Low FiO2 Preterm Resuscitation

Low FiO₂Preterm Resuscitation

Vento M, Moro M, Escrig R, et al. Preterm resuscitation with low oxygen causes less oxidative stress, inflammation, and chronic lung disease. Pediatrics 2009;124:e448-58. Abstract | HTML | PDF

Objective: The goal was to reduce adverse pulmonary adverse outcomes, oxidative stress, and inflammation in neonates of 24 to 28 weeks of gestation initially resuscitated with fractions of inspired oxygen of 30% or 90%.

Methods: Randomized assignment to receive 30% (N = 37) or 90% (N = 41) oxygen was performed. Targeted oxygen saturation values were 75% at 5 minutes and 85% at 10 minutes. Blood oxidized glutathione (GSSG)/reduced glutathione ratio and urinary o-tyrosine, 8-oxo-dihydroxyguanosine, and isoprostane levels, isofuran elimination, and plasma interleukin 8 and tumor necrosis factor alpha levels were determined.

Results: The low-oxygen group needed fewer days of oxygen supplementation (6 vs 22 days; P < .01) and fewer days of mechanical ventilation (13 vs 27 days; P < .01) and had a lower incidence of bronchopulmonary dysplasia at discharge (15.4% vs 31.7%; P < .05). GSSG/reduced glutathione x 100 ratios at day 1 and 3 were significantly higher in the high-oxygen group (day 1: high-oxygen group: 13.36 +/- 5.25; low-oxygen group: 8.46 +/- 3.87; P < .01; day 3: high-oxygen group: 8.87 +/- 4.40; low-oxygen group: 6.97 +/- 3.11; P < .05). Urinary markers of oxidative stress were increased significantly in the high-oxygen group, compared with the low-oxygen group, in the first week after birth. GSSG levels on day 3 and urinary isofuran, o-tyrosine, and 8-hydroxy-2'-deoxyguanosine levels on day 7 were correlated significantly with development of chronic lung disease.

Conclusions: Resuscitation of preterm neonates with 30% oxygen causes less oxidative stress, inflammation, need for oxygen, and risk of bronchopulmonary dysplasia.

Comments: It is quite remarkable that these authors found an association between different FiO₂ concentrations used in the DR during the first 5 minutes of life (they were identical thereafter) and the incidence of BPD. How can this be explained? Perhaps epigenetics can provide an answer (see previous article and Hitchler MJ, Domann FE. An epigenetic perspective on the free radical theory of development. Free Radic Biol Med 2007;43:1023-36)? Whatever the explanation, evidence continues to accumulate indicating that neonatologists should use oxygen carefully, and they should start doing so in the DR. The Swiss physician Paracelsus warned already 500 years ago: "All things are poison and nothing is without poison, only the dose permits something not to be poisonous." TMB

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