The Effect of Initial High vs. Low FiO2 on Breathing Effort in Preterm Infants at Birth: A Randomized Controlled Trial

Abstract

Background: Infants are currently stabilized at birth with initial low FiO 2 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 O 2 concentration, followed by titration, would improve breathing effort when compared to a low O 2 concentration, followed by titration.Conclusion: Initiating stabilization of preterm infants at birth with 100% O 2 led to higher breathing effort, improved oxygenation, and a shorter duration of mask ventilation as compared to 30% O 2 , without increasing the risk for hyperoxia or oxidative stress.Clinical Trial Registration: This study was registered in www.trialregister.nl, with registration number NTR6878.

Optimizing Oxygenation of the Extremely Premature Infant during the First Few Minutes of Life: Start Low or High?

“…They also state that hyperoxia should be avoided during resuscitation of extremely preterm infants. 12 We agree with Dekker et al that we currently do not know the optimal initial FiO 2 for immature infants, but we question whether this means that an FiO 2 of 1.0 should always be used instead of the recommended 0.3, and we believe that the data are insufficient to support such a conclusion. The study included a small population of selected infants, did not report separate data for those infants born at 24-26 weeks of gestation vs 27-29 weeks as stratified during allocation, and did not include neurodevelopmental outcomes.…”

“…Dekker et al randomized preterm infants <30 weeks of gestation to be stabilized at birth with either 30% or 100% oxygen ( Figure 2) based on the Dawson curves. 1,12 When the initial FiO 2 setting was 0.3 and the SpO 2 was below the 25th percentile, the FiO 2 was titrated up to 0.5 and subsequently to 1.0. If the SpO 2 exceeded 90% with this initial setting, the FiO 2 was titrated down to 0.21 directly.…”

“…Even though the number of patients was small, the rates of intubation (only 2 infants in the 30% oxygen group needed intubation in the delivery room), intraventricular hemorrhage grade ³III, or death before hospital discharge did not significantly differ between the 2 groups. 12 Based on these data, Dekker et al suggest "that oxygenation might be an important determinant in stimulating breathing and decreasing the need for positive-pressure ventilation," and argue that it is best to start with a brief pulse of high oxygen and titrate down, with the goal of avoiding any hypoxemia in the first minutes after birth. They also state that hyperoxia should be avoided during resuscitation of extremely preterm infants.…”

Aerosol drug delivery to spontaneously-breathing preterm neonates: lessons learned

“…Consequently, the lungs of nRDS infants are characterized by widespread atelectasis, reduced pulmonary compliance, and low tidal volumes (V T ) for which they try to compensate increasing the respiratory rate. Dekker et al determined the tidal volume (V T ) of 23 premature infants (GA 29 +0 ; 27 +5 -31 +0 ; mean and interquartile range, IQR) with a mean birth weight of 1 252 g (IQR 1 050-1 388 g) immediately after birth [61]; infants showed a mean V T of 2.7 mL/kg (IQR 1.0-5.7 mL/kg) in the first 4 min of life, which increased to 2.9 mL/kg (IQR 1.3-5.4 mL/kg) in the first 7 min of life. The mean respiratory rate of the group of infants in the Dekker study was 23 breath/min (IQR 7-36 breath/min).…”

Seeing the fetus from a DOHaD perspective: discussion paper from the advanced imaging techniques of DOHaD applications workshop held at the 2019 DOHaD World Congress

“…[188][189][190]192,193 This new knowledge has also provided critical information about why some babies do not benefit from noninvasive respiratory support at birth, and identified key factors including oxygenation, pharmacological targets, and noninvasive interventions in the delivery room that can be targeted to aid in a more rapid and successful transition to breathing in newborns to reduce the risk of adverse outcomes. 192,194,195 Together, this use of imaging has provided the vitally important physiological evidence required to drive safe and effective interventions in newborn clinical trials, which have been incorporated into resuscitation guidelines to make resuscitation safer and more effective for newborns worldwide. The use of synchrotron-based PCX imaging technology has enabled the highest level of physiological evidence to be generated by understanding the intricate details of complex processes at birth, rather than evidence solely guided by expert opinion, to aid in the transition at birth to prevent lifelong disease in vulnerable newborns.…”