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What initial oxygen is best for preterm infants in the delivery room?-A response to the 2015 neonata

CSAR along with other world leaders in neonatal resusictatin research was part of a commentary about the initial percentage of oxygen use during neonatal resuscitation of infanst <29 weeks gestation.

Please see Resuscitation Journal (Abstract)

The 2015 ILCOR guidelines include a strong recommendation to initiate stabilization of preterm infants <35 weeks’ gestation with lower initial inspiratory fraction of oxygen (FiO2) (21–30%) and not higher FiO2 (>65%).

In 2010, AHA Guidelines recommended titration of FiO2 according to SpO2 targets of ∼60–65% at 1 min and ∼85–95% at 10 min after birth.

In 2014, a meta-analysis by Saugstad et al., including randomized trials (RCT) comparing higher (60–100%) versus lower (21–30%) initial oxygen in 677 preterm infants ≤32 weeks’ gestation showed no differences in morbidity but a trend towards lower mortality in the lower oxygen group. It was concluded that preterm infants could be initially stabilized with FiO2 of 0.21–0.3.

Oei et al. presented in 2015 results of the largest RCT comparing

the effects of resuscitation with room-air (RA) versus 100% oxygen

in 289 preterm infants <32 weeks’ gestation, targeting for SpO2

65–95% up to 5min and 85–95% until admission.10 Mortality in

the subgroup of babies <29 weeks’ gestation was 16.2% in the RA

group and 6% in the 100% oxygen group (p=0.013). This differ-

ence, although statistically marginal, emphasized the urgent need

for prospective studies. European RCTs were performed with SpO2 targets available, and >50% of babies enrolled in blinded studies. The Canadian study included centers with different oxygenation protocols and no SpO2 reference ranges. It is plausible that during this transition period, without clear SpO2 targets, FiO2 adjustments began to evolve with progressively more clinician experience.

We are of the opinion that the recommendation does not reflect the present state of uncertainty regarding best initial FiO2 for extremely preterm infants, and cer- tainly, not how to optimally titrate FiO2.

We therefore conclude that well-designed and adequately pow- ered RCTs such as the PRESOX and Torpido 2 deem essential.

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