Making a choice: initial fraction of inspired oxygen for resuscitation at birth of a premature infant less than 32 weeks gestational age

Figures & data

Table 1 Summary of findings in the five relevant randomized controlled trials

Reference	Population	Study type	Intervention	Titration method	Key outcomes	Results
Escrig et al^Table Footnote2,Table Footnote*	Preterm neonates ≤28 weeks GA requiring resuscitation	Prospective, randomized controlled trial; blinded	LOG (30%, n= 19) versus HOG (90%, n=23)	FiO2 increased/decreased by 10% every 60–90 seconds based on HR and SpO2 Goals: HR > 100 at all times and a preductal SpO2 rising towards 85% over first 10 minutes of life	Preductal SpO2 at 10 minutes after birth Difference in preductal SpO2 at 1, 2, 3, 4, 5, 10, 15, and 20 minutes after birth Ventilatory support in delivery room (eg, CPAP, intubation) FiO2 in first 3 minutes of life FiO2 after first 3 minutes of life	No significant difference between LOG (86.9%±2.5%) and HOG (88.7%±2.5%) No significant differences between LOG and HOG No significant difference between LOG and HOG Significantly higher in HOG versus LOG (P<0.01) No significant difference between LOG and HOG
Wang et al^Citation3	Preterm neonates <31 weeks GA requiring resuscitation	Prospective, randomized controlled trial; nonblinded	LOG (21%, n= 18) versus HOG (100% for initial 5 minutes, n=23)	LOG: FiO2 increased to 50% if preductal SpO2 <70% at 3 minutes or <85% at 5 minutes; FiO2 then increased by 25% every 30 seconds to reach target SpO2 HOG: FiO2 kept at 100% for the first 5 minutes, then weaned if preductal SpO2 >95% Treatment failure: preductal SpO2 <70% at 3 minutes of life, requiring an increase in FiO2	LOG requirement of an increase in FiO2 at or before 3 minutes of life Preductal SpO2 at 2, 3, 4, 5, and 10 minutes of life Heart rate in first 10 minutes of life FiO2 administered at 1, 2, 3, 4, 5, 6, 7, 8, 9, and 10 minutes of life Percent of neonates with preductal SpO2 of >95% at 5 minutes	100% of infants required an increase in FiO2 because all failed to meet the target with room air as the initial FiO2 Significantly higher SpO2 at all time points (P<0.01) in HOG although by 10 minutes of life, the mean SpO2 in both groups was >85% No significant differences between LOG and HOG Significantly lower at all time points (P<0.01) up to 7 minutes in LOG; no significant differences between LOG and HOG at 8, 9, or 10 minutes HOG ~57% versus LOG ~17% (P<0.05)
Vento et al^Citation4	Preterm neonates ≤28 weeks GA requiring resuscitation	Prospective, randomized controlled trial; nonblinded	LOG (30%, n=37) versus HOG (90%, n=41)	FiO2 increased/decreased by 10% every 60–90 seconds based on HR and SpO2 Goals: preductal SpO2 of 75% at 5 minutes and 85% at 10 minutes	Percent of neonates reaching target preductal SpO2 values of 75% at 5 minutes and 85% at 10 minutes FiO2 administered at 2, 3, 4, 5, and 10 minutes of life Heart rate in first 10 minutes of life Preductal SpO2 at 2, 3, 4, 5, and 10 minutes of life On FiO2 of 21% on arrival at NICU	No significant differences between LOG and HOG; both groups reached the targets Significantly lower at all time points (P<0.01) up to 4 minutes in LOG; no significant differences between LOG and HOG at 5 or 10 minutes No significant differences between LOG and HOG No significant differences between LOG and HOG Significantly higher in LOG (76%) versus HOG (56%, P<0.05)
Rabi et al^Citation5	Preterm neonates ≤32 weeks GA requiring resuscitation	Prospective, randomized controlled trial; blinded	LOG (21%, n=34) versus HOG (100%, n=34)	FiO2 increased/decreased by 20% every 15 seconds based on HR and SpO2 Goals: target preductal SpO2 of 85%–92% Treatment failure: HR <100 beats per minute for >30 seconds	Proportion of resuscitation time spent in target SpO2 range^** Time to reach target SpO2 of 85%–92% Proportion of infants in target SpO2 range at 10 minutes Proportion of infants with SpO2 above 92% at 10 minutes Proportion of infants meeting treatment failure criteria	No significant difference between LOG (16%) and HOG (21%) No significant difference between LOG and HOG (P=0.56); mean SpO2 for each group was >85% by 5 minutes No significant difference between LOG (38%) and HOG (38%); there was also no significant difference at 5 minutes No significant difference between LOG (33%) and HOG (34%); there was also no significant difference at 5 minutes No significant difference between LOG (24%) and HOG (9%)
Kapadia et al^Citation6	Preterm neonates ≤34 weeks GA requiring resuscitation	Prospective, randomized controlled trial; nonblinded	LOG (21%, n=44) versus HOG (100%, n=44)	FiO2 increased/decreased by 10% every 30 seconds based on HR and SpO2 Goals: target preductal SpO2 of NRP-recommended transitional goal saturations^Citation7 Treatment failure: HR <60 beats per minute despite 30 seconds of effective PPV	Proportion of infants in LOG requiring an increase in FiO2 to meet target SpO2 range Preductal SpO2 at 2, 3, 4, 5, 6, 7, 8, 9, and 10 minutes of life Proportion of infants with SpO2 above 94% at 2, 3, 4, 5, 6, 7, 8, 9 and 10 minutes of life Proportion of infants with SpO2 below lower limit of target SpO2 range at 2, 3, 4, 5, 6, 7, 8, 9, and 10 minutes of life Proportion of infants meeting treatment failure criteria	All infants in LOG required an increase in FiO2 Significantly higher SpO2 at 3–6 minutes of life (P<0.05) in HOG Significantly higher at 2–10 minutes of life (P<0.05) in HOG Significantly higher at 3–6 minutes of life (P<0.05) in LOG No significant difference between LOG (0%) and HOG (0%)

Notes:

* The population in this study makes up a portion of the infants in the study by Vento et al.⁴ The reported findings from this study provide readers with different clinical data of importance

** study was powered based on this primary outcome. No other study was specifically powered to assess any of their clinical outcomes.

Abbreviations: LOG, low-oxygen group; HOG, high-oxygen group; NRP, Neonatal Resuscitation Program; NICU, neonatal intensive care unit; CPAP, continuous positive airway pressure; HR, heart rate; GA, gestational age; PPV, positive pressure ventilation; SpO₂, oxygen saturation; FiO₂, fraction of inspired oxygen.

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