Lower versus higher oxygen concentrations titrated to target oxygen saturations during resuscitation of preterm infants at birth

Lui, Kei ¹; Lui, Kei ^{1 2}; Jones, Lisa J ^{3 4}; Foster, Jann P ^{3 5 6}; Davis, Peter G ^{7 8 9}; Ching, See Kwee ¹⁰; Oei, Ju Lee ¹¹; Osborn, David A ¹²; Lui, Kei ¹

Cochrane Database of Systematic Reviews. This document is a Academic Journal
Review first published in Issue 5, 2018.
Protocol first published in Issue 11, 2012.
This version first published online: 04 May 2018 in Issue 5, 2018.

Publication Status: Edited (no change to conclusions) in Issue 5, 2018
Most recent changes:
Information not supplied by reviewer.

Kei Lui ¹; k.lui@unsw.edu.au

¹Royal Hospital for Women, Department of Newborn Care, Barker Street, Randwick, New South Wales, Australia, 2031
²Lei Lui, School of Women's and Children's Health, Sydney, NSW, Australia, 2052
³University of Sydney, Central Clinical School, Discipline of Obstetrics, Gynaecology and Neonatology, Camperdown, NSW, Australia,
⁴John Hunter Children's Hospital, Department of Neonatology, New Lambton, NSW, Australia, 2305
⁵Western Sydney University, School of Nursing and Midwifery, Penrith DC, Australia,
⁶Ingham Research Institute, Liverpool, NSW, Australia,
⁷The Royal Women's Hospital, Newborn Research Centre and Neonatal Services, Melbourne, Australia,
⁸Murdoch Childrens Research Institute, Melbourne, Australia,
⁹University of Melbourne, Department of Obstetrics and Gynecology, Melbourne, Australia,
¹⁰Hospital Sungai Buloh, STAR NICU, Selangor, Malaysia,
¹¹Royal Hospital for Women, Newborn Care, Barker Street, Randwick, NSW, Australia, 2031
¹²University of Sydney, Central Clinical School, Discipline of Obstetrics, Gynaecology and Neonatology, Sydney, NSW, Australia, 2050

Intramural sources of support: No sources of support supplied.
Extramural sources of support: No sources of support supplied.

Background: Initial resuscitation with air is well tolerated by most infants born at term. However, the optimal fractional inspired oxygen concentration (FiO2 ‐ proportion of the breathed air that is oxygen) targeted to oxygen saturation (SpO2 ‐ an estimate of the amount of oxygen in the blood) for infants born preterm is unclear. Objectives: To determine whether lower or higher initial oxygen concentrations, when titrated according to oxygen saturation targets during the resuscitation of preterm infants at birth, lead to improved short‐ and long‐term mortality and morbidity. Search methods: We conducted electronic searches of the Cochrane Central Register of Controlled Trials (13 October 2017), Ovid MEDLINE (1946 to 13 October 2017), Embase (1974 to 13 October 2017) and CINAHL (1982 to 13 October 2017); we also searched previous reviews (including cross‐references), contacted expert informants, and handsearched journals. Selection criteria: We included randomised controlled trials (including cluster‐ and quasi‐randomised trials) which enrolled preterm infants requiring resuscitation following birth and allocated them to receive either lower (FiO2 < 0.4) or higher (FiO2 ≥ 0.4) initial oxygen concentrations titrated to target oxygen saturation. Data collection and analysis: Two review authors independently assessed the eligibility of studies for inclusion, extracted data and assessed methodological quality. Primary outcomes included mortality near term or at discharge (latest reported) and neurodevelopmental disability. We conducted meta‐analysis using a fixed‐effect model. We assessed the quality of the evidence using GRADE. Main results: The search identified 10 eligible trials. Meta‐analysis of the 10 included studies (914 infants) showed no difference in mortality to discharge between lower (FiO2 < 0.4) and higher (FiO2 ≥ 0.4) initial oxygen concentrations targeted to oxygen saturation (risk ratio (RR) 1.05, 95% confidence interval (CI) 0.68 to 1.63). We identified no heterogeneity in this analysis. We graded the quality of the evidence as low due to risk of bias and imprecision. There were no significant subgroup effects according to inspired oxygen concentration strata (FiO2 0.21 versus ≥ 0.4 to < 0.6; FiO2 0.21 versus ≥ 0.6 to 1.0; and FiO2 ≥ 0.3 to < 0.4 versus ≥ 0.6 to 1.0). Subgroup analysis identified a single trial that reported increased mortality from use of lower (FiO2 0.21) versus higher (FiO2 1.0) initial oxygen concentration targeted to a lowest SpO2 of less than 85%, whereas meta‐analysis of nine trials targeting a lowest SpO2 of 85% to 90% found no difference in mortality. Meta‐analysis of two trials (208 infants) showed no difference in neurodevelopmental disability at 24 months between infants receiving lower (FiO2 < 0.4) versus higher (FiO2 > 0.4) initial oxygen concentrations targeted to oxygen saturation. Other outcomes were incompletely reported by studies. Overall, we found no difference in use of intermittent positive pressure ventilation or intubation in the delivery room; retinopathy (damage to the retina of the eyes, measured as any retinopathy and severe retinopathy); intraventricular haemorrhage (any and severe); periventricular leukomalacia (a type of white‐matter brain injury); necrotising enterocolitis (a condition where a portion of the bowel dies); chronic lung disease at 36 weeks' gestation; mortality to follow up; postnatal growth failure; and patent ductus arteriosus. We graded the quality of the evidence for these outcomes as low or very low. Authors' conclusions: There is uncertainty as to whether initiating post birth resuscitation in preterm infants using lower (FiO2 < 0.4) or higher (FiO2 ≥ 0.4) oxygen concentrations, targeted to oxygen saturations in the first 10 minutes, has an important effect on mortality or major morbidity, intubation during post birth resuscitation, other resuscitation outcomes, and long‐term outcomes including neurodevelopmental disability. We assessed the quality of the evidence for all outcomes as low to very low. Further large, well designed trials are needed to assess the effect of using different initial oxygen concentrations and the effect of targeting different oxygen saturations.

1465-1858

Copyright © 2018 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

Resuscitation*/adverse effects
Resuscitation*/methods
Infant, Premature /*blood
Oxygen /*administration & dosage
Oxygen /*analysis
Child, Preschool
Humans
Infant
Infant, Newborn
Cerebral Hemorrhage /epidemiology
Enterocolitis, Necrotizing /epidemiology
Infant Mortality
Intubation, Intratracheal /statistics & numerical data
Lung Diseases /epidemiology
Neurodevelopmental Disorders /epidemiology
Neurodevelopmental Disorders /etiology
Randomized Controlled Trials as Topic
Retinopathy of Prematurity /epidemiology

This record should be cited as: Lui, Kei, Lui, Kei, Jones, Lisa J, Foster, Jann P, Davis, Peter G, Ching, See Kwee, Oei, Ju Lee, Osborn, David A, Lui, Kei. Lower versus higher oxygen concentrations titrated to target oxygen saturations during resuscitation of preterm infants at birth. (Protocol) Cochrane Database of Systematic Reviews 2018, Issue 5. Art. No.: CD010239. DOI: 10.1002/14651858.CD010239.pub2.

edschh.CD010239