Background: Neonatal resuscitation and positive pressure ventilation.

Decision node: Oxygen concentration: 21%... 40% ... 100%

Question: which one is better, under what circumstances?

Carlos DELGADO

Pediatrician Neonatologist

Instituto Nacional de Salud del Niño

Lima PERU

There's a revision in pipeline, of the Swedish guidelines on resuscitation. There were quite a lot of discussion regarding the evidence of using O2 immediately after birth, at the workshop discussing this revision.

The data from Saugstads group in Norway and others would suggest that room air would be fine, but practises vary a lot. I'd reckon our new (Swedish) guidelines will be suggesting less/no extra oxygen from the start of the resuscitation, but vaguely suggest that oxygen may me added/increased later during the resuscitation.

Now, while awaiting the new guidelines we use 40% in our unit.

PS. I added a poll to this discussion. DS.

Do the swedish guidlines differ from the ILCOR guidance?

Do the swedish guidlines differ from the ILCOR guidance?

Well, I don't think the new guidelines will differ at any major points. The conclusion of the workshop last year was that the (Swedish) working group needed to await the ILCOR report.

The new guidlines do not offer any clear guidance re: use of oxygen. The latest version of the UK guidelines will state that there is no clear evidence for which oxygen concentration to use- so it is a personal choice where to start but increase fio2 if no improvement. Sounds like they are sitting on the fence on that one.

Andrew Kapetanakis

University Hospital London

Dear Andrew, you're absolutely right that the latest ILCOR document gives no strict guidelines regarding O2 during resuscitation, although ILCOR explicitely say that room air could be used at the initiation of resuscitation (see quoted section below).

I'd guess the new upcoming Swedish guidelines will contain similar statements as to the British recommendation you refer to, ie joining at the same fence!

*******

From the ILCOR report:

"Although the standard approach to resuscitation is to use 100% oxygen, it is reasonable to begin resuscitation with an oxygen concentration of less than 100% or to start with no supplementary oxygen (ie, start with room air). If the clinician begins resuscitation with room air, it is recommended that supplementary oxygen be available to use if there is no appreciable improvement within 90 seconds after birth. In situations where supplementary oxygen is not readily available, positive-pressure ventilation should be administered with room air."

Dear Andrew,

Would you be so kind to explain a little bit wider your phrase "it is a personal choice where to start but increase fio2 if no improvement''. I liked it very much, but I am not sure of the same meaning with your vision and mine. Thank you. Comments of other colleagues are also welcome.

Audrius

Kaunas Medical University Hospital,

Lithuania

we do the same 21%

I usually start my resuscitation with 50% and if baby doesnot response to it than increase to 100%.

start with 21%, add oxygen if no response in 60 -90 sec

Livia Ognean, Sibiu, Romania

Dear swedish netters:

I read a very interesting article in Pediatrics: Saugstad OD, Ramji S, Vento M. Oxygen for newborn resuscitation: how much is enough? Pediatrics. 2006 Aug;118(2):789-92. PMID: 16882835

Authors say that "... initiation of 40% has been recommended for the last 10 years (In Sweden)", Them believed it's safe, and also, them think that blenders should be installed in all other countries for use this concentration.

I also found that the bag and mask, could offer Oxygen concentration near 40%, without reservoir. (AHA-AAP cpr guidelines).

What do you think about this last approach?

Best Regards,

Carlos DELGADO

Pediatrician Neonatologist

Instituto Nacional de Salud del Niño

Lima PERU

Dear Carlos,

I have just read this commentary by Saugstad, it is highly recommended reading! Saugstad is one of the leading researchers on neonatal resuscitation and oxygen effects.

According to Saugstad and co-authors, there are sufficient data to conclude that 100% oxygen at resuscitation should generally be avoided. I also interpret their views that oxygen administration should be rather low at initiation of resuscitation, but increased at 90 seconds if the infant has not improved. They put forward the Swedish strategy (which has been 40%) as an example.

I think they have a point about the idea to reduce oxygen administration to the "lowest level needed as fast as possible". A blender is probably the best way to control oxygen administration. However, one may also consider alternative ways to achieve differentiated oxygen levels in simplier setups, such as

* bag/mask with room air

* bag/mask with oxygen connected but no reservior (approx 40%)

* bag/mask with reservoir (100%).

Background: Neonatal resuscitation and positive pressure ventilation.

Decision node: Oxygen concentration: 21%... 40% ... 100%

Question: which one is better, under what circumstances?

Carlos DELGADO

Pediatrician Neonatologist

Instituto Nacional de Salud del Niño

Lima PERU

dear colleagues..

best wishes, i'm here for the first time in your forum, i'm a neonatologist working in Palestine, Shifa Hospital...in our NICU..we still follow the recommendation to use 100% oxygen for rescusitation, but when i teach NRP course, i put a note that air or less oxygen may be used at start , but..still don't change your first practice of using 100% oxygen in rescusitation..thanks

we still follow the recommendation of AAP/NRP 2000 for using 100% oxygen in rescusitation ..that is in our NICU/ Palestine/ shifa Hospital

we still use the recommended 90-100% oxygen for neonatal resuscitation.

start with 21%, add oxygen if no response in 60 -90 sec

Difficult to answer the question, without more specifics. Resuscitate who?

