation targeting, and addresses implications for practice.

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Section: Randomized Clinical Trials Of Oxygen Targetingmentioning

confidence: 88%

Section: Randomized Clinical Trials Of Oxygen Targetingmentioning

confidence: 92%

Section: Alarm Limitsmentioning

confidence: 99%

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Oxygen Targeting in Extremely Low Birth Weight Infants

Cummings¹,

Polin²,

Newborn³

2016

Pediatrics

114

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“…A great deal is known about the short-term and long-term consequences of hyperoxia, but not so much about the effects of hypoxia. Experiments have shown that fluctuations in oxygen saturation in arterial blood, even within values considered to be normal, may increase the incidence of ROP, but also reduce it (30).…”

Section: Discussionmentioning

confidence: 99%

The Effect of Oxygen Therapy on the Development of Retinopathy of Prematurity

Jojić¹,

Predojević-Samardžić²,

Mavija³

et al. 2015

Pedaiatr Today

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Objective -The aim of this study is to show the effect of oxygen therapy in premature babies on the development of severe ROP. Materials and methods -This retrospective research covered a period of two years, and included 108 premature babies, with birth weight <1500 g and gestational age <33 weeks, at the Children's Ward of the University Hospital Clinical Centre, Banja Luka. The effects of the length of oxygen therapy and episodes of hypoxia and hyperoxia on the development of severe ROP were analysed. Results -ROP was present in 64 (59.2%) newborns, of which 21 (19.4%) had severe ROP. The incidence of severe ROP is statistically higher with lower birth weight, <1150 g (p<0.01), lower gestational age <30 weeks, longer oxygen therapy and when there were frequent episodes of hyperoxia and hypoxia. By multiple logistic regression analysis, a very strong connection was established between severe ROP and exposure to episodes of hyperoxia (OR 32.73; CI 4.14-255.37), episodes of hypoxia (OR 14.08; CI 3.81-51.94), and oxygen therapy longer than 10 days (OR 15.54;. For most risk factors tested, there was a strong connection between severe ROP and birth weight <1250 g, gestational age <30 weeks, respiratory distress syndrome and perinatal asphyxia. Conclusion -Long-term oxygen therapy, prematurity and low birth weight with hypoxia are important factors in the development of severe ROP. Constant education is necessary of staff regarding the potentially harmful effects of oxygen in order to prevent both hypoxia and hyperoxia.

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“…35,36 Some experts have suggested reducing the lower limit of SpO 2 alarm to the high 80s. 32 Target ranges should not be equated to alarm settings. Alarm limits (lower limit of 89% and upper limit of 96%) have not been rigorously studied, but may offer a practical solution.…”

Section: Conclusion and Practical Recommendationsmentioning

confidence: 99%

Oxygen Saturation Targets in Preterm Infants and Outcomes at 18–24 Months: A Systematic Review

2017

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CONTEXT: The optimal oxygen saturation target for extremely preterm infants remains unclear.OBJECTIVE: To systematically review evidence evaluating the effect of lower (85%-89%) versus higher (91%-95%) pulse oxygen saturation (SpO 2 ) target on mortality and neurodevelopmental impairment (NDI) at 18 to 24 months. DATA SOURCES:Electronic databases and all published randomized trials evaluating lower versus higher SpO 2 target in preterm infants. STUDY SELECTION:A total of 2896 relevant citations were identified; 5 trials were included in the final analysis.DATA EXTRACTION: Data from 5 trials were analyzed for quality of evidence and risk of bias. LIMITATIONS:Limitations include heterogeneity in age at enrollment and comorbidities between trials and change in oximeter algorithm midway through 3 trials. RESULTS:There was no difference in the incidence of primary outcome (death/NDI at 18-24 months) in the 2 groups; risk ratio, 1.05, 95% confidence interval 0.98-1.12, P = .18. Mortality before 18 to 24 months was higher in the lower-target group (risk ratio, 1.16, 95% confidence interval 1.03-1.31, P = .02). Rates of NDI and severe visual loss did not differ between the 2 groups. Proportion of time infants spent outside the target range while on supplemental oxygen ranged from 8.2% to 27.4% <85% and 8.1% to 22.4% >95% with significant overlap between the 2 groups.CONCLUSIONS: There was no difference in primary outcome between the 2 SpO 2 target groups. The collective data suggest that risks associated with restricting the upper SpO 2 target limit to 89% outweigh the benefits. The quality of evidence was moderate. We speculate that a wider target range (lower alarm limit, 89% and upper, 96%) may increase time spent within range, but the safety profile of this approach remains to be determined. Dr Manja conceptualized and designed the study, reviewed the literature, carried out the initial analyses, and reviewed and revised the manuscript; Dr Saugstad critically reviewed and extensively revised the manuscript; Dr Lakshminrusimha was the second reviewer of the literature and drafted the initial manuscript; and all authors approved the fi nal manuscript as submitted and agree to be accountable for all aspects of work.

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Safe oxygen saturation targeting and monitoring in preterm infants: can we avoid hypoxia and hyperoxia?

Cited by 112 publications

References 67 publications

Oxygen Targeting in Extremely Low Birth Weight Infants

Oxygen Targeting in Extremely Low Birth Weight Infants

The Effect of Oxygen Therapy on the Development of Retinopathy of Prematurity

Oxygen Saturation Targets in Preterm Infants and Outcomes at 18–24 Months: A Systematic Review

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