Home oxygen therapy: the jury is still in session

Transmitted Home Oximetry and Duration of Home Oxygen in Premature Infants

OBJECTIVES

To determine if a home oxygen therapy (HOT) management strategy that includes analysis of recorded home oximetry (RHO) data, compared with standard monthly clinic visit assessments, reduces duration of HOT without harm in premature infants.

METHODS

The RHO trial was an unmasked randomized clinical trial conducted in 9 US medical centers from November 2013 to December 2017, with follow-up to February 2019. Preterm infants with birth gestation ≤37 + 0/7 weeks, discharged on HOT, and attending their first pulmonary visit were enrolled. The intervention was an analysis of transmitted RHO between clinic visits (n = 97); the standard-care group received monthly clinic visits with in-clinic weaning attempts (n = 99). The primary outcomes were the duration of HOT and parent-reported quality of life. There were 2 prespecified secondary safety outcomes: change in weight and adverse events within 6 months of HOT discontinuation.

RESULTS

Among 196 randomly assigned infants (mean birth gestational age: 26.9 weeks; SD: 2.6 weeks; 37.8% female), 166 (84.7%) completed the trial. In the RHO group, the mean time to discontinue HOT was 78.1 days (SE: 6.4), compared with 100.1 days (SE: 8.0) in the standard-care group (P = .03). The quality-of-life scores improved from baseline to 3 months after discontinuation of HOT in both groups (P = .002), but the degree of improvement did not differ significantly between groups (P = .75).

CONCLUSIONS

RHO was effective in reducing the duration of HOT in premature infants. Parent quality of life improved after discontinuation. RHO allows physicians to determine which infants can be weaned and which need prolonged oxygen therapy between monthly visits.

Definition and outpatient management of the very low-birth-weight infant with bronchopulmonary dysplasia

Bronchopulmonary dysplasia (BPD), also known as chronic lung disease of prematurity, is the major cause of pulmonary disease in infants. The pathophysiology and management of BPD have evolved over the past four decades as improved neonatal intensive care unit (NICU) modalities have increased survival rates. The likelihood for developing BPD increases with the degree of prematurity and reaches 25-35% in very low-birth-weight and extremely low-birth-weight infants. BPD affects many organ systems, and infants with BPD are at increased risk for rehospitalization and numerous complications following NICU discharge. The management of BPD and medically related problems, particularly during the first 2 years of life, remains a continuing challenge for parents and healthcare providers. It is important that a multidisciplinary team consisting of the neonatologist/attending physician, primary care physician, and other specialized support staff work in concert and meet regularly to provide continuity of care and accurate patient assessments.

Programa de oxigenoterapia domiciliar para crianças egressas de uma unidade neonatal: relato da experiência de dez anos

OBJETIVO: Descrever os resultados do programa de oxigenoterapia domiciliar, com uso de concentrador de oxigênio, utilizado por crianças egressas de uma unidade neonatal ao longo de seus primeiros dez anos. MÉTODOS: Estudo de corte transversal com componente analítico para avaliar o programa de oxigenoterapia domiciliar de uma unidade neonatal de um hospital público universitário do interior do Estado de São Paulo durante o período de novembro de 1996 a dezembro de 2006. RESULTADOS: Foram identificadas 160 crianças com indicação de oxigenoterapia domiciliar, das quais 63,3% apresentavam displasia broncopulmonar. Em média, 3,0% de todos os pacientes internados e 8,6% dos recém-nascidos com peso inferior a 1500g ao nascer receberam alta em oxigenoterapia. A duração média do uso de O2 no domicílio foi de 42,3±54,0 dias. Na comparação das características demográficas da população e do tempo de uso de O2 domiciliar, não se observaram diferenças significativas entre os anos. Não houve correlação entre o tempo de ventilação mecânica e a duração da terapia domiciliar. Houve necessidade de cuidados especiais, além do uso de O2 e medicações, em 22,3% dos casos. Nos primeiros dois anos de vida, a taxa de morbidade e de mortalidade foram, respectivamente, 40,1 e 14,1%. CONCLUSÕES: O uso de oxigênio domiciliar, com sistema de concentrador de oxigênio, é uma alternativa terapêutica factível em nosso meio, merecendo mais atenção dos profissionais de saúde e maior investimento das instituições de saúde. São necessários mais estudos nacionais para se aprimorar a qualidade do atendimento e a segurança destes programas para a população neonatal.

Domiciliary oxygen for children

Domiciliary oxygen is used increasingly in pediatric practice, and the largest patient group to receive it is ex-premature babies with chronic neonatal lung disease. Because of a scarcity of good evidence to inform clinicians, there is a lack of consensus over many issues, even those as fundamental as the optimum target oxygen saturation. Nevertheless, many children benefit from receiving supplemental oxygen at home, particularly because it helps to keep them out of the hospital.

Follow-up care for infants with chronic lung disease: a randomized comparison of community- and center-based models

OBJECTIVES

Premature infants with chronic lung disease benefit from comprehensive care, which typically is based in tertiary medical centers. When such centers are not easily accessible, alternative models of care are needed. The purpose of this work was to compare community-based follow-up, provided via telephone contacts, to traditional center-based follow-up of premature infants with chronic lung disease.

PATIENTS AND METHODS

After discharge from neonatal intensive care, 150 premature infants with chronic lung disease were randomly assigned to either community-based (n = 75) or center-based (n = 75) follow-up. In community-based follow-up, a nurse specialist maintained telephone contact with the infant's primary caregiver and health care providers. Center-based follow-up consisted of visits to a medical center-based multidisciplinary clinic staffed by a neonatologist, a nurse specialist, and a social worker. The outcomes of interest were Bayley Scales of Infant Development mental developmental index and psychomotor developmental index, Vineland Adaptive Behavioral Composite, and growth delay (weight for length <5th percentile) at 1-year adjusted age and respiratory rehospitalizations through 1-year adjusted age.

RESULTS

In each randomization group, 73 infants survived, and 69 were evaluated at 1-year adjusted age. The median mental development index (corrected for gestational age) was 90 for both groups. The median psychomotor developmental index was 82 for the center-based group and 81 for the community-based group. The median Vineland Adaptive Behavioral Composite was 100 and 102 for the center-based and community-based groups, respectively. In the center-based and community-based groups, respectively, the proportions with growth delay were 13% and 26%, and the proportions rehospitalized for respiratory illness were 33% and 29%.

CONCLUSIONS

Infants randomly assigned to community-based, as compared with those randomly assigned to center-based follow-up, had similar developmental and health outcomes. The former approach might be a preferred alternative for families in rural settings or families for whom access to a tertiary care medical center is difficult.

The medically complex premature infant in primary care

The survival rate of the smallest and youngest of premature infants has continued to improve as medical technology has progressed. The current edge of viability is represented by infants born at 23 to 25 weeks' gestation. Neonatal survival of infants at 23 weeks' gestation ranges from 11% to 30%. Survival to hospital discharge for infants ranging from 23 to 26 weeks' gestation is about 70%; 30% to 50% of these infants have moderate to severe disability. Nurse practitioners and physicians will be meeting these young infants in primary care offices after they have been discharged from the neonatal intensive care unit. This article is Part III in a series addressing issues related to the premature infant. This installment focuses on medically complex premature infants and their health issues after discharge. Part I addressed issues common to all premature infants. Part II looked at the healthy premature infant and their management in primary care.