A review of international clinical practice guidelines for the use of oxygen in the delivery room resuscitation of preterm infants

Abstract

Aim: To collate and assess international clinical practice guidelines (CPG) to determine current recommendations guiding oxygen management for respiratory stabilisation of preterm infants at delivery.Methods: A search of public databases using the terms 'clinical practice guidelines', 'preterm', 'oxygen' and 'resuscitation' was made and complemented by direct query to consensus groups, resuscitation expert committees and clinicians. Data were extracted to include the three criteria for assessment: country of origin, gestation and initial FiO 2 and target SpO 2 for the first 10 minutes of life.Results: A total of 45 CPGs were identified: 36 provided gestation specific recommendations (<28 to <37 weeks) while eight distinguished only between 'preterm' and 'term'. The most frequently recommended initial FiO 2 were between 0.21 and 0.3 (n = 17). Most countries suggested altering FiO 2 to meet SpO 2 targets recommended by expert committees, However, specific five-minute SpO 2 targets differed by up to 20% (70-90%) between guidelines. Five countries did not specify SpO 2 targets.Conclusion: CPG recommendations for delivery room oxygen management of preterm infants vary greatly, particularly in regard to gestational ages, initial FiO 2 and SpO 2 targets and most acknowledge the lack of evidence behind these recommendations. Sufficiently large and well-designed randomised studies are needed to inform on this important practice. BACKGROUNDPure oxygen (FiO 2 1.0) has been used for the respiratory support of newborn infants for more than a century (1) but

Oxygen therapy of the newborn from molecular understanding to clinical practice

“…The lack of evidence is reflected in the astoundingly wide variations in clinical practice guidelines for oxygen use around the world, where SpO 2 recommendations can vary by as much as 25%. 100 Certainly, due to the widespread implementation of low oxygenation resuscitation within the last decade, sufficiently powered studies to determine the impact of both starting FiO 2 and recommended FiO 2 targets of preterm infants are needed.…”

Optimal Inspired Fraction of Oxygen in the Delivery Room for Preterm Infants

“…In a survey performed among 630 clinicians from 25 countries the majority (77%) would target SpO 2 between the 10th and 50th percentiles values for term infants as shown in the AHA 2015 guidelines [9] and expressed their preference for the use of 0.3–0.4 or even lower initial FiO 2 (0.21) for preterm infants in the DR. Of note, a substantial number of responders agreed that there was a gap of knowledge and further studies would need to be performed [12]. More recently, a review of the guidelines for oxygen use in the DR in 45 different countries showed a great variability regarding gestational ages, initial FiO 2 and SpO 2 targets [38]. Initial FiO 2 recommendations ranged from 0.21–1.0; however, the most frequently recommended were 0.21–0.3 (38%), 0.3 (20%) and 0.21 (18%).…”

“…Differences in target SpO 2 at five minutes were notably different between countries. Therefore, while Scandinavian countries recommended 70%, other countries such as New Zealand or Australia recommended 90% and some countries did not make any recommendation [38]. Another relevant question is around the adherence to guidelines.…”

Commentary on ‘Lower versus Higher OxygenConcentrations Titrated to Target OxygenSaturations during Resuscitation of PretermInfants at Birth’

“…The review’s conclusion that there remains considerable uncertainty about whether lower versus higher delivery room FiO 2 has an important effect on mortality or morbidity in very preterm infants is reflected in international clinical practice guidelines [4]. Most guidelines, including the current International Liaison Committee on Resuscitation statement, suggest using a lower FiO 2 initially and titrating this to the infant’s SpO 2 to avoid exposure to additional oxygen without proven benefit [5].…”