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Efficacy of High-Flow Nasal Cannula vs Standard Oxygen Therapy or Nasal Continuous Positive Airway Pressure in Children with Respiratory Distress: A Meta-Analysis.
Luo, J, Duke, T, Chisti, MJ, Kepreotes, E, Kalinowski, V, Li, J
The Journal of pediatrics. 2019;:199-208.e8
Abstract
OBJECTIVES To evaluate the efficacy of high-flow nasal cannula (HFNC) oxygen therapy in providing respiratory support of children with acute lower respiratory infection (ALRI), hypoxemia, and respiratory distress. STUDY DESIGN We performed a meta-analysis of randomized controlled trials that compared HFNC and standard flow oxygen therapy or nasal continuous positive airway pressure (nCPAP) and reported treatment failure as an outcome. Data were synthesized using Mann-Whitney U test. RESULTS Compared with standard oxygen therapy, HFNC significantly reduced treatment failure (risk ratio [RR] 0.49, 95% CI 0.40-0.60, P < .001) in children with mild hypoxemia (arterial pulse oximetry [SpO2] >90% on room air). HFNC had an increased risk of treatment failure compared with nCPAP in infants age 1-6 months with severe hypoxemia (SpO2 <90% on room air or SpO2 >90% on supplemental oxygen) (RR 1.77, 95% CI 1.17-2.67, P = .007). No significant differences were found in intubation rates and mortality between HFNC and standard oxygen therapy or nCPAP. HFNC had a lower risk of nasal trauma compared with nCPAP (RR 0.35, 95% CI 0.16-0.77, P = .009). CONCLUSIONS Among children <5 years of age with ALRI, respiratory distress, and mild hypoxemia, HFNC reduced the risk of treatment failure when compared with standard oxygen therapy. However, nCPAP was associated with a lower risk of treatment failure than HFNC in infants age 1-6 months with ALRI, moderate-to-severe respiratory distress, and severe hypoxemia. No differences were found in intubation and mortality between HFNC and standard oxygen therapy or nCPAP.
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Achieved Oxygenation Saturations and Outcome in Extremely Preterm Infants.
Stenson, BJ
Clinics in perinatology. 2019;(3):601-610
Abstract
Infants in the Neonatal Oxygenation Prospective Meta-analysis trials were randomized to SpO2 targets of 85% to 89% or 91% to 95%. Group allocation was masked. Different outcomes are likely partially attributable to differences in achieved SpO2. Infants randomized to the lower range had higher than intended readings. SpO2 distributions of infants in the low-range group of the Benefits of Oxygen Saturation Targeting II UK trial who died or developed necrotizing enterocolitis were centered around 90% to 92%. These achieved SpO2 distributions caution against using lower SpO2 target ranges early or throughout the clinical course in extremely preterm infants.
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Meta-analysis of Oxygenation Saturation Targeting Trials: Do Infant Subgroups Matter?
Askie, LM
Clinics in perinatology. 2019;(3):579-591
Abstract
Participant data from approximately 5000 infants have been meta-analyzed to guide oxygen saturation policy for extremely preterm infants. The Neonatal Oxygenation Prospective Meta-analysis showed that targeting a higher oxygen saturation range compared with a lower range resulted in decreased death and necrotizing enterocolitis and no difference in major disability but increased treated retinopathy of prematurity (ROP) and supplemental oxygen use at 36 weeks' postmenstrual age. The 91% to 95% range can be recommended for all extremely preterm infants from birth but should be accompanied by stringent surveillance for the prevention and early treatment of ROP.
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Current Recommendations and Practice of Oxygen Therapy in Preterm Infants.
Tarnow-Mordi, W, Kirby, A
Clinics in perinatology. 2019;(3):621-636
Abstract
This narrative review identified 23 publications in 2011 to 2019 discussing randomized trials of oxygen saturation targets of 85% to 89% versus 91% to 95% in infants below 28 weeks' gestation. Of 18 commentaries or consensus statements, 17 recommended saturation targets above 89%. Five systematic reviews reported that the 85% to 89% target increased mortality but not the composite of death or disability. The evidence for increased mortality was assessed as of "high", "moderate," or "low," quality, reflecting substantial differences in interpreting the GRADE guidelines. Systematic reviews and guidelines without biostatisticians or epidemiologists as co-authors should be considered potentially problematic.
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Oxygen Saturation and Retinopathy of Prematurity.
Higgins, RD
Clinics in perinatology. 2019;(3):593-599
Abstract
Retinopathy of prematurity (ROP) is a serious disease affecting premature infants. Rates of ROP increase with decreasing gestational age. Duration of oxygen exposure is correlated with ROP. Many studies evaluating oxygen have been performed to assess impact on ROP. This article describes recent findings for oxygen saturation target studies and suggests area of future study for ROP.
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Oxygen Toxicity in the Neonate: Thinking Beyond the Balance.
