Oxygen in the delivery room: how ... - MCA Scientific Events · Saugstad OD, 2016 1-OR/RR < 1...
Transcript of Oxygen in the delivery room: how ... - MCA Scientific Events · Saugstad OD, 2016 1-OR/RR < 1...
Oxygen in the delivery room: how much?
Ola Didrik Saugstad, MD, PhD
Department of Pediatric Research
University of Oslo
Norway
Oxygen Therapy of the Newborn
between
Skylla and Karibdis
Σκύλλα
Χάρυβδις
SaO2
FiO2 FiO2
PaO2
SaO2
SaO2
SaO2
Disclosure
OD Saugstad has received:
• An unrestricted grant from Chiesi Pharma AB
• Reseach grants from Laerdal Medical
World Map Before 1998Resuscitation of Newborn Infants
100% O2
Before
1998
1998: Resair 2 . Pediatrics 1998WHO Basic Newborn Resuscitation:Use air
Neonatal Mortality after 21% or 100% O2 resusctiation
10 studies incuding 2134 infants
Saugstad, Ramji, Soll, Vento. Neonatology 2008
Fetus Birth 1 5 10 min 7d 14d 28d Childhood
21% O2
PaO2
100% O2
PaO2
100% O2 free
radicals
Cerebral vasoconstriction
and brain inflammation
↑ pulmonary vascular reactivity
Myocardial damage
Acute renal injury
Childhod leukemia
21% O2 free
radicals
Lakshminrushimha S, Saugstad OD, J Perinatol 2016
Oxygen Management in the Delivery Room Has Changed Over 10 Years
• <2000: FiO2 100%
• 2000: FiO2 100%, RA if O2 is not available
• 2005: Air CAN be used for term infants
• 2010: Air SHOULD be used for term infants, oxygen should be used judiciously in preterm infants
• 2010: FiO2 should be adjusted to meet target preductal SpO2
Ressucitation World Map 2010-11?Term or Near term Infants
Low oxygen approach
ILCOR October 18th 2010
Unresolved question:
how to resuscitate very small babies?
Vento al, 2009
0,00
0,10
0,20
0,30
0,40
0,50
0,60
0,70
0,80
0,90
1,00
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 20 30
Time after birth (min)
FiO
2
60
100
140
180
220
0 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 20 30
Time after birth (min)
Heart
rate
(b
pm
)
Lox Hox
FIO2
HEART RATE
******
**
**
Esriq, Vento et al, 2009
High: 0.9Low: 0.3
< 29 weeks
Wang CL et al Pediatrics 2009
Resuscitation of preterm neonates <32 w using 21% or 100% oxygen.
High versus low iFiO2 preterm infants< 32 w GA
Updated review & meta-analysis.
High: 60-100% O2
Low: 21-30% O2
Relative risk meta-analysis plot (random effects)
0.01 0.1 0.2 0.5 1 2 5 10 100
Kapadia, 2013 0.77 (0.16, 3.59)
Aguar, 2013 0.44 (0.15, 1.26)
Kumar, 2012 0.39 (0.00, 3.96)
Rook, 2012 0.57 (0.22, 1.45)
Rabi, 2011 0.71 (0.10, 4.69)
Vento, 2009 1.48 (0.39, 5.61)
Wang, 2008 1.28 (0.14, 11.72)
See, 2008 0.80 (0.09, 7.35)
Lundstrøm, 1995 0.34 (0.08, 1.37)
combined [random] 0.62 (0.37, 1.04)
relative risk (95% confidence interval)
Mortality
Saugstad, Aune, Aguar, Kapadia, Finer, Vento, Acta Paediatr, 2014; 103:744-51
Oei JL, Ghadge A, Coates E, Wright IM, Saugstad OD, Vento M,Buonocore G, Nagashima T, Suzuki K, Hosono S, Davis PG, Craven P, Askie L, Dawson J, Garg S, Keech A, Rabi Y, Smyth J, Sinha S, Stenson B, Lui K, Hunter CL, Tarnow Mordi W; HOLISTIC (Higher Or Lower oxygen and Infant Saturation Targeting: International Collaboration) Study Group.
Acta Paediatr. 2016 Sep;105(9):1061-6
Clinicians in 25 countries prefer to use lower levels of
oxygen to resuscitate preterm infants at birth
Oei J et al Acta Paediatr. 2016 Sep;105(9):1061-6
Archives Dis Child Fetal and Neonatal Ed 2017
Starting FiO2 Levels Do not Influence Death in Preterm Infants
Hospital Death RR 0.99 95% CI 0.52-1.91)
Ju-lee Oei et al Archives Dis child Fetal and Neonatal Ed 2017
Secondary outcomes.
Ju Lee Oei et al. Arch Dis Child Fetal Neonatal Ed 2017;102:F24-F30
High or Low Oxygen for Delivery Room Resuscitation of Preterm
Infants below 29 weeks Gestation – a meta-analysis and systematic review
Updated metaanalysis
* Trend to increased mortality when iFiO2 21%
in the smallest babies
Oei JL, Vento M, Rabi J, Wright I, Finer N, Rich W, Kapadia V, Aune D, Rock D, Tarnow-Mordi W, Saugstad OD
ADCFN 2017;102:F24-F30
TORPIDO Patient recruitment.