Preemie where I assume some pulmonary insufficiency I use 40%, term NB with perinatal depression but presumably normal lungs I use RA.

There are enough data, I believe, to be on pretty solid ground with the term NB resuscitation. For preemies, we really don't know, hence the compromise.

Poll questions need to be very specific in order to get truly useful information.....

Cheers,

M. Keszler MD

Georgetown U.

In Switzerland, we are currently revising our recommendations and have decided to recommend a starting FiO2 of 40%; this was chosen for pragmatic reasons: if you have no blender available, bagging with an ambu bag without oxygen reservoir using an oxygen flow of 4l/Min will result in an FiO2 of approximately 40%, similarly providing oxygen at 4l/Min with a face mask with side holes will result in an FiO2 of approximately 40%. In addition, the use of pulse oxymetry is recommended to guide adjustment of the FiO2.

In Spain the Neonatal Resuscitation Working Group recomended to start with FiO2 30-35% and increase or decrease if cardiac rate is increasing or the baby goes OK. We recomended included in the delivery room : blender oxygen-air and and pulse oxymetry. But, is only bag and mask is able. 40% is OK.

we still follow the recommendation of AAP/NRP 2000 for using 100% oxygen in rescusitation ..that is in our NICU/ Palestine/ shifa Hospital

You can communicate with our unit in Mansoura,Egypt Dr. Thabet. We welcome u. We do the same thing like u.

Dear 99nicu netters:

There is a new article for discussion about our subject (40% oxygen):

Hellstrom-Westas L, Forsblad K, Sjors G, Saugstad OD, Bjorklund LJ, Marsal K, Kallen K. Earlier Apgar score increase in severely depressed term infants cared for in Swedish level III units with 40% oxygen versus 100% oxygen resuscitation strategies: a population-based register study.

Pediatrics. 2006 Dec;118(6):e1798-804.

Do you think that a better Apgar means that 40% is a better oxygen choice?

Best Regards,

Carlos DELGADO

Pediatrician Neonatologist

Instituto Nacional de Salud del Niño

Lima PERU

We have been using 40% in deliveries for nearly a year now and with good results. It is up to the Neonatologist or NNP to set concentration at delivery. We have also reset our O2 sat limits lower in the NICU to 85-94%. It is driving us nuts because the monitor will alarm if the sats are above 94% as well as below, so you are constantly rechecking your infant. We are trying to find a solution for the higher O2 sats. We can no longer have the O2 sat parameters set at 85-100%. BluelightRN:)

IT DIFFES WIDELY,e.g.IN PERINATAL ASPHYXIA ,EXTREME P.T.,OR RDS,....etc.,WE USUALLY START WITH 100%O2, OTHERWISE WE CAN START 21% OR 40%

21% oxygen ( in air,lack /cut off of electricity in our hospital ) is also effective in any resuscitation. In our hospital , air sep ( New intensifier ) was broken down and sent to repair for one month,at that time any resuscitation during this period,we used 21% oxygen in air . It also effective like as 100% oxygen,but a lot of cases had been done longer duration of resuscitation time ( 20min to 30 min )

I think that 40% oxygen is also better in apgar for severely depressed baby same as 100% oxygen. We have many cases of resuscitation done without airsep/oxygen cylinderin severely depressed baby,but respond of resuscitation is also good,but a little longer duration of resuscitation time consuming.

In Canada, our Neonatal Resuscitation Guidelines say to start at 21%. We do this for all our babies (primarily premature infants ranging 420 - ~1200g), although depending on the neonatologist, we may not stay on r/a for the full 90 seconds recommended before increasing (usually to 30%, then 40% etc.). Overall I'd say we are pretty cautious, only looking to increase FiO2 if sats are consistently less than 80% with good ventilation. We are able to stay either on r/a or less than 40% with most of our babies, even before we get the surfactant (bLES) into the babies.

All of our resuscitation warmers, and every NICU bedside has a blender to control FiO2 to the baggers.

depend if the baby is term or preterm. There is a evidence that in term babies to beginn with air and in preterms with 30% O2 Saugstad in many articles discuss about this problem.

In our unit we use 100% o2 for term baby and <100% for preterm baby ,but 40% o2 is logic and if the baby not improved after 60-90 sec the use of 100% o2 is needed.

I usually begin by 21% then increase percentage of O2

We prefer to start resuscitation at 21% and increase the FiO2 if necessary thereafter.

Thanks everyone for the Information, I understand the whole Preductal O2 sats for the first 5 mins but after we are settled in the Nicu, what is the Ballpark range you Neonatal MD's like your Saturations on the ABG results?

Thanks

It would be interesting to see how this poll would be answered today - after the ERC guidelines recommend using 21% now when initiating resuscitation after birth.

We use 21% for term babies and titrate up according to response.  For preterm babies (<34 weeks) we start at 30% and titrate as needed.  We would only start in 100% if the baby was apnoeic with a heart rate < 60 bpm.  These are the ANZCOR guidelines, released early this year.