Tipple, TE, Ambalavanan, N
Clinics in perinatology. 2019;(3):435-447
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Abstract
Fetal development occurs in a relatively hypoxemic environment, and birth represents significant oxidative stress. Premature infants are disadvantaged by a lack of maternal antioxidant transfer and impaired endogenous antioxidant responses. O2 metabolism is essential for life and its biochemical reactions are dynamic, compartmentalized, and difficult to characterize in vivo. There is a growing appreciation for the role of reactive oxygen species in nonpathologic processes, including regulation of cell signaling and mitochondrial function. There are several gaps in the knowledge about the role of reactive oxygen species in normal development and how oxidative stress alters normal signaling and subsequent development.
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Pharmacologic interventions for the prevention and treatment of retinopathy of prematurity.
Beharry, KD, Valencia, GB, Lazzaro, DR, Aranda, JV
Seminars in perinatology. 2016;(3):189-202
Abstract
Retinopathy of prematurity (ROP), a significant morbidity in prematurely born infants, is the most common cause of visual impairment and blindness in children and persists till adulthood. Strict control of oxygen therapy and prevention of intermittent hypoxia are the keys in the prevention of ROP, but pharmacologic interventions have decreased risk of ROP. Various drug classes such as methylxanthines (caffeine), VEGF inhibitors, antioxidants, and others have decreased ROP occurrence. The timing of pharmacologic intervention remains unsettled, but early prevention rather than controlling disease progression may be preferred. These drugs act through different mechanisms, and synergistic approaches should be considered to maximize efficacy and safety.
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Advances in acute asthma.
Rodrigo, GJ
Current opinion in pulmonary medicine. 2015;(1):22-6
Abstract
PURPOSE OF REVIEW The purpose of this study is to highlight some of the recent findings related with the management of acute exacerbations in the context of the emergency department setting. RECENT FINDINGS β₂-agonist heliox-driven nebulization significantly increased by 17% [95% confidence interval (CI) 5.2-29.4] peak expiratory flow, and decreased the rate of hospital admissions (risk ratio 0.77, 95% CI 0.62-0.98), compared with oxygen-driven nebulization. Other findings indicate that there is no robust evidence to support the use of intravenous or nebulized magnesium sulphate in adults with severe acute asthma, and that levalbuterol was not superior to albuterol regarding efficacy and safety in individuals with acute asthma. Finally, hyperlactatemia developed during the first hours of acute asthma treatment has a high prevalence, is related with the use of β₂-agonists and had no clinical consequences. SUMMARY After a comprehensive review of the best quality pieces of literature published in the last year, it is possible to conclude that the goals of acute asthma management remain almost unchanged.
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Automated adjustments of inspired fraction of oxygen to avoid hypoxemia and hyperoxemia in neonates - a systematic review on clinical studies.
Hummler, H, Fuchs, H, Schmid, M
Klinische Padiatrie. 2014;(4):204-10
Abstract
Supplemental oxygen is commonly provided during transition of neonates immediately after birth. Whereas an initial FiO2 of 0.21 is now recommended to stabilize full-term infants in the delivery room, the best FiO2 to start resuscitation of the very low birth weight infant (VLBWI) immediately after delivery is currently not known. Recent recommendations include the use of pulse oximetry to titrate the use of supplemental oxygen. As reference values for pulse oximetry during the first minutes of life have become available, automated FiO2-adjustments are feasible and may be very useful for delivery room care to limit oxygen exposure. Beyond neonatal transition, preterm infants in the neonatal intensive care unit (NICU) commonly require supplemental oxygen to avoid hypoxemia, especially VLBWI receiving respiratory support because of poor respiratory drive and/or lung disease. For respiratory care of newborn infants in the NICU automated FiO2-adjustment systems have been developed and have been studied in preterm infants for limited time frames using short-term physiological outcomes. These studies could demonstrate short-term benefits such as more stable arterial oxygen saturation. Recent clinical trials have shown that oxygen targeting may significantly affect mortality and morbidity. Therefore, randomized controlled trials are needed to study the effects of automated FiO2-adjustment on long-term outcomes to prove possible benefits on survival, the rate of retino-pathy of prematurity and on neuro-development-al outcome.
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Effects of oxygen on the development and severity of retinopathy of prematurity.
Hartnett, ME, Lane, RH
Journal of AAPOS : the official publication of the American Association for Pediatric Ophthalmology and Strabismus. 2013;(3):229-34
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Abstract
In 1942, when retinopathy of prematurity (ROP) first manifested as retrolental fibroplasia, the technology to monitor or regulate oxygen did not exist, and a fundus examination of preterm infants was not routinely performed. Supplemental, uncontrolled oxygen at birth has since been found to cause retrolental fibroplasia. At the same time, technological advances have made it possible to regulate oxygen and detect early forms of ROP. Nevertheless, despite our better understanding of ROP and ongoing investigations of supplemental therapeutic oxygen, including recent clinical trials (Surfactant, Positive Airway Pressure, Pulse Oximetry Randomized Trial [SUPPORT] and Benefits of Oxygen Saturation Targeting [BOOST]), the best oxygen profiles to reduce ROP risk while optimizing preterm infant health and development remain unknown. This article reviews major studies on oxygen use in preterm infants and the effects on the development of ROP.