The novel PID algorithm was very effective for automated oxygen control in preterm infants, and deserves further investigation.

Background The factors influencing the severity of apnea‐related hypoxemia and bradycardia are incompletely characterized, especially in infants receiving noninvasive respiratory support. Objectives To identify the frequency and predictors of physiological instability (hypoxemia—oxygen saturation (SpO2) <80%, or bradycardia—heart rate (HR) < 100 bpm) following respiratory pauses in infants receiving noninvasive respiratory support. Methods Respiratory pause duration, derived from capsule pneumography, was measured in 30 preterm infants of gestation 30 (24‐32) weeks [median (interquartile range)] receiving noninvasive respiratory support and supplemental oxygen. For identified pauses of 5 to 29 seconds duration, we measured the magnitude and duration of SpO2 and HR reductions over a period starting at the pause onset and ending 60 seconds after resumption of breathing. Temporally clustered pauses (<60 seconds separation) were analyzed separately. The relative contribution of respiratory pauses to overall physiological instability was determined, and predictors of instability were sought in regression analysis, including demographic, clinical and situational variables as inputs. Results In total, 17 105 isolated and 9180 clustered pauses were identified. Hypoxemia and bradycardia were more likely after longer duration and temporally‐clustered pauses. However, the majority of such episodes occurred after 5 to 9 second pauses given their numerical preponderance, and short‐lived pauses made a substantial contribution to physiological instability overall. Birth gestation, hemoglobin concentration, form of respiratory support, caffeine treatment, respiratory pause duration and temporal clustering were identified as predictors of instability. Conclusions Brief respiratory pauses, especially when clustered, contribute substantially to hypoxemia and bradycardia in preterm infants.

ObjectiveTo evaluate the performance of a rapidly responsive adaptive algorithm (VDL1.1) for automated oxygen control in preterm infants with respiratory insufficiency.DesignInterventional cross-over study of a 24-hour period of automated oxygen control compared with aggregated data from two flanking periods of manual control (12 hours each).SettingNeonatal intensive care unit.ParticipantsPreterm infants receiving non-invasive respiratory support and supplemental oxygen; median birth gestation 27 weeks (IQR 26–28) and postnatal age 17 (12–23) days.InterventionAutomated oxygen titration with the VDL1.1 algorithm, with the incoming SpO2 signal derived from a standard oximetry probe, and the computed inspired oxygen concentration (FiO2) adjustments actuated by a motorised blender. The desired SpO2 range was 90%–94%, with bedside clinicians able to make corrective manual FiO2 adjustments at all times.Main outcome measuresTarget range (TR) time (SpO2 90%–94% or 90%–100% if in air), periods of SpO2 deviation, number of manual FiO2 adjustments and oxygen requirement were compared between automated and manual control periods.ResultsIn 60 cross-over studies in 35 infants, automated oxygen titration resulted in greater TR time (manual 58 (51–64)% vs automated 81 (72–85)%, p<0.001), less time at both extremes of oxygenation and considerably fewer prolonged hypoxaemic and hyperoxaemic episodes. The algorithm functioned effectively in every infant. Manual FiO2 adjustments were infrequent during automated control (0.11 adjustments/hour), and oxygen requirements were similar (manual 28 (25–32)% and automated 26 (24–32)%, p=0.13).ConclusionThe VDL1.1 algorithm was safe and effective in SpO2 targeting in preterm infants on non-invasive respiratory support.Trial registration numberACTRN12616000300471.

Oxygen is one of the most commonly used therapies in neonatology but optimum oxygen saturations for preterm infants have been debated for the past 50 years. The history of oxygen use in this population and multiple clinical trials over the years have shown that liberal oxygen administration is associated with retinopathy of prematurity (ROP) and bronchopulmonary dysplasia (BPD) whereas restrictive use results in increased mortality and neurodisability. Pulse oximetry (SpO 2) is a bedside tool to guide the fraction of inspired oxygen (FiO 2) delivered to the patient, and is the current standard of care for continuous monitoring. Although evidence favours targeting predetermined oxygen saturation ranges, achieving this goal consistently in clinical practice has been challenging due to intrinsic pulmonary immaturity, the need for respiratory support therapies and factors relating to the bedside caregivers ability to adjust FiO 2. This review article focuses on the difficulties of titrating oxygen therapy in this vulnerable group and provides recommendations for the best practice based on up to date evidence.

ObjectiveTo study the feasibility of automated titration of oxygen therapy in the delivery room for preterm infants.DesignProspective non-randomised study of oxygenation in sequential preterm cohorts in which FiO2 was adjusted manually or by an automated control algorithm during the first 10 min of life.SettingDelivery rooms of a tertiary level hospital.ParticipantsPreterm infants <32 weeks gestation (n=20 per group).InterventionAutomated oxygen control using a purpose-built device, with SpO2 readings input to a proportional-integral-derivative algorithm, and FiO2 alterations actuated by a motorised blender. The algorithm was developed via in silico simulation using abstracted oxygenation data from the manual control group. For both groups, the SpO2 target was the 25th–75th centile of the Dawson nomogram.Main outcome measuresProportion of time in the SpO2 target range (25th–75th centile, or above if in room air) and other SpO2 ranges; FiO2 adjustment frequency; oxygen exposure.ResultsTime in the SpO2 target range was similar between groups (manual control: median 60% (IQR 48%–72%); automated control: 70 (60–84)%; p=0.31), whereas time with SpO2 >75th centile when receiving oxygen differed (manual: 17 (7.6–26)%; automated: 10 (4.4–13)%; p=0.048). Algorithm-directed FiO2 adjustments were frequent during automated control, but no manual adjustments were required in any infant once valid SpO2 values were available. Oxygen exposure was greater during automated control, but final FiO2 was equivalent.ConclusionAutomated oxygen titration using a purpose-built algorithm is feasible for delivery room management of preterm infants, and warrants further evaluation.

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Objective: Ventricular dysfunction may be found in 40% of newborns with CDH. Ventricular performance is not only a predictor of disease severity but also mortality and need for ECMO. We studied the utility of serial echocardiography in the management of newborns with CDH and on survival outcomes.Study Design: This is a retrospective study wherein the demographic, clinical and echocardiographic data were retrieved from the local CDH registry and hospital clinical database. We studied the correlation of timed echocardiographic findings with mortality and other outcomes.Results: Fourty-two newborns with CDH were admitted during the study period (M/F:19/23), with median gestation of 38 weeks (IQR:36-39) and birth weight of 2.83 kg (IQR 2.45-3.17). Thirty-one were left-sided, seven right, one central, and three bilateral hernias. Twelve infants (28%) died in early infancy. Three infants were excluded from our analysis due to either palliation at birth or significant cardiac anomaly, resulting in a total of 137 echos from 39 infants being included in the analysis. Seventy percent of newborns who died and had an echo in first 72 hours, suffered from moderate to severe PH. Birth weight <2.8Kg, RVSP> 45.5 in the first 72 hours and postoperative VIS >23.5 and RSS >4.3 were good predictors of mortality in our cohort. Markers of elevated pulmonary pressures and cardiac function were useful in guiding therapy.Conclusions: Serial timed functional echocardiography (f-Echo) monitoring allows targeted therapy of patients with CDH. Birth weight, initial severity of pulmonary hypertension and postop RSS and VIS may be useful in predicting mortality.