Oei JL, Saugstad OD et al. Pediatrics 2017;139:e20161452
©2017 by American Academy of Pediatrics
Infants <32 w GA Randomized toAir or 100% O2
No difference in mortality for all babies
< 28 w Mortality RA: 17% 100% O2: 6%
RR 3.9 (95%CI 1.1-13.4)
Hospital OutcomesAir
(n = 144)100% O2 (n = 142)
P/OR (95% CI)
Respiratory support (days)*
11 (3, 39) 22 (5, 48) 0.01
O2 (days)* 18 (2, 55) 28 (2, 61) 0.54
BPD 34 (24%) 40 (28%) 1.3 (0.7-2.2)
Dexamethasone 8 (6%) 8 (6%) 1.0 (0.4-2.8)
ROP (>grade 3) 4 (3%) 8 (6%) 2.1 (0.6-7.2)
PDA 37 (27%) 40 (29%) 1.1 (0.71-1.9)
IVH>grade 3 2 (1%) 6 (4%) 3.2 (0.6-15.9)
NEC 5 (4%) 1 (1%) 0.2 (0.02-1.7)
*median, 1st and 3rd quartiles, exclude diseased infants. Abbreviations: HFOV: high frequency oscillatory ventilation, BPD: bronchopulmonary dysplasia, ROP: retinopathy of prematurity, PDA: patent ductus arteriosus, IVH: intraventricular hemorrhage, NEC: necrotizing enterocolitis
Oei JL, et al, Pediatrics 2017
POST HOC- Hypothesis Generating OnlyNeonatal and Hospital Mortality
• There was an unexpected increase in neonatal and hospital mortality in infants < 28 w GA who were initially resuscitated with air.
All infants <28 weeks 28-31 weeks
RA 144
100% O2142
RA46
100% O253
RA98
100%O289
Neonatal death 12 (8%) 5 (4%) 8 (17%) 3 (6%) 4(4%) 2 (2%)
POR (95%CI)
0.130.40 (0.14-1.17)
0.110.28 (0.07-1.15)
0.690.54 (0.09-3.02)
Hospital death 15 (10%) 5 (4%) 11 (24%)
3 (6%) 4 (4%) 2 (2%)
POR (95%CI)
0.030.32 (0.11-0.89)
0.0180.19 (0.05-0.74)
0.680.54 (0.09-3.02)
Oei JL, et al, Pediatrics 2017
Gestational age weeks
OR
/RR
0
10
20
> 31 28-31 < 28
0.69(0.54-0.88)
1.9(0.33-11.1)
5.3(1.35-20)
High Vs Low FiO2 for Newborn ResuscitationOR/RR vs Gestational Age
Saugstad OD, 2016
1-
OR/RR < 1 favours air
OR/RR > 1 favours supplemental oxygen
Soraisham AS et al. J Perinatol 2017;00:1-7
Soraisham AS et al. J Perinatol 2017;00:1-7
Adjusted OR for Outcome - Room Air as reference
Outcome Intermediate 100% O2
Primary Death or NDI 1.01 (0 .77-1.34) 1.03 ( 0.78-1.35)
Death or severe NDI 1.14 (0.82-1.58) 1.22 (0.90- 1.67)
SecondaryDeath 1.03 (0.68 -1.56) 0.93 ( 0.63-1.37)
NDI 1.00 (0.74- 1.35) 1.08 (0.81-1.45)
Severe NDI 1.22 (0.78-1.91) 1.57 (1.05-2.35)
Language score < 70 1.54 (0.89-2.67 1.73 (1.02-2.91)
No significant differences: CP, Cognitive score < 85, Cogntive score < 70, Visual impairmen , Hearing impariment
Soraisham AS et al. J Perinatol 2017;00:1-7
Use of 100% oxygen at the initiation of DR resuscitation was associated with increased odds of severe NDI at 18-21 months CA among survivors
The correct oxygen concentration to initiate resuscitation of extremely preterm infants has yet to be determined and future randomized trials should focus on the assessment of long-term neurodevelopmental outcomes.
Soraisham AS et al. J Perinatol 2017;00:1-7
Canadian network 2017
Oei, J L, Finer N, Saugstad OD, Wright I, Rabi Y, Tarnow-Mordi W, Rich, W, Kapadia V, Rook D, Vento M. Pediatrics, 2017
Oie J et al Archiv Dis Childhood FN Ed in prep
Outcomes of Babies Who Do Not Reach SpO2 80% at 5 minutes
OR 4.5 (2.1-9.8)OR 2.4 (1.3-4.4)
• Almost 50% of infants < 32 weeks do not reach SpO2 study targets at 5 minutes of age
• Those who do not reach SpO2 80% by 5 minutes are at increased risk of death and IVH
• Larger well designed controlled studies of outcomes of infants randomized to different targets are needed to review current oxygen management strategies
Recommendations of FiO2 and Resuscitation of Newborns
Term and near term infantsOR for mortality 0.69 ( 0.54-0.88) in favour of air
Start with air - adjust according to SpO2
Preterm 28-31 weeks GA
OR for mortality 1.9 (0.33- 11.1)Start with 21-30% - adjust according to SpO2
Preterm < 28 weeks GA
OR for mortality 5.3 (1.35-20) Don’t start with 21%
Start with 30% - adjust according to SpO2
Until more data are available from randomized studies
Aim at a SpO2 of 80-85% within 5 min
OD Saugstad 2017
Thank you so much for your attention!